4.1Ortho

8/29/2019 Orthopaedics Full | Plab 1 Keys and Notes - All You Need To Pass PLAB 1 Exam
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We are taking care of every single high-yield detail in our notes. However, you
are advised to go over a reliable MCQ question bank so you can familiarise
yourself with exam-type questions and easily apply our keys on your answers.
Key Bone pain (e.g. in a leg) especially in young people that is unre lated to activity
1 and responds quickly to NSAIDs (e.g. Aspirin)
➔ losteoid Osteoma l. " benign long bones tumour e.g. femur, tibia "
Key On Foot bone Fractures:

2
rt Falling "Vertically" on feet, t he likely foot bone to fracture
➔ lcalcaneusl.
(Also check for lspinal Fractursl as they are also common in vertical falls)
rt Stress Fracture of Foot, the likely affected bones

➔ !Metatarsals !.
Pha ta n g
Distal
Stress Middle
Fractu-re _ -11 ,.__ ___ _ Prox r1nal
Vertical
Falls
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Key
Slipped Upper Femoral Epiphysis (SUFE)
3
I I
11-15YO Boy Limping The affected leg is shorter than the other
I Externally rotated hip that t with hip flexion I Painful knee/ hip/
I
thigh/ groin Limited hip abduction.
Head of SCFE
femur
Slipped Upper
Femoral Epiphysis
11-15 YO Bo
Limping
Affected leg i sh ter than the other.
Externally rotated ip that 1' with hip
PLAB exion
I
EY Plablkeys.com Painful knee/hip/thigh/groin
Key Sensory Loss Responsible Nerve Roots

4
• Groin and pelvic Girdle ➔ ~

• Anterior thigh ➔~
• Inner (Medial) thigh and distal anterior thigh ➔ L3
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I• I\ I •
• inner lmeaia 1J snin 7 ~
• Outer (Late ral) shin + Dorsum of th e foot ➔ ~
• Lateral Foot ➔~
Key Prostate cancer can metastasise to sp i ne causing ➔ Cauda Equina Syndrome ➔

5 Perianal/ groin numbness (Saddle Paraesthesia) IInability to initiate voiding
"urination " IBack pain .
Cauda Equina Syndrome

• Cauda equina = bundle of nerves and nerve roots at the lower end of spin al cord.
• It resembles the horse's tail, starts from (T12/Ll to Coccyx).
• Compression of the cauda equina is a surgical emergency!
• Features:
♦ Sciatica (pain along the sciatic nerve course Low back, hips , buttocks , legs).
♦ Saddle Paraesthesia (ana l/ periana l/ groin numbness ).
♦ Urinary retention (inability to void).
♦ Fecal incontinence (inability to control bowel movements, resulting in invo luntary
soiling}.
• The commonest cause ➔ Central Disc Prolapse that compresses cauda equina.
• It is a surgical emergency
• !urgent MRI!
• Sometimes the answer would be ➔ Urgent referral to orthopaedic surgeon.
• !urgent Surgicaldecompression!(to avoid persistent loss of sphincter and motor
functions).
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Conus
medullaris
Cauda equina
Illustration of saddle anesthesia;
• The SS, 54, and S3 nerves provide sensory
innervation to the rectum, perineum, and
inner thigh.
In a patient with lowe r back pain, the presence of (~addle Paraesthesia l)

wa rrants urgent referral to neurosurgical/ orthopaedic team for MRI.
Key Lumbosacral Disc Herniation/ Disc Prolapse

6
ti IFeatures l:
v Severe lower back pain that radiates to a leg (could be Acute sudden onset)
v Lying supine with legs raised ➔ 1' pain. (+ve straight leg raising test)
v When getting up from a lying positing ➔ 1' Pain.
v Walk ing/ Prolonged sitt i ng ➔ 1' Pain
v Lying down ➔ relieves ( ~) pain .
v ± Nerve e n trapment ➔ Sciatica ➔ shooting, electric shock pain moving down a
leg (leg pain> back pain) . "Back pain radiates to a lower limb,,
♦ Next step ➔ Reassure and prescr ibe analgesics

♦ If any red-flags or this option is not given ➔ MRI Spine
See below
ti IManagement l:
♦ If not severe, it usually resolves in 6 weeks t o a few mont hs.
♦ NSAIDs are preferred "fo r pain rel ief,,. "Describe PP/ with it}}.
♦ If there is sciatica ➔ Amitriptyline "prefer red}}, Gabapentin , Pregabalin .
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♦ Important: If associated wit h Saddle Paraesthesia (anal/ periana l/ groin

numbness ), Fecal incontinence, urinary retention ➔ suspect cauda equina
syndrome and refer urgently to orthopaedics for MRI.
r1INotes l:
(+) lntervertebral disc:
v Hern iated disc is more common in people< 40 YO.
v Degenerative disc is more common in people> 40 YO.
(+) The commonest site is (LS/Sl fo llowed by L4/LS).
Normal d isc Herniated disc
Healthy
~Ji: .':a.•?.-.;'
.' 1 disc
Vertebra
Herniated
disc
(b)
(a)
Disc ¢
Degenera tion
s equestrat ion ¢
(c) (d)
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Exam le 1
A 22 YO male presents complaining of a sudden onset severe lower back pain
which was elicited when trying to get up. The pain 1' in intensity when lying
down with legsbeing raised.There is also a tense electric shock like pain
radiates down to his left leg.
The likely Dx ➔ ILumbosacraldischerniation!.

Its not sciatica because there is no shooting pain down the leg.
CiJClincher~ +ve straight leg raising test (+) back pain with a lower limb radiation .
!Example 2~
A 35 YO male presents complaining of back pain which started 2 days ago when
he was moving to a new house. The pain radiates to his left foot and increases in
severity when he coughs. 0/E: +ve straight leg raising test, loss of deep tendon
reflexes of his left leg, Sensory loss over the anterior knee.
The likely Dx ➔ l1ntervertebralDiscProlapse!.
ttJClincher ~ +ve straight leg raising test (+) back pain with a lower limb radiation .
Note, this cannot be a (LS nerve root compressio n). Remember, this patient's
deep te ndo n refl exes are lost on the affec t ed leg. Knee reflex (L3, L4) has
not hing to do w ith LS!
Key Repetitive "overhead" "above the shoulder'' activities. Examples:

7 ~ Volleyball - Tennis - Badminton player, Swimmer .
~ Carrying heavy objects (e.g. a recent move to a new house ).
(+)
Shoulder weakness, Pain especially on raising arm above shoulder and at night
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Thick of ➔ ~upraspinatus Tendinitis!.
Key v The elderly people with osteoporosis are subjects to bone fractures
8 following a trivial fall or trauma.
An elderly + Hx of fall + Painful hip + Shortened, Externally rotated leg
➔ Suspect !Fracture of the Neck of the Femu~. (neck, not head of the femur)!
a We can suspect an elderly of being at a risk of Osteoporosis or already has

Osteoporosis if he/ she is taking Bisphosphonates (e.g. Alendronate).
a Alendronate is first-line management in Osteoporosis.
a Osteoporosis Patients can easily get fractures particularly the neck of femur.
~Remember,
I
~ A child "Boy" w ith limping shortened leg Iexternally rotated leg
➔ ~lipped upper femoral epiphysisl.
~ A child "girl"I Breech presentat ion I FHx I Limping I Painless leg that is
shorter than the other I Unequal skin folds
➔ !Developmental Dysplasia of the Hip (DDH). I
Key une ot the commonest tractures Lry totalling on " outstretched " hand
9
➔ ~caphoid fracture !
(Painfulbase of thumb I tender anatomic snuff-box I Ulnar deviation producespain).
How to manage? "important v"
• If X-ray is +ve ➔ caphoid Castfor 6 week .

• If X-ray is -ve "does not show the fracture" ➔ Castand Repeated X-ray in 2 week .
Key Developmental Dysplasia of the Hip (DDH)

10 A former name: Congenital Dislocation of the Hi (CDH)
CiJRisk factors " Important v"

v Female sex: 6 times greater risk (80%) ~
v Breech presentation ~
v Positive fa mily histo ry ~
v Firstborn children
v Oligo hydramnios ~
v Birth weight> 5 kg
v Congenital calcaneova lgus foot deformity
DDH is slightly more common in the left hip. Around 20% of cases are bilateral.
CiJClinical examinationis made using the Barlow and Orto lani tests:
Barlow test: attempts to dislocate an articulated femora l head
Ortolani test : attempts to relocate a dislocated femoral head
Ultrasound is used to confirm the diagnosis if clinically suspected.
CiJManagement
+ Most unstable hips will spontaneously stabilise by 3-6 weeks of age.
+ Pavlik harness (dynamic flexion-abduction orthosis) in children younger than
4-5 months
+ Older children may requ ire surgery
IMAF.IYN!li
111·12a111·1r
,J Slipped Upper Femoral Epiphysis (SUFE) ➔ > in o" males "
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v Developmental Dysplasia of the Hip (DDH ) ➔ > in ~ "females , Breech, FHx"
Ci A child "Boy" with limping I

shortened leg externally rotated leg I Painful LL
➔ lipped upper femoral epiphysi .
Ci A child "girl" I
with limping Breech presentation I FHx I Painless leg that is
shorter than the other Unequal skin fold
➔ Developmental Dysplasia of the Hip (DDH).
Normal
Developmental Dysplasiaof the Hip (DDH)
= CongenitalDislocationof the Hip (CDH)
-~· Hip socket RFs➔ Female I Breech Presentation socket

~~
ms I FHx I Oligohydramnios I Firstborn
Key Achilles tendon ru ture

11
Achilles tendon rupture should be suspected if the person describes the
following whilst playing a sport or running; an audible 'pop' in the ankle ,
sudden onset significant pain in the calf or ankle or the inability to walk or
continue the sport.
➔ !An acute referral should be made to an orthopaediq specialist following a

suspected rupture.
C+JDiagnosis ➔ Mainly clinically by lsimmond's triad !

Ask the patient to lie prone with their feet over the edge of the bed.
o Look for an abnormal angle of declination.
o Feel for a gap in the tendon.
o Gently squeeze the calf muscles (Thompson Test) ➔ No Plantar flexion
(Negative Plantar Flexion), (affected leg remains in a more dorsiflexed position).
Achilles Tendon Rupture

[!J A Sudden "pop" sound might be heard at the back of a leg whilst playing a sport.
II A common description "Someone has kicked my leg from behind "
til Calf and Heel Pain.
II On squeezing the calf ➔ Negative plantar flexion .
➔ !Refer to Orthopaedic~
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Thompson
Test
Squeezing the Calf -+
Absent Plantar Flexion.
Key Du tren I s contractur

12 • a condition in which there is fixed forward curvature of one or
more fingers, caused by the development of a fibrous connection
between the finger tendons and the skin of the palm.
• It is more common in older male patients.
• 60-70% have a positivefamily history.
• Specific causes include➔ Manual labour phenytoin treatment alcoholic
liver disease trauma to the hand DM Smoking
• Mechanism ➔ Formation of thickened fibrous tissue within the palmar fascia.
• Rx ➔ Fasciotomy
Scenario:
A 38-year old man is unable to extend and straighten his 4 th and 5th fingers (ring
and little fingers). A firm nodule was found on the distal palmar crease in the
same line with the ring finger. His father has a Hx of a similar condit ion.
The likely diagnosis ➔ IDupuytren's contracturel.

Mechanism ➔ !Formation of thickened fibrous tissue within the palmar fascia!.
RFs:Most related Male gender

• Age • Alcohol Excess
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• Alcohol excess • Smoking
• Sex (male) • Liver cirrhosis
• Previous hand injuries • COPD
Key • Diabetes mellitus
13 • Heavy manual labour
t+JMore common in the thumb, middle, or ring finger.
t+JStiffnessof a finger, and snapping(click) sound when extendinga flexed digit.
t+JA nodule may be felt at the base of the affected finger.
Key
14 Osteoarthritis and Rheumatoid Arthritis Com arison
Osteoarthritis ~ heumatoid Arthritis

Causes Mechanical - wear & tear Autoimmune
• Localised loss of cart ilage

• Remodelling of adjacent bone
• Associated inflammation
Gender Similarincidence in men and women More common in women

Age Seen most commonly in the elderly Seen in adults of all ages
Typical Large weight-bearing joints (hip, knee ) MCP,
affected Carpometacarpa l joint PIP joints
joints DIP, PIPjo ints

Typical a Monoarthritis (Hip, Knee, Shoulder) a Involves> 1 joint.
history a Pain following use (tired joints at a Morning stiffness,
the end of the day) a Improves with use
a Improves with rest a Bilateral symptoms
a Unilateral symptoms a Systemic upset
a No systemic upset
± Crepitus
X-ray LOSS • Loss of joint space

findings + Lossof joint space ~ J uxta-a rticu lar osteoporosis
+ Osteophytes forming at joint margins + Periarticular erosions
+ Subchondral sclerosis + Subluxation
+ Subchondral cysts
In osteoarthritis of the hip joint (and other hip joint pathologies), the first movement
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internal rotation of the hip followed by hip flexion.
Important Notes
v Remember the X-ray findings in osteoarthritis (LOSS)
v Remember that osteoarthritis is triggered and worsen by joint use and
relieved by rest "less pain in the morning, more pain at night".
v On the other hand, RA improves by using the joints as the day goes.
v Note that associated "Nodules"= "swellings" due to "Osteophytes formation"

can be seen on fingers. These nodules are called :
{Heberden: affecting Distal IP joints) landl
(!!ouchard: affecting ~roximal IP joints).
HD :BP
c+JManagement of Osteoarthritis (important )

♦ Exercise+ Physiotherapy+ Weigh loss
♦ Start with IParacetamoll.If pain is still present and there are no RFsfor gastric
ulcers ➔ Add NSAIDs "Consider Topical NSAIDs before trying Oral NSAIDs11 •
(e.g. If he is on NSAIDs and still pain ➔ Add paracetamol and vice versa).
- Whenever you are prescr ibing NSAIDs (e.g. Celecoxib),remember to ladd PPII
(e.g. Omeprazole) to prevent gastric ulcers.
♦ Last option ➔ Surgery .
"Paracetamol" is often the valid answer in an osteoarthritis scenario.

Opiates and tramdol are drugs of choice If NSAIDs
Key Very Important contraindicaton=> go for weak opiod (codein) rather
Collection!
15
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than tramadol 11/32
A fall or a hit on outstretched hand can cause:
v ~caphoid bone fracture!.

I I
(Painful baseof t humb tender anatomic snuff-box Ulnar Deviation produces Pain).
,J ~olle's Fractur ~ (!Dinner f ork deformit ~) (!Median Nerve injur~) "especially if

there is associated osteoporosis "
➔ Distal radius is Dorsally displaced "fractured", Dorsally angulated .
Post-reduction redisplacement is the most common complication of Calles fracture. This can result in
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malunion as the second most common . Nonunion, wrist joint stiffness, osteoarthritis of the wrist,
regional pain syndrome, median nerve injury and inferior radioulnar joint laxity are other less
common complications associated with Calles fracture . Of these, Volkmann contracture develops earliest.
v !Reverse Colle's Fracture = Smith's Fractur ~ (~arden Spade Deformit ~)

➔ Distal radius is Anteriorly displaced "fractured" , Anteriorly angulated .
Rx of Colle's fracture in Elderl "important v" ➔

losed reduct io n (followed by) Plaster of Paris (POP) Cast Below Elbo
v !Malletfinged "especially if hit by a ball into his finger ➔ finger bends"

➔ Avulsion of extensor digitorum tendon at the "distal" IP joint s ➔ flexed -bent-
finger .
v k;amekeeper thum~ (Skier's thumb}

➔ injury to ulnar collateral ligament ➔ painful swelling/ bruises+ weakness and
pain when grasping things with the thumb+ Tenderness over MCP joints .
v IM onteggia Fracture! (Radial Nerve is affected) (!MUI: Ulna fractured)

➔ Dislocation of the head of radius+ Fracture of the proximal 1/3 of the Ulna .
,J ~ aleazzi'sFracture.I( ~ : Radius fractured)

➔ Distal Radio-ulnar joint Dislocation + Fractured Distal 1/3 of Radius Shaft.
Colle's Fracture
(Dinner fork deformity)
Avuhd'on or dlSUll
nt•rph.alanga.al Jo n t
( mallat: fing•r )
I 1 111 \ '
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' ( I II ------ ~1
MONTEC:rC:rlA MUC,C':,
ER" II
ErALEAZZI
ULNAFRACTUl2E RADIUS
FRACTURE
WITHDISLOCATION
OF WITHDISLOCATION
OFTHE
THERADIAL
HEAD DISTAL
RADIOULNAR
JOINT
MU
'A' ISPROXIMAL: 'Z'ISDISTAL,
BONES
AFfECTE0
PROXIMALLY BONES
AFrEcnDDISTALLY
Key Remembe
16
Repetitive "overhead" "above the shoulder" activities. Examples:
~ Volleyball - Tennis - Badminton player, Swimmer.
~ Carrying heavy objects (e.g. a recent move to a new house).
(+)
Shoulder weakness, Pain especially on raising arm above shoulder (e.g. inability
to comb hair) and also pain 1- night
Thick of ➔ ~upraspinatus Tendinitis! .
Key Remember that

17 • Normal Ca+ Normal Phosphate+ Normal ALP ➔ Osteoporosis .
• Normal Ca+ Normal Phosphate+ High ALP ➔ Paget's disease.
• Low Ca+ Low Phosphate+ High ALP-+ Osteomalacia .
Bone pain+ 1' Alkaline Phosphatase {ALP)+ Multifocal Sclerotic patches on X-Ray
➔ IPaget's disease!. (the other name is "Osteitis Deformans ").
o Note that Paget's disease may rarely present with hypercalcemia in case of
immobilisation.
o The presence of hearing loss+ heart failure with bone manifestations (e.g.
Bone pain, fracture) favours the Dx of Paget's disease even if calcium is high.
X-ray in Paget's disease

a The blade of grass lesion (V-shape pattern between healthy and disease long
bone).
a Multifocal Sclerotic Patches (Cotton wool pattern in the skull)
Rx ➔ Bisphosphonates
~ Sclerotic lesions on X-ray ➔ Paget's disease.

~ Lytic (Punched-out) lesions on X-ray ➔ Multiple Myeloma .
Whenever you see High Alkaline ehosphatase , think of 2 Bs + P:

1) Bone: Osteomalacia, Paget' s disease, Hyperparathyroidism, Bone
metastases.
2) Biliary tract: Cholestasis (Obstructive Jaundice).
3) Pregnancy (Physiological).
Key In PLAB l, if you see a patient presenting with yperca/cemi (1' Thirst
18 "Polydipsia", Polyuria, bone pain), think ot
• Bone metastasis "e.g. from prostate (o ) I breast (~ )".
• SCC of the lung.
• Mult iple Myeloma.
• Primary Hyperparathyroidism (rarely asked).
- Hypercalcemia picture:
• Neuro ➔ lethargy, Confusion, Depression.
• GIT ➔ Constipation.
• Renal ➔ polyuria (increased urination), Polydipsia (Thirst).
• CVS ➔ ECG:Short QT interval .
Multiple Myeloma
v It is a cancer of Plasma Cells.
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v "Overgrowth of plasma cells replacing the bone marrow tissues"+

Overproduction of Non-functioning lgs (lmmunoglobulins).
vThe main presenting Symptoms:

• Bone pain "Particularly in the back and ribs".
• Hypercalcemia ➔ Polyuria, Polydipsia, Low mood, Confusion.
• Anemia ➔ Fatigue, Weakness, Pallor, Dyspnea on exertion.
v Others:
• Recurrent Infections ➔ As the immunoglobulins are functionless.
• Renal Failure.
v Important Notes on Investigations:

♦ Bone Marrow Biopsy ➔ Abundant Plasma cells (Diagnostic v ).
♦ Serum Protein Electrophoresis ➔ 1'1'1' Monoclonal
lmmunoglobulin Spike.
♦ Urine Protein Electrophoresis ➔ Bence Jone's Protein. v
♦ Blood Film ➔ Rouleaux Formation .
♦ X-Ray Skeleton ➔ Lytic Lesions "plasma cells ➔ Osteoclasts ➔ Bone Lysis".
♦ 1' ca++ (>2.6 mmol/L) but with Normal Alkaline Phosphatase (30-150 U/L).
♦ Anemia (Normocytic Normochromic).
♦ Renal functions could be impaired (Low GFR, High Urea and Creatinine ).
♦ High ESR
Important: Don't mix up things. Plasma cells are cells seen on BM biopsy
whereas Bence Jone's is Protein seen on urine protein electrophoresis!
EXttWlp{e (:t.),
o
60 YO presents with Hx of Back and Ribs pain +being Thirsty+ Tiredness.
I I
Hb is 90 g/L (low) ca++is 4 (high) ALP is 115 (normal) ESRis 88 eGFR is 45 I I
(low).
CiJThe likely Dx ➔ !Multiple Myeloma .

CiJThe cell type to be found in BM ➔ Plasma Cell~.
CiJThe Diagnostic Test ➔ Bone Marrow Biops .

CiJThe likely finding on blood film ➔ Rouleaux Formation .
v Anemia is the commonest laboratory finding in MM.

v Renal Impairment presents in 50% of MM cases.
v In MM, High Calcium but normal ALP.
EXttWlp{e (2),
92 YO ~ complains of severe back pain. She claims that she had a fight and
someone has broken her back and insists that her mother is coming to visit her
at the hospital.
I I
Hb 109 (low) Urea 7.5 (high) Creatinine 285 (high) Calcium 3 (high) I
CiJThe likely Dx ➔ !Multiple Myelomal .
lli1 The rell tune tn he fn, ,nrl in Rl\n -4 !Dl:3cn,,:3 rollc l
13 I 11\... \.,\-.II '-Y t-''- '-V U\... IVUI I\.A II I ..,,.-1 ✓ 1■ IY~I IIU "" '- 11~ •
The
C+J protein to be found on Urine Electrophoresis ➔ !Bence-Jones Protein!.
v The features present in this stem supporting the Dx of Multiple Myeloma:

Back pain I
Confusion "her mother is visiti ng her" I
Anemia Hypercalcemia I
Impaired Renal Function. I
Key Following a femur fracture, the absence of proximal and distal pulses in a lower
19 limb indicates an injury to ➔ !Femoral arteryj. "a patient may be hypotensive "
Notes :
v Posterior tibial artery ➔ Posterior compartment of a leg + Planter surface of a
foot .
v Dorsalis Pedis ➔ Foot.
Key In any fracture (e.g. leg), if there is one of the following:

20 a Absence of Pulses "Neurovascular compromise"
a Obvious Deformity .
The immediate "Next" action after ABCD to be done is

Intranasal fentanyl and IV
➔ !Urgent Reduction under Sedation or Analgesia!
midazolam.
After that, A referral to neurovascular/ orthopaedics should be made.
"We aim at restoring the blood supply "the pulses" by an immediate reduction
"usually under IV Midazolam" even before X-ray. The time is key in such cases.
Urgent reduction often succeed to restore pulses and thus save that limb!
ti Remember form "Emergency Chapter":
In a u::.nm •• •r. r 1n 1•:.1, if the patient is hemodynamically stable (SBP>100) ➔

~homas Splint first "Before IV fluid and before ABCDE"
This is to align the fracture; thus, reducing the blood loss as the femur
fracture bleeds significantly).
You need to know that splinting the femur ➔ Alignment of the fracture ➔
Reduce the blood loss.
Coovriehts (a) PlablKevs .com

Key A child presenting with Painful Hip ( +)

21
Ci Mild fever I WBCs and ESRare normal or mild ly elevated I No local signs (no
redness, tenderness, swelling) Happy and systemically well child
➔ frransient Synovitisl.
Ci Fever> 38.5 I WBCs > 12000, ESR> 40 IThere are tenderness, redness,
I
swe lling locally Systemica lly unwell
➔ !Septic Arthritis!.
CiA child "Boy" with limping I shortened leg Iexternally rotated leg
➔ !Slipped upper femoral epiphysi~.
CiA child "girl"I Breech presentation I FHx I Limp ing I Painlessleg that is
shorter than the other I Unequal skin fold
➔ !Developmental Dysplasiaof the Hip (DDH).I
Key An elderly man fe ll at home 2 days ago and presents with hip pain and inability to
22 bear we ight on his right leg. X-ray shows a fracture of acetabulum.
The most likely affected nerve ➔ !sciaticnervel.
The following Keysare Criticalfor PLAB1 exam and for General Knowledge:
- Wrist Drop ➔ Radial Nerve.

- Foot Drop ➔ Either CommonPeroneal (More common) Nerve or Sciaticn.
- Claw Hand ➔ Ulnar Nerve.
- Paraesthesia of thumb, index, MIDDLE finger ➔ Median Neve.
- Paraesthesia of little finger+ ring finger ➔ Ulnar nerve
- Paraesthesia of the dorsal aspect of the THUMB+/- a small area over the
((dorsal)) area between 1st (Thumb) and 2nd (Index) fingers ➔ Radial Nerve.
- Numbness on Superior aspect of upper arm just below shoulder joint ➔
Axillary Nerve .
- Fibular Neck Fracture ➔ Common Peroneal Nerve .
- Femur Neck Fracture ➔ Sciatic Nerve .
- Acetabular Fracture ➔ Sciatic Nerve .
- Posterior dislocation of the hip ➔ Sciatic Nerve .
- Humera l Shaft Fracture ➔ Radial Nerve .
- Humera l Neck Fracture ➔ Axillary Nerve .
- Monteggia Fracture ➔ Radial Nerve .
- Celle's fracture "dinner fork deformity" ➔ Median Nerve (Hand numbness).
- Paraesthesia and impaired sensation in both hands (Glove distribut ion) ➔
Peripheral Neuropathy .
Key ~ Scenario to StudYI

23
A 47 YO ~ with a Hx of breast cancer presents with painful, dull-aching
pain over her right shoulder and thoracic spine. The pain is worse on
lyirig down. She goes to gyrvt frequently as we(I. X-ray snows sorvte
degenerative changes.
ttJThis is NOT a case of osteoarthritis. Why?

'\/ The X-ray findings specific for osteoarthritis are not present here which are LOSS:
Loss of joint space, Osteophytes, Subchond ral cysts, Subchond ral sclerosis)
'\/ The pain in osteoarthritis is worse on use "activi t y". Here, it is worse on lying.
ttJThis is likely a case of breast metastasis to bone.
[!] About the investigations, (Important ✓) If no serum calcium start with xray
♦ The most IINITIA~test ➔ ~erum Calcium!
Pain is the most common symptom in of metastatic bone disease
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A history of cancer, except non-melanoma skin cancers , is the strongest-alarm in the

history of any patient with back pain
♦ The most PPROPRIATEtest ➔ MRI if not in the options ➔ Bone scintigraph .
'II The gold standard for bone metastasis is {MRI},followed by (Bone Scintiqraphy}.
Be careful about the question's wording!
~.
~➔ measur es bone densitv ➔ in Osteooorosis .
~keletal S~r~e~➔ in Multiple Myel~m-a" lytic - ~unched out lesions on X-ray).
Key Ci Bear in mind that a prolonged use of Steroids can cause

24 ➔ losteoporosisl.
Ci Osteoporosis affects bone but the effect is silent (no pain or aches) until a
fracture occurs.
CiOsteoporosiscan also affect oral and dental health ➔ Lossof teeth .
CiThe side effects of Long-termuse of steroidsare numerous,examples:

!osteoporosis 11~ataract 11Peptic Ulcers 11IHyperglycemi~
v Remember, osteoporosis is painless, osteomalacia is painful.
hk4ifihS-
An old female with a Hx of multiple fractures a few years ago. She is also on
long-term corticosteroids for Inflammatory bowel disease.
The best modality ➔ IDEXAScanl(Dual-Energy X-ray Absorptiometry).
She is a "female" on prolonged Steroid ➔ Osteoporosis ➔ Multiple fracture .

IDEXAScanl➔ measures bone density ➔ in Osteoporosis

.
Key Ci A young boy+ Painful knee+ Gait abnormality+ Tender, smooth, fixed mass
25 over a knee side.
➔ losteosarcomal"the commonestbone tumor in children ".
Ci A young boy+ Painful knee+ Gait abnormality+ Tender, smooth, fixed mass
over a knee side+ Other systemic (Fever, Weight loss, Tiredness)
➔ !EwingSarcoma!"the 2nd commonestbone tumor in children ".
Key Fracture of the Head of the radius

26 Fracture of the Neck of the radius
130thhave similar symptoms:
v Lateral elbow swelling .
v Limited range of elbow movement .
v Passive rotation of elbow ➔ 1' Pain
[t] However,
Radius HeaD Fracture ➔ More common in ADults (HeADult)
Radius Neck Fracture ➔ More common in childre N.
[t] Therefore, look at the age in the scenario,

If ~aunt age ( up 16} ➔ Radius Neckfracture.
If Olde age ➔ Radius Head fracture.
Key Femur fracture ➔ the patient's level of consciousness and 02 saturation

27 deteriorate after surgery (24-72 hours)
➔ Suspect IFat Embolism! "common in long bone fractures especially femur ".
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Polytrauma -Multiple fractures- (femur, tibia fractures), followed by open

reduction surgery, followed by deterioration (hypoxemia and neuro -.J.,
consciousness-)
➔ Fat Embolism is the likely cause.
Key Remembe ,
28
[t] Fracture of distal radius + Dorsal Angulation (Dorsally displaced fragments)
➔ !Colle's fracture ! (!Dinner Fork Deformit~ ) Most common complication:Malunion
[t] The likely injured nerve ➔ !Median Nerve!. (Numbness of hand ).
~ Rx in elderly
➔ Closed reduction followed by POP "Plaster of Paris" cast below elbow
Partial flexion of the wrist with ulnar deviation.
~ Rx in Young
➔ bove elbow Backslab cast
~If there are intra-articular fractures/ incongruity

➔ Open reduction and internal fixation.
Key The commonest Origins of Bone Metastasis

29 (commonly Spine, then pelvis, then ribs, then skull and long bones)
In Males 3 ➔ IPROSTAT§ then Lung.
In Females Sj2➔ IBREAS] then Lung.
Key Whenever high Alkaline phosphatase with Normal Calcium

30 ➔ Think IPaget's disease!.
Other features ➔ Knee pain, Back pain, Kyphosis, Hearing Joss, Heart Failure.
• Normal Ca+ Normal Phosphate+ Normal ALP-+ Osteoporosis.

• Normal Ca+ Normal Phosphate+ High ALP-+ Paget's disease .
• Low Ca+ Low Phosphate+ High ALP-. Osteomalacia.
Key CilNumbness and Tingling of the thumb, index and middle fingers ➔ Think of
31 !carpal Tunnel Syndrome!
CilThe Transverse Carpal Ligament compresses the MEDIANnerve
CilThus, the treatment would be ➔ lcut

the Transverse Carpal Ligament =I
!Release Flexor Retinaculum l
to release the pressure on the median nerve.
t Note: Transverse Carpal Ligament is also called= Flexor Retinaculum =

Anterior Annular Ligament .
Compressed
median
CfJINotesl:
v Pregnancy is an important RF for Carpal Tunnel Syndrome (due to fluid retention).
v Tinel Test is not always positive in Carpal Tunnel Syndrome "very low sensitivity".
v After applying cast for scaphoid bone fracture, tension may develop resulting in
Carpal Tunnel Syndrome . Release of flexor retinaculum to alleviate the tingling, pain
of thumb, index and middle fingers due to the compressed median nerve might be
ind icated.
v If pregnant with Carpal Tunnel Syndrome

➔ wear Wrist Splints until delivery (usually resolves after delivery).
v If it does not resolve and long-standing ➔ cut the transverse carpal ligament.
Key Sprain injury

32
CfJA sprain, also known as a torn ligament , is damage to one or more ligaments
in a joint, often caused by trauma or the joint being taken beyond its functional
range of motion (overstretched).
CfJSprains can occur in any joint but are most common in the ankle and wrist .
CfJSigns and symptoms:

Severe Pain
Rapid Swelling
Bruising
Decreased ability to move the limb
Difficulty using the affected extremity
CfJManagement~ P.R.I .C.E

Protect
Rest
Ice
Compress
Elevate (e.g. high arm sling for a few days).
t Exam le
Cnnvrii?ht s (@ Pl;ibl KP.vs.mm

A factory worker has his hand stuck in a machine. He presents w ith extremely
painful wr ist, rapidly increasing swelling, limited range of hand movement.
X-ray shows no fractures.
♦ The like ly Ds ➔ ~prain injur~.
♦ Management ➔ JPRICEJ➔ JHigh arm slingfor 3 day~ (elevation).
Key Septic Arthritis

33
Monoarthritis = Single jo int involvement (commonly Knee)
JFeve
rl;JPainV
~wellingj/ !Limited movemen~
+ A Riskfactor (e.g. lDM

~Jsteroid~~ !RheumatoidArthriti~) "important v"
Think of ➔ ~eptic Arthritis!
♦ The commonest causative organism ➔ StaphylococcusAureus.

♦ A common organism in young SEXUALLYactive ➔ N. Gonorrhea.
♦ Dx
,J Aspirationof Synovia/Fluid ➔ send for staining, microscopy, WBC count, Culture.
,J Blood Culture.
♦ Management
v IFlucloxacillinl (for 4-6 weeks) "first-line" "like cellulitis"
v If penicillin allergic ➔ Clindamycin .
v If the causative organism is N. Gonorrhea nor Staph ➔ Cefotaxime or Ceftriaxone .
v If still not responding ➔ Repeated percutaneous aspiration .
"IV antibiotics for 1 week until blood cultures become -ve and swelling resolves
Then, Oral antibiotics for 4 weeks"
ti Note, do not forget (JDM~~) as risk factors for SepticArthritis.
Septic arthritis is different from Reactive arthritis.
Reactive arthritis : Seronegative Spondyloa rthri t is
(Migratory Oligoarthritis of lower limbs+ Back pain+ Extraarticular features)
• Typically , there is no fever .

• Typically, seen in young adults .
• Typically follows Urogenital infection "STls"or GI infection "dysenteric illness".
• Asymmetric , Migratory Oligoarthritis of LL(Knees and Ankles).
• Extraarticular features: (Reiter's Triad)

v Cannot see ➔ Conjunctivitis, Uveitis.
v Cannot pee ➔ Urethritis.
v Cannot climb a tree ➔ Arthritis.
+ Skin manifestations
circinatebalanitis(painless vesicles on the coronal margin of the prepuce),
keratodermablenorrhagica(waxy ye llow/brown papu les on palms and soles)
Erythemanodosum(Tender, red nodules ove r shins).
Management
♦ Symptomat ic: analgesia, NSAIDS, intra-articu lar steroids.
♦ Sulfasalazine and methotrexate are somet imes used for persistent disease.
♦ Symptoms rarely last more than 12 mont hs
Key A child (4-8 YO) fell on his outstretched "arm "

34 +
Absent radial/ brachia! pulse
Th i nk ➔ ~ngulated Supracondylar Fracture of Humerus!.
The most likely structure to be damaged ➔ IBrachial arter~ .
"Supracondylarfracture ''extension type" is the commonest fracture in children

who fall on extended -outstretched- arm"
If Supracondylar fracture of hume rus is not in the options, and the falling victim
on an outstretched "arm" is a child, look for ➔ ~reenstick fracture !.
As the bones in young children are still soft, they tend not to break completely,
forming what's called "Greenstick Fracture".
Greenstick Fracture - in a child
Key Important, do not get tricked

35
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v olle's Fractur (!Dinner fork deformit~) {!Median Nerve injur ~)

"Colle's fracture occurs especially if there is associated osteoporosis "
➔ Distal radius is Dorsally displaced "fractured", Dorsally angulated .
v !Reverse Colle's Fracture = Smith's Fracture! (!Garden-SpadeDeformit~)

➔ Distal radius is Anteriorly displaced "fractured", Anteriorly angulated .
IMPORTANT
Ci Fracture of distal radius with !DORSAY"posterior" displacement
➔ ~olle's fracture !➔ !Dinner Fork DeformitYI .
Ci Fracture of distal radius with jANTERIOR

I displacement
➔ !Reverse Colle's Fracture = Smith's fractur~ ➔ ~arden Spade DeformitYI .
Plablkeys.com
---------- P~ B
KEYS
Colle's fracture Smith's (Reverse Colle's) fracture

Dinner-Fork Deformity Garden-Spade Deformity
Distal Radius fracture Distal Radius fracture
with ~ "posterior" displacement. with Anterior displacement.
-~ For All FULL Notes on All Ch rs _, Visit Our Website: www.Plob1ke s.com ·®-
~~
e: 01 facebook.com/plablkeys 1 1@plab.lkeys 1 (I I PLfB
KEYS
Key Clinchers for Knee Injuries

36
Before the clinchers, look at this picture and locate the anterior cruciate
ligament, the menisci, and the medial and lateral Collate ral ligaments.
Posterior cruciate
ligament
Lateral collateral Medial coUateral

ligament ligament
Example, a player jumps and lands on a slightly twisted knee, presents with:
♦ [Lockin~ (Locked leg ) ➔ Meniscal tear . (usually medial meniscal tear). Delayed swelling
♦ [Poppin~ ➔ Anterior Cruciate Ligament injury . Immediate swelling
~ Note, Menisca/ tears are often associated with Anterior Cruciate Ligament injury.
♦ Immediate swelline ➔ Anterior Cruciate Lieament iniurv

♦ Delayed swelling ➔ Meniscal tears
♦Hyperflexion or Anterior direct impact (Dashboard)

➔ !POSTERIORCruciate Ligament injurv l.
+ Direct impact to the lateral side (Valgus stress test is +ve )

➔ Medial Collateral Ligament injury .
+ Directimpact to the medial side (Varus stress test is +ve )

➔ Lateral Collateral Ligament injury .
(The opposite Rule)
No rmal Varus Va Igus
Valgus = impact to lateral collateral ligament ➔ injury to Medial collateral.

e.g. a player fell on his knee and presents with Valgus stress test being +ve
➔ !Medial collateral ligament injurvJ.
Varus = impact to Medial collateral ligament ➔ injury to Lateral collate ral.

e.g. a player fell on his knee and presents with Varus stress test being +ve
➔ !Lateral collateral ligament injuryj.
Other tests:
v Anterior drawer test (Lachman test) ➔ Anterior Cruciate Ligament.
v Posterior drawer test ➔ Posterior Cruciate Ligament.
Key Fracture of middle to distal third of humerus (shaft of humerus)

37 ➔ !Radialnerve injury]
➔ Wrist Drop (unable to dorsiflexwrist).
Key 'I After applying cast for scaphoid bone fracture, tension may develop resulting in
38 Carpal Tunnel Syndrome. Management? Avascular necrosis => most common in
scaphoid fractures.
➔ !Release of flexor retinaculumj to alleviate the tingling, pain and the limited
movements of thumb, index and middle fingers due to the compressedmedian nerve .
♦ Remember,
Flexer retinaculum = Transverse carpal ligament= Anterior annular ligament
Key ti A young boy+ Painful knee+ Gait abnormality+ Tender, smooth, fixed mass
39 over a knee side.
➔ losteosarcomal"the commonestbone tumor in children ".
ti A young boy+ Painful knee+ Gait abnormality+ Tender, smooth, fixed mass
over a knee side+ Other systemic(Fever, Weight loss,Tiredness)
➔ !EwingSarcoma!"the 2nd commonest bone tumor in children ".
So, if no fever ➔ Osteosarcoma I If with fever ➔ Ewing Sarcoma.

!Another differentiation point is X-ray!
✓ X-ray~ Sunburst lytic bone lesions~ Osteosarcoma

✓ X-ray~ Lytic lesion+ Onion-Skin layers~ Ewing Sarcoma .
I ~ci
I Remember,
vSevere lower back pain that radiates to a leg (could be Acute sudden onset)
v Lying supine with legs raised ➔ 1' pain. (+ve st raight leg raising test)
v Lying down ➔ relieves (~)pa in
♦ The likely Dx ➔ ILumbosacral disc hern iation !.
♦ Next step ➔ !Reassure and prescribe analgesics!.
♦ If any red-flags I if the "reassure" option is not given ➔ !MRI Spine!.
MRI is very sensitive in herniated/ prolapsed disc.
Key Remember,
41 The best modality for bone metastasis ➔ IMRI I, followed by !Bone Scintigraph~ .
MR I should be done within 7 days if there is bone pain only.

MRI should be done w ithin 24 hours if pain+ Neurologica l signs.
Key - Proximal BicepsTendon Ruptur~: Muscle bunches up in the distal arm, Popeye
42 appearance.
- Distal BicepsTendon Rupture,: Single traumatic event (e.g. flexion against

resistance), sudden sharp tearing sensation, painful swollen elbow, weakness of
flexion and supination .
f,.Thepatient feels that something in the cubitaJfossa has ruptured' I
- Notes:
- De Quervain's disease:(= washer woman= mammy thumb): Pain under root of
thumb (tenosynovitis).
- Tennis elbow= lateral epicondylitis ➔ affected wrist extension. Mainly due to
overuse e.g. in tennis players.
- Golfer's Elbow= Medial epicondylitis: all flexors to fingers and pronat or are
affected. Seen in baseball players, construction injury, plumber injury.
Important ,
+ Lateral epicondylitis (Tennis Elbow) ➔ Lateral epicondy le tenderness ➔ Affected

lwrist extensor4 (pain 1' on resisted extension of wrist).
+ Medial epicondylitis (Golfer's Elbow) ➔

Medial epicondyle tenderness ➔ Affected
lwrist Flexorsl. (pain 1' on resisted flexion of wrist).
Tennis = Extensors of wrist= Lateral epicondylitis.

Golf er= Flexors of wrist = Medial epicondylitis.
Key Celle'sfracture occurs commonly in patients with Osteoporosis.Thus, to assess

43 risk for future fracture , we need to measure the bone density by
➔ IDEXAScan!.
Key Remember and Do not mix up:

44
- Humeral Shaft Fracture ➔ RadialNerve.
- Humeral Neck Fracture ➔ AxillaryNerve. (NERVEnot artery !!)
Key Remember,
45 a Monoarthritis (Hip, Knee mainly)
a Pain following use (tired joints at the end of the day)
a Improves with rest
a Unilateral symptoms
a No systemic upset
± Crepitus
➔ losteoarthritis l
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!Manage
men~:
♦ Exercise+ Physiotherapy+ Weigh loss

♦ Start with !Paracetamol!. If pain is still present and there are no RFsfor gastric
ulcers ➔ Add NSAIDs "Consider Topical NSAIDs before trying Oral NSAIDs".
(e.g. If he is on NSAIDs and st ill pain ➔ Add paracet amol and vice versa).
- Whenever you are prescribing NSAIDs (e.g. Celecoxib),remember to ladd PPII
(e.g. Omeprazole) to prevent gastric ulcers.
♦ Last option ➔ Surgery .
'jParacetamok ' is often the valid answer in an osteoarthritis scenario.
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1
Key IPerthes• diseas ej

57
a Perthes i diseas' is a degenerative 'ondition affect ing tlhe· hip joints of

children, typically betw ,een t he ages 0 f 3-9 years. 1 1
a It is due,t o avascular necrosis of the f em1oral lhead} sp ecifically the fe,mo ral
1 1
epiphysis. Jmpaired bloi0dsupply to tlhe femoral head causes bone infarcUon. 1
a Perthe-si diseaseis 5 times more,co' mon in boys. Around 10% of casesare

bilatera l.
■ !Features
p,ain: developspr_qgr_ig~
,J Hip, 1 -~-~v.~
.!~.9..V.~
.r..wg~-~~-~- ...h~-
'I'.Qf.l
-.JLimping.
-.JStiffness and reduced ran,ge of hi'P movement
,J X-ray: early chang ,es include w idening 0f j oint 1 spac,e, later clhanges include
decreased femo ral head size/f! :~!~~-~-in_g,radiolucency of the _prox·imal
.IJJ.~J~
_p_
lhY.~!~.·
DDx acc:ordin,g to age:

• k3 y,ear~ ➔ Developme ntal dysp lasia of the lhip ,(us.ually g·ir l, bree ,clh
presentation) Itoddle r' s frac t ure e.g .. spiral inj ury, m,ay not be seen on X-ray
. , ~ ..g y,ear~ ➔ Pertlhes diseas,e (Chronic, sti ff ness,, fl.attening on x~ray )i.
•, ~ 9 voj➔· Slipped uppe ,r femioral epiphys is (boy 1 shorter leg, lim1ping).
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69 I P a g e [ o r t h a p a
1 E d 1 c 5] © Copyr ight www.plab1keys.com (Constantly updated for onHRe subscribers )
1
Buckle} ,or torus,.fractures are, inco,mipl,ete fractures of the shaft of a long bone
that is charact,erised by bulging of the, eiortex. They typi cailly occurin children 1
a,ged 5-10 years..
As the,y ar e typically self-Um1iting, the,y do not usually re,quire operative

1
intervention and can sometimes be m1anaged with splinting and

immobilisation rather than a cast.
Scenari ,o:
An B YO bo•y felllon his outstretchedrilght hand and pre·sentswith m1ark,ed
pain, swelling.and bruisin,g ,of his right hand a1
nd wrist. There i,s no
1
neurovasculardefiicit. What is the most Hkelyfracture to be seen on X-ray?
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70 IP a g e [ o r t h a p a E d 1 c 5] © Copyr ight www.plab1keys.com (Constantly updated for on HRe subscribers )
1
➔ Bu,cklingof the distall radiu_.
v As children have m1ore elastic bones than adullts,.the buckling (not fu H

fracture, l,eaving a ci0rt,ex portion intact) is com mo-nam1,ong ,children .
v The most common type of fracture m
n chHdho,od is buckle, (torus ) fr.actur,e .
v The most common site is ➔ distal radius.
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s @ Plab1Keys.oom
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Ke.y Bone pain + ~ Al'kaline Phosphata .se (ALP) + Mull: focal ' Sclerotic pat ·ches on
59' .X-Ray :I: HF(e.g. shortnessof bre.ath on exertion).
➔ iPaget'sdisease!.. (th e ,oth er name, i5,UOsteitis Deformans 11
) .
A swelling behind the knee (in the popliteal fossa), usually

asymptomatic, round, smooth, non-tender !Baker cyst
(popliteal cyst)I
A toddler (1-3 YO) presents with severe pain and tenderness of

shin. He cannot walk or stand. This happened after a fall. No
deformity, No Bruises. X-ray looks normal .
The likely Dx spiral fracture ! (toddler's fracture , often not
seen on X-ray)
In any patient on warfarin the most important symptom that
he needs to urgently report is Headache
Key Very Important notes
53
♦ After prescribing oral bisphosphonate (e.g. Alendronic Acid)
-4 Inform the patient that dyspepsia and reflux are common in the
first month of treatment and often improve with continuous use.
Also, inform the patient to seek advice if he develops a new

symptom 1of heartburn. ,J imp.
♦ To reduce severity of these symptoms~ Take the oral

bisphosphonate while in an upright position and maintain an upright
position for a minimum of 30 minutes after taking the medication .
♦ Swallow the pills with a glass of plain water, do not suck or chew them
(risk of oropharyngeal ulcers).
♦ In osteoporosis patients who are already on alendronate-+ DEXA
scan (for bone mineral density) should be checked every 3 to 5 years.
♦ In osteoporosis patients who have stopped taking alendronate ____.

DEXA scan (for bone mineral density) should be checked after 2 years.
♦ 2 forms of oral alendronic acid:
~ 70 mg once weekly OR 10 mg once daily. There is no monthly

regimen .
• T-Score: assessed ~y DEXAI and reflects Bone Mine ral Density (BMD) :
1) -1 or higher ➔ Normal
2) Between -1 and -2.5 ➔ Osteopenia
3) -2 .5 or lower ➔ Osteoporosis (e.g. -2.7 ➔ osteoporosis)
Key A 54-year-old woman complains of low back pain for which she needed
54 long-term steroid use. She is now complaining of her teeth being loose.
Other examinations appear normal.
What investigation will best lead to a diagnosis?
A. CT of the low back
B. IDEXAscanl
C. MRI of the spine
D. Radio nuclear scan
good leg (stick)=> bad leg (affected)

Although the stress fracture of the right lateral epicondyle can
present with an almost similar presentation to lateral epicondylitis (expect for the
maximal tenderness being elicited over the lateral epicondyle itself rather than 1-2 cm
below it), it is not a likely diagnosis because it is a very rare condition that often occurs in
children. Stress fractures of the medial epicondyles are much more common
than those of right epicondyle .
Volkmann contracture develops earliest In colle's fracture.

Volkmann ischemic contracture is the permanent shortening of forearm muscles, usually
resulting from compartment syndrome in the forearm. It causes a claw-like deformity of
the wrist, hand and fingers. The clinical presentation of Volkmann contracture includes
five
Ps: pain, pallor, pulselessness, paresthesia, and paralysis. Of these, pain is the earliest sign.
On physical examination, pain accentuated by passive stretching seems to be the most
reliable finding. Firmness of the tissues often is noted on palpation . Pulselessness and
paralysis are late findings. lnduration of the forearm is another useful diagnostic finding.
Wound debridement including surgical removal of all devitalized soft tissues and bone is a crucial step in
management of any open fracture/dislocation because infections may ensue and result in poor outcomes .
However , debridement should be performed in the sterile environment of the operating room , not in the non-
sterile environment of the Emergency Department where more exploration of the wound can lead to increased risk
of infection.

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8/29/2019 Orthopaedics Full | Plab 1 Keys and Notes - All You Need To Pass PLAB 1 Exam

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Key On Foot bone Fractures:

rt Stress Fracture of Foot, the likely affected bones

Key Sensory Loss Responsible Nerve Roots

• Groin and pelvic Girdle ➔ ~

Key Prostate cancer can metastasise to sp i ne causing ➔ Cauda Equina Syndrome ➔

Cauda Equina Syndrome

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In a patient with lowe r back pain, the presence of (~addle Paraesthesia l)

Key Lumbosacral Disc Herniation/ Disc Prolapse

♦ Next step ➔ Reassure and prescr ibe analgesics

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♦ Important: If associated wit h Saddle Paraesthesia (anal/ periana l/ groin

(+) The commonest site is (LS/Sl fo llowed by L4/LS).

Normal d isc Herniated disc

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The likely Dx ➔ ILumbosacraldischerniation!.

The likely Dx ➔ l1ntervertebralDiscProlapse!.

Key Repetitive "overhead" "above the shoulder'' activities. Examples:

Thick of ➔ ~upraspinatus Tendinitis!.

An elderly + Hx of fall + Painful hip + Shortened, Externally rotated leg

a We can suspect an elderly of being at a risk of Osteoporosis or already has

• If X-ray is +ve ➔ caphoid Castfor 6 week .

Key Developmental Dysplasia of the Hip (DDH)

CiJRisk factors " Important v"

Ultrasound is used to confirm the diagnosis if clinically suspected.

v Developmental Dysplasia of the Hip (DDH ) ➔ > in ~ "females , Breech, FHx"

Ci A child "Boy" with limping I

-~· Hip socket RFs➔ Female I Breech Presentation socket

Key Achilles tendon ru ture

➔ !An acute referral should be made to an orthopaediq specialist following a

C+JDiagnosis ➔ Mainly clinically by lsimmond's triad !

Achilles Tendon Rupture

II A common description "Someone has kicked my leg from behind "

til Calf and Heel Pain.

II On squeezing the calf ➔ Negative plantar flexion .

Key Du tren I s contractur

The likely diagnosis ➔ IDupuytren's contracturel.

RFs:Most related Male gender

Osteoarthritis ~ heumatoid Arthritis

• Localised loss of cart ilage

Gender Similarincidence in men and women More common in women

joints DIP, PIPjo ints

X-ray LOSS • Loss of joint space

v Note that associated "Nodules"= "swellings" due to "Osteophytes formation"

c+JManagement of Osteoarthritis (important )

"Paracetamol" is often the valid answer in an osteoarthritis scenario.

A fall or a hit on outstretched hand can cause:

v ~caphoid bone fracture!.

,J ~olle's Fractur ~ (!Dinner f ork deformit ~) (!Median Nerve injur~) "especially if

v !Reverse Colle's Fracture = Smith's Fractur ~ (~arden Spade Deformit ~)

Rx of Colle's fracture in Elderl "important v" ➔

v !Malletfinged "especially if hit by a ball into his finger ➔ finger bends"

v k;amekeeper thum~ (Skier's thumb}

v IM onteggia Fracture! (Radial Nerve is affected) (!MUI: Ulna fractured)

,J ~ aleazzi'sFracture.I( ~ : Radius fractured)

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