Common MSK Swellings

Question 1

important questions in swelling history?

Answer 1

when did it appear - sudden or gradual?
trauma?
painful?
change in size?
systemic symotoms?
anything similar?
what functional problems does it cause?

Question 2

important examination features of a swelling?

Answer 2

site
shape
size
well defined?
consistency - fluctuant?
surface texture
mobile or fixed
temp
transluminable?
skin changes
local lymphadenopathy

Question 3

history features of an infective cause for swelling?

Answer 3

systemic upset
pyrexia
trauma
association with medical co-morbidities
rubor, calor, dolor, tumor

Question 4

how does cellulitis present?

Answer 4

generalised swelling rather than discreet lump
pain
erythema

Question 5

what commonly causes cellulitis?

Answer 5

Beta haemolytic strep

staph

Question 6

how is cellulitis managed?

Answer 6

rest
elevation
analgesia
splint
antibiotics (oral or IV)
- penicillin

Question 7

presentation of abscesses?

Answer 7

discreet collection of pus - defined and fluctuant swelling
erythema
pain
history of trauma

Question 8

how is an abscess managed?

Answer 8

surgical incision and drainage always
rest
elevation
analgesia
splint
antibiotics

Question 9

what causes septic arthritis?

Answer 9

bacterial infection of a joint - trauma or haematogenous spread
staph aureus
strep
E coli

Question 10

how does septic arthritis present?

Answer 10

acute monoarthropathy
reduced ROM +/- swelling
systemic upset
raised WCC + inflammatory markers

Question 11

how is septic arthritis managed?

Answer 11

urgent orthopaedic review
aspiration
urgent open/arthroscopic washout + debridement

Question 12

what is a ganglia?

Answer 12

outpouching of synovium lining of joints and filled with synovial fluid

Question 13

how does a ganglia present?

Answer 13

discreet round swelling
non-tender
<10mm - several cm
skin mobile, fixed to underlying structures
seen in wrists, feet and knees

Question 14

how is a ganglia managed?

Answer 14

nothing
NOT ASPIRATION
percutaneous rupture (hit it)
surgical excision

Question 15

what is a bakers cyst?

Answer 15

cyst/ganglion of the popliteal fossa

Question 16

how does a bakers cyst present?

Answer 16

general fullness of the popliteal fossa
soft and non-tender
associated with OA
painful rupture

Question 17

how is a bakers cyst managed?

Answer 17

non-operative

Question 18

what is bursitis?

Answer 18

inflammation of the synovium lined sacs that protect bony prominences and joints
can become secondarily infected and form an abscess

Question 19

how is bursitis managed?

Answer 19

NSAIDs/analgesia
antibiotics
incision and drainage (if secondary infection)
V. rarely needs excision

Question 20

what is gout?

Answer 20

inflammatory arthritis most commonly affected the great toe but can affect other joints - knee etc
caused by elevated serum urate resulting in a deposition of uric acid crystals in joints

Question 21

what is gout associated with?

Answer 21

purine rich food
alcohol
dairy

Question 22

how does gout present?

Answer 22

severe pain
red, hot swollen joint
can have acute attacks and chronic progressive joint damage

Question 23

how is gout diagnosed and treated?

Answer 23

diagnosis = clinical, aspiration - negatively befringed monosodium urate crystals

Question 24

how is gout managed?

Answer 24

NSAIDs
steroids
allopurinol

Question 25

what are rheumatoid nodules?

Answer 25

nodules around joints in RA patients | associated with repetitive trauma

Question 26

how are rheumatoid nodules managed?

Answer 26

don't respond to DMARDs excision of problematic recurrence high

Question 27

Bouchards vs Heberdens nodes?

Answer 27

``` bouchard = PIPs (OA or RA) heberdens = DIPs (only OA) ```

Question 28

what is dupuytrens disease and what causes it?

Answer 28

progressive disease of fascia causing digital flexion contractures excessive myofibril proliferation and altered collagen matrix composition lead to thickened and contracted palmar fascia type 3 collagen bands avascular process involving O2 free radicals

Question 29

3 contributing factors in dupuytens?

Answer 29

``` genetic predisposition (northern Europe, Men > women, AD) environmental factors (alcohol, diabetes, trauma) local and global protein expression ```

Question 30

how is dupuytrens managed?

Answer 30

``` depends on functional impediment needle fasciotomy collagenase injection limited fasciectomy dermofasciectomy + graft ```

Question 31

what is giant cell tumour of the tendon sheath?

Answer 31

regenerative hyperplasia with inflammatory process benign, common don't confuse with giant cell tumour of bone

Question 32

what are the 2 types of GCT of tendon sheath?

Answer 32

localised (common) | diffuse (rare)

Question 33

how does a GCT of tendon sheath present?

Answer 33

slowly enlarging firm discreet swelling on volar aspect of digits can occur in toes may or may not be tender

Question 34

how is GCT of tendon sheath managed?

Answer 34

leave alone if not causing issue | surgical excision if needed (often only marginal excision)

Question 35

what is an osteochondroma?

Answer 35

benign tumour most commonly occurring near the knee (distal femur or proximal tibia) cartilage capped ossified pedicle

Question 36

how does osteochondroma present?

Answer 36

``` hard, painless lump growth parallel to the patient pain and numbness on activity can rarely get pain from a fracture occurs in adolescence can have multiple tumours in multiple hereditary exostosis ```

Question 37

malignant potential in osteochondroma?

Answer 37

<1% | 5% in multiple hereditary exostosis

Question 38

how is osteochondroma managed?

Answer 38

close observation | surgical excision if needed

Question 39

what is ewings sarcoma?

Answer 39

malignant primary bone tumour of the endothelial cells in the marrow usually occurs at the diaphysis/metaphysis of long bones and pelvis

Question 40

how does ewings sarcoma present?

Answer 40

hot swollen tender joint or limb with raised inflammatory markers (mimics infection) ask about night pain and duration of symptoms

Question 41

how is ewings sarcoma managed?

Answer 41

poor prognosis surgical excision difficult often chemo and radio sensitive

Question 42

what is a lipoma?

Answer 42

benign neoplastic proliferation of fat | often subcutaneous

Question 43

how does a lipoma present?

Answer 43

``` can be discreet or less well defined slow growing and painless can be large soft, moveable mass no overlying skin changes ```

Question 44

how is a lipoma managed?

Answer 44

based on symptoms can be left alone surgical excision if causing symptoms

Question 45

what is a sebaceous cyst and how does it present?

Answer 45

originate at the hair follicle and fill with caseous keratin slow growing, painless, mobile discreet swellings can become infected

Question 46

how are sebaceous cysts managed?

Answer 46

excision if required

Question 47

what is myositis ossificans?

Answer 47

abnormal calcification of a muscle haematoma | usually initial trauma > initial small swelling > hardness develops over several weeks

Question 48

how is myositis ossificans diagnosed and managed?

Answer 48

diagnosis = X ray and MRI showing peripheral mineralisation management - observation - only intervene if symptoms - must wait until maturity of ossification otherwise risk of recurrence (6-12 months)