Clinical SBAs
Clinical Trauma & Orthopaedics: (32 questions)

Questions

• 1
  Which one of the following statements about the feet is not correct?
  Difficulty: Medium     Topic: Foot deformities
  a

  Talipes equinovarus is treated with Ponsetti casting

  b

  Medial deviation of the great toe at the MTP joint is known as hallux valgus

  c

  Tarsal coalition is a cause of pes planus

  d

  New onset pes cavus is likely to be of neurological cause

  e

  Hammer toe has MTP joint extension, hyperflexion at the PIP joint and extension at the DIP joint
  Explanation: Hallux valgus is lateral deviation of the great toe at the first MTP by over 15 degrees. It is more common in women and may be asymptomatic or cause pain. Good fitting shoes and splints are initial treatment with surgical correction for severe cases. Talipes equinovarus (congenital clubfoot) is the presence of: foot inversion, adduction of the forefoot, plantar flexion and the heel is in varus. It is associated with oligohydramnios and other malformations e.g. myelomeningocele. It is treated with Ponsetti casting, which is a long leg cast used from as early as possible plus surgery for tendon lengthening as required. Pes planus is flat feet, one cause is tarsal coalition, which is due to abnormal joints between the tarsal bones. It causes multiple ankle sprains and presents in teenagers. Pes planus may also be neuropathic or secondary to trauma. Pes cavus is an accentuated longitudinal arch, which is often neurological in origin and this is more likely if the foot was previously normal. Hammer toe is as described above, if the deformity is flexible then metatarsal shortening is used, if the deformity if rigid then PIP arthrodesis is the surgical treatment.
• 2
  A 17-year old boy presents with pain around his right knee that is not associated with exercise and wakes him at night. X-ray shows a soft tissue swelling in the metaphysis with sunray spiculation. What is the most likely diagnosis?
  Difficulty: Hard     Topic: Primary bone malignancies
  a

  Osteosarcoma

  b

  Osteoclastoma

  c

  Ewing's sarcoma

  d

  Osteoid osteoma

  e

  Chondrosarcoma
  Explanation: Osteosarcomas are the most common primary bone malignancy. They are most frequent in young adults and boys. They typically arise in the metaphysis of the femur or tibia. X-ray shows sunray spiculation, which is extension of the bone into the soft tissues, or Codman's triangle, which is an area of new subperiosteal bone made when the tumour has lifted the periosteum. They may also occur secondary to Paget's disease. Osteoclastoma (Giant cell tumour) forms in the epiphyses of bones and is osteolytic therefore usually presents with pathological fracture. Ewing's sarcoma tends to occur in the diaphysis and shows 'onion ring' sign on X-ray from concentric layers of new bone formation. Osteoid osteomas are benign tumours that cause severe pain that is rapidly and effectively relieved with aspirin. On X-ray they show cortical sclerosis. Chondrosarcomas occur most in middle-aged men and on X-ray they show 'popcorn calcification'.
• 3
  A 12-year old boy presents to A&E with a painful ankle after falling. There is no bony tenderness noted on examination. He was unable to weight bear at the time but can just stand now. What is the most appropriate management?
  Difficulty: Medium     Topic: X-ray of after fall
  a

  X-ray ankle and foot

  b

  X-ray ankle only

  c

  X-ray ankle and knee

  d

  X-ray ankle, knee and foot

  e

  None of the above
  Explanation: The Ottawa rules define those who need an ankle X-ray following trauma. There must be pain around the medial malleolus accompanied by either: bony tenderness at the posterior edge of the medial or lateral malleolus for 6cm, or an inability to weight bear immediately and in the emergency department. This boy meets neither of the criteria therefore does not need and X-ray. The knee and foot should always be examined as inversion/eversion injuries can cause proximal fibular fractures. If one were suspected (foot drop or localised tenderness) then a knee x-ray is also appropriate.
• 4
  A 42-year old man injures his knee playing football. On examination there is increased movement when a valgus force is applied across the knee compared to a varus force. Which of the following is most likely to be injured?
  Difficulty: Easy     Topic: Knee ligament injury
  a

  Lateral collateral ligament

  b

  Medial collateral ligament

  c

  Poster cruciate ligament

  d

  Anterior cruciate ligament

  e

  Patellar tendon
  Explanation: This man has torn his medial collateral ligament. This is a common injury in sport and occurs due to a valgus force exerted on the lateral aspect of the leg. It is tested by exerting a valgus force across the knee and the medial joint line will open and it will cause pain. It will move more than when the lateral collateral is tested using a varus force. There is also tenderness and swelling over the ligament. It is often associated with a medial meniscal tear and an anterior cruciate ligament tear. The cruciate ligaments are tested using the anterior and posterior drawer tests or Lachmann's test. The patellar ligament is tested using the straight leg raise against force.
• 5
  A 61-year old lady suffers an intracapsular fracture of the neck of femur. X-ray shows Garden classification II and there is no shortening or rotation of the limb on examination. What is the most appropriate management?
  Difficulty: Hard     Topic: Neck of femur fractures
  a

  Reduce and immobilise with Pavlik harness

  b

  Austin-Moore hemiarthroplasty

  c

  Excision total arthroplasty

  d

  Multiple hip screw fixation

  e

  Reduction and traction with Thomas' splint
  Explanation: Neck of femur (NOF) fractures are common in the elderly especially if osteoporosis is also present. The Garden classification applies to intracapsular NOF fractures. A II is a complete fracture however there is no displacement. The femoral head receives most of its blood supply via the medial circumflex artery that runs via the neck and is often disrupted in displaced intracapsular fractures. Therefore these fractures are at risk of delayed union, non-union or avascular necrosis. If displaced, intracapsular fractures should be treated with hemi- or total-arthroplasty. Non-displaced intracapsular fractures can be treated with multiple hip screws because the risk of malunion is lower. 'A' is the treatment for development dysplasia of the hip and 'E" is used for paediatric femoral shaft fractures.
• 6
  A 41-year old woman has sustained a laceration to the hand that has severed flexor digitorum superficialis. Which of the following is most likely to be present?
  Difficulty: Hard     Topic: Hand tendon injuries
  a

  Failure to flex at the MCP joint but flexion at DIP and PIP intact

  b

  Failure to flex at DIP joint but flexion at PIP and MCP intact

  c

  Failure to flex at PIP joint but flexion at DIP and MCP intact

  d

  Failure to flex at the wrist but all others intact

  e

  No abnormality on examination
  Explanation: Each finger is supplied by 2 flexor tendons. Superficialis inserts into the middle phalanx therefore only causes flexion at the proximal interphalangeal joint. If it ruptures then the defect many not be immediately obvious but it can be tested for. if the other fingers are held in extension the affected finger is unable to flex at the PIP. The deep (profundus) flexor inserts into the distal phalanx therefore flexes at both the PIP and DIP joints. If flexion at the DIP is possible then the profundus tendon must be intact. MCP flexion is mediated by both superficialis and profundus, as is wrist flexion.
• 7
  What is an indication for operative treatment of fractures?
  Difficulty: Easy     Topic: Operative treatment of fractures
  a

  Clavicle fracture

  b

  Paediatric fracture

  c

  Stress fracture

  d

  Traumatic fracture

  e

  Early mobilisation needed
  Explanation: There are several fractures that always need operative treatment. Some patients need early mobilisation and surgery allows use of plates/nails that help support weight and allow earlier limb use. Most clavicular fractures do not even need reduction, those that involve the joints may need surgery. The patient being a child is not an indication for surgery. Consideration must be made to the bone's growth but most paediatric fractures can be treated without operation. Stress fractures are managed with non-weight bearing and rest. Trauma alone is not an indication for surgery, unlikely pathological atraumatic fractures.
• 8
  A 65-year old woman slips on some ice and sustains a fracture to her distal upper limb. There is a fracture to the distal radius only, with volar displacement of the distal fragment. What name is best given to this fracture?
  Difficulty: Medium     Topic: Distal radial fractures
  a

  Colles' fracture

  b

  Smith's fracture

  c

  Barton's fracture

  d

  Bennett's fracture

  e

  Galeazzi fracture
  Explanation: Depending on the orientation of the hand and arm when falling FOOSH can cause many different fractures. A Smith's fracture is as described above. Wire fixation is usually needed after reduction. A Colles' fracture is the most common distal radial fracture, where there is dorsal angulation of the distal fragment. A Barton's fracture is a distal radial fracture that communicates with the radio-carpal joints. Bennett's fracture is fracture of the carpometacarpal joint of the thumb. A Galeazzi fracture is a radial shaft fracture in association subluxation of the distal ulna.
• 9
  A 72-year old lady falls and lands on her right hand. There is marked tenderness and swelling mid-way over her upper arm. Which of the following is most likely to be present?
  Difficulty: Easy     Topic: FOOSH with upper arm tenderness
  a

  Weakness of thumb abduction

  b

  Compartment syndrome

  c

  Weakness of wrist extension

  d

  Flexion of interphalangeal joints in the medial fingers

  e

  Absent radial pulse
  Explanation: This woman has suffered a humeral shaft fracture, which is common following FOOSH in the elderly. The radial nerve runs in a groove around the humerus and fractures may cause radial nerve lesions that cause wrist drop and loss of sensation on the lateral dorsum of the hand. Median nerve lesions cause weakness of thumb abduction which is most commonly due to carpal tunnel syndrome, distal radial fracture or upper brachial plexus injury (Erb's palsy). Compartment syndrome rarely occurs with humeral shaft fractures, it most commonly occurs in the forearm and distal lower limb. Medial finger flexion occurs with an ulnar nerve lesion that has caused a 'claw hand' in the ring and little fingers. Absent radial pulse suggests arterial injury, which is rare following humeral fractures.
• 10
  A 12-year old boy suffers a supracondylar humeral fracture after falling in the playground. Which of the following is incorrect regarding his management?
  Difficulty: Medium     Topic: Supracondylar fractures
  a

  The elbow should be kept flexed to prevent brachial artery injury

  b

  There is a high risk of compartment syndrome

  c

  Open reduction with K-wire fixation may be needed

  d

  Radial nerve palsy is unlikely

  e

  Cubitus varus deformity may develop if not properly reduced
  Explanation: Supracondylar fractures of the humerus most occur in children following FOOSH. There are a number of complications but the most serious immediate risk is brachial artery damage. The brachial artery lies anterior to the humerus therefore the elbow should be kept in extension to reduce the risk of arterial damage. Flexing would push the fracture onto the artery. Compartment syndrome can occur with supracondylar fractures and monitoring for this is required. Some can be reduced under GA but many do require ORIF with K-wires. Neural palsies are possible but are rare, especially radial nerve palsy. If reduction is not adequate, a 'gunstock' cubitus varus deformity may result.
• 11
  A 30-year old man is brought to A&E after being involved in a fight. Which of the following would not suggest spinal cord injury may be present?
  Difficulty: Medium     Topic: Spinal cord injury
  a

  Priapism

  b

  Blunt trauma to the face

  c

  Tachycardia in the presence of hypovolaemia

  d

  Loss of anal tone

  e

  Ankylosing spondylitis
  Explanation: Trauma patients must be initially treated as if spinal cord injury is present. Mechanism of injury may further increase the chance: fall from a height, blunt injury above the clavicles, RTA (especially with ejection) etc. Tachycardia in the presence of hypovolaemia is the normal response to loss of intravascular volume, mediated by sympathetics. A bradycardia (or normal heart rate) with hypotension would suggest interruption of nervous supply to the heart. Priapism is a painful prolonged erection and may result from loss of sympathetic vasoconstriction leading to vasodilatation in the corpus spongiosum. Loss of anal tone is classic sign of spinal cord injury. Ankylosing spondylitis leads to fusion of the vertebrae, which in trauma increases the risk of vertebral fractures and spinal cord injury. It may also be caused by use of a hard collar and spinal board therefore these should only be used if absolutely necessary for patients with ankylosing spondylitis.
• 12
  Which of the following is not a cause of kyphosis?
  Difficulty: Hard     Topic: Kyphosis
  a

  Paget's disease

  b

  Ankylosing spondylitis

  c

  Tuberculosis

  d

  Scheuermann's osteochondritis

  e

  Marfan's syndrome
  Explanation: Kyphosis is an increased thoracocervical flexion in the spine. Marfan's syndrome is not specifically associated with kyphosis. Paget's disease is a metabolic bone disease that causes deformity and spinal involvement may result in kyphosis. Ankylosing spondylitis causes marked kyphosis with fusion of vertebrae by syndesmophytes. If associated with neck extension it causes the 'question mark posture'. Tuberculosis infection of the spine can cause destruction of the anterior vertebral body. Scheuermann's osteochondritis is the most common cause of teenage kyphosis. Inflammation of the ring epiphyses results in collapse at the anterior aspect. Wedging of 3 adjacent of vertebral bodies is pathognmonic.
• 13
  A 3-year old girl is brought to the GP by her parents who are concerned that she walks with a limp. She walked at a normal age and without pain but has always had a limp. There is limited abduction of the left hip with a positive Thomas’ test. Which of the following statements about this condition is incorrect?
  Difficulty: Medium     Topic: Limp in 3-year old
  a

  It is associated with oligohydramnios

  b

  Ortolani's test acts to relocate the hip

  c

  The Barlow manoeuvre acts to relocate the hip

  d

  Ultrasound is the imaging modality of choice

  e

  Pavlik harnesses are used
  Explanation: This girl has development dysplasia of the hip, which has not been diagnosed therefore she has presented late with a painless limp. Failure to abduct the hip and fixed flexion deformity are characteristic of a hip that is not located in the acetabulum. DDH is associated with: high birth weight, post-maturity and family history. The Barlow manoeuvre acts to dislocate a susceptible hip by depressing an adducted femur. Ortolani's test relocates a dislocated hip by elevation of an abducted femur. Ultrasound scan is the best imaging to use because it is quick and safe. There is a high rate of spontaneous resolution but if unstable at 3 months, then Pavlik harnesses are given to hold the in the acetabulum. If presenting over 18 months then the acetabulo-femoral joint will have not formed and open reduction with osteotomies are required.
• 14
  A 6-year old boy presents with a painful limb and limitation to all movements of his left hip. X-ray shows joint space widening with patchy density of the femoral head. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Paediatric hips
  a

  Septic arthritis

  b

  Perthes' disease

  c

  Slipped upper femoral epiphysis (SUFE)

  d

  Irritable hip

  e

  Developmental dysplasia of the hip (DDH)
  Explanation: Perthes' disease is osteochondritis of the femoral head that results in deformity of the head with and predisposes to arthritis. MRI is more sensitive than X-ray for diagnosis. If less than half the femoral head is affected then treatment is conservative with bed rest. If more is affected the surgery is likely to be needed. Septic arthritis would not cause joint space widening and there would be features of systemic upset with a raised CRP and WCC count. SUFE is displacement of the epiphysis from metaphysis by slip through the growth plate. It tends to occur at 10-15 years and the limitation in movement is more restricted, especially flexion, abduction and external rotation. On flexion the leg passively moves into external rotation. Irritable hip is a transient synovitis and a diagnosis of exclusion; it is managed with analgesics. DDH is congenital hip instability and is much more common in girls. Importantly, it is a painless condition therefore children may walk at a normal age but with a limp.
• 15
  Which of the following eponymous test associations is not correct?
  Difficulty: Easy     Topic: Eponymous orthopaedic tests
  a

  McMurray's test - medial collateral ligament tear

  b

  Trendelenburg test - weak hip abduction

  c

  Thomas' test - fixed flexion deformity at the hip

  d

  Appley's test - meniscal tear

  e

  Lachmann's test - cruciate ligament injury
  Explanation: McMurray's test is for meniscal tears. It is performed by flexing and extending the knee with the tibia in various degrees of external rotation on the femur. The Trendelenburg test involves the patient standing on one foot and is positive if the pelvis falls on the side that the patient is not standing on. This demonstrates weakness in abductors on the side that the patient stood on; it is also caused by hip osteoarthritis. Thomas's test is performed by obliterating the lumbar lordosis and then asking the patient to flex their unaffected hip. A fixed flexion deformity of the contralateral hip may then become visible. Appley's test is also for meniscal tears and requires a grinding force to be exerted while the patient lies prone with the knee flexed to 90 degrees. Lachmann's test is the most sensitive test for crucial ligament injuries. The knee is held in 20-30 degrees of flexion and the tibia is moved anteriorly on the femur. More than 1cm movement or absence of an end-point suggests an ACL tear.
• 16
  A 43-year old man of no fixed abode presents with severe thoracic back pain. He does not report any trauma but describes malaise and weight loss. There is tenderness over the T5 vertebrae and limitation of all back movements. ESR is 52mm/hr but U&E are normal. CXR shows upper lobe cavitation with calcification. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Severe thoracic back pain
  a

  Myeloma

  b

  Tuberculosis infection

  c

  Osteoporotic vertebral fracture

  d

  Paget's disease

  e

  Spondylolisthesis
  Explanation: Spinal TB (Pott's disease) is rare but more common in patients at increased risk of TB: alcohol dependency, immunosuppression, homelessness. In addition to the features described, it can cause spinal cord compression and abscess formation. MRI may show an abscess, which can be drained to help give the diagnosis. Treatment also requires anti-tuberculous medication and reconstructive spinal surgery may been needed. Myeloma is unlikely in a man of his age and his urea and electrolytes are normal. It is an important differential in elderly patients presenting with back pain, especially in association with anaemia, renal impairment or hypercalcaemia. An osteoporotic fracture is possible however ESR is markedly raised and there is no history of trauma. Paget's disease is a condition of deregulated bone turnover and is rare under the age of 60. Spondylolisthesis occurs when one vertebrae moves forward on another and is almost always due to trauma.
• 17
  A 10-year old boy presents acutely pyrexial with a painful right thigh, which appears red and swollen. CRP is 61mg/L. What is the most likely underlying cause?
  Difficulty: Medium     Topic: Painful thigh with pyrexia
  a

  Infection with Staphylococcus aureus

  b

  Infection with Haemophilus influenzae

  c

  Haemophilia B

  d

  Primary bone neoplasm

  e

  Femoral fracture
  Explanation: This boy has acute osteomyelitis and has presented with classical features: systemically unwell with infection and a painful, swollen limb that the child is reluctant to move. Acute osteomyelitis is most common in children and it most often occurs in the distal tibia or femur due to immature blood flow. A raised CRP helps to differentiate this as inflammatory rather than trauma. The most common cause of osteomyelitis at any age is S. aureus. There is an increased rate of H. influenzae infection in children compared to adults but it is not the most common cause overall. Haemophilia B (due to impaired factor IX) causes impaired coagulation and often causes atraumatic haemarthroses or intramuscular bleeding however this does not fit with the pyrexia or raised CRP. For the same reasons, a primary neoplasm is unlikely. Osteosarcomas (the most common malignant primary) usually present with a prolonged history of pain, night sweats or pathological fracture.
• 18
  A 42-year old woman presents with inability to dorsiflex the foot and reduced sensation over the dorsal aspect. Which of the following is highly unlikely to be a cause of this neuropathy?
  Difficulty: Medium     Topic: Loss of dorsiflexion
  a

  Plaster cast

  b

  Tibial plateau fracture

  c

  Diabetes

  d

  Femoral metaphyseal fracture

  e

  Eversion ankle injury
  Explanation: This woman has a common peroneal nerve lesion, which normally supplies the dorsiflexors and sensation to the dorsum of the foot. The nerve wraps around the head of the fibula and is in close proximity to the skin, which leaves it susceptible to lesions by compression e.g. plaster cast. Trauma to the tibial plateau or proximal fibula fractures (that can occur in eversion injuries) may result in disruption of the nerve. Diabetes is one of the causes of mononeuritis multiplex, other causes include: amyloidosis, sarcoidosis, vasculitis and rheumatoid arthritis. Femoral shaft fractures may cause damage to the sciatic nerve or femoral artery because the distal fragment is pulled by the hamstrings onto the structures that run behind it. A complete sciatic nerve lesion at this level would cause loss of sensation and movement below the knee. Common peroneal nerve lesions normally recover spontaneously but can be decompressed surgically if there is no improvement. Splinting and physiotherapy is important in the meantime.
• 19
  A 32-year old woman presents with clumsiness of her right hand. She complains of having a weak thumb and tingling over the index and middle fingers. On occasion it is painful at night. Which of the following is not associated with this condition?
  Difficulty: Medium     Topic: Clumsy and weak hand
  a

  Cardiac failure

  b

  Amyloidosis

  c

  Dialysis

  d

  Gout

  e

  Prolactinoma
  Explanation: This woman has carpal tunnel syndrome (CTS), where there is compression of the median nerve when it passes through the carpal tunnel under the flexor retinaculum. It is associated with a number of conditions, in addition to those listed above: hypothyroidism, the OCP, obesity, rheumatoid arthritis, sarcoidosis, diabetes, acromegaly, pregnancy and SLE. Prolactinomas are not associated with CTS. It causes weakness of the thenar eminence and impaired sensation the lateral 3 and half digits. There may be sparing of the skin on the lateral aspect of the palm because it is supplied by a branch of the median nerve that does not pass through the carpal tunnel. Phalen's test (wrist hyperflexion for 1min) and Tinel's test (tapping over the flexor retinaculum) are positive if symptoms are reproduced. Nerve conduction studies can be done but are usually not required. First line treatment is local steroid injection with use of a Futuro splint at night. Division of the flexor retinaculum is the surgical treatment, but is inappropriate if the cause is transient e.g. pregnancy
• 20
  A 54-year old tiler presents with a painful left knee. Anterior to the patella is swollen, erythematous, tender and fluctuant. There is no erythema or tenderness around the remainder of the joint. What is the most likely diagnosis?
  Difficulty: Medium     Topic: Patella swelling
  a

  Cellulitis

  b

  Pre-patellar bursitis

  c

  Infra-patellar bursitis

  d

  Septic arthritis

  e

  Gout
  Explanation: This patient's pre-patellar bursitis (= Housemaid's knee) is most likely to be due to friction as his job may involve time kneeling-down. Simple analgesia is given as required. It can be aspirated and hydrocortisone injections will help to reduce recurrence. Excision is needed if very recurrent. It can be of infectious origin and if thought to be the case then aspiration will differentiate the two. Infectious bursitis is treated with drainage and flucloxacillin. The pre-patellar bursa is immediately anterior to the patella, whereas the infra-patellar bursa is closer to the tibial tuberosity. Cellulitis is infection of the subcutaneous tissue and is most often caused by S. aureus. It is unlikely because the erythematous area is fluctuant and systemic features may be present (pyrexia or leukocytosis). Septic arthritis (infection of the joint space) and gout (precipitation of sodium urate crystals in the joint) globally affect the joint. They would both cause tenderness and erythema along the whole joint line.
• 21
  A 21-year old runner presents with right knee pain. It is most severe on the lateral aspect of the knee and it comes on during training, forcing her to stop. There is tenderness over the lateral femoral condyle. She reports no trauma and the remainder of examination is normal. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Lateral knee pain
  a

  Lateral meniscus tear

  b

  Osteosarcoma

  c

  Patella tendinopathy

  d

  Osgood-Schlatter's disease

  e

  Ilio-tibial tract syndrome
  Explanation: Ilio-tibial tract syndrome is very common in runners and occurs when there is inflammation of the subcutaneous tissue underneath the ilio-tibial tract where it passes over the lateral condyle of the femur. Tenderness over this area is common and the remainder of examination is normal, as would be all imaging. The patient should rest from training until the inflammation has subsided. Treatment involves physiotherapy, NSAIDs and, if severe, steroid injections (e.g. triamcinolone with lidocaine) can be used, however these must be into the surrounding tissue and not into the tendon itself or it risks rupture. A meniscal tear is associated with trauma, medial tears are more common that lateral, both tend to occur following a rotational injury with a fixed foot. Osteosarcomas are the most common primary bone malignancy and peak in young adults, especially around the knee. They would cause pain at night, not associated with exercise as well as a soft-tissue swelling. Patella tendinopathy (or Jumper's knee) occurs due to multiple micro tears and pain is localised to the patellar tendon. Osgood-Schlatter's disease causes pain and swelling over the tibial tuberosity due to micro-avulsions of the patella tendon. In most occurs in teenage athletes and with weight-bearing sports.
• 22
  A 52-year old man presents with 6 weeks of right shoulder pain. They cannot lie on their right side at night. Passive abduction and external rotation are markedly reduced. Which of the following if least likely to form part of this patient’s management?
  Difficulty: Medium     Topic: Shoulder pain with reduced movement
  a

  Manipulation under anaesthesia (MUA)

  b

  Ibuprofen

  c

  Intra-articular steroids

  d

  Local nerve block

  e

  Joint replacement
  Explanation: This man has frozen shoulder, or adhesive capsulitis. There is inflammation of the shoulder capsule, which may be precipitated by mild trauma. This stimulates myofibroblasts which cause fibrosis and contraction, resulting in reduction of active and passive movements. It is painful, especially when lying on the affected side at night. It is also associated with diabetes and MI. It is initially treated conservatively with NSAIDs and intra-articular steroids. MUA helps to break adhesions and increase movement range. Severe pain can be treated short-term with a nerve block. Joint replacement is treatment for shoulder OA, which causes pain in all movement and less specific restriction of movement.
• 23
  A 31-year old pole-vaulter suffers an anterior shoulder dislocation after a fall. He has never dislocated a joint before and neither instability or hypermobility are not present on examination. Following reduction, what is the most appropriate definitive management?
  Difficulty: Hard     Topic: Anterior shoulder dislocation
  a

  Rehabilitation

  b

  Inferior capsule shift

  c

  Bankart lesion repair

  d

  Cuff and collar

  e

  Cross-arm sling
  Explanation: This man has had a traumatic anterior shoulder dislocation in a previously normal joint. This causes a Bankart lesion, a detachment of the shoulder capsule from the glenoid labrum, which predisposes to further dislocations and repair of this is known to be effective. Rehabilitation, followed by inferior capsule shift if required, is the treatment of choice for atraumatic shoulder dislocations that occur in people with widespread joint laxity. Cuff and collar is used for humeral shaft fractures. Cross-arm sling would be used to support the joint but is not the definitive treatment.
• 24
  A 52-year old man presents with shoulder pain, which is worst from 70-100 degrees of abduction and Hawkin’s sign is positive. Which of the following is the least likely diagnosis?
  Difficulty: Easy     Topic: Shoulder pain and Hawkin's sign
  a

  Calcific tendinopathy

  b

  Adhesive capsulitis

  c

  Supraspinatus tear

  d

  Rotator cuff haemorrhage

  e

  Acromioclavicular (A-C) joint osteoarthritis
  Explanation: This man has impingement syndrome, pain through the middle range of abduction as the humeral head moves under the subacromial arch. The 4 main causes are those listed above. Adhesive capsulitis, or frozen shoulder, causes severe pain and limitation of movement such that abduction to 100 degrees would not be possible and impingement is not a feature. Calcific tendinopathy is an extremely painful localised deposition of calcium in the supraspinatus tendon. A tear of the supraspinatus tension causes weakness and pain. There may be haemorrhage into the rotator cuff tendons with oedema. A-C joint OA narrows the subacromial space.
• 25
  A 31-year old man has his brachial artery damaged during a RTA. The limb is eventually saved but was ischaemic for several hours. Months later her presents unable to use his hand. He hand and wrist are contracted due to muscle fibrosis. What hand joints are most likely to be contracted in fixed extension?
  Difficulty: Easy     Topic: Complications of limb ischaemia
  a

  Distal inter-phalangeal joints

  b

  Wrist

  c

  Metacarpo-phalangeal joints

  d

  Proximal inter-phalangeal joints

  e

  Thumb inter-phalangeal joint
  Explanation: This man has suffered Volkmann's ischaemic contracture, a complication or prolonged interruption to the arm's blood supply due to arterial damage of compartment syndrome. Muscles rapidly undergo necrosis and are replaced by fibrous tissues that contracts. There is pronation with flexion of all wrist joints apart form at the MCP, where there is extension. It is treated with tendon lengthening and nerve decompression may also be required.
• 26
  A 43-year old woman presents with a painful right wrist. It is tender at the radial base of the thumb and especially painful when carrying saucepans. Finkelstein’s sign is positive. What is the most likely diagnosis?
  Difficulty: Easy     Topic: Painful wrist when carrying
  a

  Ganglion

  b

  Osteoarthritis

  c

  Rheumatoid arthritis

  d

  Trigger finger

  e

  De Quervian's disease
  Explanation: De Quervian's tenosynovitis is inflammation of abductor pollicis longus and extensor pollicis brevis. It causes pain when lifting and tenderness over the radial styloid. Finkelstein's test elicits sharp pain over the affected tendons by wrist ulnar deviation with the thumb adducted. Ganglia and trigger finger are not painful. OA of the 1st carpo-metacarpal joint may present similarly but the pain is more proximal in De Quervian's. Rheumatoid arthritis causes wrist swelling and stiffness.
• 27
  A man with Dupuytren’s contracture is assessed using a test that demonstrates he requires surgery. He is unable to put his hand flat on the table. What name is given to this test?
  Difficulty: Medium     Topic: Eponymous orthopaedic tests
  a

  Neer's test

  b

  Simmond's test

  c

  Hawkin's test

  d

  Hueston's test

  e

  Schober's test
  Explanation: Inability to put the hand flat is known as Hueston's table-top table and indicates that contracture is severe enough to require surgery. Neer's and Hawkin's tests demonstrate impingement at the shoulder. For Neer's, pressure is placed on the acromion whilst the shoulder is passively flexed, a painful arc is positive. Hawkin's test elicits pain on internal rotation with forward flexion. Schober's examines lumbar spine flexion, which is typically reduced in ankylosing spondylitis.
• 28
  A 41-year old man presents complaining of being unable to use his right hand properly. The palmar fascia appears thickened and there is fixed flexion at the PIP & DIP of the little and ring fingers. Which of the following is not associated with this condition?
  Difficulty: Medium     Topic: Thickened palmar fascia
  a

  Chronic kidney disease

  b

  Diabetes

  c

  Epilepsy

  d

  Phenytoin

  e

  Peyronie's disease
  Explanation: This man has Dupuytren's contracture where diffuse thickening of the palmar fascia causes flexion of the medial fingers. It has many associations, others are: male, adhesive capsulitis, Ledderhosen's disease, alcohol, acromegaly, cirrhosis, smoking, family history, RA and hypothyroidism. CKD is not a recognised association. Both epilepsy and anti-epileptic medications increase risk. Peyronie's disease is fibrosis of the penile fascia causing pain and deviation when erect.
• 29
  A 72-year old man presents with neck pain and arm weakness with paraesthesiae over the middle finger. Neck movements are limited and there is crepitus. Triceps reflex is reduced. What is the most likely underlying pathology?
  Difficulty: Easy     Topic: Neck pain and paraesthesiae
  a

  Spondylosis

  b

  Spondylolisthesis

  c

  Cervical rib

  d

  Prolapsed cervical disc

  e

  Spinous process fracture
  Explanation: Spondylosis is a condition of degenerative changes in the spine that occurs in all with age. There is disorganisation of the annulus fibrosis and osteophyte growth that compresses the cord (myelopathy) or nerve roots (radiculopathy), as in this case. This man has C7 compression with LMN signs and altered dermatomal sensation. Spondylolithesis and spinous process fracture are usually associated with a history of trauma. Cervical rib and prolapse disc do not cause cervical crepitus.
• 30
  A 8-year old boy presents with a distal tibial fracture that passes through the growth plate and proximally, leaving the whole epiphysis intact. What Salter-Harris classification is this?
  Difficulty: Medium     Topic: Salter-Harris classification
  a

  I

  b

  II

  c

  III

  d

  IV

  e

  V
  Explanation: Salter-Harris classified fractures that involve the growth plate. I - fracture through the plate with separation of epiphysis intact. II (75% of all) - fracture through the plate that also extends into the proximal bone. III - through the plate and extends distally through the epiphysis. IV - fracture through metaphysis, growth plate and epiphysis. V - a compression fracture.
• 31
  Which of the following is not a delayed complication of fractures?
  Difficulty: Medium     Topic: Fracture complications
  a

  Complex regional pain syndrome (CRPS)

  b

  Fat embolus

  c

  Delayed union

  d

  Pressure sores

  e

  Myositis ossificans
  Explanation: There are many complications of fractures and these can be categorised as immediate or delayed. Immediate complications include: shock, SIRS, infection, organ damage and fat embolus. This occurs when marrow is released into the circulation after fracture of a long bone. It causes a severe reaction in the lungs and brain resulting in hypoxia and seizures. ITU admission is usually required and the prognosis is poor. The rate of fat embolism and SIRS is reduced by early reduction and stabilisation of fractures in multiple trauma. CRPS is a poorly understood condition with limb pain and altered sensation that develops after the fracture has healed. Delayed union is where the fracture takes longer than expected to unite and is often due to infection, poor blood supply or other stress. Pressure sores are common and occur due to immobility. Myositis ossificans is fibrosis and stiffening of muscle that can happen with disuse, especially after major trauma with prolonged bed rest.