UKMLA High-Yield Topics in Musculoskeletal

Hello everyone, my name is Her Lacey and I'll be hosting today's webinar on high-yield UKMLA topics relating to musculoskeletal and trauma and orthopaedics. Just a bit of background about myself before we get started. I'm the author of Crash Course Surgery, fourth edition. The Crash Course series is a series of high-yield textbooks relating to medical finals with the new editions all being updated to match the UKMLA syllabus and expectations. I'm the Clinical Key Student Question Bank Assessment Editor. This question bank contains over 6,000 high-yield questions for medical finals. Today's webinar will cover 10 high-yield SBA questions relating to musculoskeletal and trauma and orthopaedic topics on the UK MLA syllabus, which is demonstrated below. All questions are formatted in the style of the MLA exam, with information covers relating to NICE guidelines or society guidelines. Let's get started with the first question. A 61 year old woman has four days of left knee pain, stiffness and inability to weight bear. She has room to arthritis, managed with methotrexate and folic acid. Her temperature is 37.8 degrees C, pulse 109 beats per minute. and blood pressure 131 over 81 mmHg. There is tense swelling around the left knee with erythema and severe pain and reduced range of motion. Investigations are performed including aspiration of the knee joint which demonstrates turbid fluid, white blood cell count over 80,000m3 and 99% neutrophils. Which is the most appropriate management? Colchicine, B, intravenous antibiotic therapy, C, intravenous hydrocortisone, D, intraarticular steroid injections, or E, naproxen. I'll just give you a few moments to think about the correct answer. The correct answer is B, intravenous antibiotic therapy, as the features of this stem suggest possible septic arthritis. Septic arthritis describes infection of a joint space, relating to a haematogenous or contiguous serotonin infection, or direct inoculation of a pathogen into a joint. The most common etiological organism is Staphylococcus aureus, although Streptococci organisms and Neisseria gonorrhoeae have also been implicated. Risk factors include prosthesis, intra-articular interventions such as intra-articular steroid injections, pre-existing joint disease such as rheumatoid arthritis, immunosuppression which is often also seen with autoimmune arthritis, increasing age and intravenous drug use which is a risk factor for direct inoculation of pathogens. Symptoms include the acute onset of monoarticular pain, reduced range of motion, heat, erythema and swelling of the affected joint and there may be features of systemic illness including fever and hemodynamic instability, however features may be milder or more chronic in nature in prosthetic joints. To diagnose septic arthritis, an arthrocentesis with synovial fluid analysis and culture is performed. Typical features seen on synovial fluid analysis include turbid fluid, a white blood cell count over 50,000, A neutrophil dominance of over 90%, glucose levels lower than that of blood glucose, and a gram-sane should be performed to guide antibiotic therapy. Blood cultures should be taken, and x-rays of the joint should be performed to identify any bony lesion or destruction. CT or MRI imaging can be indicated in chronic infection or those with suspected osteomyelitis. And here we can see an image of... arthrocentesis with aspiration of blood-stained pus from the knee of a child with septic arthritis. Management of septic arthritis involves therapeutic arthrocentesis to remove pus from the joint space and empirical intravenous antibiotic therapy for up to six weeks, which is targeted once culture results are available. For those with a prosthetic joint infection, surgical debridement with or without revision arthroplasty is required. and intravenous antibiotics may be prescribed for a prolonged course for up to three months. Supportive measures include analgesia, VTE prophylaxis and early mobilisation with physiotherapy to prevent joint stiffness in the long term. Without effective treatment, septic arthritis can result in a number of complications, including chronic osteoarthritis, osteomyelitis with spread of infection to the bone, osteonecrosis or avascular necrosis with compromisation of the bone blood supply, bony and cartilaginous destruction and associated fracture of the bone. In prosthetic joints, it can result in periprosthetic loosening, fracture or dislocation, which may require a vision surgery, chronic pain, and leg lymph discrepancies can develop and in severe infection sepsis and death can be the result. Question 2. A 31 year old woman who is 36 weeks pregnant has three days of burning, tingling and weakness in her right hand which is worse at night. She has sensory loss over the right index and middle finger, weakness in thumb, abduction and thenar atrophy. Her symptoms are reproducible with tapping over the volar wrist. Which is the most likely diagnosis? A. Carpal tunnel syndrome B Cervical radiculopathy C Cubital tunnel syndrome D Dequivanes tenosynovitis or E Alnune neuropathy I'll just give you a few moments to think about the correct answer. The correct answer in this case is A, carpal tunnel syndrome. Carpal tunnel syndrome is an entrapment neuropathy caused by compression of the median nerve in the carpal tunnel at the wrist. Risk factors include activities with a high hand-to-wrist repetition rate, obesity and pregnancy can cause increased fluid accumulation in the tissue spaces in the carpal tunnel and produce symptoms, Metacarpophalangeal or thumb joint osteoarthritis can cause spurs to form on the carpal bones, trapping the nerve and resulting in symptoms. Both rheumatoid arthritis and hypothyroidism are associated with synovial enlargement and swelling and can cause carpal tunnel syndrome. And in diabetes it is thought that glucose can attach to the proteins of the tendons in the carpal tunnel resulting in inflammation and preventing the tendons from moving properly, producing symptoms. The carpal tunnel is found on the volar wrist. Its boundaries include the deep carpal arch on the dorsal aspect and the superficial flexor retinaculum on the volar aspect. The carpal arch is a concave arch formed by the scaphoid and trapezium tubercles and the hook of the hamate and the pisiform. Contained within the carpal tunnel are the median nerve, compression of which produces the symptoms in carpal tunnel syndrome. the four tendons of flexor digitorum superficialis and tendons of flexor digitorum profundus and the tendon of flexor pollicis longus. Symptoms of carpal tunnel syndrome relate to compromisation of the motor and sensory functions of the median nerve. Impaired sensory function results in intermittent paresthesia, numbness or altered sensation with burning or pain in distribution of the median nerve on the hand as demonstrated on the right. Uncompromised motor function can result in wasting of the femur eminence muscles, weakness of thumb abduction and opposition, reduced hand grip and pinch grip strength, and reduced hand coordination. There are several tests that are commonly used to assess the function of the median nerve and for features of carpal tunnel. In A we can see testing thumb abduction against resistance. B we can see a demonstration of Phalanx Maneuver which involves having the patient place the wrists. In complete unforced flexion for 30 seconds which should produce symptoms. And C we can see the performing of Tinnall's sign which is performed by percussing over the median nerve in the carpal tunnel which should elicit the symptoms in patients with carpal tunnel syndrome. Carpal tunnel is a clinical diagnosis. Management in the first instance is conservative. with avoiding repetitive wrist movements and taking regular breaks from precipitating movements, optimising underlying risk factors including weight loss and management of associated conditions such as diabetes, hypothyroidism and rheumatoid. Wrist splints should be recommended to patients and patients can be offered a single corticosteroid injection into the carpal tunnel which can alleviate symptoms. If there is any failure of conservative management, Patients can be referred to secondary care for nerve conduction studies and a surgical carpal tunnel release. Moving on to the next question. A 71-year-old man has severe right groin pain and inability to wait there after a fall. He has a shortened and externally rotated right leg with bruising and pain over the lateral thigh. An x-ray of the right hip is shown. Which is the most appropriate management? A. Dynamic hip screw. B Hemiarthroplasty. C Intramodulatory nail. D Open reduction and internal fixation or E A total hip replacement I'll just give you a few moments to think about the correct answer. This question relates to a neck of femur fracture and the correct answer is E, a total hip replacement. A hip fracture describes a fracture of the femur which commonly occurs in the femoral neck. A NOF or a neck of femur fracture is the commonest reason for an orthopaedic admission and it's a significant injury with over 10% mortality within one month. In older patients it typically relates to a fragility fracture after a low impact injury, but in younger patients a femoral fracture is typically the result of high impact trauma. Risk factors include osteoporosis, typically in postmenopausal women, increasing age, smoking, malnutrition, any vitamin D or calcium deficiency or sarcopenia, and any risk factors for falls including reduced mobility or impaired coordination. Features suggestive of an off include in those with displaced fractures, a shortened and externally rotated leg with groin pain radiating to the knee with or without pain in the entire hip region. In undisplaced fractures symptoms may be minimal with minor clinical deformity or mild pain or movement. The diagnosis of hip fracture is made with AP and lateral x-ray imaging of the affected An MRI can be performed if there is a high index of clinical suspicion but negative x-rays. Hip fractures are classified based on their relationship to the hip joint capsule which attaches at the intertrochanteric line. Intracapsular fractures are those involving the femoral neck or femoral head and extracapular fractures are intertrochanteric fractures, so between the greater and lesser trochanters, those involving either the greater or lesser trochanter in isolation. and subtrochanteric which are below the intertrochanteric line. A common method for diagnosing hip fractures on x-ray is assessing for disruption in Shenton's line which is a curved line seen between the femur and the pubic groma. On the right here you can see a smooth curve with no interruptions but on the left here you can see a clear disruption at this curve suggesting neck of femur fracture. You can also see a previous hemiarthroplasty on the right. Another commonly used classification system for intracapsular fractures is the garden classification, which relates to the degree of displacement of the femoral head. Type 1 is an incomplete fracture. Type 2 is a complete fracture which is undisplaced. Type 3 is a complete fracture which is partially displaced. And type 4 demonstrates a complete fracture which is fully displaced. The management of any acute traumatic injury should involve ATLS principles with effective resuscitation where required. All injuries and complications must be identified, which can involve a CT traumagram and significant trauma or x-ray imaging of symptomatic joints. Neurovascular assessment of all limbs should be performed and there should be assessment for any evidence of open fractures, which requires specific management. Pain should be managed with paracetamol and opioid analgesia. Commonly used in hip fractures are fascial iliaca blocks, which are local anaesthetic nerve blocks, a type of regional anaesthesia used to provide anaesthesia to the hip and thigh, and NSAIDs should be avoided. Best practice in management of hip fractures involves preparing the patient for theatre on the day of or the day after admission. Any comorbidities that may delay operative management should be corrected involving correction of anemia with a target for transfusion of above 80 at least. Anticoagulation may need to be reversed to a target INR. Any patients with evidence of dehydration or volume depletion should be resuscitated appropriately. Electrolyte imbalances should be corrected. Patients with uncontrolled diabetes should be put on a variable rate to control this perioperatively. Uncontrolled heart failure should be diagnosed with a preoperative echo and diuresis can be required if there is symptomatic fluid overload. Any correctable cardiac arrhythmias or ischemia should be corrected and treated. Evidence of acute chest infection warrants treatment with intravenous empirical antibiotics. and if there is any associated exacerbation of chronic chest conditions these should be treated appropriately. Operative management involves spinal or general anaesthesia with or without nerve blocks. For displaced intracapsular fractures operative management involves a total hip replacement or a hemiarthroplasty. A total hip should be considered for patients with a displaced intracapsular hip fracture who could walk independently outdoors with no more than use of a stick. do not have a contra-intra-agic condition or comorbidity and are expected to be able to carry out their ADLs independently beyond two years. In the question we went through there were no associated comorbidities and the patient was walking independently so a total hip replacement was the correct answer. For trochanteric fractures extramedullary implants such as our dynamic hip screw are used in preference to intramedullary nailing but for sub trochanteric hip fractures, intramodulatory nails should be used. In all cases, intracapsular fractures require a replacement with a hemi or a total hip. This is because the blood supply to the neck of the femur is retrograde, passing from distal to proximal along the femoral neck to the femoral head, predominantly through the medial circumflex femoral artery. As a result of this, displaced intracapsular fractures disrupt the blood supply to the femoral head. and therefore the head will undergo avascular necrosis even if the hip fracture is fixed. Hence, patients with displaced intracapsular fractures require joint replacement rather than fixation. And here on the x-ray on the right we can see the bite sign which demonstrates a gouged out defect due to destruction with collapsed bone in the head of a femur which has undergone avascular necrosis. On the left here you can see What a total hip replacement looks like on x-ray post-operatively, you can see that both the acetabulum has been replaced with a cup and then you can see the head of the hip replacement replacing the femoral head with the stem going down the shaft of the femur. On the right you can see that this is a hemiarthroplasty as there is no evidence of an acetabular cup being implanted. On the left here you can see the x-ray findings of a dynamic hip screw. As the fracture naturally heals and compresses, the DHS slides in the plate along the longitudinal axis of the femoral neck, permitting compression of the fracture and aiding healing. On the right here you can see a complex proximal femur fracture treated with an intra-dinary nail. Both long and short nails can be used depending on the extent of injury. Further management of hip fracture involves MDT management with physiotherapist assessment and mobilisation on post-operative day one unless contraindicated. There should be an orthogeriatric assessment from admission with continued and coordinated orthogeriatric and multispring team review. Optimisation of functional status involves techniques to prevent further falls, optimisation of bone health with bisphosphonates and calcium vitamin D replacements. Mental and social health assessment and support and assessment and support for any cognitive impairment and delirium. Patients should be supported with early discharge or transfer to rehabilitation unit. Moving on to question four. A 32-year-old woman has six months of bilateral pain and stiffness in her hands and fingers, which is worse in the morning and improves throughout the day. The right hand is shown here. Which is the most likely diagnosis? A. Gout B Osteoarthritis C Reactive arthritis D Rheumatoid arthritis or E Septic arthritis I'll just give you a few moments to think about the correct answer. The correct answer in this case is D, rheumatoid arthritis. Rheumatoid arthritis is a chronic systemic inflammatory disease affecting up to 1% of the UK population. It is two to four times more common in women than the typical onset between 30 to 50 years. It presents with a persistent inflammatory arthritis affecting synovial joints and typically affects the small joints of the hands and feet. It presents with pain which is usually worse at rest or during periods of activity and improves with exertion. Swelling will be present around the affected joints giving a boggy feel on palpation. And there will be stiffness, typically early morning stiffness usually lasting over one hour. It typically presents on both sides equally and symmetrically. And with progressive disease there will be progressive involvement of bodily systems presenting with cardiovascular disease, osteoporosis, anemia. and increased susceptibility to infection. This diagram compares the distribution of joint involvement in both rheumatoid arthritis and osteoarthritis. On the left we can see the typical joints involved in rheumatoid arthritis as the small proximal joints of the hands and feet and those involving the pelvic and shoulder girdle. The atlanto-axial joint is also commonly implicated. On the right here we can see the joints typically involved in osteoarthritis, typically the larger joints, joints of the spine and neck, and the distal joints of the hands and feet. Without effective treatment rheumatoid arthritis is destructive and can result in progressive hand deformities. The typical ones seen we see as ulnar deviation, butonia deformity, zed thumb and swan neck deformities. and there are several extra-articular manifestations of rheumatoid arthritis seen on the right here which can involve the eyes, lungs, heart, haematological system and neurological system. Patients with persistent synovitis with no other obvious underlying cause should be referred to secondary care for suspected rheumatoid arthritis. Several investigations can be performed to support the diagnosis. Rheumatoid factor is very sensitive for rheumatoid and positive in about 60-70% of cases. Anti-CCP antibodies are more specific and present in about 80% of cases. CRP and ESR will be typically raised and full blood count, user needs and LFTs should be performed to assess for any complications. Imaging of the affected joints should be performed involving x-rays or ultrasound MRI if required to aid the diagnosis. and assessment of severity. Management of rheumatoid arthritis involves treating to the target of achieving remission or low disease activity. First line is conventional disease modifying anti-rheumatic drug monotherapy typically with methotrexate, leflunomide, sulfasalazine or hydroxychloromocaine. Short-term bridging glucocoids such as oral pronisoline can be used while waiting for the DMR to start to work and there should be dose escalation until the treatment target is achieved. C-DMAG combination therapy is then offered if the treatment target is not achieved with monotherapy and biological DMADs with or without methotrexate can be used if the treatment target is not achieved with combination conventional DMADs. Intra-articular, intramuscular or oral glucocorticoids can be used for flares. The complications of rheumatoid are widespread and significant and relate both to articular manifestations and extra-articular manifestations. Untreated or severe cases can result in permanent joint destruction with stiffening and deformity, presenting with the rheumatoid hand deformities mentioned previously. Further complications include septic arthritis, vasculitis, amyloidosis, anemia of chronic disease, osteoporosis and increased fracture risk, an increased cardiovascular disease risk, an increased risk of stroke, myocardial infarction, atrial fibrillation and heart failure, interstitial lung disease, pleuritis and pleural effusions. and secondary Trojan syndrome, all in addition to the extra-articular manifestations mentioned previously. There are several more complications of rheumatoid and this list is not exhaustive but just covers a few. Moving on to the next question. A 76 year old woman has two months of central lower back pain and reduced mobility. She had breast cancer four years ago, managed with radical mastectomy and auxiliary lymph node clearance. She has focal L2-L3 tenderness, bilateral weakness to hip flexion and knee extension, diffuse sensory loss in the lower limbs and brisk knee and ankle jerk reflexes. Which is the most appropriate investigation? A. Bladder scan, B CT myelogram, C MR whole spine, D Nerve conduction studies, or E X-ray of lumbar spine. I'll just give you a few moments to think about the correct answer. The correct answer is C, MR whole spine. The features in this stem are suggestive of metastatic spinal cord compression, which describes compression of the spinal cord relating to metastatic disease. It should be suspected in any patients with a history of past or current diagnosis of cancer, with severe and remitting progressive back pain which may disturb sleep, pain worsened by standing, sitting, moving or straining, Localised spinal tenderness, claudication in the lower limbs and any features of cord compression including bladder or bowel dysfunction, gait disturbance, limb weakness, focal neurological signs or features of caudal equine syndrome including loss or reduction of sensation below the affected spinal cord level, bilateral paralysis below the affected level, lower limb hyperreflexia, positive vibrancy skin ataxia. and any sphincter dysfunction with urinary or bowel urgency, retention or incontinence. Further neurological features may include paraseizure, numbness, sensory loss and radicular pain. This diagram demonstrates the clinical findings of cord compression by a lesion of the thoracic cord at T7. We can see that in the upper limb there is no motor or sensory loss and the reflexes are normal. We can see a clear sensory level at the level of T7 with loss of all sensory modalities below the level of the lesion, loss of abdominal reflexes which can result in bowel and bladder dysfunction, and a spastic paresis of the lower limbs with brisk reflexes and extensive planters. Management of metastatic spinal cord compression involves urgent spinal immobilisation and a whole spine MRI within 24 hours. 16mg of oridexamethadone should be given to reduce oedema. while awaiting surgery or radiotherapy. Mobilisation should only be allowed if there is spinal stability confirmed after imaging. This can be before or after surgery. There should be individualised pain assessment and management, typically requiring use of opiates with or without neuropathic agents. Bisphosphonates can be offered if the patient has myeloma, breast or prostate cancer. which could aid management of pain and reduce the risk of skeletal events, and denosumab can be considered as an alternative, except in patients with prostate cancer. Here we can see MRI findings for spinal cord compression. On the left we can see cord compression relating to multiple myeloma. We can see a pathological collapse of T11 with cord compression in this area and multiple smaller areas of focal marrow involvement. On the right, we can see on this MRI we can see a metastasis at the level of L1 causing compression of the spinal cord. Management of metastatic SCC is typically interventional. Urgent 8-grade single fracture radiotherapy can be offered within 24 hours if patients aren't suitable for spinal surgery unless there has been complete paraplegia for over two weeks with good pain control or a poor overall prognosis and post-operative radiotherapy can be considered after spinal surgery. there is a good response and recurrent symptoms. Surgical intervention involves surgical cord decompression and stabilisation and supportive measures include VTE prophylaxis, management of urinary or faecal incontinence, physiotherapy and rehabilitation support. Moving on to question six. A 20 year old man has sudden right knee pain while playing football with a popping sound, locking of the knee joint and inability to weight bear, followed by a mild swelling around the knee over the following 12 hours. He has medial joint line tenderness, reduced range of knee extension, diffuse suprapatellar infusion and palpable creptus on passive movement of the knee joint. Which is the most likely diagnosis? A. Anterior cruciate ligament rupture. B Medial collateral ligament tear. C Medial meniscal tear. D Patellar tendon rupture. Or E Pre-patellar bursitis. I'll just give you a few moments to think about the correct answer. The correct answer is C, a medial meniscal tear. A meniscal tear describes injury to the meniscus of the knee. Traumatic meniscal tears typically relate to twisting or pivoting injuries with axial loading, common in sporting professionals. A degenerative tear is very common in older adults and is typically asymptomatic and picked up incidentally on imaging. The medial meniscus is most frequently torn, typically in adults between 18 to 50 years of age. Typical features of the meniscal tear include acute knee pain after trauma or a twisting injury with a popping sound, a slow onset of mild to moderate effusion over hours compared with a cruciate ligament rupture which is acute onset of tense swelling, there'll be medial joint line tenderness and a medial meniscal tear and locking and restricted range of movement with knee joint instability. The diagnosis is made with an MRI of the knee which will show a hyper intense line in the meniscus with distorted meniscal morphology. Management of meniscal injuries are typically conservative with rest, ice, elevation, analgesia and physiotherapy and in particular degenerative tears which are asymptomatic should not be managed operatively. Surgery is reserved for those with persistent disabling symptoms or functional limitation or complex tears and involve arthroscopy with meniscectomy or meniscal repair if possible. Here we can see an injury commonly described as a bucket handle tear which will be managed with arthroscopy, meniscectomy or meniscal repair. Question 7. A 48-year-old woman has two months of worsening left groin pain radiating to the knee. She has systemic lupus erythematosus managed with hydroxychloroquine and has had oral prednisolone three times in the last 12 months for flares of her joint symptoms. She has pain and limited active and passive movement of the right hip. Which is the most likely diagnosis? A. Osteoarthritis. B, osteonecrosis, C, osteomalacia, D, osteopetrosis, or E, osteoporosis? I'll just give you a few moments to think about the correct answer. The correct answer in this case is B, osteonecrosis. Here we have a patient with non-traumatic hip pain and reduced range of motion with a history of steroid use, which is a risk factor for avascular necrosis of the femoral head. Osteonecrosis or avascular necrosis describes ischaemia of the bone with pathological decomposition and joint dysfunction. There are several risk factors for osteonecrosis development. Trauma to joints with a retrograde blood supply, such as the femoral head or the scaphoid, can result in osteonecrosis. Common associations are with steroids and alcohol, and other factors causing cellular insults such as chemoradiotherapy and smoking can cause osteonecrosis. There can be mechanical compression of the bone blood supply with bone marrow haemorrhage and comorbidities including developmental dysplasia of the hip, slips, capito-femoral epiphysis and sickle cell disease can increase the risk of development of this condition. Clinical features include the gradual onset of joint, thigh and buttock pain if the joint affected is the hip. There will be a history of risk factors such as steroids or alcohol use. and in advanced stages restricted range of motion can develop. The diagnosis is made with typical clinical features and supportive imaging findings. On x-ray you can see subcontraindiculatory fractures, sclerosis, cystic changes and bone collapse. On MRI there will be evidence of hypotense necrotic tissue within the bone marrow seen on the right here. Management of osteonecrosis involves reducing weight bearing status, management of pain, modification of risk factors such as reduction in alcohol, smoking and steroid use, and physiotherapy. Surgical management involves core decompression, seen on the right here, where a drill is used to decompress the necrotic bone, which is then replaced with either metal, an augment or a bone graft, and joint replacement surgery may be required if there is significant bony destruction. Moving on to question eight. A 22 year old man has right shoulder pain and inability to weight bear after falling onto an outstretched hand. He had a previous rotator cuff tear managed with surgical repair. He has tenderness over the anterior glenohumeral joint line, numbness over the lateral upper arm and inability to abduct the arm. X-ray of the right shoulder is shown. Which is the most appropriate management? A. Analgesia B Closed reduction C Open reduction and internal fixation D Splint and functional brace or E A total shoulder replacement I'll just give you a few moments to think about the correct answer. Here, the correct answer is B, a closed reduction, as these findings are suggestive of anterior shoulder dislocation. Shoulder dislocation describes dislocation of the humeral head from the glenomid fossa. It's very common as the humeral head is much larger than the glenomid fossa in which it sits. Anterior dislocation is most common, though the shoulder joint can also dislocate posteriorly or inferiorly. It typically results following trauma such as a full-on outstretched hand. Risk factors include previous shoulder injury and rotator cuff instability and seizures are a particular risk factor for posterior dislocation. Clinical features include shoulder pain and reduced range of motion, there will be an empty glenoid fossa with anterior dislocation presenting with a humeral head powerful below the coracoid and the arm held in abduction and external rotation, and posterior dislocation presenting with a prominent coracoid process and the arm held in adduction and internal rotation. There may be a history of a triggering movement or any previous dislocations which can increase the risk of subsequent dislocation. The diagnosis of shoulder dislocation is confirmed with x-ray imaging of the affected joint. On the left here you can see an anterior dislocation with anterior inferior displacement of the humeral head and on the right here you can see typical findings of a posterior dislocation commonly described as the light bulb sign with vertical positioning and lateral displacement of the humeral head. The management of all acute trauma should be with ED referral for full assessment and involve an ATLS approach. Following imaging confirmation of the diagnosis, management of shoulder dislocation involves analgesia, reduction and several of the methods of reduction are shown on the right. Sling immobilisation is typically offered post-reduction and rehabilitation with physiotherapy is essential to prevent functional impairment. There should be a clear neurovascular assessment pre and post reduction. Axillary nerve injury is a common finding in anterior dislocations due to the close relationship of the axillary nerve with the humerus and in this question there was numbness over the deltoid bulk and weakness to abduction suggesting potential axillary nerve injury. Question 9. A 23-year-old man has right ankle pain after a fall. He has severe pain and swelling over the medial and lateral malleoli with reduced range of motion and inability to weight bear. X-rays of the right ankle are seen on the right. Which is the most likely diagnosis? A. Masoner fracture B Trimalleolar fracture C Whether A fracture, D, whether B fracture, or E, or whether C fracture? I'll just give you about 30 seconds to think about the correct answer. The correct answer in this case is B, a trimalleolar fracture. An ankle fracture is an acute fracture of distal tibia or fibula. They typically relate to twisting injuries. Ankle fractures present with ankle pain, decreased range of movement and inability to weight bear. They are classified based on which malleolus is involved and whether they are unimalleolar, bimalleolar or trimalleolar. A masonerb fracture is a specific type of ankle fracture describing a proximal fibular fracture with syndesmotic disruption and medial malleolus injury. Lateral ankle fractures can be further classified using the Weber classification system, where Weber A describes a fracture below the level of syndesmosis, Weber B describes a fracture at the level of syndesmosis, and Weber C describing a fracture above the level of the syndesmosis. Management of any acute fracture is a referral to the emergency department for full assessment involving ACLS principles with neurovascular assessment of the affected limb essential. The Ottawa ankle rules should be used to guide whether a x-ray is required in an ankle injury. An ankle x-ray series is only necessary under these rules if there is pain near the malleola and any of the following findings. Inability to weight bear both immediately and in the emergency department or bony tenderness at the posterior edge or tip of either malleolus. Following confirmation of the diagnosis management relates to the stability of the fracture and whether the fracture is displaced or undisplaced. Stable undisplaced fractures can be managed with splint immobilization and unstable or displaced fractures must be managed with open reduction and internal fixation or external fixation. Isolated lateral or medial malleolar fractures are typically stable. Posterior malleolar fractures or bimalleolar fractures and masoner fractures are usually unstable and trimalleolar fractures are always unstable. Pain management is essential with paracetamol or OPS. Moving on to the final question. A 28 year old man has three hours of worsening left lower leg pain after a crush injury at work. He is unable to weight bear with severe pain in his left lower leg worse on passive extension. His left calf is swollen five centimetres larger than the right with sensory loss and paresthesia in the left foot. His dorsalis pedis pulse is impalpable. Which is the most important immediate investigation? A. Compartmental pressure monitoring B Creatinine kinase C CT angiogram lower limb D Doppler ultrasound lower limb arteries or E X-ray of right lower leg I'll just give you a few moments to think about the correct answer. The underlying diagnosis in this case is acute compartment syndrome and there is evidence of acute limb ischemia hence the correct answer is D Doppler ultrasound lower limb arteries. Compartment syndrome describes tissue ischemia due to raised pressure in a fascial compartment. This can progress to irreversible tissue necrosis within four to six hours without effective treatment. Risk factors include trauma with hematoma relating to fractures in the regional area or hemorrhage relating to arterial or crush injuries. Constrictive burn eschars can produce tissue ischemia. and also oedema from reperfusion injuries can relate from burns. Constructive casts or bandaging can cause compartment syndrome and excessive repetitive muscle use can cause a phenomena described as chronic compartment syndrome. Clinical features include pain out of proportion to initial clinical findings, pain on passive muscle stretch and subsequently signs of ischemia including pain, pulselessness, paralysis, paresthesia, pallor. or poikilothermia of the affected limb. This cross section of the leg allows appreciation of the individual fixed fascial compartments with increasing pressure in one of which can result in acute compartment syndrome. Here we can see evidence of tissue ischemia in anterior compartment syndrome. Management of acute compartment syndrome involves removing any constrictive casts or bandages, Investigations to confirm the diagnosis, which can involve x-ray or MRI imaging, particularly if there is any associated trauma. Urgent arterial assessment with Doppler ultrasound or CT angiography is essential if there is evidence of limb ischaemia, and Doppler ultrasound is typically used in the acute setting. And compartmental pressure measurements can be obtained to confirm elevated compartmental pressures. Management is with an ATLS approach, with stabilisation of the patient, Immediate orthopaedic consult, serial compartmental pressure monitoring and emergency fasciotomy in all cases to prevent irreversible tissue ischemia. This image depicts a fasciotomy for compartment syndrome. And here we can see where the anterior and lateral compartments of the leg have been decompressed with a longitudinal incision over the anterolateral aspect of the lower leg. That brings us to the end of this webinar on high yield UK MLA topics relating to MSK and TNO. Today we have covered septic arthritis, radiculopathy, upper limb soft tissue injury, lower limb fractures, rheumatoid arthritis, spinal cord compression, lower limb soft tissue injury and compartment syndrome. Thank you very much for joining me today and look forward to welcoming you next time.

The Crash Course series is a series of high-yield textbooks relating to medical finals with the new editions all being updated to match the UKMLA syllabus and expectations. I'm the Clinical Key Student Question Bank Assessment Editor. This question bank contains over 6,000 high-yield questions for medical finals.

Today's webinar will cover 10 high-yield SBA questions relating to musculoskeletal and trauma and orthopaedic topics on the UK MLA syllabus, which is demonstrated below. All questions are formatted in the style of the MLA exam, with information covers relating to NICE guidelines or society guidelines. Let's get started with the first question.

A 61 year old woman has four days of left knee pain, stiffness and inability to weight bear. She has room to arthritis, managed with methotrexate and folic acid. Her temperature is 37.8 degrees C, pulse 109 beats per minute. and blood pressure 131 over 81 mmHg.

There is tense swelling around the left knee with erythema and severe pain and reduced range of motion. Investigations are performed including aspiration of the knee joint which demonstrates turbid fluid, white blood cell count over 80,000m3 and 99% neutrophils. Which is the most appropriate management? Colchicine, B, intravenous antibiotic therapy, C, intravenous hydrocortisone, D, intraarticular steroid injections, or E, naproxen.

I'll just give you a few moments to think about the correct answer. The correct answer is B, intravenous antibiotic therapy, as the features of this stem suggest possible septic arthritis. Septic arthritis describes infection of a joint space, relating to a haematogenous or contiguous serotonin infection, or direct inoculation of a pathogen into a joint.

The most common etiological organism is Staphylococcus aureus, although Streptococci organisms and Neisseria gonorrhoeae have also been implicated. Risk factors include prosthesis, intra-articular interventions such as intra-articular steroid injections, pre-existing joint disease such as rheumatoid arthritis, immunosuppression which is often also seen with autoimmune arthritis, increasing age and intravenous drug use which is a risk factor for direct inoculation of pathogens. Symptoms include the acute onset of monoarticular pain, reduced range of motion, heat, erythema and swelling of the affected joint and there may be features of systemic illness including fever and hemodynamic instability, however features may be milder or more chronic in nature in prosthetic joints. To diagnose septic arthritis, an arthrocentesis with synovial fluid analysis and culture is performed.

Typical features seen on synovial fluid analysis include turbid fluid, a white blood cell count over 50,000, A neutrophil dominance of over 90%, glucose levels lower than that of blood glucose, and a gram-sane should be performed to guide antibiotic therapy. Blood cultures should be taken, and x-rays of the joint should be performed to identify any bony lesion or destruction. CT or MRI imaging can be indicated in chronic infection or those with suspected osteomyelitis. And here we can see an image of... arthrocentesis with aspiration of blood-stained pus from the knee of a child with septic arthritis.

Management of septic arthritis involves therapeutic arthrocentesis to remove pus from the joint space and empirical intravenous antibiotic therapy for up to six weeks, which is targeted once culture results are available. For those with a prosthetic joint infection, surgical debridement with or without revision arthroplasty is required. and intravenous antibiotics may be prescribed for a prolonged course for up to three months.

Supportive measures include analgesia, VTE prophylaxis and early mobilisation with physiotherapy to prevent joint stiffness in the long term. Without effective treatment, septic arthritis can result in a number of complications, including chronic osteoarthritis, osteomyelitis with spread of infection to the bone, osteonecrosis or avascular necrosis with compromisation of the bone blood supply, bony and cartilaginous destruction and associated fracture of the bone. In prosthetic joints, it can result in periprosthetic loosening, fracture or dislocation, which may require a vision surgery, chronic pain, and leg lymph discrepancies can develop and in severe infection sepsis and death can be the result.

Question 2. A 31 year old woman who is 36 weeks pregnant has three days of burning, tingling and weakness in her right hand which is worse at night. She has sensory loss over the right index and middle finger, weakness in thumb, abduction and thenar atrophy. Her symptoms are reproducible with tapping over the volar wrist.

Which is the most likely diagnosis? A. Carpal tunnel syndrome B Cervical radiculopathy C Cubital tunnel syndrome D Dequivanes tenosynovitis or E Alnune neuropathy I'll just give you a few moments to think about the correct answer. The correct answer in this case is A, carpal tunnel syndrome. Carpal tunnel syndrome is an entrapment neuropathy caused by compression of the median nerve in the carpal tunnel at the wrist.

Risk factors include activities with a high hand-to-wrist repetition rate, obesity and pregnancy can cause increased fluid accumulation in the tissue spaces in the carpal tunnel and produce symptoms, Metacarpophalangeal or thumb joint osteoarthritis can cause spurs to form on the carpal bones, trapping the nerve and resulting in symptoms. Both rheumatoid arthritis and hypothyroidism are associated with synovial enlargement and swelling and can cause carpal tunnel syndrome. And in diabetes it is thought that glucose can attach to the proteins of the tendons in the carpal tunnel resulting in inflammation and preventing the tendons from moving properly, producing symptoms. The carpal tunnel is found on the volar wrist. Its boundaries include the deep carpal arch on the dorsal aspect and the superficial flexor retinaculum on the volar aspect.

The carpal arch is a concave arch formed by the scaphoid and trapezium tubercles and the hook of the hamate and the pisiform. Contained within the carpal tunnel are the median nerve, compression of which produces the symptoms in carpal tunnel syndrome. the four tendons of flexor digitorum superficialis and tendons of flexor digitorum profundus and the tendon of flexor pollicis longus. Symptoms of carpal tunnel syndrome relate to compromisation of the motor and sensory functions of the median nerve. Impaired sensory function results in intermittent paresthesia, numbness or altered sensation with burning or pain in distribution of the median nerve on the hand as demonstrated on the right.

Uncompromised motor function can result in wasting of the femur eminence muscles, weakness of thumb abduction and opposition, reduced hand grip and pinch grip strength, and reduced hand coordination. There are several tests that are commonly used to assess the function of the median nerve and for features of carpal tunnel. In A we can see testing thumb abduction against resistance. B we can see a demonstration of Phalanx Maneuver which involves having the patient place the wrists.

In complete unforced flexion for 30 seconds which should produce symptoms. And C we can see the performing of Tinnall's sign which is performed by percussing over the median nerve in the carpal tunnel which should elicit the symptoms in patients with carpal tunnel syndrome. Carpal tunnel is a clinical diagnosis.

Management in the first instance is conservative. with avoiding repetitive wrist movements and taking regular breaks from precipitating movements, optimising underlying risk factors including weight loss and management of associated conditions such as diabetes, hypothyroidism and rheumatoid. Wrist splints should be recommended to patients and patients can be offered a single corticosteroid injection into the carpal tunnel which can alleviate symptoms. If there is any failure of conservative management, Patients can be referred to secondary care for nerve conduction studies and a surgical carpal tunnel release.

Moving on to the next question. A 71-year-old man has severe right groin pain and inability to wait there after a fall. He has a shortened and externally rotated right leg with bruising and pain over the lateral thigh. An x-ray of the right hip is shown.

Which is the most appropriate management? A. Dynamic hip screw.

B Hemiarthroplasty. C Intramodulatory nail. D Open reduction and internal fixation or E A total hip replacement I'll just give you a few moments to think about the correct answer. This question relates to a neck of femur fracture and the correct answer is E, a total hip replacement. A hip fracture describes a fracture of the femur which commonly occurs in the femoral neck.

A NOF or a neck of femur fracture is the commonest reason for an orthopaedic admission and it's a significant injury with over 10% mortality within one month. In older patients it typically relates to a fragility fracture after a low impact injury, but in younger patients a femoral fracture is typically the result of high impact trauma. Risk factors include osteoporosis, typically in postmenopausal women, increasing age, smoking, malnutrition, any vitamin D or calcium deficiency or sarcopenia, and any risk factors for falls including reduced mobility or impaired coordination.

Features suggestive of an off include in those with displaced fractures, a shortened and externally rotated leg with groin pain radiating to the knee with or without pain in the entire hip region. In undisplaced fractures symptoms may be minimal with minor clinical deformity or mild pain or movement. The diagnosis of hip fracture is made with AP and lateral x-ray imaging of the affected An MRI can be performed if there is a high index of clinical suspicion but negative x-rays. Hip fractures are classified based on their relationship to the hip joint capsule which attaches at the intertrochanteric line.

Intracapsular fractures are those involving the femoral neck or femoral head and extracapular fractures are intertrochanteric fractures, so between the greater and lesser trochanters, those involving either the greater or lesser trochanter in isolation. and subtrochanteric which are below the intertrochanteric line. A common method for diagnosing hip fractures on x-ray is assessing for disruption in Shenton's line which is a curved line seen between the femur and the pubic groma.

On the right here you can see a smooth curve with no interruptions but on the left here you can see a clear disruption at this curve suggesting neck of femur fracture. You can also see a previous hemiarthroplasty on the right. Another commonly used classification system for intracapsular fractures is the garden classification, which relates to the degree of displacement of the femoral head.

Type 1 is an incomplete fracture. Type 2 is a complete fracture which is undisplaced. Type 3 is a complete fracture which is partially displaced. And type 4 demonstrates a complete fracture which is fully displaced. The management of any acute traumatic injury should involve ATLS principles with effective resuscitation where required.

All injuries and complications must be identified, which can involve a CT traumagram and significant trauma or x-ray imaging of symptomatic joints. Neurovascular assessment of all limbs should be performed and there should be assessment for any evidence of open fractures, which requires specific management. Pain should be managed with paracetamol and opioid analgesia. Commonly used in hip fractures are fascial iliaca blocks, which are local anaesthetic nerve blocks, a type of regional anaesthesia used to provide anaesthesia to the hip and thigh, and NSAIDs should be avoided.

Best practice in management of hip fractures involves preparing the patient for theatre on the day of or the day after admission. Any comorbidities that may delay operative management should be corrected involving correction of anemia with a target for transfusion of above 80 at least. Anticoagulation may need to be reversed to a target INR. Any patients with evidence of dehydration or volume depletion should be resuscitated appropriately. Electrolyte imbalances should be corrected.

Patients with uncontrolled diabetes should be put on a variable rate to control this perioperatively. Uncontrolled heart failure should be diagnosed with a preoperative echo and diuresis can be required if there is symptomatic fluid overload. Any correctable cardiac arrhythmias or ischemia should be corrected and treated. Evidence of acute chest infection warrants treatment with intravenous empirical antibiotics. and if there is any associated exacerbation of chronic chest conditions these should be treated appropriately.

Operative management involves spinal or general anaesthesia with or without nerve blocks. For displaced intracapsular fractures operative management involves a total hip replacement or a hemiarthroplasty. A total hip should be considered for patients with a displaced intracapsular hip fracture who could walk independently outdoors with no more than use of a stick.

do not have a contra-intra-agic condition or comorbidity and are expected to be able to carry out their ADLs independently beyond two years. In the question we went through there were no associated comorbidities and the patient was walking independently so a total hip replacement was the correct answer. For trochanteric fractures extramedullary implants such as our dynamic hip screw are used in preference to intramedullary nailing but for sub trochanteric hip fractures, intramodulatory nails should be used.

In all cases, intracapsular fractures require a replacement with a hemi or a total hip. This is because the blood supply to the neck of the femur is retrograde, passing from distal to proximal along the femoral neck to the femoral head, predominantly through the medial circumflex femoral artery. As a result of this, displaced intracapsular fractures disrupt the blood supply to the femoral head. and therefore the head will undergo avascular necrosis even if the hip fracture is fixed. Hence, patients with displaced intracapsular fractures require joint replacement rather than fixation.

And here on the x-ray on the right we can see the bite sign which demonstrates a gouged out defect due to destruction with collapsed bone in the head of a femur which has undergone avascular necrosis. On the left here you can see What a total hip replacement looks like on x-ray post-operatively, you can see that both the acetabulum has been replaced with a cup and then you can see the head of the hip replacement replacing the femoral head with the stem going down the shaft of the femur. On the right you can see that this is a hemiarthroplasty as there is no evidence of an acetabular cup being implanted.

On the left here you can see the x-ray findings of a dynamic hip screw. As the fracture naturally heals and compresses, the DHS slides in the plate along the longitudinal axis of the femoral neck, permitting compression of the fracture and aiding healing. On the right here you can see a complex proximal femur fracture treated with an intra-dinary nail.

Both long and short nails can be used depending on the extent of injury. Further management of hip fracture involves MDT management with physiotherapist assessment and mobilisation on post-operative day one unless contraindicated. There should be an orthogeriatric assessment from admission with continued and coordinated orthogeriatric and multispring team review.

Optimisation of functional status involves techniques to prevent further falls, optimisation of bone health with bisphosphonates and calcium vitamin D replacements. Mental and social health assessment and support and assessment and support for any cognitive impairment and delirium. Patients should be supported with early discharge or transfer to rehabilitation unit. Moving on to question four.

A 32-year-old woman has six months of bilateral pain and stiffness in her hands and fingers, which is worse in the morning and improves throughout the day. The right hand is shown here. Which is the most likely diagnosis? A. Gout B Osteoarthritis C Reactive arthritis D Rheumatoid arthritis or E Septic arthritis I'll just give you a few moments to think about the correct answer.

The correct answer in this case is D, rheumatoid arthritis. Rheumatoid arthritis is a chronic systemic inflammatory disease affecting up to 1% of the UK population. It is two to four times more common in women than the typical onset between 30 to 50 years.

It presents with a persistent inflammatory arthritis affecting synovial joints and typically affects the small joints of the hands and feet. It presents with pain which is usually worse at rest or during periods of activity and improves with exertion. Swelling will be present around the affected joints giving a boggy feel on palpation.

And there will be stiffness, typically early morning stiffness usually lasting over one hour. It typically presents on both sides equally and symmetrically. And with progressive disease there will be progressive involvement of bodily systems presenting with cardiovascular disease, osteoporosis, anemia.

and increased susceptibility to infection. This diagram compares the distribution of joint involvement in both rheumatoid arthritis and osteoarthritis. On the left we can see the typical joints involved in rheumatoid arthritis as the small proximal joints of the hands and feet and those involving the pelvic and shoulder girdle. The atlanto-axial joint is also commonly implicated.

On the right here we can see the joints typically involved in osteoarthritis, typically the larger joints, joints of the spine and neck, and the distal joints of the hands and feet. Without effective treatment rheumatoid arthritis is destructive and can result in progressive hand deformities. The typical ones seen we see as ulnar deviation, butonia deformity, zed thumb and swan neck deformities.

and there are several extra-articular manifestations of rheumatoid arthritis seen on the right here which can involve the eyes, lungs, heart, haematological system and neurological system. Patients with persistent synovitis with no other obvious underlying cause should be referred to secondary care for suspected rheumatoid arthritis. Several investigations can be performed to support the diagnosis.

Rheumatoid factor is very sensitive for rheumatoid and positive in about 60-70% of cases. Anti-CCP antibodies are more specific and present in about 80% of cases. CRP and ESR will be typically raised and full blood count, user needs and LFTs should be performed to assess for any complications.

Imaging of the affected joints should be performed involving x-rays or ultrasound MRI if required to aid the diagnosis. and assessment of severity. Management of rheumatoid arthritis involves treating to the target of achieving remission or low disease activity.

First line is conventional disease modifying anti-rheumatic drug monotherapy typically with methotrexate, leflunomide, sulfasalazine or hydroxychloromocaine. Short-term bridging glucocoids such as oral pronisoline can be used while waiting for the DMR to start to work and there should be dose escalation until the treatment target is achieved. C-DMAG combination therapy is then offered if the treatment target is not achieved with monotherapy and biological DMADs with or without methotrexate can be used if the treatment target is not achieved with combination conventional DMADs.

Intra-articular, intramuscular or oral glucocorticoids can be used for flares. The complications of rheumatoid are widespread and significant and relate both to articular manifestations and extra-articular manifestations. Untreated or severe cases can result in permanent joint destruction with stiffening and deformity, presenting with the rheumatoid hand deformities mentioned previously. Further complications include septic arthritis, vasculitis, amyloidosis, anemia of chronic disease, osteoporosis and increased fracture risk, an increased cardiovascular disease risk, an increased risk of stroke, myocardial infarction, atrial fibrillation and heart failure, interstitial lung disease, pleuritis and pleural effusions. and secondary Trojan syndrome, all in addition to the extra-articular manifestations mentioned previously.

There are several more complications of rheumatoid and this list is not exhaustive but just covers a few. Moving on to the next question. A 76 year old woman has two months of central lower back pain and reduced mobility. She had breast cancer four years ago, managed with radical mastectomy and auxiliary lymph node clearance. She has focal L2-L3 tenderness, bilateral weakness to hip flexion and knee extension, diffuse sensory loss in the lower limbs and brisk knee and ankle jerk reflexes.

Which is the most appropriate investigation? A. Bladder scan, B CT myelogram, C MR whole spine, D Nerve conduction studies, or E X-ray of lumbar spine. I'll just give you a few moments to think about the correct answer.

The correct answer is C, MR whole spine. The features in this stem are suggestive of metastatic spinal cord compression, which describes compression of the spinal cord relating to metastatic disease. It should be suspected in any patients with a history of past or current diagnosis of cancer, with severe and remitting progressive back pain which may disturb sleep, pain worsened by standing, sitting, moving or straining, Localised spinal tenderness, claudication in the lower limbs and any features of cord compression including bladder or bowel dysfunction, gait disturbance, limb weakness, focal neurological signs or features of caudal equine syndrome including loss or reduction of sensation below the affected spinal cord level, bilateral paralysis below the affected level, lower limb hyperreflexia, positive vibrancy skin ataxia.

and any sphincter dysfunction with urinary or bowel urgency, retention or incontinence. Further neurological features may include paraseizure, numbness, sensory loss and radicular pain. This diagram demonstrates the clinical findings of cord compression by a lesion of the thoracic cord at T7. We can see that in the upper limb there is no motor or sensory loss and the reflexes are normal. We can see a clear sensory level at the level of T7 with loss of all sensory modalities below the level of the lesion, loss of abdominal reflexes which can result in bowel and bladder dysfunction, and a spastic paresis of the lower limbs with brisk reflexes and extensive planters.

Management of metastatic spinal cord compression involves urgent spinal immobilisation and a whole spine MRI within 24 hours. 16mg of oridexamethadone should be given to reduce oedema. while awaiting surgery or radiotherapy.

Mobilisation should only be allowed if there is spinal stability confirmed after imaging. This can be before or after surgery. There should be individualised pain assessment and management, typically requiring use of opiates with or without neuropathic agents. Bisphosphonates can be offered if the patient has myeloma, breast or prostate cancer.

which could aid management of pain and reduce the risk of skeletal events, and denosumab can be considered as an alternative, except in patients with prostate cancer. Here we can see MRI findings for spinal cord compression. On the left we can see cord compression relating to multiple myeloma. We can see a pathological collapse of T11 with cord compression in this area and multiple smaller areas of focal marrow involvement.

On the right, we can see on this MRI we can see a metastasis at the level of L1 causing compression of the spinal cord. Management of metastatic SCC is typically interventional. Urgent 8-grade single fracture radiotherapy can be offered within 24 hours if patients aren't suitable for spinal surgery unless there has been complete paraplegia for over two weeks with good pain control or a poor overall prognosis and post-operative radiotherapy can be considered after spinal surgery.

there is a good response and recurrent symptoms. Surgical intervention involves surgical cord decompression and stabilisation and supportive measures include VTE prophylaxis, management of urinary or faecal incontinence, physiotherapy and rehabilitation support. Moving on to question six. A 20 year old man has sudden right knee pain while playing football with a popping sound, locking of the knee joint and inability to weight bear, followed by a mild swelling around the knee over the following 12 hours. He has medial joint line tenderness, reduced range of knee extension, diffuse suprapatellar infusion and palpable creptus on passive movement of the knee joint.

Which is the most likely diagnosis? A. Anterior cruciate ligament rupture. B Medial collateral ligament tear. C Medial meniscal tear.

D Patellar tendon rupture. Or E Pre-patellar bursitis. I'll just give you a few moments to think about the correct answer. The correct answer is C, a medial meniscal tear.

A meniscal tear describes injury to the meniscus of the knee. Traumatic meniscal tears typically relate to twisting or pivoting injuries with axial loading, common in sporting professionals. A degenerative tear is very common in older adults and is typically asymptomatic and picked up incidentally on imaging.

The medial meniscus is most frequently torn, typically in adults between 18 to 50 years of age. Typical features of the meniscal tear include acute knee pain after trauma or a twisting injury with a popping sound, a slow onset of mild to moderate effusion over hours compared with a cruciate ligament rupture which is acute onset of tense swelling, there'll be medial joint line tenderness and a medial meniscal tear and locking and restricted range of movement with knee joint instability. The diagnosis is made with an MRI of the knee which will show a hyper intense line in the meniscus with distorted meniscal morphology.

Management of meniscal injuries are typically conservative with rest, ice, elevation, analgesia and physiotherapy and in particular degenerative tears which are asymptomatic should not be managed operatively. Surgery is reserved for those with persistent disabling symptoms or functional limitation or complex tears and involve arthroscopy with meniscectomy or meniscal repair if possible. Here we can see an injury commonly described as a bucket handle tear which will be managed with arthroscopy, meniscectomy or meniscal repair.

Question 7. A 48-year-old woman has two months of worsening left groin pain radiating to the knee. She has systemic lupus erythematosus managed with hydroxychloroquine and has had oral prednisolone three times in the last 12 months for flares of her joint symptoms. She has pain and limited active and passive movement of the right hip.

Which is the most likely diagnosis? A. Osteoarthritis. B, osteonecrosis, C, osteomalacia, D, osteopetrosis, or E, osteoporosis? I'll just give you a few moments to think about the correct answer.

The correct answer in this case is B, osteonecrosis. Here we have a patient with non-traumatic hip pain and reduced range of motion with a history of steroid use, which is a risk factor for avascular necrosis of the femoral head. Osteonecrosis or avascular necrosis describes ischaemia of the bone with pathological decomposition and joint dysfunction. There are several risk factors for osteonecrosis development. Trauma to joints with a retrograde blood supply, such as the femoral head or the scaphoid, can result in osteonecrosis.

Common associations are with steroids and alcohol, and other factors causing cellular insults such as chemoradiotherapy and smoking can cause osteonecrosis. There can be mechanical compression of the bone blood supply with bone marrow haemorrhage and comorbidities including developmental dysplasia of the hip, slips, capito-femoral epiphysis and sickle cell disease can increase the risk of development of this condition. Clinical features include the gradual onset of joint, thigh and buttock pain if the joint affected is the hip.

There will be a history of risk factors such as steroids or alcohol use. and in advanced stages restricted range of motion can develop. The diagnosis is made with typical clinical features and supportive imaging findings.

On x-ray you can see subcontraindiculatory fractures, sclerosis, cystic changes and bone collapse. On MRI there will be evidence of hypotense necrotic tissue within the bone marrow seen on the right here. Management of osteonecrosis involves reducing weight bearing status, management of pain, modification of risk factors such as reduction in alcohol, smoking and steroid use, and physiotherapy.

Surgical management involves core decompression, seen on the right here, where a drill is used to decompress the necrotic bone, which is then replaced with either metal, an augment or a bone graft, and joint replacement surgery may be required if there is significant bony destruction. Moving on to question eight. A 22 year old man has right shoulder pain and inability to weight bear after falling onto an outstretched hand.

He had a previous rotator cuff tear managed with surgical repair. He has tenderness over the anterior glenohumeral joint line, numbness over the lateral upper arm and inability to abduct the arm. X-ray of the right shoulder is shown. Which is the most appropriate management?

A. Analgesia B Closed reduction C Open reduction and internal fixation D Splint and functional brace or E A total shoulder replacement I'll just give you a few moments to think about the correct answer. Here, the correct answer is B, a closed reduction, as these findings are suggestive of anterior shoulder dislocation.

Shoulder dislocation describes dislocation of the humeral head from the glenomid fossa. It's very common as the humeral head is much larger than the glenomid fossa in which it sits. Anterior dislocation is most common, though the shoulder joint can also dislocate posteriorly or inferiorly.

It typically results following trauma such as a full-on outstretched hand. Risk factors include previous shoulder injury and rotator cuff instability and seizures are a particular risk factor for posterior dislocation. Clinical features include shoulder pain and reduced range of motion, there will be an empty glenoid fossa with anterior dislocation presenting with a humeral head powerful below the coracoid and the arm held in abduction and external rotation, and posterior dislocation presenting with a prominent coracoid process and the arm held in adduction and internal rotation. There may be a history of a triggering movement or any previous dislocations which can increase the risk of subsequent dislocation.

The diagnosis of shoulder dislocation is confirmed with x-ray imaging of the affected joint. On the left here you can see an anterior dislocation with anterior inferior displacement of the humeral head and on the right here you can see typical findings of a posterior dislocation commonly described as the light bulb sign with vertical positioning and lateral displacement of the humeral head. The management of all acute trauma should be with ED referral for full assessment and involve an ATLS approach. Following imaging confirmation of the diagnosis, management of shoulder dislocation involves analgesia, reduction and several of the methods of reduction are shown on the right.

Sling immobilisation is typically offered post-reduction and rehabilitation with physiotherapy is essential to prevent functional impairment. There should be a clear neurovascular assessment pre and post reduction. Axillary nerve injury is a common finding in anterior dislocations due to the close relationship of the axillary nerve with the humerus and in this question there was numbness over the deltoid bulk and weakness to abduction suggesting potential axillary nerve injury. Question 9. A 23-year-old man has right ankle pain after a fall. He has severe pain and swelling over the medial and lateral malleoli with reduced range of motion and inability to weight bear.

X-rays of the right ankle are seen on the right. Which is the most likely diagnosis? A.

Masoner fracture B Trimalleolar fracture C Whether A fracture, D, whether B fracture, or E, or whether C fracture? I'll just give you about 30 seconds to think about the correct answer. The correct answer in this case is B, a trimalleolar fracture.

An ankle fracture is an acute fracture of distal tibia or fibula. They typically relate to twisting injuries. Ankle fractures present with ankle pain, decreased range of movement and inability to weight bear.

They are classified based on which malleolus is involved and whether they are unimalleolar, bimalleolar or trimalleolar. A masonerb fracture is a specific type of ankle fracture describing a proximal fibular fracture with syndesmotic disruption and medial malleolus injury. Lateral ankle fractures can be further classified using the Weber classification system, where Weber A describes a fracture below the level of syndesmosis, Weber B describes a fracture at the level of syndesmosis, and Weber C describing a fracture above the level of the syndesmosis.

Management of any acute fracture is a referral to the emergency department for full assessment involving ACLS principles with neurovascular assessment of the affected limb essential. The Ottawa ankle rules should be used to guide whether a x-ray is required in an ankle injury. An ankle x-ray series is only necessary under these rules if there is pain near the malleola and any of the following findings.

Inability to weight bear both immediately and in the emergency department or bony tenderness at the posterior edge or tip of either malleolus. Following confirmation of the diagnosis management relates to the stability of the fracture and whether the fracture is displaced or undisplaced. Stable undisplaced fractures can be managed with splint immobilization and unstable or displaced fractures must be managed with open reduction and internal fixation or external fixation. Isolated lateral or medial malleolar fractures are typically stable. Posterior malleolar fractures or bimalleolar fractures and masoner fractures are usually unstable and trimalleolar fractures are always unstable.

Pain management is essential with paracetamol or OPS. Moving on to the final question. A 28 year old man has three hours of worsening left lower leg pain after a crush injury at work. He is unable to weight bear with severe pain in his left lower leg worse on passive extension. His left calf is swollen five centimetres larger than the right with sensory loss and paresthesia in the left foot.

His dorsalis pedis pulse is impalpable. Which is the most important immediate investigation? A. Compartmental pressure monitoring B Creatinine kinase C CT angiogram lower limb D Doppler ultrasound lower limb arteries or E X-ray of right lower leg I'll just give you a few moments to think about the correct answer.

The underlying diagnosis in this case is acute compartment syndrome and there is evidence of acute limb ischemia hence the correct answer is D Doppler ultrasound lower limb arteries. Compartment syndrome describes tissue ischemia due to raised pressure in a fascial compartment. This can progress to irreversible tissue necrosis within four to six hours without effective treatment.

Risk factors include trauma with hematoma relating to fractures in the regional area or hemorrhage relating to arterial or crush injuries. Constrictive burn eschars can produce tissue ischemia. and also oedema from reperfusion injuries can relate from burns. Constructive casts or bandaging can cause compartment syndrome and excessive repetitive muscle use can cause a phenomena described as chronic compartment syndrome. Clinical features include pain out of proportion to initial clinical findings, pain on passive muscle stretch and subsequently signs of ischemia including pain, pulselessness, paralysis, paresthesia, pallor.

or poikilothermia of the affected limb. This cross section of the leg allows appreciation of the individual fixed fascial compartments with increasing pressure in one of which can result in acute compartment syndrome. Here we can see evidence of tissue ischemia in anterior compartment syndrome. Management of acute compartment syndrome involves removing any constrictive casts or bandages, Investigations to confirm the diagnosis, which can involve x-ray or MRI imaging, particularly if there is any associated trauma.

Urgent arterial assessment with Doppler ultrasound or CT angiography is essential if there is evidence of limb ischaemia, and Doppler ultrasound is typically used in the acute setting. And compartmental pressure measurements can be obtained to confirm elevated compartmental pressures. Management is with an ATLS approach, with stabilisation of the patient, Immediate orthopaedic consult, serial compartmental pressure monitoring and emergency fasciotomy in all cases to prevent irreversible tissue ischemia. This image depicts a fasciotomy for compartment syndrome.

And here we can see where the anterior and lateral compartments of the leg have been decompressed with a longitudinal incision over the anterolateral aspect of the lower leg. That brings us to the end of this webinar on high yield UK MLA topics relating to MSK and TNO. Today we have covered septic arthritis, radiculopathy, upper limb soft tissue injury, lower limb fractures, rheumatoid arthritis, spinal cord compression, lower limb soft tissue injury and compartment syndrome.

Thank you very much for joining me today and look forward to welcoming you next time.

Transcript for:UKMLA High-Yield Topics in Musculoskeletal

Transcript for:
UKMLA High-Yield Topics in Musculoskeletal