Title: Orthopaedics

Q: Overall mortality for pelvic fractures
A: 5%

Q: Mortality of pelvic fractures if shocked on arrival?
A: 50%

Q: Proportion of pelvic fractures with intra-abdominal injuries?
A: 30%

Q: Sensitivity of examination for pelvic fracture in awake patients
A: 93%

Q: What is Destot's sign?
A: Scrotal haematoma suggesting pelvic fracture

Q: Who should have a single pelvic spring test?
A: Stable patients only without obvious pelvic injury

Q: What other examinations are indicated in suspected pelvic fracture?
A: Lower limb neurovascular
PR
Bimanual/speculum for open wounds

Q: Indications for plain pelvic X-ray in trauma
A: Unstable blunt trauma patient - Identification of fracture will allow binder (if not already on), early stabilisation and mobilisation of resources for angiography or OT
Pelvic tenderness
Other findings to suggest pelvic #

Q: When is plain film pelvic X-ray contraindicated?
A: Stable and undergoing CT pelvis anyway

Q: How sensitive is contrast extravasation on CT for arterial bleeding?
A: 80-90%

Q: What proportion of 'isolated' anterior pubic symphysis fractures in the elderly have posterior pelvic ring disruptions on CT?
A: 50%

Q: What proportion of isolated rami fractures in the elderly return to baseline
A: Only 2/3

Q: Which pelvic fractures have highest rate of severe haemorrhage?
A: Vertical shear (75%)

Q: What are the most common pelvic fractures?
A: Lateral compression (60-70%)

Q: Management of isolated single bone pelvic fractures
A: Get CT to rule out associated injuries
If sacrum or iliac wing - high forces so look carefully
Ortho consult for likely outpatient analgesia, crutches/NWB and follow-up

Q: What are Judet views?
A: AP, 45 degree iliac oblique and 45 degree obturator oblique.
Used to visualise acetabular fossa

Q: Management of acetabular fractures
A: Admission under Ortho and rule out sciatic nerve injuries

Q: Which patients should have pelvic binders?
A: Suspected or proven open book or vertical shear fractures only
NOT lateral compression fractures

Q: Predictors of need for intervention for haemorrhage in pelvic trauma
A: Initial Hct <0.3
Pelvic haemorrhage on CT
SBP <90 on arrival
BE > -6 or drop by 2

Q: Treatment of the unstable pelvic fracture
A: Positive FAST
 - Need CT if able or straight to laparotomy if no time
Negative FAST
 - IR for embolisation

Q: What are the indications for pelvic angiography and embolisation?
A: FAST negative unstable pelvic trauma
Arterial haemorrhage on CTA

Q: What are the indications for X-fix of pelvis
A: Unstable FAST positive gone to OT with pelvic fractures +- retroperitoneal packing
Venous haemorrhage on CT

Q: Which arteries are most commonly involved in pelvic trauma?
A: Superior gluteal and obturator arteries

Q: L2 myotome and dermatome
A: Hip flexion, anterior thigh

Q: L3 myotome and dermatome
A: Knee extension and over the knee

Q: L4 myotome and dermatome
A: Ankle dorsiflexors and medial shin

Q: L5 myotome and dermatome
A: Dorsiflexion and top of foot

Q: S1 myotome and dermatome
A: Plantarflexion and over heel

Q: S2 myotome and dermatome
A: Knee flexion and posterior calf

Q: S3 myotome and dermatome
A: Adduction of toes and posterior buttocks

Q: Three parts of lateral ankle complex
A: Anterior talofibular, posterior talofibular, calcaneofibular

Q: What proportion of ankle sprains are lateral?
A: 85%

Q: Describe the Ottawa ankle rule
A: X-ray only required if pain in malleolar zone with bony tenderness or inability to weightbear both immediately and in ED:
 - Posterior edge or tip of medial malleolus (6cm)
 - Posterior edge or tip of lateral malleolus (6cm)
i.e. if can weight bear in ED or at the time of the incident, only need X-ray if tenderness present

Q: What age is the Ottawa ankle rule validated in
A: Anyone over 2yo

Q: Describe the Ottawa midfoot rule
A: X-ray only required if painful midfoot with bony tenderness or inability to weight bear both immediately and in ED:
 - Base of 5th
 - Navicular

Q: How sensitive is ankle X-ray for fracture?
A: 95% if 2/3 views obtained

Q: What should overlap between tibia and fibula at ankle be on AP?
A: >10mm

Q: What does an ankle joint effusion on lateral view suggest?
A: Talar dome fracture

Q: What is a Grade I ankle sprain?
A: No tearing of ligaments, minimal functional loss, pain, swelling and ecchyomosis

Q: What is a Grade II ankle sprain?
A: Partial tear with some loss of function

Q: What is a Grade III ankle tear?
A: Complete tear with laxity on stress testing

Q: Management of ankle sprains
A: Grade I and II
 - NWB 2 days, PRICE, ice 10 min each 2 hours for 48 hours, mobilise with ankle strapping (for at least 6 months for sports), ROM, inversion/eversion + proprioceptive exercises, f/u GP in 1 week
Cast only if severe pain or swelling and unable to weight bear.
Grade III
 - Short-leg cast, # clinic f/u

Q: Management of isolated medial ankle sprain
A: Very rare. Highly likely to have syndesmotic or Maissoneuve fracture so early fracture clinic follow-up in moon boot is smart to avoid missing underlying fracture/syndesmotic injury

Q: What is a Maissoneuve fracture?
A: Medial deltoid sprain with proximal third of fibula spiral shaft fracture

Q: When are motion and strength exercises recommended for simple ankle sprains?
A: From 48-72 hours

Q: When is return to activity recommended for simple ankle sprains?
A: Day 4-7 have best outcomes

Q: Management of ankle dislocation
A: Check neurovascular
Procedural sedation ketamine 1mg/kg
Grasp heel, traction and rotation opposite to MOI
Re-check neurovasc, splint, re-Xray and ortho admission

Q: Are isolated medial malleolar fractures common?
A: Rare. Look at other malleoli (incl. posterior) and entire length of fibula

Q: Which fibular avulsion fractures can be managed as ankle sprains?
A: <3mm size, <3mm displaced and no sign of medial ligament damage

Q: Describe Weber A fracture
A: Fibular fracture below level of talar dome. Intact tibiofibular syndesmosis, deltoid ligament.

Q: Which Weber A fractures are stable?
A: If medial malleolus is intact i.e. isolated

Q: Describe a Weber B fracture
A: Fibular shaft fracture at level of talar dome. Intact tibiofibular syndesmosis.

Q: What does a Weber B fracture stability depend upon?
A: Medial structures being intact (malleolus and deltoid ligament)

Q: Describe a Weber C fracture
A: Fibular fracture above talar dome with disruption to syndesmosis. Can be as high as proximal third (Maissoneuve).
Usually medial structures are disrupted

Q: What is normal intra-compartmental pressure?
A: <10mmHg

Q: What is delta pressure?
A: Diastolic - Compartment pressure. If <30mmHg requires fasciotomy

Q: What is the most sensitive finding of compartment syndrome?
A: Pain with passive stretch

Q: Why is loss of pulses a late sign in compartment syndrome?
A: Compartment pressures do not rise above arterial pressure

Q: Where should pressures be measured in injured limb?
A: Within 5cm of fracture site as this is where pressures are highest

Q: When are pressure measurements requirement in suspected compartment syndrome?
A: If diagnosis unclear. Not recommended to measure in hands or feet as too fraught with mistake

Q: What proportion of compartment syndrome presentations occur in lower leg?
A: 40%

Q: Describe 5 major causes of compartment syndrome
A: Fracture
Vascular - Ischaemia/reperfusion injury
Iatrogenic - Vascular puncture in coagulopathy
Soft tissue - Crush injury
Haematological - Haemophilia

Q: How long is muscle thought to be salvageable in compartment syndrome?
A: 4-6 hours

Q: How long until irreversible nerve damage occurs in compartment syndrome?
A: 8 hours

Q: At what level should compartment syndrome limb be elevated to?
A: Level of heart

Q: What are the three phases of orthopaedic healing?
A: Inflammatory
Reparative (callus)
Remodelling

Q: What does degree of remodelling depend upon?
A: Age
Proximity to end of bone (closer = better but not involving epiphysis)
Lesser angulation
Plane of natural joint movement

Q: What mechanism causes Lisfranc?
A: Inversion or stress to forefoot
Axial load on metatarsal heads with ankle plantarflexed (in stirrup)

Q: How is the axillary nerve tested?
A: Sensory - Deltoid patch
Motor - Deltoid muscle activity

Q: How is musculocutaneous nerve tested?
A: Sensory - Lateral aspect of forearm (lat. cut. n. of forearm)
Motor - Elbow flexion

Q: How is radial nerve tested?
A: Sensory - Anatomical snuff box
Motor - Wrist extension

Q: How is median nerve tested?
A: Sensory - Lateral aspect of palm
Motor - Thumb abduction

Q: How is ulnar nerve tested?
A: Sensory - Ulnar aspect of palm
Motor - Finger adduction

Q: How is C5 tested?
A: Dermatome - Deltoid patch
Myotome - Elbow flexion

Q: How is C6 tested?
A: Dermatome - Thumb
Myotome - Wrist extensors

Q: How is C7 tested?
A: Dermatome - Middle finger
Myotome - Elbow extension

Q: How is C8 tested?
A: Dermatome - Little finger
Myotome - Finger extension/flexion

Q: How is T1 tested?
A: Dermatome - Axillae
Myotome - Finger abduction/adduction

Q: How do you test the femoral nerve?
A: Motor - Knee extension
Sensory - Anterior thigh

Q: How do you test sciatic nerve?
A: Motor - Knee flexion
Sensory - Sensation below knee (except saphenous nerve branch of femoral)

Q: What does saphenous nerve innervate?
A: Skin of medial aspect of lower leg

Q: How is the obturator nerve tested?
A: Hip adduction

Q: How is the tibial nerve tested?
A: Motor - Plantarflexion
Sensory - Heel sensation

Q: How is the deep fibular nerve tested?
A: Sensory - 1st web space
Motor - Foot dorsiflexion

Q: What does the superficial fibular nerve innervate?
A: Dorsum of foot apart from 1st web space

Q: What does the sural nerve innervate?
A: Lateral ankle and calf (branch of sciatic)

Q: How is L1 tested?
A: Underpants sensation

Q: How is L2 tested?
A: Dermatome - Anterior thigh
Myotome - Hip flexion

Q: How is L3 tested?
A: Dermatome - Knee
Myotome - Knee extension

Q: How is L4 tested?
A: Dermatome - Medial calf
Myotome - Ankle dorsiflexion

Q: How is L5 tested?
A: Dermatome - Lateral calf
Myotome - Hallux dorsiflexion

Q: How is S1 tested?
A: Dermatome - Lateral aspect of foot (sural)
Myotome - Plantarflexion

Q: How is S2 tested?
A: Dermatome - Behind knee

Q: How is S3 tested?
A: Dermatome - Buttock

Q: How is S4/5 tested?
A: Perianal sensation

Q: What antibiotics are indicated in open fracture?
A: Cefazolin 2g q6h IV
+- Gentamicin 5mg/kg IV if significant tissue loss
+- Metronidazole 500mg IV BD if contamined or likely amputation

Q: How many layers of POP should be used for casting?
A: At least 12 (more for children as do not protect limbs)

Q: Describe the ideal height of crutches
A: One hand width below axilla and grip bar at level so elbows slightly flexed while supporting body weight

Q: Describe instruction on crutch use
A: Three-point gait with injured limb off ground and swing-to or swing-through of good leg.
To ascend stairs: Good leg up first with weight on crutches, then crutches and then injured leg
To descend stairs: Crutches down first, then good leg.

Q: Which side should cane be held?
A: On well side and advanced forwards with injured leg

Q: What are three branches of the radial nerve?
A: Proximal - Motor innervation to wrist extensors
Deep (posterior interosseous) - Motor innervation to finger extensors
Superficial - Sensory over radial aspect of hand

Q: Where should radiocapitellar line run?
A: Through middle fo capitellum

Q: Where should anterior humeral line run?
A: Through middle 1/3 of capitellum

Q: Which head of biceps usually ruptures?
A: Short head off coracoid

Q: How do you clinically detect distal biceps tendon rupture?
A: Strength loss (esp. supination)
Positive biceps squeeze test (failure to supinate in 80 degrees flexion when squeezing biceps belly)
Positive hook test (cannot hook biceps tendon in 90 degrees flexion at elbow)

Q: Management of proximal biceps tendon rupture?
A: Surgical if young/active otherwise conservative as ADL's often not affected

Q: Management of distal biceps tendon rupture?
A: Surgical unless sedentary as lose 50% supination and 30% flexion strength if not repaired

Q: Management of triceps tendon rupture?
A: Surgical unless only partial

Q: Management of lateral epicondylitis
A: Rest, ice, NSAID's, immobilisation
Physio forearm stretching and strengthening
Surgery for refractory cases

Q: What is the terrible triad at the elbow?
A: Elbow dislocation, radial head and coronoid fracture

Q: What type are the majority of elbow dislocations?
A: Posterolateral (90%)

Q: Which artery is at risk in elbow dislocation?
A: Brachial artery

Q: Which nerves are at risk with elbow dislocation?
A: Ulnar mostly + Radial/median

Q: How common are neurovascular complications in elbow dislocation?
A: 15%

Q: How common are vascular injuries in elbow dislocation?
A: 10%

Q: How are dislocated elbows reduced?
A: Supine, gentle longitudinal traction + counter-traction
Correct any medial/lateral displacement then apply downward pressure on proximal forearm to disengage coronoid process from olecranon fossa
Then continue traction while flexing elbow

Q: Definition of unstable elbow dislocations
A: Medial instability that cannot be stabilised by 90 degrees flexion and pronation

Q: Management of stable elbow dislocations (once reduced)
A: If ROM normal and stable clinically, splint in above elbow backslab in 90 degrees flexion and slight pronation

Q: What age do supracondylar fractures mostly occur in?
A: 5-10yo

Q: What proportion of supracondylar fractures are extension-type?
A: 95%

Q: Which supracondylar fractures need reduction?
A: >20 degrees angulation

Q: Management of flexion-type supracondylar fractures?
A: Ortho consult, reduction and neurovascular obs

Q: What proportion of supracondylar fractures have neurological complications?
A: 7%

Q: Which artery is most at risk in supracondylar fractures?
A: Brachial artery (with absent radial pulse). Must check before and after any positioning

Q: Management of intercondylar fractures in adults?
A: CT useful for operative planning
High arm cast at 90 and neutral if non-displaced
Closed reduction if displaced for joint congruence +- ORIF
Ortho consult for all

Q: How are lateral epicondyle fractures managed?
A: Very rare. More commonly get lateral condylar fractures.
High risk of complications if do occur, so get ortho consult in ED prior to discharge in high-arm 90 degree backslab

Q: Management of trochlea and capitellum fractures?
A: Isolated fractures are rare so CT recommended
Long-arm 90 degree cast and ortho consult in ED

Q: Management of olecranon fractures
A: Long-arm cast in 90 degrees flexion with ortho consult for operative planning.
Non-operative only the very old and those with intact extensor mechanism against resistance with non-displaced fractures

Q: What is the most common fracture of the elbow?
A: Radial head fracture

Q: What is an Essex-Lopresti lesion?
A: Radial head fracture with injury to triangular fibrocartilage at wrist and IO membrane

Q: Management of radial head fractures?
A: Non-displaced with no mobility restriction - Sling immobilisation with # clinic in 1 week
Displaced, restricted ROM - Ortho consult for operative planning

Q: How can rotational deformity of the radius and ulna be detected on plain films?
A: Radial tuberosity and radial styloid point in opposite directions normally on AP
Ulnar styloid and coronoid process point in opposite directions normally on lateral

Q: Management of isolated ulna shaft fractures
A: Non-displaced: Short-arm cast
Unstable: ORIF

Q: Define unstable ulnar shaft fracture
A: >50% displacement, >10 degrees angulated, proximal third

Q: What is a Monteggia fracture-dislocation?
A: Proximal third ulnar shaft fracture with radial head dislocation

Q: What age suffer Monteggia fracture-dislocations?
A: Peaks at 4-10yo * same as supracondylar

Q: What classification scheme is used for Monteggia fracture-dislocations?
A: Bado classification

Q: What is a Bado I?
A: Proximal or middle third ulnar shaft fracture with anterior angulation and anterior dislocation of radial head (60% - mostly children)

Q: What is a Bado II?
A: Proximal or middle third ulnar shaft fracture with posterior angulation and posterior dislocation of radial head (15% - mostly adults)

Q: What is a Bado III?
A: Fractured ulnar metaphysis with lateral dislocation of radial head

Q: What is a Bado IV?
A: Proximal or middle third ulnar shaft fracture with associated radial shaft fracture and radial head dislocation

Q: Management of proximal 2/3 radial shaft fractures
A: Non-displaced: Long-arm cast and fracture clinic (but d/w Ortho as some surgeons operate on all)
Displaced - Ortho consult for ORIF planning

Q: What is a Galeazzi fracture-dislocation?
A: Distal radius fracture with distal RUJ dislocation

Q: How are Galeazzi fracture-dislocations managed?
A: All get ORIF

Q: What is the Chopart joint?
A: Hindfoot-midfoot junction

Q: What is the Boehler angle?
A: Angle between lines along articular surface of calcaneus and posterior articular point and posterior tuberosity. <25 degrees suggests fracture

Q: Management of calcaneal fractures
A: CT for delineation, posterior splint, analgesia, NWB and ortho consult

Q: What is Snowboarder's ankle?
A: Lateral talar process fracture (often mistaken for ankle sprain)

Q: What are minor talus fractures?
A: Those not involving the central portion
i.e. Lateral process, posterior process or osteochondral dome fractures

Q: What are major talus fractures?
A: Those involving the head, neck or central body

Q: Management of minor talus fractures
A: Posterior splint, NWB, fracture clinic

Q: Management of major talus fractures
A: ANalgesia, posterior splint, analgesia and ortho consult

Q: What is a subtalar dislocation of the ankle?
A: Tibiotalar intact. Talocalcaneal and talonavicular joints dislocated

Q: Where does the lisfranc ligament run?
A: Medial cuneiform and base of 2nd metatarsal

Q: How much displacement between 1st and 2nd metatarsals is considered unstable?
A: >1mm

Q: How are Lisfranc injuries graded?
A: Nunley classification
I - Non-displaced
II - Diastasis between 1st and 2nd metatarsal heads
III - Diastasis and loss of arch height

Q: What are the three types of Lisfranc injuries?
A: Homolateral: Lateral displacement of 1st to 5th metatarsals or 2nd-5th metatarsals
Divergent: Lateral dislocation of 2nd-5th with medial displacement of 1st metatarsal
Isolated: Involves one or two metatarsals that displace dorsally in isolation

Q: Which bones in the foot are at risk of AVN?
A: Displaced calcaneal, talus, navicular

Q: What is a Pseudojones fracture?
A: Fracture of the base of the 5th metatarsal distal to the joint between 4th/5th metatarsals (tuberosity or styloid process)

Q: How are Pseudojones fractures managed?
A: Moonboot and WBAT + fracture clinic

Q: What is a Jones fracture?
A: Metaphyseal/diaphyseal fractures of the 5th metatarsal at level of 4th/5th articulation

Q: How are Jones fractures managed?
A: Short-leg cast and fracture clinic. Much higher risk of AVN and non-union

Q: How are isolated non-displaced proximal metatarsal fractures managed?
A: Short-leg backslab and fracture clinic

Q: How are isolated non-displaced metatarsal shaft fractures managed?
A: Short-leg cast, moonboot or surgical shoe with fracture clinic f/u

Q: Which metatarsal fractures need surgical reduction?
A: Displacement >3-4mm or angulation >10 degrees

Q: What is turf toe?
A: Sprain with hyperdorsiflexion of first MTP. Get capsular avulsion on X-ray.

Q: How is turf toe managed?
A: PRICE, surgical shoe, fracture clinic

Q: What nerve supplies abductor pollicus brevis?
A: Median nerve

Q: What nerve supplies adductor pollicis brevis?
A: Ulnar nerve

Q: Is extension of digits possible with laceration to extensor digitorum?
A: Tendons are connected by juncturae so laceration of one digit-specific tendon may not preclude extension of that digit

Q: How do the extensor digitorum tendons attach to the digits?
A: Central tendon to middle phalanx and lateral slips join with lumbricals and interossei to attach to dorsal base of distal phalanx as the terminal tendon

Q: What tendons run through carpal tunnel?
A: 4xFDP, 4x FDS and FPL

Q: Where do FDS tendons insert?
A: Proximal half of middle phalanx

Q: Where do FDP tendons insert?
A: Volar base of distal phalanx

Q: Does palmaris longus run in carpal tunnel?
A: No

Q: What are the 4 Kanavel signs of flexor tenosynovitis?
A: 1. Finger held in flexion
2. Fusiform swelling of phalanx
3. Tenderness along flexor sheath
4. Worsening of pain on passive extension

Q: Which finger flexor tendon sheaths extend to the carpal tunnel/wrist?
A: Thumb and little finger

Q: Management of flexor tenosynovitis?
A: IV fluclox 2g QID +- vanc 30mg/kg load then 15mg/kg BD or lincomycin 600mg q8h if MRSA risk
Elevation
Analgesia
Ortho consult re: surgical drainage

Q: What does the ulnar artery supply in the hand?
A: Superficial palmar arch and common digital arteries

Q: What does the radial artery supply in the hand?
A: Deep palmar arch, princeps pollicis artery and the radialis indicis artery

Q: Normal two-point discrimination in hand?
A: 5mm

Q: Where do the main digital nerves run?
A: Ventrolaterally either side of flexor sheath

Q: Where do small dorsal digital nerves run?
A: Dorsolaterally up to PIP joint to supply back of fingers

Q: What does the OK sign test?
A: FPL and 2nd digit FDP. If flexes IP of thumb and DIP of 2nd digit = intact median nerve

Q: If there is suspicion for median nerve damage at the wrist, how is this best tested?
A: Abductor pollicis brevis action + sensation at palmar aspect of 2nd/3rd digits
This is because median nerve supply to FPL and lateral half of FDP is proximal to the wrist

Q: What is positive Froment's sign?
A: Cannot hold paper between thumb and 2nd digit without flexing thumb IP with FPL
= ulnar nerve palsy

Q: Best way to test radial nerve function?
A: Hand palm down on table and hyperextend each digit in turn (MCP must be extended or interossei can extend PIP joints)
Sensation at anatomical snuff box

Q: Signs of posterior interosseous nerve injury?
A: Cannot extend digits but still able to extend wrist (intact supply to extensor carpi radialis and extensor radialis brevis)

Q: What level of accuracy is required for two-point discrimination testing?
A: >80%

Q: How is FDS tested?
A: Flexion of digit with rest of fingers held in extension

Q: How is FDP tested?
A: Flexion of DIP joint with PIP held in extension

Q: What are the 8 zones of extensor tendon injury?
A: Zone I - DIP joint to distal phalanx
Zone II - Over Middle phalanx
Zone III - Over PIP joint
Zone IV - Over proximal phalanx
Zone V - Over MCP joint
Zone VI - Dorsum of hand
Zone VII - Over wrist
Zone VIII - Distal forearm

Q: What are the 3 types of mallet finger?
A: Type I - Tendon only. Extension splint 6-10 weeks
Type II - Small avulsion fracture. Same Rx if joint congruent
Type III - Large avulsion with >25% articular surface involvement. Requires surgery

Q: Management of zone II extensor tendon injuries?
A: Over middle phalanx. Extension splint for 6-10 weeks. Surgery if significant articular surface fractures

Q: Management of Zone III extensor tendon injuries?
A: Over PIP joint. PIP in extension for 6-10 weeks with hand surgeon follow-up

Q: How are PIP joints reduced?
A: Hyperextension and traction

Q: How are MCP joints reduced?
A: Flexion of wrist (to loosen tendons) and then pressure over proximal phalanx dorsal surface

Q: How are CMC joints reduced?
A: Flexion of wrist, traction and dorsal pressure on metacarpal

Q: What is Gamekeeper's/Skier's thumb?
A: Thumb MCP ulnar collateral ligament rupture

Q: Management of Gamekeeper's thumb?
A: If suspected full rupture of ulnar collateral (>30 degrees angulation on testing or 10-15 degrees more than contralateral side), thumb spica and ortho consult for early repair.
If partial tear, thumb spica and fracture clinic within 1 week for consideration of repair

Q: Which phalanx fractures need internal fixation?
A: Midshaft transverse fractures, intra-articular fractures, spiral fractures, open, comminuted

Q: Management of metacarpal head fractures?
A: Hand surgeon consult

Q: Management of metacarpal neck fractures
A: Reduction required if:
 - >15 degrees angulation or any rotational deformity of 2nd/3rd
 - >20 degrees angulation or any rotational deformity in 4th
 > 40 degrees angulation or any rotational deformity in 5th
Usually unstable and require POSI cast and fracture-clinic follow-up

Q: Management of metacarpal shaft fractures?
A: If reduction required, will need operative fixation as inherently unstable

Q: Management of metacarpal base fractures?
A: CT as difficult to interpret plain films and most will need operative intervention

Q: Management of extra-articular thumb metacarpal fractures?
A: Up to 30 degrees angulation allowed.
If >30 degrees or spiral - needs reduction and operative fixation

Q: What is a Bennet's fracture?
A: Intra-articular fracture of base of thumb metacarpal with CMC sublux/dislocation

Q: What is a Rolando's fracture?
A: Intra-articular comminuted base of 1st metacarpal fracture

Q: Management of Bennet's fracture?
A: Reduction of CMC joint and thumb spica with ortho consult

Q: Management of Rolando's fracture?
A: Thumb spica and ortho consult

Q: Management of high-pressure injection injury to hand
A: PRICE, analgesia, ADT, IV Cefazolin 2g q8h + Metronidazole 500mg IV q12h + Ortho consult for urgent decompression and debridement

Q: How should amputated digits be stored?
A: Handle minimally, clean, wrap in saline-soaked gauze and keep on ice (without freezing)

Q: Mortality of hip fractures at 1 year?
A: 25-30%

Q: Which hip fractures are intracapsular?
A: Head and neck

Q: Do men or women do worse after hip fractures?
A: Men

Q: Are hip fractures more common in men or women?
A: Women by 2x

Q: How can the sciatic nerve and its branches be tested?
A: Sciatic nerve - Knee flexion
Common fibular
 - Sensation: Lateral lower leg and first web space
 - Dorsiflexion
Tibial
 - Sensation on sole of foot
 - Plantarflexion

Q: How can the femoral nerve and its branches be tested?
A: Anterior branch
Motor: Hip flexion
Sensation: Anterior thigh
Posterior branch
Motor: Knee extension
Sensation: Medial lower leg (saphenous nerve)

Q: Describe the Pipkin classification of femoral head fractures
A: I - Above fovea (conservative)
II - Below fovea (conservative)
III - Associated femoral neck #
IV - Associated acetabular fracture

Q: What is Shenton's line?
A: Inferior arc at femoral neck

Q: What is neck-shaft angle?
A: Femoral neck-shaft angle should be 120-130 degrees and anything otherwise suggests fracture

Q: What proportion of femoral neck fractures have ipsilateral femoral shaft fracture?
A: 6-9%

Q: Describe the Garden classification of femoral neck fractures?
A: I - Incomplete
II - Complete but non-displaced
III - Partially displaced
IV - Completely displaced

Q: Management of isolated trochanter fractures
A: Younger - Non-displaced avulsion fractures require crutches, WBAT and ortho f/u in 3-5 days
Older - Same treatment if socially able. Lesser trochanter avulsions are pathological until proven otherwise
Displaced - ORIF

Q: What has higher mortality: Intertrochanteric or neck fractures?
A: Intertrochanteric

Q: What is the calcar femorale?
A: Dense bone from posteromedial shaft of femur to posterior femoral neck. Disruption of this in some intertrochanteric fractures = unstable

Q: Is traction helpful for intertrochanteric femoral fractures?
A: No

Q: Is traction helpful for subtrochanteric femoral fractures?
A: Yes

Q: Which nerves are supposed to be blocked by a 3 in 1?
A: Obturator, femoral nerve and lateral femoral cutaneous

Q: What type of hip dislocations predominate?
A: Posterior dislocations of native hips (90%)

Q: How soon should native hips be reduced?
A: As soon as possible and <6 hours

Q: What proportion of posterior hip dislocations have sciatic nerve injury?
A: 10%

Q: What is the Allis maneuver?
A: Supine, counter-traction at ASIS with hip and knee flexed to 90. Then medially and laterally rotate hip while traction on femur.

Q: What are the two different types of anterior hip dislocation?
A: Superior (pubic) and inferior (obturator)

Q: How are anterior hip dislocations managed?
A: Reduction in OR

Q: How do anterior hip dislocations occur?
A: Forced abduction with anterior capsular tear

Q: What proportion of prosthetic hips dislocate?
A: 1-10%. Usually in first few months

Q: How are prosthetic hip dislocations managed?
A: D/W Ortho first as multiple different types of implants alter mode of reduction

Q: What is meralgia paraesthetica?
A: Lateral femoral cutaneous nerve entrapment at inguinal ligament

Q: Treatment of bursitis
A: Aspiration, MCS + Crystals, empirical treatment for S. aureus and Strep (flucloxacillin 500mg QID) and PRICE. May be inflammatory so if MCS not indicative of infection can cease antibiotics

Q: What is hip overuse syndrome?
A: External snapping hip syndrome aka dancer's hip. Get audible snapping sound as iliotibial band moves across greater trochanter with associated inflammation

Q: What is patellofemoral syndrome?
A: Runner's knee. Abnormal patellar tracking, mainly due to weak quad's.

Q: How much more common are knee injuries in women?
A: 2x

Q: What is the Q angle?
A: ASIS to central patella vs. central patellar to tibial tuberosity. >20 degrees in women (broader hips) leads to patellofemoral syndrome

Q: What is iliotibial band syndrome?
A: Pain at iliotibial band insertion at posterolateral knee. Seen in long-distance training

Q: What is popliteus tendonitis?
A: Inflammation of popliteus bursa in posterolateral knee, worsened by running downhill

Q: DDx of Baker's cyst?
A: DVT, aneurysm, vascular tumor, fibrosarcoma, lipoma

Q: What proportion of osteomyelitis is by contiguous spread?
A: 80%

Q: What proportion of osteomyelitis is via haematogenous spread?
A: 20%

Q: Sensitivity of MRI for osteomyelitis?
A: 95%

Q: Risk factors for osteomyelitis in diabetic foot infection?
A: >2cm ulcer, positive probe to bone, ESR >70 and abnormal XR

Q: Osteomyelitis organisms in the elderly
A: Typically haematogenous S. aureus or H.influenzae

Q: Osteomyelitis in sickle cell
A: Salmonella, Gram neg., S. aureus

Q: Empirical treatment of osteomyelitis in sickle cell disease
A: Ciprofloxacin 750mg BD and Vancomycin

Q: Organisms in diabetic osteomyelitis
A: S. aureus, Strep. agalactiae, S. pyogenes, Coliforms, anaerobes (polymicrobial is norm)

Q: Empirical treatment of diabetic osteomyelitis
A: PipTaz 4.5g QID + Vancomycin 30mg/kg IV load then 15mg/kg BD guided by levels

Q: What is osteochondritis dissecans?
A: Portion of joint surface cartilage separates (usually lateral aspect of medial femoral condyle).
Often occult trauma diagnosed on MRI

Q: Sensitivity of abnormal peripheral pulses for popliteal injury?
A: 79%

Q: Specificity of abnormal peripheral pulses for popliteal artery injury?
A: 91%

Q: How sensitive is ABPI + Duplex USS for popliteal artery injury?
A: 95%

Q: What proportion of fibular head injuries have common fibular nerve injuries?
A: 50%

Q: What are the Ottawa knee rules?
A: X-ray if one or more of:
>55yo
Tenderness at head of fibula
Isolated tenderness of patella
Inability to flex knee to 90
Inability to transfer weight 4 steps immediately after injury AND in ED

Q: What proportion of the population have a bipartite patella?
A: 8%

Q: Where is the incongruity seen usually in bipartite patella?
A: Superolateral aspect

Q: Management of patellar fractures
A: Non-displaced intact extensor mechanism: Brace, PRICE, # clinic
Displaced >3mm, articular incongruity >2mm, disruption of extensor mechanism: ORIF

Q: Management of tibial spine fractures
A: Incomplete/non-displaced: Brace and # clinic
Displaced: ORIF

Q: What is a Segond fracture?
A: Lateral tibial condule avulsion. 95% associated witih ACL

Q: Management of tibial plateau fractures
A: Non-displaced lateral plateau: Brace, NWB and # clinic
Displaced or any medial plateau fracture: ORIF

Q: What is the Schatzker classification?
A: I - lateral split
II - Lateral split with depression
III - Pure depression of lateral or central tibial plateau
IV - Unicondylar medial
V - bicondylar
VI - Transverse + any tibial plateau fracture

Q: How are medial and lateral collateral ligaments of the knee tested?
A: Test at 30 degrees flexion. If lax, test in full extension.
If remains lax in full extension suggests:
Varus laxity - Posterolateral corner or cruciate injury
Valgus laxity - Complete medial collateral complex rupture or cruciate/posterior capsule tear

Q: Mechanisms of ACL injury
A: Deceleration, hyperextension and/or internal rotation of tibia on femur

Q: How sensitive is the Lachman test?
A: 84%

Q: How specific is Lachmann test?
A: 100%

Q: How sensitive is the anterior drawer test?
A: Only 62%

Q: What meniscus is associated with ACL injuries?
A: Medial meniscus

Q: Management of isolated minor knee ligament strains
A: Immobilise, PRICE, ambulation ASAP, ROM exercises 3-4 times daily and physio referral

Q: Management of isolated complete ligamentous ruptures of knee
A: Immobiliser, straight leg quad strengthening/ROM exercises, GP referral for MRI for consideration of conservative vs. operative Rx if confirmed

Q: Management of knee single complete tears in athletes or adults with multiple ligament tears
A: Always consider reduced knee dislocation if multiple structures torn and get ortho consult for operative repair

Q: Where are most meniscal tears?
A: Posterior peripheral aspect of medial meniscus

Q: How common is spontaneous reduction of knee dislocations?
A: 50%

Q: How are dislocated knees reduced?
A: Traction under PS then splint in 20 degrees flexion

Q: Management of dislocated knees?
A: Reduce, re-assess neurovascular status (incl. ABPI) and CT-A for all

Q: What is the Kennedy classification of knee dislocations?
A: Anterior (30-50%) - Intimal tear of popliteal artery common + PCL tear
Posterior (25%) - 25% vascular inj.
Lateral (13%) - Common fibular nerve inj.
Medial (3%) - PCL disrupted
Rotational (4%) - Often irreducible

Q: Management of patellar dislocation
A: Flex hip, hyperextend knee and push back medially under gas
Check X-rays for fracture, immobiliser, PRICE, partial weight bear status, quad exercises and # clinic f/u

Q: How common is patellar dislocation recurrence?
A: 15%

Q: Management of quadriceps/patellar tendon injuries
A: Quadriceps usually ruptures if >40 vs. patellar tendon if <40.
If incomplete and intact extensor mechanism - Immobiliser, # clinic
If complete needs ortho consult for surgical repair

Q: What proportion of septic arthritis is monoarthritis?
A: 85%

Q: Differential of monoarthritis
A: Septic arthritis
Gout/Pseudogout
Gonococcal septic arthritis
Trauma
Osteoarthritis
AVN
Tumor

Q: Define oligoarthritis
A: 2-3 joints involved

Q: DDx for polyarthritis
A: Rheumatoid arthritis
SLE
Viral arthritis
Osteoarthritis
Serum sickness

Q: DDx of migratory arthritis
A: Gonococcal arthritis
Viral arthritis
Acute rheumatic fever
SLE

Q: What proportion of patients with septic arthritis have positive Gram stain?
A: <50%

Q: Above what WCC and PMN % should empirical treatment be initiated for septic arthritis?
A: >50 000 WCC/mm3 or >75% PMN's
If at higher risk or systemic infection evident treat if >25 000 or >90% PMN's
If immunocompromised, treat if >200 WCC/mm3 or >25% PMN's
If RA > 2000\mm3

Q: How sensitive is a WCC >50 000/mm3 or PMN's >75% for septic arthritis?
A: 75%

Q: How specific is WCC > 50 000/mm3 or PMN's > 75% for septic arthritis?
A: 75%

Q: Typical WCC in synovial fluid for gonococcal arthritis?
A: 10 000 to 80 000/mm3

Q: Threshold WCC in synovial fluid for RA with superimposed infection
A: >2000/mm3

Q: Normal synovial fluid WCC and PMN %?
A: <200 and <25%

Q: Risk factors for non-gonococcal septic arthritis?
A: Prosthetic joint (knee/hip mostly)
Age >80
Immunosuppressed
 - Diabetic, Hypogammaglobulinaemia, malignancy, alcoholism, CKD, liver disease, HD, steroid therapy, immunosuppression therapy
IVDU
RA
Skin source
Haemophilia

Q: Risk factors for gonococcal septic arthritis
A: HIV
IVDU
Pregnancy
Menses
SLE
Complement deficiency

Q: What proportion of BC are positive in septic arthritis?
A: Only 33%

Q: How should skin be cleansed prior to arthrocentesis?
A: Povidone-iodine solution then wipe away with alcohol (as sterilises fluid and irritates joint)

Q: Should local anaesthetic be injected into the joint prior to aspiration?
A: No. Can inhibit bacterial growth in aspirated sample

Q: What proportion of patients with non-gonococcal septic arthritis have fever?
A: 57%

Q: What proportion of joint aspirate cultures are positive in gonococcal septic arthritis?
A: 25-50%

Q: Management of suspected gonococcal septic arthritis?
A: Treat as for septic arthritis with empirical antibiotics and daily aspirations until resolved. Once non-gonococcal ruled out, can switch to ceftriaxone

Q: Typical bacteria in septic arthritis in children
A: S. aureus, Group A strep (GBS in neonates), H. influenzae

Q: Typical bacterial agents in septic arthritis in young adults
A: N. gonorrhoea or S. aureus

Q: Typical bacteria in septic arthritis in the elderly
A: S. aureus, Pseudomonas, Enterobacteriaecaeae, GAS

Q: What proportion of patients with gout have normal uric acid levels?
A: 30%

Q: Management of gout
A: Indomethacin 50mg TDS for 5-7 days
If renal impairment: Narcotics + Prednisone 50mg daily for 5-7 days
Colchicine 600mcg/hr until side effects or efficacy ensues
Allopurinol once symptoms abate and look for precipitant e.g. diet/diuretics

Q: Is there a benefit to traumatic haemarthrosis drainage?
A: Analgesia and improved ROM but no long-term benefit and does risk infection

Q: When is joint aspiration recommended for spontaneous haemarthroses?
A: If can drain within 12 hours and very large causing significant pain

Q: What is Reiter's syndrome?
A: Seronegative spondyloarthopathy following urethritis/dysentery
Acute asymmetric oligoarthritis 2-6 weeks after infection

Q: Which organisms lead to Reiter's syndrome?
A: Chlamydia, Ureaplasma
Shigella, Salmonella, Campylobacter, Yersinia, E.coli, C. diff

Q: How common is conjunctivitis in Reiter's syndrome?
A: 1/3 post-venereal and 1/2 following dysentery

Q: Management of Reiter's syndrome?
A: NSAID's
Doxycycline 100mg BD for 3 months if post-Chalmydial

Q: What findings confirm infectious bursitis?
A: Positive Gram stain, WCC >3000/mm3, >50% PMN, Glucose <1.7mmol/L, bursal:serum glucose ratio < 50%

Q: Management of infectious bursitis
A: IV flucloxacillin 2g QID (+- MRSA cover) and I&D if extensive/purulent/suspected joint involvement/systemic illness/immunosuppressed or failure of antibiotic therapy

Q: Where do children mostly suffer osteomyelitis?
A: Metaphyses of long bones via haematogenous spread.
If metaphysis is intracapsular (humerus, femur, proximal radius) carries risk of septic arthritis

Q: How many compartments has the lower leg?
A: Four
 - Deep posterior
 - Superficial posterior
 - Lateral
 - Anterior

Q: What is the most commonly fractured long bone?
A: Tibial shaft

Q: What is the Gustilo classification?
A: For open tibial shaft fractures
I - Minimal soft tissue injury and lac <1cm
2 - >1cm lac with moderate soft tissue injury and moderate contamination
3 - Vascular injury, highly contaminated or >10cm lac

Q: What determines the outcome of tibial shaft fractures?
A: Soft tissue injury

Q: What is acceptable reduction of tibial shaft fractures?
A: >50% cortical contact
<10 degrees angulation on lateral
<10 degrees angulation on AP
<5 degrees rotational deformity

Q: What is a pilon fracture?
A: Tibial plafond fracture from axial load

Q: Management of pilon fractures
A: Multiplanar usually so get CT and will require ORIF + Rule out compartment syndrome and calcaneal/vertebral fractures

Q: What is a triplane fracture?
A: Only in adolescents. Fracture through lateral growth plate of distal tibia (as medial fuses earlier in teens) then out through sagittal and coronal planes

Q: Management of triplane fractures
A: Need CT as complicated fractures lines

Q: Management of isolated fibular shaft fracture?
A: Rule out Maissoneuve
Short-leg cast, weight-bear with crutches and # clinic f/u

Q: Where do stress fractures occur in the tibia?
A: In runners occurs in junction of middle and distal thirds.
In teenagers occurs in proximal third

Q: Management of tibia shaft stress fractures
A: Rest, backslab if significant pain

Q: Management of Achilles rupture
A: Short-leg backslab in plantarflexion, NWB + crutches with # clinic f/u

Q: What is the re-rupture rate of Achilles tendon ruptures?
A: <5% either conservative or surgical Rx

Q: Management of medial gastroc strain?
A: Plantarflexion immobilisation, PRICE, crutches and # clinic

Q: Management of shin splints?
A: Several weeks of avoidance of activity that caused them is usually adequate.
Bone scan can help rule out stress fracture

Q: What is Tillaux fracture?
A: Salter-Harris III fracture at distal tibia with involvement of lateral growth plate (as medial fuses earlier in teens)
Seen in older group than triplane and no coronal plane fracture

Q: Point prevalence of back pain?
A: 5%

Q: Point prevalence of neck pain
A: 9%

Q: What does localised ipsilateral neck pain with movement of head suggest?
A: Zygapophyseal joint irritation

Q: What does localised contralateral neck pain with head movement suggest?
A: Ligamentous/muscular injury

Q: What is the abduction relief test?
A: Abduction of the shoulder eases radicular neck pain

Q: What is Spurling's sign?
A: Pushing down on head with neck in extension and leaning to side of radicular symptoms elicits pain down arm.
90% specific for radiculopathy; 45% sensitive

Q: What is Lhermitte's sign?
A: Electric shock sensation down both arms with neck flexion. Suggests cord compression

Q: What is Hoffman's sign?
A: Flicking middle finger downwards with hand pronated results in adduction and flexion of thumb. Suggests UMNL

Q: Where is C1/2 disc space pathology felt?
A: Neck and scalp pain

Q: Which patients with neck pain require no acute imaging?
A: Acute, uncomplicated, non-radicular, non-myelopathic and atraumatic

Q: Which patients with neck pain need plain films?
A: Chronic
Malignancy
Neck surgery
Rheumatological disorders

Q: Which patients with neck pain need MRI?
A: Acute or chronic neck pain with neurological symptoms/signs, suspected epidural abscess/malignancy, abnormal plain film

Q: DDx of cervical myelopathy
A: Degenerative - Cervical spondylosis
Infectious - Epidural abscess, osteomyelitis, discitis
Transverse myelitis
Traumatic - Epidural haematoma, disc herniation
Malignant tumour
Congenital stenosis

Q: Most common sites of cervical disc herniation?
A: C5/6 (C6 nerve root) and C6/7 (C7 nerve root)

Q: What is cervical spondylosis?
A: Degenerative disc disease/osteoarthritis

Q: What are the signs of cervical spondylosis on plain film?
A: Osteophytes, facet joint narrowing and disc space narrowing

Q: Where is cervical spondylosis most common?
A: C5/6 and C6/7 (same as disc herniation

Q: Most common sources of metastatic cervical deposits?
A: Lung Ca, breast Ca, prostate, lymphoma, MM

Q: Sensitivity of plain films for metastatic cervical lesions?
A: 83-90%

Q: Management of uncomplicated neck pain
A: Act as usual, avoid precipitating activities, NSAID's, short-course oral opioids if necessary and GP follow-up.
Minimal evidence for allied health input.

Q: Management of cervical radiculopathy
A: Conservative activity modification
Simple analgesia
GP f/u +- Ortho/Neurosurg

Q: When is MRI indicated for cervical radiculopathy?
A: Failure to resolve with conservative measures, progressive weakness or intractable pain

Q: Indications for admission with cervical radiculopathy
A: Progressive weakness (esp. C7/triceps weakness), intractable pain

Q: When is surgery indicated for cervical radiculopathy?
A: Progressive, symptoms/signs correlate with MRI findings

Q: Management of cervical myelopathy
A: Find cause (MRI) and spinal consult for consideration of decompression

Q: What defines acute thoracolumbar back pain?
A: <6 weeks

Q: What proportion of acute thoracolumbar back pain resolves within 6 weeks?
A: 80-90%

Q: What defines subacute thoracolumbar back pain?
A: 6-12 weeks

Q: Risk factors for spinal infection
A: Fever, chills, night sweats, night pain, weight loss, malaise, recent UTI/pneumonia/skin infection, recent GU/GI procedure, immunocompromised, IVDU, alcoholism, renal failure or diabetic

Q: Historical features to suggest infection or malignancy in back pain?
A: Night pain, unremitting despite simple analgesia, waking from sleep

Q: Is disc herniation better with lying or standing?
A: Lying

Q: What is an increased post-void residual?
A: >100mL

Q: What proportion of patients diagnosed with spinal malignancy have a history of cancer?
A: 30%

Q: What constitutes a positive SLR?
A: Radicular pain below knee of raised leg at 30-70 degrees, worsened by ankle dorsiflexion

Q: How sensitive is SLR?
A: 68-80% for herniated disc

Q: Is crossed SLR sensitive or specific for herniated disc?
A: Specific but insensitive

Q: What is the sensitivity of an ESR >20 for infectious cause for back pain?
A: 90-98% (even if immunocompromised)

Q: Is WCC sensitive or specific for infectious back pain?
A: Neither

Q: How sensitive is plain film for tumor in back pain?
A: 83%

Q: Management of non-specific back pain
A: Avoid precipitants, regular analgesia and referral to physio

Q: When should further investigations be instituted in non-specific back pain?
A: 6 weeks or earlier if things change

Q: What should be the advice on activity in non-specific back pain?
A: Continue activities to furthest extent possible. Improved functional status at 3-4 weeks

Q: Is diazepam beneficial for non-specific back pain?
A: Equal to NSAID's but no cumulative benefit

Q: Is heat or ice better for non-specific back pain?
A: Heat seems better

Q: What proportion of lower back pain presentations have sciatica?
A: 1%

Q: What proportion of patients have resolution of sciatica with conservative therapy?
A: 90%

Q: In sciatica, is activity or bed rest better?
A: No difference

Q: Where do lumbar disc herniations usually occur?
A: L4/5 (L5 nerve root) or L5/S1 (S1 nerve root) - 95%

Q: Which patients with sciatica require MRI?
A: Suspicion of infection/haematoma, severe or rapidly progressive neurological deficits

Q: When is surgery for sciatica deemed necessary?
A: Definitive evidence on imaging, corresponding neurological signs, failure of conservative therapy over 4-6 weeks

Q: How does spinal stenosis present?
A: Usually >60yo with lower back pain aggravated by standing and extending, with relief by sitting and flexing. Presents as spinal claudication with walking.

Q: How can you differentiate spinal claudication from vascular claudication?
A: Both occur with walking but vascular will get better just with cessation of walking, while spinal requires sitting or lying to improve

Q: Management of spinal stenosis
A: As for non-specific back pain unless concern re: cauda equina/conus medullaris/progressive neurology

Q: What does plain film show in ankylosing spondylitis?
A: Usually men under 40 with bamboo spine and sacroiliitis

Q: What is epidural compression syndrome?
A: Collective term for cauda equina, conus medullaris and spinal cord compression

Q: DDx of epidural compression syndrome
A: Haematoma
Infection
Herniation
Malignancy

Q: Predictors of cauda equina
A: Urinary retention >500mL +- 2 or more of:
 - Bilateral sciatica
 - Subjective urinary retention
 - Rectal incontinence symptoms

Q: How sensitive is urinary retention +- overflow for epidural compression syndrome?
A: 90%

Q: How specific is urinary retention +- overflow for epidural compression syndrome?
A: 95%

Q: What is the most common sensory deficit in epidural compression syndrome?
A: Saddle anaesthesia

Q: How often is anal sphincter tone reduced in epidural compression syndrome?
A: 60-80% of the time

Q: Management of suspected epidural compression syndrome
A: Dexamethasone 10mg IV (esp. if suspected tumor compression)
MRI (whole spine if suspected tumor)

Q: What does functional outcome in epidural compression syndrome depend upon?
A: Symptoms prior to decompression
If cannot walk - unlikely to
If too weak to walk without assistance - 50% never walk
If able to walk - likely to stay that way
If needing catheterisation - 85% need this lifelong

Q: What is conus medullaris?
A: T12 to L2 lesions with mixed upper and lower MN symptoms/signs (vs. cauda equina)

Q: What proportion of patients with conus medullaris have functional recovery?
A: 10%

Q: Causes of transverse myelitis
A: Post-viral, SLE, cancer or multiple sclerosis

Q: CSf findings in transverse myelitis?
A: Raised protein and lymphocytosis

Q: Management of transverse myelitis
A: Initially presents as cauda equina so Ix as such, then steroids and plasma exchange/IVIG

Q: How long does it take for vertebral osteomyelitis to be seen on plain films?
A: 2-8 weeks

Q: How do >90% of patients with discitis present?
A: Unremitting midline back/neck pain, waking them at night and not alleviated by rest or analgesics

Q: What proportion of patients with discitis have fever?
A: 60-70%

Q: What proportion of patients with discitis have neurological deficits?
A: 10-50%

Q: What proportion of patients with discitis have raised ESR and WCC respectively?
A: ESR 90%
WCC <50%

Q: What proportion of patients with spinal epidural abscess show the classic triad of severe back pain, fever and neuro deficit?
A: 10%

Q: How sensitive is absence of any risk factors for epidural abscess?
A: 98%

Q: Should patients with vertebral osteomyelitis receive IV antibiotics?
A: Yes but consult with spinal team first as antibiotics may reduce yield of culture samples

Q: Management of mild hand cellulitis
A: Flucloxacillin 500mg QID PO 7/7 or
Clindamycin 450mg q8h PO if MRSA risk or allergic

Q: Management of severe hand cellulitis
A: Flucloxacillin 2g IV q6h +/-
Lincomycin 600mg q8h or Vancomycin 30mg/kg load then 15mg/kg daily IV
Gallows
PRICE
Ortho admission

Q: Management of hand cellulitis associated with saltwater
A: Usual therapy + Doxycycline 200mg PO then 100mg BD for 14 days

Q: Management of hand cellulitis associated with freshwater
A: Must cover aeromonas
Usual therapy +
Ciprofloxacin 500mg PO BD or 400mg IV BD for 14 days

Q: Organisms in fight-bite infections
A: S. aureus, Eikenella, Fusobacterium, Peptostreptococcus and Candida

Q: Management of fight bites?
A: Uninfected - Thorough washout in OT (for all) + Augmentin prophylaxis 625/125 BD for 3-5 days
Infected - Thorough washout in OT + PipTaz 4.5g QID for 7 days

Q: Management of paronychia
A: Infected - Ring block and incise most fluctuant area. Remove nail if pus beneath.
Non-infected - Warm soaks and elevation of perinychium and eponychium
Antibiotics only if surrounding cellulitis (Fluclox +- Vanc)
Review in 48 hours

Q: What is paronychia?
A: Infection of lateral nail fold

Q: What is a felon?
A: Pyogenic infection of finger pulp space

Q: How should a felon be drained?
A: Ring block and longitudinal lateral incision of fluctuant region (avoid central pad).
Irrigate wound, place sterile dressing and keep elevated with review in 48 hours
Regular warm soaks keep clean
Antibiotics for surrounding cellulitis (most) - Fluclox +- Cipro/Vanc if MRSA suspected

Q: What causes herpetic whitlow in children?
A: HSV-1 (gingivostomatitis)

Q: What causes herpetic whitlow in adults?
A: HSV-2

Q: How does a felon differ from herpetic whitlow?
A: Felons are tense fluctuant regions on pulp while herpetic whitlow is not tense. Do not incise herpetic whitlow as can lead to secondary bacterial infection

Q: Management of herpetic whitlow?
A: Resolves within 3 weeks.
Antivirals only to prevent recurrent infections or for protracted cases

Q: What is deQuervain's stenosing tenosynovitis?
A: EPB and abductor pollicis tendon tenosynovitis in groove of radial styloid

Q: What is the Finkelstein test?
A: Patient grips examiners thumb, who then ulnar deviates patients wrist causing pain for dequervain’s tenosynovitis

Q: Management of deQuervain's tenosynovitis?
A: Wrist splint, daily ROM exercises, NSAId's and hand surgeon f/u

Q: Causes of carpal tunnel syndrome
A: Diabetes, Hypothyroidism, CCF, pregnancy, trauma, infectious

Q: What is Tinel's sign?
A: Tapping on wrist extensor retinaculum in extension causes paraesthesia in median nerve distribution

Q: What is Phalen's sign?
A: Reverse prayer position for 1 min elicits paraesthesia in median nerve distribution. more sensitive and specific.

Q: Management of carpal tunnel?
A: Motor deficit - Ortho consult for decompression
Sensory only - Wrist splint in neutral + NSAID's and hand surgeon if persistent

Q: What is the mortality of open pelvic fractures?
A: 50%

Q: What proportion of sacral fractures have neurological impairment?
A: 25%

Q: Describe the Denis classification of sacral fractures?
A: Denis I - Lateral to transverse foramina. 5% neuro deficit.
Denis II - Through tranverse foramina.
Denis III - Involving spinal canal. 60% neuro deficit.

Q: Which sacral fractures have the highest risk of neurological impairment?
A: Transverse fractures, then Denis III and U-shaped

Q: What is the last epiphysis to ossify and fuse in the body?
A: Medial clavicular epiphysis (18yo and 25yo)

Q: Management of sternoclavicular joint sprain?
A: Ice, analgesics and sling

Q: Management of anterior SC joint dislocation
A: If uncomplicated (normal contrast CT chest)
 - Ice, analgesics, rest, sling and # f/u for consideration of reduction within 10 days

Q: Management of posterior SC joint dislocation
A: Urgent ortho consult for open reduction in theatre with vascular/cardiothoracic staff in attendance

Q: Which patients with clavicular fractures need ortho consult?
A: Proximal third: All to ensure no posterior displacement
Middle third: Athletes, grossly displaced, shortened >15mm, severely comminuted, impact on employment, tenting or cosmetic concerns
Displaced distal third (IF)

Q: Conservative management of middle third clavicular fractures?
A: Sling, use arm as desired but avoid contact
# clinic 4-8 weeks
Daily ROM and shoulder movement

Q: Risk factors for non-union of middle-third clavicular fractures
A: >100% displaced
Initial shortening >2cm
Comminuted
Significant trauma
Female
Elderly

Q: Describe the classification of distal third clavicular fractures
A: Type I - Distal to coracoclavicular ligaments with intact ligaments
Type II - Distal to coracoclavicular ligaments but ligaments disrupted with upward displacement of proximal clavicle
Type III - Intra-articular through AC joint

Q: Mortality rate of scapular fractures?
A: 2-5%

Q: Which isolated scapular fractures require operative intervention?
A: Displaced articular fractures of glenoid
Angulated glenoid neck fractures
Acromial fractures with rotator cuff tears
Coracoid fractures

Q: What proportion of scapular fractures have associated injuries?
A: 90%

Q: What proportion of those with scapular fractures have head injury?
A: 33%

Q: What proportion of scapular fractures have spinal fractures?
A: 33%

Q: What is scapulothoracic dissocation?
A: Massive force with lateral displacement of scapula >1cm + clavicle fracture or AC disruption or sternoclavicular dissociation.
Mortality 10%

Q: What is a flail extremity?
A: Complete motor and sensory loss of limb

Q: Describe the classification of AC joint injuries
A: Type I - Sprain with no step
Type II - AC ligaments ruptured. Coracoclavicular only strained. Clavicle 25-50% above acromion
Type III - AC and coracoclavicular all ruptured. Clavicle 100-200% elevated above acromion
Type IV - All supporting structures lost. Clavicle displaced posteriorly through trapezius (need axillary X-ray to see this)
Type V - Coracoclavicular interspace 200-300% displaced
Type VI - Clavicle displaced inferiorly

Q: Management of AC joint injuries
A: Type I and II - Rest, ice, sling, early ROM within 7 days
Type III - Sling, surgery depending on occupation, age
Type IV-VI - Surgical repair with careful identification of all associated injuries

Q: What proportion of shoulder dislocations are posterior?
A: 1%

Q: What are two X-ray signs of posterior shoulder dislocation?
A: Lightbulb sign - Lateral view of humeral head looks like light bulb (loss of tuberosities due to rotation)
Trough line - Two parallel lines on medial cortex of humeral head = reverse Hill-Sachs

Q: What method of shoulder relocation should be attempted first?
A: Scapular manipulation technique

Q: Describe the scapular manipulation technique of shoulder relocation
A: Sitting up, good side against head of bed. Push tip of scapula medially and gentle traction on arm. Can do under analgesia/local intra-articular injection/gas/PS.

Q: What is the prone technique of scapular manipulation?
A: Stimson technique + scapular manipulation

Q: What is the rate of success in ED with should relocation?
A: 70-96% regardless of technique

Q: What is the modified Kocher technique?
A: Supine, arm adducted
Elbow flexed to 90, with slow external rotation (NO TRACTION)
Can then bring elbow anteriorly if required, then internally rotate to touch other shoulder

Q: What is the Milch technique?
A: Modified Kocher, then once in horizontal plane and fully externally rotated, abduct fully externally rotated arm above head with gentle traction in line of humerus and direct pressure on humeral head in axilla

Q: What is the Stimson technique?
A: Prone, arm over bed, 10lb weight in hand and inject intra-articular lignocaine. Takes 20-30min

Q: Describe the Cunningham technique
A: Sit upright, adduct humerus, flex elbow and massage trapezius - deltoids - biceps belly while patient brings scapulae together

Q: What is the spaso technique?
A: Supine, vertical traction to arm and then gently externally rotate

Q: What is the Fares technique?
A: Supine, traction on arm at patients side and gradually abduct with up/down motion in arc of 10cm. Externally rotate once at 90 degrees abduction.

Q: What is the rate of recurrence in young people of shoulder dislocation?
A: >90%

Q: How can rotator cuff tear be identified following shoulder dislocation?
A: Weakness in external rotation after reduction or persistent pain >2 weeks

Q: What is a Hill-Sachs lesion?
A: Depression fracture in posterolateral humeral head from forceful compression against anteroinferior glenoid rim

Q: What is a Bankart lesion?
A: Bony bankart is fracture at anterior labrum. Bankart is anterior labrum cartilagenous injury

Q: What proportion of anterior shoulder dislocations have axillary neurapraxia?
A: 10-25%

Q: What is this?
A: Hill-Sachs lesion

Q: What is this?
A: Bony Bankart

Q: Disposition of shoulder dislocations?
A: Shoulder immobiliser or sling for 3 weeks if under 30 (or 1 week if over 30 as need early ROM) and ortho f/u in 1 week (1-2 days if bony or soft tissue injury)

Q: How are posterior shoulder dislocations reduced?
A: Supine, traction on adducted humerus and assistant gently pushes humeral head anteriorly

Q: Disposition of posterior dislocations
A: Sling and fracture clinic within 1 week (or 1-2 days if bony/soft tissue injury)

Q: What is luxatio erecta?
A: Inferior dislocation of shoulder due to hyperabduction

Q: How is luxatio erecta reduced?
A: Traction in upward/outward direction with countertraction by assistant

Q: What proportion of older patients have rotator cuff tears with shoulder dislocations?
A: 50%

Q: Indications for operative repair post-shoulder dislocation?
A: Irreducible dislocation
Displaced greater tuberosity fracture
Bony bankart >20% of inferior glenoid area
Hill-Sachs >20% of humeral articular surface

Q: Describe the Neer classification of humeral fractures
A: 4 parts exist: Greater tuberosity, Humeral head, lesser tuberosity and humeral shaft.
Displacement >1cm or angulation >45 degrees of a fracture segment from the proximal shaft is called a 'part'.

Q: What is a one-part humeral fracture?
A: There is at least one fracture line through 1-4 parts but no displacement of a part >1cm or angulation >45 degrees.
Constitutes 70-80% of fractures and managed conservatively

Q: What is a two-part humeral fracture?
A: Fracture line involves 2-4 parts with one part displaced >1cm or >45 degrees angulated.
20% of proximal humeral fractures.

Q: What is a three-part proximal humeral fracture?
A: Fracture line through 3-4 parts with two parts displaced >1cm or >45 degrees angulation.
5% of proximal humeral fractures

Q: Management of one-part proximal humeral fractures?
A: Sling, PRICE, # clinic with early ROM once pain allows to prevent adhesive capsulitis

Q: Management of >1-part humeral fractures?
A: All need Ortho consult to consider closed reduction +- ORIF

Q: What do anatomical humeral neck fractures risk?
A: Blood supply to proximal humeral head

Q: What do angulated fractures of surgical neck of humerus risk?
A: Axillary nerve, brachial artery and brachial plexus injury. Immobilise in position of presentation until ortho consult

Q: Which mid-shaft humeral fractures can be managed non-operatively?
A: <20 degrees angulation in sagittal, <30 degrees varus/valgus angulation and <2-3cm shortening

Q: When are hanging casts advised?
A: When traction is desired i.e. shortened humeral shaft fractures

Q: How do brachial plexus injuries usually present?
A: Burning arm pain, constant and worse distally in non-dermatomal distribution

Q: What is a SLAP lesion?
A: Superior labrum anterior and posterior injury. Diagnosed on MRI after presenting with vague deep shoulder pain and popping/clicking

Q: What proportion of abduction is provided by rotator cuff?
A: 30-50%

Q: What proportion of external rotation is provided by rotator cuff?
A: 90%

Q: What is the role of supraspinatus?
A: Shoulder abduction

Q: What is the role of infraspinatus?
A: External rotation

Q: What is the role of teres minor?
A: External rotation

Q: What is the role of subscapularis?
A: Internal rotation

Q: What is impingement syndrome?
A: All-encompassing term for supraspinatus tendonitis, painful arc syndrome, rotator cuff tendinitis and subacromial bursitis

Q: What are the 3 stages of impingement syndrome?
A: I - Reversible oedema and haemorrhage. Dull ache aggravated by use, relieved by rest.
II - Fibrosis and thickening of cuff and bursa. Night pain, chronic.
III - Cuff tears, rupture of long head of biceps and subacromial spurs. Progressive disability

Q: Signs of impingement syndrome
A: Tenderness over lateral aspect of proximal humerus, crepitus with ranging, painful arc (60-100 degrees), mild-moderate external rotation weakness

Q: Test for supraspinatus
A: Empty can test

Q: Test for infraspinatus and teres minor
A: ER with arm adducted and elbow flexed to 90

Q: Test for subscapularis
A: IR with lift-off test

Q: What is the maneuver of Neer?
A: Prevent scapular rotation with one hand and then raised patients straight arm in full forward flexion. If painful arc 70-120 degrees = Positive for rotator cuff pathology

Q: What is Hawkin's impingement test?
A: Shoulder 90 degrees abducted, 90 degree elbow flexion and rotated inwards across front of patient then internally rotate.
80-90% sensitive for rotator cuff pathology

Q: Management of impingement syndrome
A: PRICE (ice 15min QID), ROM 3-4x daily (pendulums), NSAID's, paracetamol, physio, Ortho or GP f/u in 1-2 weeks

Q: Describe the drop-arm test?
A: Inability to hold arm at 90 degrees abduction. Positive = rotator cuff tear

Q: Management of suspected rotator cuff tear?
A: Sling, pendulum exercises, PRICE, ortho f/u within 1 week

Q: How does calcific tendinitis present?
A: Mild rest pain at night until resorption phase when pain becomes incapacitating

Q: What is the progress of calcific tendinitis?
A: Severe pain resolves over 1-2 weeks with subsequent post-calficic phase of variable shoulder pain. Can result in chronic adhesive capsulitis

Q: Treatment of calcific tendinitis
A: Same as for impingement syndrome.
Rest shoulder in abduction as often as possible (i.e. back of chair)

Q: What is adhesive capsulitis?
A: Frozen shoulder

Q: What is adhesive capsulitis associated with?
A: Primary - Diabetes, thyroid, post-menopausal, pulmonary neoplasm and autoimmune disorders
Secondary - Prolonged immobilisation, stroke, shoulder surgery, calcific tendinitis, impingement syndrome

Q: How long does adhesive capsulitis take to resolve?
A: 1-2 years

Q: What are the stages of adhesive capsulitis?
A: Stage 1 - 2-3 months of acute synovial inflammation
Stage 2 - Freezing. Months 3-9 reduces ROM
Stage 3 - Frozen. Months 9-15 less painful and more limited ROM
Stage 4 - Thawing. Minimal pain and progressive increase in ROM

Q: Management of adhesive capsulitis
A: Clinical diagnosis (can confirm with MRI if necessary)
Slign in Phase 1 only for a few days
Pendulum
PRICE
Physio
Intra-articular steroid is an option for short-term improvement in pain and function
Ortho f/u if ongoing symptoms at 6mo despite measures above

Q: Where does long head of biceps arise?
A: Glenoid labrum and supraglenoid tubercle of scapula

Q: What is Speed's test?
A: Shoulder flexed 90 degrees, elbow extended and supinated. Provide downward resistance to shoulder flexion. Positive if pain in biciptal groove. 80% specific for long head biceps tear

Q: Management of ingrown toenails
A: Non-infected/granulated:
 - Daily elevation of nail corner with floss
 - Daily foot soaks
 +- remove spicule of edge 1-2/3 back
Infected:
 - Larger partial removal of nail plate at least 1/4 of nail plate
 - Debride nail groove
 - Chlorsig ointment in wound and dress
 - GP f/u in 1-2 days
 - Can use phenol to chemical matricectomy and irrigate with isopropyl alcohol afterwards to neutralise phenol
 - Antibiotics if cellulitis proximal to toe
 - Podiatrist if recurrent for permanent nail ablation

Q: How does plantar fasciitis present?
A: Heel pain in overuse
Point of deep tenderness at anteromedial aspect of calcaneus
Pain and tenderness worse with toe dorsiflexion

Q: Management of plantar fasciitis
A: 80% self-resolve
PRICE, heel/arch supports in shoes, dorsiflexion night splints
Plantar stretch exercises are the most effective intervention in acute phase
Stretch Achilles
Avoid barefoot and flat shoes

Q: What is a Morton's neuroma?
A: Plantar interdigital neuroma (mostly 3rd interspace) caused by local irritation by tight-fitting shoes

Q: What proportion of cutaneous melanomas are on foot?
A: 15%

Q: Imitators of foot malignant melanoma?
A: Plantar warts, foot ulcers, fungal infections

Q: Where does spinal cord cease at birth and in adults?
A: L3 at birth then L1/2

Q: Where does the C1 spinal nerve come out?
A: Above C1

Q: Where does the C7 spinal nerve come out?
A: Above C7 horizontally, then pressured by C6/7 disc

Q: Where does the C8 spinal nerve come out?
A: Below C7

Q: Where does the T1 spinal nerve come out?
A: Below T1

Q: Where do cervical nerve roots come out?
A: Horizontally above corresponding pedicle

Q: Where do lumbar nerve roots come out?
A: Vertically below corresponding pedicle
e.g. L5/S1 disc affects S1 nerve root

Q: What does the lateral corticospinal tract carry?
A: Motor neurons (upper limb more central)

Q: What do the dorsal columns carry?
A: Sensory fibres for proprioception, vibration and deep pressure

Q: What does the anterior spinal artery supply?
A: 2/3 of anterior spinal cord (ventral and lateral corticospinal tracts + lateral spinothalamic) - voluntary motor function + light touch, pain and temperature

Q: Where does the anterior spinal artery arise?
A: Off both vertebrals

Q: What is the artery of Adamkiewitz?
A: Supplies lower 2/3 of spinal cord via the anterior spinal artery; mostly off left posterior intercostal artery

Q: What defines instability as per Denis three column?
A: 2/3 columns = unstable
Middle column most important

Q: What constitutes the posterior ligamentous complex of the vertebral column?
A: Supraspinous ligament
Interspinous ligament
Ligamentum flavum
Facet capsules

Q: What determines the neurological level of a spinal cord injury?
A: The lowest level with intact sensation and at least 3/5 motor function with all cephalad levels 5/5

Q: What does ASIA A constitute?
A: Complete. 0/5 power and no sensation below with intact bulbocavernosus (rules out spinal shock)

Q: What constitutes ASIA B?
A: Incomplete. Sensation preserved below neurological level incl. S4/5

Q: What constitutes ASIA C?
A: Motor and sensory preserved below neurological level with >50% of muscles Grade <3

Q: What constitutes ASIA D?
A: Incomplete. Motor and sensory preserved below neurological level with >50% of muscles Grade >= 3

Q: Signs of spinal cord injury in coma
A: Response to pain above certain level
Flaccid areflexia
Paradoxical breathing
Inappropriate vasodilation
Unexplained brady/hypotension
Priapism
Loss of anal tone/reflexes

Q: How does central cord syndrome present?
A: Hyperextension injury with arms > legs
Poor hand dexterity
Burning in upper limbs
Sacral sparing

Q: What is the most common incomplete cord syndrome?
A: Central cord syndrome

Q: Which incomplete cord syndrome has the worst prognosis?
A: Anterior cord syndrome

Q: How does anterior cord syndrome present?
A: Lower > upper extremity involvement
Loss of lateral corticospinal (motor) and spinothalamic tracts (pain/temp)
Dorsal column preservation

Q: What is the chance of motor recovery in anterior cord syndrome?
A: 10-20% only

Q: How does Brown-Sequard syndrome present?
A: Ipsilateral loss of motor and dorsal column fx
Contralateral loss of pain/temperature

Q: What constitutes a widened predental space on plain film and CT?
A: >3mm on plain film
>2mm on CT

Q: How is locked facets identified on imaging?
A: Facets into intervertebral foramina bilaterally
>50% anterolisthesis of vertebral body

Q: How is unilateral facet dislocation identified on imaging?
A: Anterolisthesis of vertebral body <50% of width

Q: What mechanism causes facet dislocation?
A: Flexion-distraction (+ rotation if unilateral)

Q: What is Clay Shoveller's fracture?
A: Avulsion of spinous process (usually C7)

Q: What does a flexion teardrop fracture appear like?
A: Anteroinferior portion of vertebral body avulsed and displaced by ALL
Usually wider than tall (vs. extension taller than wide)
Fanning of spinous processes
Highly unstable
Superior portion posteriorly displaced
Anterior cord syndrome can occur
Typically C4-7 (vs. extension C2)

Q: In unilateral facet dislocation, how can you work out which side is involved?
A: Spinous process points to affected side on AP

Q: How to differentiate Chance fracture from anterior wedge compression?
A: Posterior vertebral body wall fracture, spinous process fanning

Q: How to differentiate anterior wedge compression from burst fracture?
A: Burst fracture involved posterior vertebral body wall and may have vertical vertebral body fracture

Q: How wide can the nasopharyngeal soft tissue space be?
A: <10mm

Q: How wide should the nasopharyngeal, retropharyngeal and retrotracheal soft tissue spaces be?
A: Nasopharyngeal space = 10mm (adult) at C1
Retropharyngeal = <7mm at C4
Retrotracheal = 22mm at C7 (14mm in children)

Q: How wide should the retrotracheal soft tissue space be?
A: <14mm (children) and <22mm (adult)

Q: What does retropharyngeal space widening suggest on imaging in trauma?
A: Hyperextension injury

Q: How can you differentiate flexion from extension teardrop fractures?
A: In flexion get fanning of spinous processes
In extension get height of avulsed fragment > width and bunching of spinous processes

Q: What is a Hangman's fracture?
A: Fracture of both pedicles of C2 and anterior displacement C2 on C3 (traumatic spondylolisthesis)

Q: What proportion of patients with dens injuries have neurological findings?
A: 25%

Q: Describe the classification of dens fractures?
A: Type I - Tip. Stable.
Type II - Base. Unstable.
Type III - Extends into C2 body. Unstable

Q: What proportion of sacral fractures are evident on plain films?
A: Only 30%

Q: How would a C7 left sided spinal cord injury present?
A: Ipsilateral motor and dorsal column loss from C7 level
Contralateral pain/temp loss from C8/T1 level

Q: What does priapism suggest?
A: Complete spinal cord injury

Q: What proportion of spinal cord injuries show neurogenic shock?
A: 20%

Q: What level spinal cord lesions suffer neurogenic shock?
A: T6 and above

Q: What spinal level patients are at risk of bradycardia/asystole?
A: Above T4. 16% suffer asystolic arrest due to suctioning

Q: What is the presentation of neurogenic shock?
A: Relative bradycardia, hypotension and hypothermia (due to vasodilation)

Q: How long does spinal shock last?
A: Days to weeks

Q: What are the high-risk factors in the Canadian C-spine rule?
A: Age >65
Dangerous mechanism (fall >3ft, axial loading, MVA >100kmh, rollover/ejection/quadbike or bicycle collision)
Peripheral paraesthesia

Q: What are the low risk factors in the CCR?
A: Mobilised at any time
Simple rear-end MVA
Able to sit up in ED
Delayed onset neck pain
Absence of midline cervical tenderness

Q: How do you manage persistent neurological symptoms with normal CT?
A: Typically liaise with Spinal team, hard collar in SSU and if persistent symptoms after period of observation MRI

Q: Which patients can be cleared of thoracolumbar spinal injuries clinically?
A: No tenderness, neurology, normal mental status and not high energy mechanism

Q: What is the likelihood of a fracture at a non-contiguous level?
A: 20%

Q: Which anterior compression fractures of the spine are considered unstable?
A: Cervical
T/L >50% loss of height or angulation >25 degrees

Q: What proportion of burst fractures are misdiagnosed as anterior compression fractures?
A: 25%

Q: Do anterior compression fractures need CT?
A: Some authors recommend this to rule out burst fracture and pathological fracture

Q: What is the evidence for corticosteroids in spinal cord trauma?
A: Post-hoc review of NASCIS showed benefit if given within 8 hrs
Cochrane showed benefit but balanced by risks of sepsis/PUD/GI bleeding..
No consistent data to recommend this
CI in concomitant brain injury

Q: What blood pressure targets are recommended for spinal cord injuries?
A: SBP >110 (if 18 to 49yo or >70); SBP >100 if 50-69; MAP >85

Q: How long does neurogenic shock usually last?
A: 2-6 weeks

Q: When does autonomic dysreflexia become an issue?
A: Within 6 months for patients with spinal cord injuries above T6

Q: What proportion of incomplete tetraplegics become ambulatory?
A: >50%

Q: What is the usual volar tilt of the radiocarpal joint?
A: 10-15 degrees

Q: What is the radial tilt of the radiocarpal articular surface?
A: 15-25 degrees

Q: How do you stress the triangular fibrocartilage triangle?
A: Compression load to wrist in ulnar deviation

Q: What is the piano key sign?
A: Wrist held in pronation and ulnar able to be sprung up and down

Q: What are Gilula lines?
A: Three smooth arcs on PA view of wrist

Q: What is the normal scapholunate angle?
A: 30-60 degrees

Q: What is the Terry-Thomas sign?
A: Widening of scapholunate joint space >3mm (clenched fist makes more pronounced). Suggests scapholunate disruption

Q: What is the cortical ring sign?
A: Ring on scaphoid on AP suggests rotation due to scapholunate disruption

Q: What is DISI?
A: Dorsal intercalated segment instability. Get zig-zag on lateral with scaphoid tilted palmar and lunate dorsally with chronic instability due to scapholunate ligament deficiency

Q: What is Keinbock disease?
A: Ischaemic necrosis of lunate

Q: What is VISI?
A: Volar intercalated segment instability. Seen in triquetrolunate ligament disruption. Lunate tilts palmar and capitate dorsally

Q: Management of perilunate/lunate dislocations
A: All get CT
Reduce with traction and pressure over either lunate or capitate
Ortho consult

Q: Sensitivity of CT for scaphoid fracture?
A: 85-90%

Q: Sensitivity of MRI for scaphoid fracture?
A: 98%

Q: What increases risk of AVN in scaphoid fracture?
A: More proximal, oblique or displaced

Q: What proportion of initial X-rays do not show fracture in scaphoid fracture?
A: 10%

Q: What constitutes an unstable scaphoid fracture?
A: Oblique
>1mm displacement
Rotation
Comminution
Carpal bone instability

Q: Management of triquetrum avulsion fractures?
A: Avulsion - Splint 1-2 weeks with EROM and # clinic

Q: How are lunate fractures managed?
A: Short-arm thumb spica and # clinic f/u

Q: How are trapezium fractures managed?
A: Short-arm thumb spica or IF if >1mm displacement

Q: How are capitate fractures managed?
A: Mostly ORIF as mostly displaced

Q: Which carpals are at risk of AVN?
A: Scaphoid, lunate, capitate

Q: Which Colles' fractures should be in high-arm cast?
A: If associated radioulnar joint instability or ulnar styloid fracture
*Below elbow in the elderly

Q: What parameters must be met post-reduction of Colles'?
A: Dorsal tilt <5 degrees on lateral (ideally 0-20 degrees volar tilt)
<5mm radial shortening on AP (normally 13mm height)
Radial inclination 15-25 degrees on AP
Intra-articular step <1mm
No radial shift
No dorsal displacement

Q: What casts should Smith's get?
A: Volar Charnley slab with dorsiflexion

Q: What casts should Colles' get?
A: Dorsal backslab in slight palmarflexion

Q: What is a Barton's fracture?
A: Dorsal or volar rim distal radius fracture +- carpal subluxation in same direction

Q: Management of Barton's fractures?
A: Inherently unstable
Sugar tong splint with Ortho consult after closed reduction
Most need ORIF (esp. if >50% articular surface involved or associated carpal subluxation)

Q: What is a Chauffer's fracture?
A: Radial styloid fracture +- dislocation of lunate due to disruption of major carpal ligaments

Q: Management of Chauffer's fractures?
A: Short-arm backslab in mild flexion/ulnar deviation
CT wrist
Ortho consult for ORIF

Q: What is a die-punch fracture?
A: Depressed lunate fossa of distal radius

Q: Management of DRUJ injuries?
A: Often missed so if painful there with supination/pronation, positive piano key sign, get CT and get ortho consult

Q: Management of distal third clavicle fractures?
A: Class I - Conservative broad-arm sling 1-2 weeks with # clinic
Class II - Operative most likely
Class III - Usually conservative but get ortho consult

Q: How long should middle third clavicular fractures be immobilised?
A: 4 weeks young children
6 weeks older children
8 weeks in adults

Q: What is the non-union rate for conservatively managed clavicle fractures?
A: 15-25%

Q: Management of triquetral body fractures?
A: Ulnar gutter slab 6 weeks with # clinic
If unstable (>1mm displaced or carpal bone instability) - Ortho consult for IF

Q: Which ankle avulsions can be treated as sprains?
A: Those <3mm

Q: Which ankle sprains benefit from operative repair?
A: Deltoid ligament sprain if fibula and talus cannot be reduced
Distal talofibular ligament third-degree injury with widening of ankle mortise
Tears of ATFL + calcaneofibular in young/active/athletic

Q: Which radial neck fractures can be conservatively treated?
A: <20 degrees angulation in adults and <30 degrees in children

Q: How much more common are Galeazzi injuries than Monteggia?
A: 3x

Q: What are the X-ray features of DRUJ disruption?
A: Shortening of radius >5mm
Fractured ulnar styloid process
Widened DRUJ 2mm
Subluxation of DRUJ

Q: How are greater trochanter fractures of the femur classified?
A: Type I: No intertrochanteric fracture and <1cm displaced. NWB with gradual remobilisation
Type II: >1cm displacement. ORIF

Q: How are Garden 1 and 2 NOF's managed?
A: DHS

Q: How are Garden 3 and 4 NOF managed?
A: Hemiarthroplasty

Q: Which NOF's get THR?
A: Younger patients with longer life expectancy

Q: How are femoral shaft fractures classified?
A: Winquist Classification
Type I - Minimal comminution or small butterfly <25% width of bone
Type II - Comminuted. Butterfly fragment <50% width of bone. IM nail
Type III - Comminuted. Butterfly fragment 50-100% width of bone. IM nail + reinforcing screws
Type IV - All cortical contact lost. Segmental comminution.

Q: How are anterior superior hip dislocations managed?
A: Similar technique but instead of longitudinal traction, hip is abducted while assistant pushes posteriorly on femoral head

Q: How are anterior inferior hip dislocations managed?
A: Reduced in OT

Q: Differential diagnosis of monoarthritis?
A: Non-gonococcal septic arthritis
Gonococcal
Gout/pseudogout
Trauma
Haemarthrosis
Osteoarthritis
AVN
Tumor
TB
Viral

Q: DDx of oligoarthritis
A: Non-gonococcal septic arthritis
Gonococcal
Reactive arthritis
Acute rheumatic fever

Q: DDx of polyarthritis
A: Autoimmune
 - Rheumatoid
 - SLE
 - Seronegative spondyloarthopathy (Psoriasis, IBD, Ankylosing spondylitis)
 - Reiters
 - Amyloidosis
 - Sarcoidosis
 - Serum sickness
 - Dermatomyositis
 - Polymyalgia rheumatica
Infectious
 - Gonococcal
 - Viral: parvovirus, rubella, HepB, HepC, RRF, Dengue
 - Endocarditis
 - Yersinia
 - Typhus

Q: Normal synovial fluid WCC
A: <200/uL

Q: Classic inflammatory synovial fluid counts
A: 2000 - 50 000/uL, >50% polymorphs, turbid

Q: Classic infectious synovial fluid
A: >50 000/uL, >75% polymorphs, opaque

Q: What proportion of gonococcal arthritis have positive joint culture?
A: <50%

Q: When is arthrocentesis contraindicated?
A: INR >4 or overlying cellulitis
Prosthetic joints need Ortho

Q: Empirical treatment of septic arthritis
A: Flucloxacillin 2g q6h IV + BenPen 1.2g q6h +- Gent (if <6yo or IVDU) +- Vanc

Q: What proportion of patients with gout have normal serum uric acid levels?
A: 30%

Q: What serum urate in untreated patients essentially rules out gout?
A: <450umol/L

Q: Dose of prednisone in gout
A: 30mg daily for 5 days then taper to stop by 2 weeks

Q: Which joint most commonly suffers pseudogout?
A: Knee (50%)

Q: How does HepB arthritis present?
A: Fever, lymphadenopathy and joint pain followed by jaundice

Q: What proportion of traumatic haemarthroses without fracture have ACL injury?
A: 70%

Q: What proportion of adolescents with traumatic haemarthrosis have ACL tear?
A: 10%

Q: What proportion of adolescents with traumatic haemarthrosis have osteochondral fractures and intra-articular foreign bodies on arthroscopy?
A: 60% and 50% respectively

Q: What is the sensitivity for the Ottawa rules?
A: All 98-100%

Q: How are femoral supracondylar fractures classified?
A: Muller classification
A - Extra-articular. Transverse
B - Unicondylar
C - Bicondylar

Q: Management of type I tibial plateau fractures?
A: Conservative

Q: Management of Type III tibial plateau fractures?
A: Conservative mostly as usually low energy in older people

Q: Management of Type IV, V and VI tibial plateau fractures?
A: All ORIF

Q: Which type of tibial plateau fracture has the worst prognosis?
A: Type IV

Q: What are the sensitivity of McMurray's and the Apley Grind test for meniscal injuries?
A: 50%. Useless

Q: Knee injuries in order with increasing valgus force
A: Medial ligament
Medial meniscus
ACL
PCL
Lateral tibial condyle
Lateral ligament

Q: How common is compartment syndrome in tibial shaft fractures?
A: 20%

Q: DDx of neck pain
A: Mechanical: Herniation, spondylosis, cervical stenosis, myofascial, torticollis
Malignant
Infectious: Abscess, osteomyelitis, discitis, transverse myelitis, meningitis, soft tissue abscess
Autoimmune: RA, MS
Vascular: Neck dissection, thoracic dissection, IHD

Q: Treatment of torticollis
A: Place hand on chin opposite to side of head rotation and get patient to rotate head towards midline with decreasing resistance

Q: What proportion of patients unrecovered from back pain at 6 months will return to work?
A: <50%

Q: DDx of thoracolumbar back pain
A: Spinal:
 - Herniation
 - Epidural abscess
 - Discitis
 - Osteomyelitis
 - Epidural haematoma
 - Malignancy
 - Transverse myelitis
 - Osteoporotic fracture
 - Muscualr
Non-spinal
 - Pancreatitis
 - PE
 - Pneumonia
 - AAA
 - Aortic dissection
 - Renal colic/pyelo
 - AMI

Q: How much more likely is fracture in thoracolumbar back pain if over 65 or 70?
A: 2x and 11x respectively

Q: How much more likely is a fracture in thoracolumbar back pain if a visible contusion is present?
A: 20x

Q: Indications for surgery for sciatica?
A: Progressive unilateral neurological impairment
Confirmed compression > 6 weeks with conservative therapy
*Makes no real difference to long-term outcome

Q: What occurs first in metastatic back pain?
A: Pain precedes neurology by months in 95%

Q: How does metastatic back pain present?
A: Pain first with radicular features
Motor > sensory once neurology does arise

Q: How sensitive is plain film for thoracolumbar metastatic disease?
A: 85%

Q: How sensitive is MRI for metastatic back disease?
A: 95% (higher with gadolinium enhancement)

Q: Treatment of metastatic back pain
A: Dexamethasone 10mg IV stat then 4-10mg QID if signs of cord compression
Radiotherapy within 24 hours

Q: Which metastatic cancers are highly responsive to radiotherapy?
A: Lymphoma and myeloma

Q: Which metastatic cancers are intermediate responsive to radiotherapy in back pain?
A: Breast, ovarian prostate

Q: How sensitive is MRI for acute osteomyelitis?
A: >90%

Q: Empirical treatment for osteomyelitis in children <5yo?
A: Fluclox 50mg/kg q6h + Cefotaxime/Ceftriaxone 50mg/kg q8h for 4 weeks

Q: Empirical treatment for osteomyelitis in children >5yo?
A: Flucloxacillin 50mg/kg IV for at least 3 days then oral for minimum 4 weeks

Q: Empirical treatment for osteomyelitis in adults?
A: Fluclox 2g QID IV + Vancomycin +- ceftriaxone 2g daily if Gram neg suspected

Q: How long should antibiotic therapy be continued for osteomyelitis in adults?
A: At least 6 weeks (not all IV)

Q: What is the rate of prosthetic joint infection?
A: <2%

Q: What organisms most commonly cause prosthetic joint infection?
A: S. epidermidis (35%), P. acnes, S. aureus, Strep, Gram-neg bacilli

Q: If prosthetic joint infection occurs in first 3 months what does this suggest?
A: Surgical contamination

Q: Cut-off for synovial fluid in prosthetic joint infection
A: WCC > 1700/mm3 or >65% neutrophils (95% sensitive; 90% specific)

Q: What proportion of women and men suffer osteoporotic fractures in lifetime?
A: 30% and 15% respectively

Q: How effective are bisphosphonates?
A: Increase BMD 4-8% over 3 years
Reduce vertebral fracture rate by 50%

Q: Complications of Paget's
A: Pathological chalk stick fracture
CN deficit (Sensorineural deafness)
Osteosarcoma
High output cardiac failure

Q: How common is complex regional pain syndrome?
A: 5% of all upper limb trauma
Up to 20% of stroke victims that do not receive active physical therapy

Q: What proportion of metastatic tumors to bone are painless?
A: 70%

Q: What are the common primaries for metastatic bone tumors?
A: Adult - Lung, kidney, breast, prostate, thyroid, colon
Child - Leukaemia, Neuroblastoma

Q: DDx of osteolytic bone tumors?
A: Metastatic cancer (Renal, small cell, thyroid, melanoma, lymphoma)
Osteoarthritis subchondral cysts
Metabolic bone disease
Cystic angiomatosis

Q: DDx of osteosclerotic bone tumors?
A: Metastases: Prostate, carcinoid, small cell, Hodgkin's, medulloblastoma
Bone islands
Tuberous sclerosis

Q: Radiological features suggestive of malignancy in bone tumor
A: Periosteal reaction
Poorly defined margins
Absence of surrounding sclerosis
Break in cortex

Q: DDx of malignant primary bone tumors
A: Osteosarcoma
Chondrosarcoma
Giant cell sarcoma
Ewing's sarcoma
Paget's sarcoma
Irradiation sarcoma

Q: What proportion of children have fibrous cortical defects?
A: 30%

Q: Where are fibrous cortical defects mostly seen?
A: Knee/tibia

Q: How do osteoid osteomas present?
A: Night pain, respond to NSAID's, femur or tibia usually

Q: What is the mortality rate of soft tissue sarcomas?
A: 50%

Q: How are periprosthetic fractures classified?
A: A - Apophyseal
B - Bed of implant
C - Clear of implant
D - Dividing one bone which supports two joint replacements
E - Each of two bones supporting one joint replacement
F - Facing or articulating with joint replacement

Q: When testing the ulnar collateral ligament of the thumb MCP, how should this be done?
A: In full extension - tests both true and accessory ligaments
In 30 degrees flesion - tests only the true ligament
>30 degrees laxity or >15 degrees compared to contralateral = rupture

Q: Methods of posterior hip dislocation reduction?
A: Allis maneuver - In-line traction while supine with countertraction and internal/external rotation
Bigelow - In-line traction by doctors elbow under knee; straighten with external rotation and countertraction
Captain Morgan - Doctors knee standing on bed as fulcrum under patients knee with pressure down on ankle and gently rotating hip

Q: Antibiotic therapy for septic arthritis
A: Flucloxacillin 2g IV QID
+ BenPen 1.2g IV QID
+- Gent if IVDU or <6yo
+- Vanc if MRSA risk factors

Q: Multiple nerve root impairment =
A: Spinal tumor until proven otherwise

Q: What is Freiburgs disease?
A: Avascular necrosis of the head of the 2nd metatarsal seen in young athletic women mostly

Q: What is Hoffa's disease?
A: Infrapatellar fat pad syndrome with pain on leg straightening and going up stairs

Q: What supplies back of tips of lateral fingers?
A: Median nerve

Q: Rate of occult scaphoid fracture on plain imaging?
A: Up to 30%

Q: Describe the Mason classification of radial head fractures
A: Type I - Non-displaced --> Conservative
Type II - Displaced >2mm --> ORIF
Type III - Comminuted and displaced --> Resection
Type IV - Fracture with elbow dislocation

Q: Describe Young-Burgess classification
A: •APC
–I: Symphysis pubis diastasis <2.5cm
–II: Diastasis >2.5cm with SI joint anterior rupture
–III: Diastasis >2.5cm with SI joint ant + post rupture
•LC
–I: Oblique ramus + sacral ala crush
–II: Above + posterior iliac wing
–III: Above + contralareral AP fracture
•VS

Q: How does Garden classification help?
A: Predicts AVN
I and II - Head preservation e.g. ORIF/DHS
III and IV - Arthroplasty

Q: Do pseudojones fractures enter the joint?
A: Yes. They enter the metatarso-cuboid joint in most cases

Q: Do Jones fractures enter the joint?
A: Often the 4th-5th metatarsal articulation

Q: Why are Jones fractures concerning?
A: High risk of non-union as watershed area

Q: What is this?
A: Bilateral perched facets

Q: What is this?
A: Unilateral facet dislocation (<50% anterolisthesis)

Q: What is this?
A: Bilateral facet dislocation (>50% anterolisthesis)

Q: Why does priapism occur in spinal cord injury?
A: High-flow due to loss of sympathetic outflow

Q: How does the bulbocavernosus reflex assist in spinal cord injury prognostication?
A: Absence suggests ongoing spinal shock
Presence suggests spinal shock resolved and can accurately determine complete vs. incomplete

Q: What does ulnar styloid fracture suggest?
A: High energy trauma
If through base, suggests TFCC injury

Q: Where does fibrous dysplasia arise?
A: Lytic lesion in diaphysis of long bones of children

Q: Where do osteoid osteomas arise?
A: Cortex of metaphysis

Q: Where do osteochondromas arise?
A: Cortex of metaphysis

Q: Where do simple bone cysts arise?
A: Lytic lesions with thin margin in metaphysis of long bones

Q: Where do non-ossifying fibromas arise?
A: Cortex of metaphysis

Q: Where do chondroblastomas arise?
A: Epiphysis of long bones

Q: How do you differentiate adhesive capsulitis and rotator cuff pathology?
A: In rotator cuff, passive ROM is preserved

Q: What is this?
A: Chauffer's fracture

Q: What is a chauffer's fracture associated with?
A: Scapholunate dissocation
Trans-scaphoid perilunate dislocation

Q: What does Down syndrome predispose to in the spine?
A: Atlanto-axial dislocation

Q: What does RA predispose to in the spine?
A: Transverse ligament rupture of C2

Q: How can cervical spine stability be determined?
A: Two-column model - If only one column, far more stable than if both.
Anterior includes vertebral bodies, discs, ALL and PLL only

Q: What does Harris lines >12mm suggest?
A: Atlanto-occipital dislocation

Q: What does a Powers ratio >1 suggest?
A: Anterior subluxation of occiput on atlas (atlanto-occipital dislocation)

Q: Which is the first carpal bone ossification centre?
A: Hamate

Q: What is jersey finger?
A: Injury to FDP tendon at point of attachment on distal phalanx +- avulsion