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Question 1 of 67 A young patient is tilting her pelvis while walking. They are having difficulty maintaining independent mobility. Which clinical test is used to assess the hip abductors? Barlow’s test Ober’s test Ortolani’s test Thomas’ test Trendelenburg’s test Explanation Trendelenburg’s test Trendelenburg’s test assesses for weak or paralysed the hip abductor muscles. This test is performed with the patient standing. The patient is asked to raise one leg; the test is positive if the pelvis on the raised side drops. A positive test suggests weakness of the abductors of the other hip. Barlow’s test Barlow’s test is performed on infants to screen for developmental dysplasia of the hip and assessing the stability of the hip. Ober’s test Ober’s test is performed to assess the tightness of the iliotibial band. Ortolani’s test Ortolani’s test is performed on infants to screen for developmental dysplasia of the hip, which is performed along with the Barlow’s test. Thomas’ test Thomas’ test is performed to assess for hip flexion contracture Question 2 of 67 A 68-year-old man presents with mechanical hip pain. He undergoes routine plain AP and lateral radiography of the hip. What is the first radiographic sign to appear in osteoarthritis? Narrowing joint space Osteopenia Osteophytes Soft tissue swelling Subchondral sclerosis Explanation Narrowing joint space Osteoarthritis is a degenerative joint disorder, which results from a loss of hyaline cartilage in synovial joints. The first radiographic sign of osteoarthritis is non-uniform joint space narrowing. Osteopenia Osteopenia is a condition in which bone mineral density is lower than normal. Osteophytes Osteophyte formation is a radiographic sign of osteoarthritis, but it is not the first to appear. As the disease progresses, subluxation may occur and osteophytes may form. Soft tissue swelling Rest pain, stiffness and bony swelling are clinical features of osteoarthritis. Soft tissue swelling is more commonly associated with rheumatoid arthritis. Subchondral sclerosis Subchrondal sclerosis occurs as cartilage loss increases and appears as an area of increased density on the radiograph. The classic radiographic signs of osteoarthritis are joint space narrowing, subchondral sclerosis, osteophytes and subchondral cysts. Osteopenia and soft tissue swelling are often associated with rheumatoid arthritis. Question 3 of 67 A 10-year-old girl is treated for a tibia and fibula fracture with above-knee plaster. She is recovering on the ward, but the nurses are concerned and have asked you to review her overnight. What early clinical signs of compartment syndrome in the leg do you look for? Loss of the dorsalis pedis pulse Mottling of the overlying skin Pain out of proportion to injury on passive dorsiflexion of the foot Paralysis of the foot Reduced sensation in the foot Explanation Pain out of proportion to injury on passive dorsiflexion of the foot Compartment syndrome is a clinical diagnosis defined as increased pressure within a fascial compartment that causes reduced tissue perfusion and cellular damage. Dorsiflexion of the foot stretches muscles in the posterior compartment, which causes an out-of-proportion pain response in the presence of high compartment pressures as myoneural blood supply is compromised. Clinical signs of compartment syndrome include pain out of proportion of the injury, pain on passive starching, pain despite analgesia, pain despite elevation and pain despite removal of constrictive dressings. Loss of the dorsalis pedis pulse Pulses are normally present in compartment syndrome. Absent pulses are usually due to systemic hypotension, arterial occlusion or vascular injury. In the context of compartment syndrome absent pulses are a late finding. Mottling of the overlying skin Mottling of the skin would be a late clinical sign of compartment syndrome. Local trauma causes bleeding and soft tissue swelling, which compromises venous return and gives rise to a mottled appearance of skin. Paralysis of the foot The loss of motor function is a late sign of compartment syndrome. Local trauma causes bleeding and soft tissue swelling, which increases compartmental pressures. This compromises venous return and propagates swelling and further increases compartmental pressures causing microvascular occlusion resulting in myoneural ischaemia. Reduced sensation in the foot The sensory loss is a late sign of compartment syndrome. Local trauma causes bleeding and soft tissue swelling, which increases compartmental pressures. This compromises venous return and propagates swelling and further increases compartmental pressures causing microvascular occlusion resulting in myoneural ischaemia. Question 4 of 67 A 30-year-old man complains of having to swing his body to help him walk after a long session of exercise in the gym. Trendelenburg’s test is performed. If the left side of the patient’s pelvis drops while he stands on his right leg, what is the likely cause? A shortened right femur Weakness of the right hip abductor muscles Weakness of the left hip abductor muscles An injury to the left gluteus medius muscle bilateral hip dysplasia Explanation Weakness of the right hip abductor muscles Trendelenburg’s test assesses for weak or paralysed hip abductor muscles. This test is performed with the patient standing. The patient is asked to raise one leg; the test is positive if the pelvis on the raised side drops. A positive test suggests weakness of the abductors of the other hip. When the gluteal muscles are compromised (weakened as a result of a hip dislocation, due to paralysis, or following hip operations) with functional deficits, they are no longer able to support the pelvis on the weight-bearing side. The pelvis than drops down on the normal, non- weight-bearing side. A shortened right femur In the case of a shortened femur the upper body is shifted slightly over the leg in the stance phase. If a patient has a shortened right femur and was standing on their right leg, their body weight would be shifted to right raising the pelvis on the opposite side. Weakness of the left hip abductor muscles Trendelenburg’s test assesses the hip abductor muscles on the side that the patient is standing, therefore weakness of the left hip abductor muscles would result in a patient’s pelvis dropping while standing on their left leg. An injury to the left gluteus medius muscle Trendelenburg’s test assesses the hip abductor muscles, these include the gluteus medius, tensor fasciae latae, gluteus minimus, piriformis and obturator internus. Injury to the left gluteus medius would result in the right side of the pelvis dropping when standing on the left leg. bilateral hip dysplasia Patients with bilateral hip dysplasia walk with a ‘waddling gait’ (myopathic gait) and the Trendelenburg’s test will be positive on both sides. Trendelenburg’s test is used to assess stability of the hip. An abnormal Trendelenburg’s test is seen with any painful disorder of the hip. It is also present with a dislocated or subluxed hip and in other conditions in which the proximal femoral anatomy is abnormal (short femoral neck with high riding trochanter). Weak abductor muscles will also lead to an abnormal test. The abductors of the hip include the piriformis, gluteus medius and minimis muscles. The pectineus muscle adducts the hip. The other adductors of the hip are the gracilis, and adductor longus, brevis and magnus muscles. Question 5 of 67 A 38-year-old builder’s labourer sustained a severe fracture of his left elbow, which damaged the ulnar nerve behind the medial epicondyle of the humerus. A month later, he still has total ulnar nerve paralysis. Which clinical sign is most likely to be present on examination? Sensory loss over the ulnar 3½ digits Inability to grip a sheet of paper between his fingers Excessive sweating over the ulnar border of the left hand Ring and little fingers on the affected side are held in the claw position Marked wasting of the thenar eminence Explanation Inability to grip a sheet of paper between his fingers To grip a sheet of paper requires finger adduction and the functioning of the palmar interossei muscles, which are supplied by the deep branch of the ulnar nerve. Sensory loss over the ulnar 3½ digits Damage to the ulnar nerve would result in sensory loss over the ulna 1½ digits. Excessive sweating over the ulnar border of the left hand Injury to the ulnar nerve may result in sympathetic interruption, with absence of sweating in the affected area. Ring and little fingers on the affected side are held in the claw position Although the ring and little finger are held in the clawed position when the ulnar nerve is injured at the wrist, a high injury at the level of the elbow paralyses the long flexors to these two fingers and results in the loss of this sign (the ulnar paradox). Marked wasting of the thenar eminence The recurrent motor branch of the median nerve supplies the thenar eminence. Wasting of the thenar eminence would suggest damaged to the median nerve, and can be seen in carpal tunnel syndrome. Question 6 of 67 A 49-year-old woman has been complaining of a tingling feeling in her right hand at night and is under the impression that her hand is swollen although there is no obvious oedema. In the last few days she has noticed numbness in her right index finger and the tip of her thumb, especially while working. Which nerve is most likely to be responsible for her symptoms? Ulnar nerve Median nerve Radial nerve Nerve root C7 Nerve root C8 Explanation Median nerve The median nerve supplies sensation to the palm and the palmer surface of the radial 3½ digits. The symptoms described are suggestive of carpal tunnel syndrome. This often spares sensory loss to the palm as the palmer branch of the median nerve comes off before it enters the carpal tunnel.

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