Clinical (Weeks 3, 4 +5) Flashcards Preview

Year 2 - Musculoskeletal (DP) > Clinical (Weeks 3, 4 +5) > Flashcards

Flashcards in Clinical (Weeks 3, 4 +5) Deck (166):
1

What are risk factors for childhood hip disorders (Developmental Dysplasia of the Hip [DDH])?

Breech birth
FHx
Other MSK abnormalities:
- Club foot
- Torticollis

2

What populations are most commonly affected by childhood hip disorders?

1st born
Girls

3

What hip is more commonly affected?

Left

4

What should you look for on examination of a suspected DDH?

Asymmetry:
- Leg position
- Leg length
- Thigh creases
Feel for click
Check abduction!

5

What special instability tests are useful in diagnosing hip disorders?

Barlow:
- Attempt to dislocate/sublux
- By flexion adduction
Ortolani:
- Relocate dislocated by abduction

6

In a 2 month old child what is the best imaging technique for a suspected hip problem?

Ultrasound

7

In a 6 month old child what is the best imaging technique for a suspected hip problem and why?

X-ray
Epiphysis has calcified

8

What is the most successful treatment for DDH?

Pavlik harness (95% success)

9

What surgical options for treatment are available for DDH at the following ages:
- Age > 3/12
- Age > 9/12
- Age > 2 years

> 3/12:
- Closed reduction
> 9/12:
- Open reduction
> 2 years:
- Bony surgery (?Femoral/?Pelvic Osteotomy)

10

A preschool child presents with a limp. What questions are important to ask?

Painful or painless?
History of injury?
Generally well or ill?

11

What questions may help include/exclude infection?

Pain at rest/movement?
Resistance to movement?
Fever?
Infection elsewhere?
Susceptibility to infection?

12

If there is a joint effusion what investigation might we carry out?

Ultrasound

13

How would a late DDH present?

Painless limp
Short leg
Asymmetric creases - Xray
Trendellenburg limp

14

A 7 year old boy is brought to the GP with a painful right hip and limp. His mother informs you he enjoys playing football regularly. On examination he is in the 5th height centile for his age (short) and has a positive Trendellenburg gait.

Perthes Disease

15

What is Perthes disease?

Idiopathic AVN of the femoral head

16

How is Perthes treated?

Influencing the shape of the recovering femoral head:
- Ensure it is contained in acetabulum

17

A 14 year old African-American boy is brought to you with the inability to bear weight on his left leg, with associated knee pain. On examination he is obese, pre-pubescent and his hip cannot be internally rotated

Slipped Upper Femoral Epiphysis (SUFE)

18

What is seen on x-ray of a SUFE?

Trethowans sign (AP)
Lateral view is imperative

19

What ages is transient synovitis most common in?

2-5 year olds

20

What typically precedes transient synovitis?

An URTI (viral)

21

What is the commonest cause of hip pain in kids? What conditions must be excluded?

Transient synovitis
Exclude:
- Septic arthritis
- Perthes
- Juvenile OA
- RA

22

What must you prevent in a patient who cannot bear weight?

Any weight bearing - Assume SUFE until it is excluded

23

What are red flag symptoms in back pain?

Non-mechanical pain:
- No variation with exercise
- Night pain
Systemic upset
Major, new neurological defect
Saddle anaesthesia:
- Painless urinary retention
- Overflow
- Bowel incontinence

24

What signs might be seen on observation of a patient presenting with back pain?

Deformity
Hair patches
Asymmetry
Neurofibroma

25

What neurological symptoms can be present in back pain?

Numbness
Weakness
Paraesthesia
Temperature disturbance

26

What myotomes should be tested in the presentation of back pain?

L1/L2:
- Hip flexion
L3/L4:
- Knee extension
L5:
- Foot dorsiflexion and EHL
S1/S2:
- Ankle plantarflexion

27

What is the sciatic stretch test?

Straight leg raise with foot extension
(Testing for nerve irritation)

28

What is the bowstring test?

Straight leg raise with pressure behind knee
(Testing for nerve irritation)

29

When will an x-ray be useful in back pain?

If spinal stenosis:
- Degenerate + hypertrophic spine
- Narrow interpedicular distance
- Obliteration of IV foraminae

30

What signs may be seen on a spinal MRI?

White triangle:
- Annular tear
'Hamburger' sign:
- Disc inflammation
- White patches either side in vertebral bodies

31

What are features of sciatica?

Buttock and/or leg pain
Dermatomal distrubution
Neurological disturbance

32

A patient presents with episodic back pain with new onset of leg pain and weakness. The leg pain has become the dominant pain.

Disc prolapse

33

When is surgery considered in disc prolapse?

Cauda equina syndrome
No resolval in 3 months

34

Back pain patients should get long-term bed rest. True or false?

False
They need early return to normal activity and physical therapy

35

What symptoms may suggest a behavioural problem?

Pain at coccyx
Whole leg pain/numbness
Absence of pain free spells
Treatment intolerance
Emergency admission

36

A 59 year old man presents to the GP with back pain. He notes that he has been unable to walk very far. He also informs you that he used to be a builder. He says that his symptoms get better on sitting and leaning forward. On examination he is obese.

Spinal claudication

37

How is spinal stenosis treated?

Step 1. Decompression -> Destabilises spine
Step 2. Stabilisation:
- Fusion and Fixation

38

What pattern of pain does disc degeneration follow?

Worse as day goes on
Worse on flexion
Worse on activity
Central, lower back pain

39

A patient presents with morning stiffness. They explain how they have a 'loosening up' routine. They have difficulty sitting and standing. They note the pain is better on exercise. Sometimes it radiates to the buttocks. On examination the pain is worsened on back extension.

Facet arthropathy

40

Between 6-9 months what should a child be able to do?

Sit alone and crawl

41

Between 8-12 months what should a child be able to do?

Stand (holding furniture)

42

Between 14-17 months what should a child be able to do?

Walk alone

43

At what age should a child be able to run/jump?

2 years

44

At what age should a child be able to climb up and down stairs?

Up - 3 years
Down - 4 years

45

How does the foot arch develop?

As we walk the muscles strengthen

46

What are the types of flat foot?

Mobile/Flexible
Fixed/Rigid

47

What is Jack's test in terms of a flat foot?

Great toe dorsiflexion:
- Arch will form in a mobile flat foot
- Due to tight tibialis anterior

48

What are some causes of in-toeing?

Femoral neck anteversion
Internal tibial torsion
Metatarsus adductus

49

How do we diagnose femoral neck anteversion?

Measure hip rotational range

50

What features are present in patients with femoral neck anteversion?

Age > 4 years
Ligamentous laxity
Unwinds slowly

51

What do we measure in suspected internal tibial torsion?

Ankle rotation

52

What features are present in patients with internal tibial torsion?

Age

53

When are bow legs physiological? What causes this?

In infants
Medial tibial torsion

54

When should bow legs be referred?

Asymmetry
Not resolving
Painful
Height

55

What is the medical term for bow legs?

Genu varum

56

What is the normal intermalleolar distance at 11 years?

8cm

57

When do you refer for knock knees?

Asymmetry
> 8cm distance at 11

58

What is the medical term for knock knees?

Genu valgum

59

What is the commonest cause of adolescent knee pain in girls?

Patellofemoral dysfunction

60

What are some of the risk factors for adolescent knee pain?

Imbalance
Ligamentous laxity
Skeletal problems:
- Valgus
- Wide hips
- Femoral neck anteversion

61

What is chondromalacia patellae and what can it be seen in?

Softening of patella's hyaline cartilage
Adolescent knee pain

62

What must you examine in an adolescent presenting with anterior knee pain?

Hips

63

Abnormalities in what bones causes clubfoot?

Talus
Calcaneus
Navicular

64

What soft tissue contractures can result from clubfoot?

Ankle equinus (plantarflex)
Varus forefoot
Forefoot supination

65

What are some risk factors for clubfoot?

Male
Breech birth
Oligohydramnios (reduced amniotic fluid)

66

How is clubfoot treated?

Ponseti technique:
- Splintage after birth
- Weekly casts (5-6 weeks)
- 80% have Achilles tenotomy
- Braced (23 hours/day for 3 months)

67

What are the National Institute for Health Criteria for NF1?

6 or more cafe au lait spots:
- > 5mm pre-puberty
- > 15mm post-puberty
>= 2 neurofibromas or 1 PFN
Axillary/Groin Freckling
>= 2 Lisch nodules (Iris hamartomas)
Pseudoarthritis/Thinning
Kyphoscoliosos
1st degree relative
(2/7 of these)

68

How does a NF1-type 'rash' look?

Soft, subcutaneous, pedunculated lumps

69

A child presents with frontal bossing, midface hypoplasia and rhizomelic disproportion

Achondroplasia

70

What is the pathogenesis resulting in bone deformities in cerebral palsy?

Brain injury -> Increased tone -> Abnormal posture -> Contracture

71

What is the pathology that results in spastic cerebral palsy?

1. Periventricular leukomalacia (white matter injury)
2. Loss of inhibition of LMN
3. Positive features of UMN syndrome
4. Spasticity/Hyperreflexia/Clonus

72

How do benzodiazepines reduce spasticity?

1. Bind to GABAa receptors
2. Increased GABA affinity for receptor
3. Reduce neurone excitability

73

What is baclofen's mode of action?

GABAb receptor agonist

74

How is Baclofen administered?

Intrathecally

75

How does Botox work?

Cleaves SNARE receptor proteins reduce neurotransmitter release

76

What is a surgical treatment for spasticity?

Selective Dorsal Rhizotomy

77

What are causes of tip-toe walking?

Mild CP
Autism
DMD
2-3 months while child learns to walk

78

What inheritance is Duchenne Muscular Dystrophy?

X-linked recessive

79

What gender is DMD presented in and at what age?

Males
2-5 years old

80

Mutations in what gene cause DMD?

Dystrophin

81

What clinical and biochemical features help diagnose DMD?

Gower's sign:
- Using hands/arms to 'walk up' from kneeling
Increased serum CK

82

What disease can cause pes cavus?

Charcot-Marie-Tooth Disease

83

A patient presents with local, nocturnal pain in their shin. On x-ray there is a 1cm round lucency surrounded by sclerosis.

Subacute osteomyelitis
(Brodie's abscess)

84

What are the two most common causes of acute osteomyelitis?

Trauma
Open fracture

85

What is the pathogenesis of acute osteomyelitis in children and the immunosuppressed?

1. Haematogenous spread
2. Trauma
3. Thromboses sinusoidal vessel
4. Bacterial colonisation

86

What is the most common infective agent in acute osteomyelitis?

MSSA
Haem. influenzae in kids

87

If there's pus...

...Let it out

88

What is the pathogenesis of chronic osteomyelitis?

1. Bone abscess -> Dead bone (Sequestrum)
2. Pus seeps out under periosteum
3. Bone forms from the periosteum (Involucrum)
4. Bone remodelling (Wolff's Law)

89

What is Wolff's Law?

Bone will remodel and shape due to the pressures it is placed under

90

What investigations are useful in chronic osteomyelitis?

X-ray
MRI

91

Where is the most common affected site of chronic osteomyelitis?

Tibia

92

How can septic arthritis be acquired?

Inoculation (penetrating injury)
Metaphyseal spread
Direct haematogenous spread

93

What is the biggest feature of septic arthritis?

Total loss of function due to pus filling joint space and forcing bones apart

94

Treatment of septic arthritis

Excision arthroplasty
Replacement of joint

95

How do we treat cellulitis and why?

Flucloxacillin and Benzylpenicillin
(Staph and Strep most common causes)

96

Black specs on x-ray suggest what?

Necrotising fasciitis

97

When is a bone infection operated upon?

Dead tissue
Foreign body
Abscess

98

What is the most likely diagnosis of a teen with back pain and how would we treat?

L5/S1 discitis
Flucloxacilin

99

What investigations would we carry out in a suspected infected arthroplasty?

CRP
Joint aspirate
Technetium 99 Bone Scan
X-ray

100

What can cause a biofilm-producing infection?

Staph epidermidis

101

What is important in determining the degree of pain a patient is experiencing in a joint?

How it affects their QoL

102

What knee ligament is most commonly injured?

MCL

103

A patient presents with a painful lump on their left leg. They explain that they are a cyclist and cut their leg about 2 weeks ago. On examination the lump is very red, well defined and fluctuant.

Abscess

104

A patient presents with a severely swollen right knee. The knee is very swollen and absolutely impossible to move, even passively. The patient has felt very tired, suffered night sweats and has a fever of 39.

Septic arthritis

105

What investigations need done into septic arthritis?

Aspiration for:
- Microscopy
- Culture
- Sensitivity

106

How do we treat septic arthritis?

Urgent open/arthroscopic washout (6L) and debridement

107

A patient presents with a 12mm swelling on their left anterior wrist. On examination it is round and discrete. It is non-tender. The skin is freely mobile over it. The patient presented because it tends to catch on his watch.

Ganglion

108

What is a ganglion?

Synovium outpouchings

109

How do you treat a ganglion?

DO NOT ASPIRATE
Surgical excision

110

What is a Baker's cyst?

Popliteal fossa ganglion

111

What is a Baker's cyst associated with?

OA

112

A patient presents with a painful right hip. It is worse when they are lying on that side. On examination there is tenderness on the anterolateral aspect of their right hip.

Trochanteric bursitis

113

How is bursitis treated?

NSAIDs/Analgesia
Antibiotics
If abscess -> Drain

114

What are rheumatoid nodules associated with?

Repetitive trauma

115

What joints are commonly affected by Dupuytren's contractures?

MCP joints
PIP joints

116

What causes Dupuytren's?

Excess myofibroblast prolifetation and altered collagen matrix (Collagen iii instead of i)

117

What happens to the palmar fascia in Dupuytren's?

Becomes:
- Thickened
- Contracted

118

Is Dupuytren's vascular or avascular?

Avascular (O2 free radicals)

119

Management of Dupuytren's

Single band:
- Needle fasciotomy
Mild disease:
- Collagenase injection
Limited fasciectomy (Band removal)
If skin involved:
- Dermofasciectomy
- Skin grafting after

120

What genetics can be involved in Dupuytren's?

Autosomal dominant condition

121

Risk factors for Dupuytren's?

Northern European
Male
Alcohol
DM
Trauma

122

A patient presents with a firm, discrete swelling on the back of their middle finger. It is painful/

Giant cell tumour of the tendon sheath

123

What are diffuse giant cells tendon sheath tumours associated with?

Pigmented Villonodular synovitis

124

In regard to lipomas, which are the following are true and which are false?
1. They grow quickly
2. They are painless
3. Have a firm feeling
4. Tend to cause skin changes
5. They move under your skin on palpation

1. False
2. True (Usually)
3. False (Feel 'fatty')
4. False
5. True

125

A 15 year old boy presents with a 2 month history of a lump just beneath his knee. He says it is usually painless, but can catch on clothes when walking. On examination there is a hard lump on his proximal tibia.

Osteochondroma

126

What is the histology of an osteochondroma?

Cartilage-capped ossified pedicle derived from aberrant cartilage from perichondral ring

127

What are the two forms of osteochondromas? What is the difference?

Solitary
Multiple Hereditary Exostosis:
- Numerous tumours
- Increased risk of malignant transformation

128

What is a Ewing's sarcoma derived from?

Marrow endothelial cells

129

A 13 year old patient presents with night pain in his left leg. He has a fever. His bloods show anaemia, increased CRP and ESR.

Ewing's sarcoma

130

What do sebaceous cysts fill with?

Keratin

131

How do sebaceous cysts present?

Slow growing
Painless
Mobile
Discrete

132

A patient was admitted to A&E 6 weeks ago following a sporting incident in which he suffered a large contusion to his right thigh. He recovered fully but initially noted some swelling a month ago but now his thigh feels 'hard'

Myositis ossifcans

133

What are some causes of 'shoulder impingement'?

Tendonitis (mostly supraspinatus)
Subacromial bursitis
OA
Hooked rotator cuff tear

134

What is the grading system used to classify the shape of the acromial angle? How do these grades impact pathology?

Bigliani Acromial Grading
Grade 1:
- Flat
- Lowest risk of cuff tear
Grade 2:
- Curved
- Most common shape
Grade 3:
- Hooked
- Highest risk of tear

135

A patient presents with sudden onset, severe shoulder pain. It is sometimes stiff. On x-ray there is a small opacified triangle proximal to the great humeral tuberosity. How can we treat this condition?

Calcific tendinitis:
- Subacromial steroid injection
- Local anaesthetic

136

What is os acromiale?

Acromion remains a separate bone

137

What type of patients tend to present with rotator cuff tears?

Patients older than 40
Those with tendon degeneration

138

What is a classical history feature of a rotator cuff tear?

Sudden jerk

139

What is the most commonly affected rotator cuff muscle?

Supraspinatus

140

How does a rotator cuff tear present?

Weakness on abduction initiation
Poor internal and external rotation
Supraspinatus wasting

141

How do we confirm a rotator cuff tear diagnosis?

USS
MRI

142

What are the two types of shoulder instability and who gets them?

Traumatic:
- Young
- Sporty people
Atraumatic:
- Older people
- Degenerative changes

143

What does TUBS stand for in terms of shoulder instability?

T - Traumatic
U - Unilateral
B - Bankart lesion:
- Injury to the anterior glenoid labrum of the shoulder
S - Surgery (Bankart repair)

144

What is a Hill-Sachs lesion and what causes it?

Cortical depression of the posterolateral humeral head
Anterior shoulder dislocation:
- (Soft) Humeral head impacts on anterior glenoid rim

145

What can a Hill-Sachs lesion contribute to?

Further dislocation
Painful clicking
Catching
Popping

146

What does AMBRI stand for in terms of shoulder instability?

A - Atraumatic
M - Multidirectional
B - Bilateral
R - Rehabilitation
I - Inferior capsular shift

147

What causes atraumatic instability?

Ligamentous laxity:
- Ehler-Danlos
- Minor trauma

148

What does the sulcus sign suggest?

Ligamentous laxity and potential ease of atruamatic shoulder dislocation

149

A 53 year old patient presents with stiffness in his shoulder for the past 6 months. He says that for the first couple of months there was a lot of pain, then pain and stiffness but now the pain has subsided as his shoulder has been almost totally immobile. He is diabetic and has Dupuytren's.

Adhesive capsulitis

150

What can trigger adhesive capsulitis?

Inocuous injury
Shoulder surgery
Diabetes
Hypercholesterolaemia
Dupuytren's

151

What nerve is affected in carpal tunnel syndrome?

Median nerve

152

What symptoms are present in carpal tunnel?

Paraesthesia:
- Thumb
- Radial 2.5 fingers
Worse at night
Loss of sensation
Weakness

153

What might be noted on examination of carpal tunnel syndrome?

Thenar muscle wasting
Tinel's test positive:
- Tapping over nerve causes symptoms
Phalen's test positive:
- Holding wrist hyper-flexed causes symptoms

154

How can we investigate carpal tunnel?

Nerve conduction studies

155

What nerve is affected in cubital tunnel syndrome?

Ulnar nerve

156

What is the typical presentation of cubital tunnel syndrome?

Paraesthesia in ulnar 1.5 fingers

157

What might be noted on examination in a cubital tunnel patient?

Weakness in index finger abduction:
- 1st dorsal interossei weakness
Fromen'ts test positive:
- Weakness in adductor pollicis
- Ask patient to hold paper between 1st finger and thumb and pull paper away (in a positive test, the patient will have to flex their thumb's IP joint to maintain grip)

158

What three sites might cause compression of the ulnar nerve?

Tight fascia
IM septum tightness above elbow
Flexor carpi ulnaris tightness

159

In what patients are pressure ulcers more likely?

Delayed surgery
Frail/malnourished patients
Patients who aren't mobilised early

160

What pre-op analgesia was traditionally given before orthopaedic surgery?

IV morphine

161

What is the newer model for pre-op analgesia?

Local nerve blocks

162

What is the system for post-op analgesia?

1. Regular paracetamol (PO or IV) (Rarely enough)
2. Codeine - 15mg at first (Can be increased)
3. Morphine - Regular/As required
3. Oxycodone if confused on morphine

163

When are anti-resorptive agents commenced after a fragility fracture and what agents may we commence?

5 weeks
Oral alendronic acid
IV bisphosphonates

164

What features of a patient's history suggest a nerve root pain?

Unilateral leg pain
Paraesthesia in a dermatome
Leg pain worse than back pain
Abnormal neurology:
- Weakness
- Decreased reflexes

165

What ages might suggest a more serious spinal pathology?

55 years old

166

What features of a patient's past medical history may suggest a severe spinal pathology?

Cancer
TB
HIV
IVDU