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Finals PACES > Musc > Flashcards

Musc Flashcards

1
Q

Pes cavus

A

high arches

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2
Q

Pes planus

A

flat feet

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3
Q

Popliteal swelling

A 
Baker's cyst
popliteal aneurysm (pulsatile - can feel)
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4
Q

Cervical spine movement

A

lateral flexion - try to touch your ear to each shoulder
flexion - put your chin down onto your chest
extension - put our head back as far as possible
rotation - look over each shoulder

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5
Q

Lumbar spine movement

A

flexion is all they are really interested in for GALS, can check by putting 2 fingers on adjacent spinous processes = Schober’s test
Can also ask to extend and lateral flexion
NB thoracic spine movement is only rotation and done while they are sitting down

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6
Q

Antalgic gait

A

a limp - less time spent on painful limb (source can be hip, knee or ankle)

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7
Q

Trendelenburg gait

A

waddling gait (hips with some sass) from:
hip ABductor weakness
NOF # (would stay external rotated in NOF)
DDH (developmental dysplasia of hip)
SUFE (slipped upper femoral epiphysis)

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8
Q

Sensory ataxic

A

broad based and looking at feet
Causes:
peripheral neuropathy
dorsal column loss (e.g. MS, tabes dorsalis)

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9
Q

Cerebellar ataxia

A

broad based, high stepping and looking carefully ahead

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10
Q

Foot drop causes

A 
common peroneal nerve palsy
sciatic nerve palsy
L4/L5 root lesion
MND
Peripheral motor neuropathy (alcohol)
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11
Q

GALS screening questions

A
  1. Do you have any pain of stiffness in your muscles, joints or back
  2. Can you dress yourself completely without any difficulty
  3. Are you able to walk up and down stairs without difficulty
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12
Q

hemiplegic gait

A

foot plantarflexed and knee extended

leg must be abducted and swung in a lateral arc

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13
Q

Acute monoarthritis

A

GRASP - Ix
Gout - serum urate
Reactive Arthritis - stool sample and STI swabs
Septic arthritis - clinical and joint aspiration with MC+S (will do anyways for all swollen joints); typically staphlyococcus in adults and gonococcus in young adults
Pseudogout - chondrocalcinosis on XR

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14
Q

Leg length

A 
True = ASIS to medial maleolus
Apparent = umbilicus to medial maleolus
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15
Q

Thomas test

A

place left hand on hollow of spine and passively flex right hip, should feel lordosis flatten and left thigh rise in positive test = fixed flexion deformity
Causes:
OA
other hip pathologies

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16
Q

Blood supply to femoral head

A

cervical arteries running in joint capsule retinaculum (main supply)
intramedullary vessels in femoral neck
vessels of ligamentum teres (negligible)

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17
Q

Types of NOF

A

Use the Garden classification for intracapsular:

  1. displaced intracapsular (high risk of AVN as both cervical arteries and intramedullary disrupted)
  2. undisplaced intracapsular (moderate risk of AVN as disruption of IM and maybe CA)
  3. intertrochanteric or subtrochanteric (low risk as vessels typically safe)
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18
Q

Rx for displaced intracapsular

A

Hip replacement:
hemi-arthroscopy in older pt
total hip replacement in younger as more active post op

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19
Q

Undisplaced intracapsular Rx

A

Usually pinned in hope that AVN doesn’t develop

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20
Q

Intertrochanteric/subtrochanteric

A

Dynamic hip screw

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21
Q

Shenton line

A

medial edge of the femoral neck and the inferior edge of the superior pubic ramus. If contour lost then likely NOF

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22
Q

Garden classification

A

Intracapsular fracture
I - Incomplete or impacted bone injury with valgus angulation of the distal component
II - Complete (across whole neck) - undisplaced
III - Complete - partially displaced
IV - Complete - totally displaced

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23
Q

Hip flexors

A 
Psoas
Iliacus
Tensor fasciae latae
Sartorius
Pectineus
ADductor longus
ADductor brevis
Rectus femoris
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24
Q

Hip extensors

A

gluteus maximus

hamstrings

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25
Q

hip ABductors

A

gluteus medius and minimus

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26
Q

Hip ADductors

A

ADductor magnus, longus and brevis

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27
Q

Hamstrings

A

Semi-tendinosis
Semi-membranosus
Biceps femoris

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28
Q

Quads

A

Vastus lateralis
Vastus medialis
Vastus intermedialis
Rectus femoris

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29
Q

Compartments of knee

A

Medial compartment
Lateral compartment
Patellofemoral compartment
OA can affect all three compartments

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30
Q

Anterior draw

A

ACL (ANTERIOR cruciate ligament)

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31
Q

Posterior draw

A

PCL

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32
Q

McMurray’s test

A

Checks for meniscal tear

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33
Q

Meniscal injuries

A

young patients common from trauma
older patients common from degenerative tear of lateral meniscus
Ask about locking (as meniscus enters joint space)

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34
Q

Common peroneal nerve (L4-S2)

A

Superficial branch innervates lateral leg compartment (foot eversion)
Deep branch innervates anterior leg compartment (dorsiflexion)
Sensory supply of lateral leg and dorsum of foot
Injury typically on lateral portion of leg, as when travels out of popliteal fossa moves laterally around fibular neck

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35
Q

Simmond’s test

A

Achilles tendon rupture if positive

Patient prone with legs hanging, would squeeze calf and plantarflexion should occur

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36
Q

Charcot joint (neuropathic joint)

A

Most common cause = diabetic foot
Others = tabes dorsalis, cerebral palsy, spinal cord injury
Deformed joint due to repeated trauma as reduced sensation and proprioception; often associated with ulceration and/or infection

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37
Q

Charcot-Marie-Tooth disease

A

Mixed motor and sensory peripheral neuropathy
Features:
Foot drop
Claw toes
Inverted champagne bottle appearance as muscle wasting in lower leg
Pes cavus

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38
Q

Ankle joints

A 
True ankle joint (dorsiflexion and plantarflexion, articulation of tibia/fibula and talus)
Subtalar joint (inversion and eversion, articulation of talus and calcaneus)
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39
Q

Hawkin’s test

A

Impingement syndrome

Flexed shoulder and elbow both at 90 degrees, internally rotate shoulder and when you do so they have pain

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40
Q

Jobe’s test

A

Supraspinatus rotator cuff injury
Straight arm ABducted to 90 degrees with thumb pointing to the floor (Gladiator position), and make them resistant you pushing it down

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41
Q

Gerber’s test

A

Subscapularis rotator cuff injury

Hands on back, dorsum resting on mid back, ask them to take hands off back whilst applying pressure to palms

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42
Q

Resisted external rotation

A

Teres minor and infraspinatus

Self-explanatory. You resist external rotation

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43
Q

Impingement syndrome

A

Pain during shoulder ABduction between 60 and 120 degrees

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44
Q

SITS

A 
Supraspinatus (anterior superior)
Infraspinatus (posterior)
Teres minor (posterior)
Subscapularis (anterior inferior)
All rest on greater tubercle apart from subscapularis which rests on lesser tubercle
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45
Q

Bankart lesion from anterior dislocation

A

injury of anterior glenoid labrum

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46
Q

Hill-Sachs lesion from anterior dislocation

A

depressed posteriolateral head of humerus due to forceful impaction

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47
Q

Frozen shoulder

A 
Adhesive capsulitis of glenohumeral joint. Diabetes and thyroid disease are RF
Phases:
1. Freezing (2-9 months)
2. Frozen (4-12 months)
3. Thawing (1-3 years)
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48
Q

Straight leg raise in spine exam

A

passively raise leg and pain occurs that travels down from back pain to posterior leg = L5/S1 nerve root compression

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49
Q

Schober’s test

A

Flexion of lumbar spine for ank spond.
At level of dimples of Venus mark as well as 10 cm above and 5 cm below and if measure on full flexion, should increase more than 5 cm (i.e. now 20 cm when was 15 cm)

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50
Q

Femoral stretch test

A

L4 nerve root compression

Pt lying on front, passively extend hip with leg straight

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51
Q

Neurogenic claudication

A

Spinal stenosis
Calf/buttock/thigh discomfort whilst walking
Relieved bending forward at waist, which can differentiate from intermittent claudication

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52
Q

Lumbar back pain DDx

A

Mechanical: muscular, disc prolapse, OA, spinal stenosis
Inflammatory: ank spond
Other serious pathology: infection and cancer. TB, bony mets, myeloma, osteomyelitis

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53
Q

Extra-articular manifestations of RA

A

Can affect any group
General: malaise, lethargy, low grade fever, WL
CVS: pericarditis/effusion
Resp: pleural effusion, pulmonary fibrosis, Caplan’s syndrome
Renal: renal amyloid
NS: carpal tunnel, polyneuropathy
Eyes: Scleritis, episcleritis, Sjogren’s
Blood: anaemia (any type - macrocytosis can be from folate deficiency withe methotrexate or pernicious anaemia); Felty’s syndrome

54
Q

Caplan’s syndrome

A

Rheumatoid pneumoconiosis is a combination of rheumatoid arthritis (RA) and pneumoconiosis that manifests as intrapulmonary nodules, which appear homogenous and well-defined on chest X-ray

55
Q

Joint characteristics of RA

A

boutonniere deformity: flexion of proximal interphalangeal joint and extension of distal interphalangeal joint of the hand
Swan neck deformity: hyperextension at proximal interphalangeal joint and flexion at distal interphalangeal joint
Z-thumb: hyperextension of the interphalangeal joint, fixed flexion and subluxation of the metacarpophalangeal joint and gives a “Z” appearance to the thumb

56
Q

LOSS and LESS

A

X-ray features of Osteoarthritis (LOSS)

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

Radiological Features of Rheumatoid Arthritis (LESS)

Loss of joint space
Erosions
Soft tissue Swelling
Soft bones (osteopenia which is periauricular)

57
Q

Psoriatic arthritis

A 
DRAMA:
DIP only
Rheumatoid like
Ank spond like
Mutilans
Asymmetrical oligoarthropathy
Negative correlation of severity
58
Q

Back Pain Red Flags

A 
Age <20 or >55yrs
  Neurological disturbance (inc. sciatica)
  Sphincter disturbance
  Bilateral or alternating leg pain
  Current or recent infection
  Fever, wt. loss, night sweats
  History of malignancy
  Thoracic back pain
  Morning stiffness
  Acute onset in elderly people
  Constant or progressive pain
  Nocturnal pain
59
Q

Back pain Mx

A

Neurosurgical referral if neurology
Conservative
Max 2d bed rest
Education: keep active, how to lift / stoop
Physiotherapy
Psychosocial issues re. chronic pain and disability Warmth

Medical
Analgesia: paracetamol ± NSAIDs ± codeine
Muscle relaxant: low-dose diazepam (short-term) Facet joint injections

Surgical
Decompression
Prolapse surgery: e.g. microdiscectomy

60
Q

Acute cord compression

A

Bilateral pain: back and radicular
LMN signs at compression level
UMN signs and sensory level below compression
Sphincter disturbance

61
Q

Acute cauda equina syndrome

A

Alternating or bilateral radicular pain in the legs
Saddle anaesthesia
Loss of anal tone
Bladder ± bowel incontinence

62
Q

Osteoarthritis signs

A

Bouchard’s (proximal)
Heberden’s (distal)
Thumb squaring of carpo-metacarpo joint
Fixed flexion deformity

63
Q

Osteoarthritis Medical Mx

A

Analgesia
Paracetamol or NSAIDS like arthrotec (diclofenac + misoprostol)
Joint steroid injections

64
Q

Osteoarthritis Surgical Mx

A

Arthroscopic washout (esp knee)
Arthroplasty - replacement
Osteotomy - small area of bone cut out
Arthrodesis - fusion of joint; last resort for pain management

65
Q

Septic Arthritis Mx

A

IV Abx - vanc + cefotaxime

Consider washout under GA (esp if prosthetic, must be replaced)

66
Q

Septic Arthritis Causes

A

Organisms:
Staph: commonest overall (60%)
Gonococcus: commonest in young sexually active

RF:
  Joint disease (e.g. RA)
  CRF
  Immunosuppression (e.g. DM)
  Prosthetic joints
67
Q

RA Hand Symptoms

A

Symmetrical, polyarthritis of MCPs, PIPs of hands and feet → pain, swelling, deformity

  1. Swan neck
  2. Boutonniere
  3. Z-thumb
  4. Ulnar deviation of the fingers
  5. Dorsal subluxation of ulnar styloid

Morning stiffness >1h that improves with exercise
Larger joints may become involved

68
Q

Rheumatoid nodules

A

Commonly elbows also fingers, feet, heal
Firm, non-tender, can be mobile or fixed
Can also occur in lungs

69
Q

Extra-articular symptoms of RA

A

Cardiac - pericarditis / pericardial effusion

Pulmonary - fibrosis (lower); pleural effusions

Ophthalmic - Epi/scleritis; Sjogren’s

Spenomegaly in 5% (Felty’s in 1%)

So much do full head to toe exam

70
Q

Felty’s syndrome

A

RA + splenomegaly + neutropenia

71
Q

RA Dx:

A 
ACR classification
4/7 of:
1. Morning stiffness >1h (lasting >6wks)
2. Arthritis ≥3 joints
3. Arthritis of hand joints
4. Symmetrical
5. Rheumatoid nodules
6.+ve RF or anti-CCP
7. Radiographic changes
72
Q

RA medical Mx:

A

DAS28: Monitor disease activity
DMARDs and biologicals: use early
Steroids: IM, PO or intra-articular for exacerbations (Avoid giving until seen by rheumatologist)
NSAIDs: good for symptom relief

Mx CV risk: RA accelerates atherosclerosis
Prevent osteoporosis and gastric ulcers

73
Q

RA surgical Mx

A

Ulna stylectomy

Joint prosthesis

74
Q

DMARDS SE

A

Main agents
Methorexate: hepatotoxic, pulmonary fibrosis
Sulfasalazine: hepatotoxic, SJS, ↓ sperm count
Hydroxychloroquine: retinopathy, seizures

Other Agents
Leflunomide: ↑ risk of infection and malignancy
Gold: nephrotic syndrome
Penicillamine: drug-induced lupus, taste change

75
Q

Boutonierre’s patho

A

rupture of central slip of extensor
expansion → PIPJ prolapse through “button-hole”
created by the two lateral slips.

76
Q

Swan-necking patho

A

rupture of lateral slips → PIPJ hyper-extension

77
Q

Biologicals

A

Anti-TNF e.g. infliximab, etanercept, adalimumab
SE = increased infection, AI disease and cancer

Rituximab (anti CD20)
Second line if not responding to anti-TNF

78
Q

Jaccoud’s arthropathy

A

Differential of rheumatoid hand caused by SLE or rheumatic fever
Features very similar to rheumatoid hand but is a reversible non-erosive chronic joint disorder occurring after repeated bouts of arthritis

79
Q

Podagra

A

Gout on great toe MTP

80
Q

Tophi

A

Urate deposits in pinna and tendons

81
Q

Gout on X-Ray

A

punched out erosions in juxta-articular bone

reduced joint space

82
Q

Gout causes

A

Drugs: diuretics, NSAIDs, cytotoxics, pyrazinamide

↓ excretion: 1O gout, renal impairment

↑ cell turnover: lymphoma, leukaemia, psoriasis,
haemolysis, tumour lysis syndrome

EtOH excess

Purine rich foods: beef, pork, lamb, seafood

Hereditary

83
Q

Acute Rx of Gout

A

NSAID: diclofenac or indomethacin

Colchicine when NSAIDs CI: warfarin, PUD, HF, CRF
SE: diarrhoea

In renal impairment: NSAIDs and colchicine are CI → Use steroids

84
Q

Prevention of gout

A

Conservative = wt. loss + avoid prolonged fasting and excessive EtOH

Medical
Allopurinol: SE rash, fever, ↓WCC ( with azathioprine). Use febuxostat if SE
Probenecid is also rarely used

85
Q

Pseudogout RF

A 
↑age
  OA
  DM
  Hypothyroidism
  Hyperparathyroidism
  Hereditary haemochromatosis   Wilson’s disease
86
Q

Pseudogout Rx

A

Analgesia
NSAIDs
May try steroids: PO, IM or intra-articular

87
Q

Ank Spond presentation

A
  • Gradual onset back pain
  • Progressive loss of all spinal movement
  • Enthesitis
  • Costochondritis
  • Question mark posture (thoracic kyphosis + neck hyperextension)

Extra-articular:

  • anterior uveitis
  • apical fibrosis
  • aortic valve imcompetence
88
Q

Ank spond Mx

A

Conservative:
Exercise!!

Medical:
NSAIDS - indomethicin
Local steroid injections
Anti-TNF if severe

Surgical:
Hip replacement to increase mobility and reduce pain if necessary

89
Q

Reactive arthritis causes

A

Urethritis: chlamydia, ureaplasma

Dysentery: campy, salmonella, shigella, yersinia

90
Q

Reactive arthritis presentation

A
  • Asymmetrical lower limb oligoarthritis: esp. knee
  • Iritis, conjunctivitis
  • Keratoderma blenorrhagica: plaques on soles/palms
  • Circinate balanitis: painless serpiginous penile ulceration
  • Enthesitis
  • Mouth ulcers
91
Q

Reactive arthritis Mx

A

NSAIDs and local steroids

92
Q

Psoriatic arthritis features

A
  • DRAMA (joint involvement)
  • psoriatic plaques
  • nail changes (POSH = pitting, onycholysis, subungal hyperkeratosis)
  • enthesitits
  • dactylitits

X-ray = pencil-in-cup deformity from punched out erosions

93
Q

Psoriatic arthritis Rx

A

NSAIDs
Sulfasalazine/methotrexate/ciclosporin
Anti-TNF

94
Q

Behcet’s disease presentation

A

Recurrent oral and genital ulceration
Eyes: ant/post uveitis
Skin lesions: EN
Vasculitis

95
Q

Behcet’s disease Ix and Rx

A

Ix: skin pathergy test (needle prick → papule formation)

Rx: immunosuppression

96
Q

Anti-dsDNA

A

SLE

97
Q

Anti-centromere

A

CREST syndrome

98
Q

Anti-scl70

A

diffuse systemic sclerosis

99
Q

Anti-histone

A

Drug induced lupus

Causes: procainamide, phenytoin, hydralazine, isoniazid

100
Q

Anti-Jo1

A

Polymyositis, Dermatomyositis

101
Q

Anti-RNP

A

SLE, MCTD

102
Q

Anti-Ro / anti-La

A

SLE, Sjogren’s

103
Q

Sjogren’s Ix and Rx

A

Ix

  • Schirmer tear test
  • Abs: ANA–RoandLa,RF
  • Hypergammaglobulinaemia
  • Parotid biopsy

Rx

  • artificial tears
  • saliva replacement solution
  • NSAID and hydroxychlorquine for arthralgia
  • immunosuppression if severe
104
Q

Raynaud’s colour change

A

WBC:
White –> blue –> crimson

Rx - nifedipine

105
Q

Systemic sclerosis Mx

A
  • Immunosuppression
  • Raynaud’s: CCBs, ACEi, IV prostacyclin
  • Renal: intensive BP control – ACEi 1st line
  • Oesophageal: PPIs, prokinetics (metoclopramide)
  • Pulmonary HTN: sildenafil, bosentan
106
Q

Polymyositis and Dermatomyositis Ix

A
  • Muscle enzymes: ↑CK, ↑AST, ↑ALT, ↑LDH
  • Abs: Anti-Jo1 (assoc. with extra-muscular features)
  • EMG
  • Muscle biopsy
  • Screen for malignancy: e.g. Tumour markers, CXR, Mammogram, pelvic/abdo US, CT
107
Q

Skin changes in dermatomyositis

A
  • Heliotrope rash on eyelids ± oedema
  • Macular rash (shawl sign +ve: over back and shoulders)
  • Nailfold erythema
  • Gottron’s papules: knuckles, elbows, knees
  • Mechanics hands: painful, rough skin cracking of finger
    tips
  • Retinopathy: haemorrhages and cotton wool spots
  • Subcutaneous calcifications
108
Q

Antiphospholipid Rx

A
  • low dose aspirin
  • warfarin if recurrent thrombosis (INR 3.5)
  • IVC filter
109
Q

SLE features

A

A RASH POINt MD

  • arthritis: jaccoud’s
  • renal: proteinuria + HTN
  • ANA
  • serositis
  • haematological: AIHA, reduced WCC and plt
  • Photosensitivity
  • oral ulcers
  • immune phenomenon: anti-dsDNA, Sm + phospholipid
  • neuro: psychosis
  • malar rash (spares nasolabial folds)
  • discoid rash: mainly affects face and chest
110
Q

Large vessel vasculitis

A

Giant cell arteritis

Takayasu’s arthritis

111
Q

Medium vessel vasculitis

A

Polyarteritis nodosa

Kawasaki disease

112
Q

Small vessel vasculitis

A

pANCA

  • Churg-Straus
  • Microscopic Polyangiitis

cANCA:
- Wegener’s Granulomatosis

ANCA –ve

  • Henoch-Schonlein Purpura
  • Goodpasture’s Disease
  • Cryoglobulinaemia
  • Cutaneous Leukocytoclastic Vasculitis
113
Q

Giant cell arteritis features

A
  • Headache
  • Temporal artery and scalp tenderness
  • Jaw claudication
  • Amaurosis fugax
  • Prominent temporal arteries ± pulsation
114
Q

Giant cell arteritis Ix and Mx

A

If suspect GCA: Do ESR and start pred 40-60mg/d PO

Temporal artery biopsy within 3 days (skip lesions can occur however)

115
Q

Kawasaki’s Mx

A

IVIG + aspirin

Fever >5 days

116
Q

PAN

A

Assoc. with Hep B

Features
Constitutional symptoms
- Rash
- Renal → HTN
- GIT → melaena and abdo pain

Rx = Pred + cyclophosphamide

117
Q

Takayasu’s arteritis features

A

Pulseless disease

  • Constitutional symptoms: fever, fatigue, wt. loss
  • Weak pulses in upper extremities
  • Visual disturbance
  • HTN
118
Q

Churg strauss features

A

Late-onset asthma
Eosinophilia
Small vessel vasculitis (RPGN and purpura)

119
Q

Microscopic polyangiitis features

A
  • RPNG
  • haemoptysis
  • purpura
  • not granulomatous
120
Q

Wegener’s features

A

URT + LRT + kidneys

URT - chronic sinusitis; epistaxis; saddle-nose deformity

121
Q

Goodpasture’s Ix and Rx

A

Ix
Anti-GBM and CXR showing bilateral lower zone infiltration (haemorrhage)

Rx
immunosuppresion + plasmapheresis

122
Q

Cutaneous Leukocytoclastic Vasculitis

A
  • Palpable purpuric rash ± arthralgia ± GN

Causes

  1. HCV
  2. Drugs: sulphonamides, penicillin
123
Q

Simple Cryoglobulinaemia

A

Monoclonal IgM linked to myeloma/CLL

leading to hyperviscousity (visual disturbance/thrombosis/headache/seizures)

124
Q

Mixed cryoglobulinaemia

A

Polyclonal IgM from SLE, HCV, mycoplasma, Sjogren’s leading to immune complex deposition (GN, purpura, arthralgia, peripheral neuropathy)

125
Q

Fibromyalgia Features

A
  • Chronic, widespread musculoskeletal pain and tenderness
  • Morning stiffness
  • Fatigue (on exercise)
  • Poor concentration
  • Sleep disturbance
  • Low mood

Diagnosis of exclusion

126
Q

Fibromyalgia Mx

A
  • Educate pt.
  • CBT
  • Graded exercise programs
  • Amitriptyline or pregabalin
  • Venlafaxine
127
Q

Bennet’s fracture

A

Intra-articular fracture of the first carpometacarpal joint (thumb)

Impact on flexed metacarpal, caused by fist fights

X-ray: triangular fragment at ulnar base of metacarpal

128
Q

Monteggia’s fracture

A

Dislocation of the proximal radioulnar joint in association with an ulna fracture

Fall on outstretched hand with forced pronation

Needs prompt diagnosis to avoid disability

129
Q

Galeazzi fracture

A

Radial shaft fracture with associated dislocation of the distal radioulnar joint

Direct blow

130
Q

Pott’s fracture

A

Bimalleolar fracture

Forced foot eversion

131
Q

Barton’s fracture

A

Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation

Fall onto extended and pronated wrist

Finals PACES (12 decks)

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