Final MSK

Question 1

In patients with a history of intravenous drug use, what organism is the most common cause for osteomyelitis?

Salmonella spp.

S. aureus

P. aeruginosa

E. coli

Answer 1

In patients with a history of intravenous drug use, what organism is the most common cause for osteomyelitis?

Salmonella spp.

S. aureus

P. aeruginosa

E. coli

Question 2

Label A-C

Answer 2

Sequestrum: Refers to a dead piece of devitalised bone that has been separated (i.e. sequestered) due to necrosis from the surrounding bone.

Involucrum: New growth of periosteal bone around a sequestrum.

Cloaca: An opening in an involuvcrum that allows the internal necrotic bone and pus to discharge out.

Question 4

Describe the treatment for osteomyelitis [3]

Answer 4

Antibiotics +/- surgical debridement forms the mainstay of management.

Abx:
- Should be held until bone cultures are completed
- Guided by microbiology
- BNF: flucloxacillin for 6 weeks; possibly with rifampicin or fusidic acid added for the first 2 weeks
- Chronic osteomyelitis usually requires 3 months or more of antibiotics.
- Clindamycin in penicillin allergy
- Vancomycin or teicoplanin when treating MRSA

Surgery:
- More common in non-haem. spread
- infected necrotic bone must be removed
- Irrigation & debridement - sequestrum must be eliminated from the body, or infection is likely to recur; replace dead bone and scar tissue with vascularized tissue

Question 5

Describe investigations for septic arthritis? [2]

Answer 5

Joint aspiration is key and should be obtained prior to antibiotics (whenever possible):
- Also decompresses joint space
- synovial fluid appearance: often yellow/green and turbid on aspiration compared to uninfected fluid which is clear and usually colourless.
- Cultures of synovial fluid in cases of gonococcal septic arthritis yield positive results in only 25% of cases.
- Synovial fluid WCC: is often raised with neutrophil predominance. WBC: >50 000 cells/mm3 with Neutrophils: >75 %

Question 6

Describe the management plan for septic arthritis

Answer 6

First: rule out sepsis

In the management of septic arthritis in adults, according to UK guidelines, it is crucial to obtain a synovial fluid sample for analysis prior to initiating antibiotic therapy.

Empirical IV antibiotics should be given until the sensitivities are known. Often following are given:
* Flucloxacillin (often first-line)
* Clindamycin (penicillin allergy)
* Vancomycin (if MRSA is suspected)
* Ceftriaxone if gonorrhoea

Antibiotics are typically continued IV for 2 weeks before switching to PO if the patient is improving. Overall 4-6 weeks

Question 7

Describe the positions of a sequestrum vs a involucrum [2]

Answer 7

A sequestrum is the necrotic bone which has become walled off from its blood supply and can present as a nidus for chronic osteomyelitis.

An involucrum is a layer of new bone growth outside existing bone seen in osteomyelitis.

Question 8

Describe the treatment algorithm for osteoporosis [4]

Answer 8

First line: Bisphosphonates
- oral alendronate or risedronate weekly oral
- zoledronic acid - yearly infusion
- MOA: interfering with the way osteoclasts attach to bone, reducing their activity and the reabsorption of bone.

Second line: Denosumab:
- monoclonal antibody agaisnt RANK ligand, inhibits osteoclasts
- SC every 6 months
- can be used for osteoporosis in post-menopausal women or OP In men
- can be used for patients on steroids

Raloxifene
- Raloxifene is approved for the treatment and prevention of osteoporosis in postmenopausal women
- selective oestrogen receptor modulator (SERM)

HRT: unopposed oestrogen or O&P
- Prevention of fracture in women at high risk. It is normally reserved for use in younger women as the side effect profile is better.

Clinical scenarios
- if a patient is deemed high-risk based on a QFracture or FRAX score they should have a DEXA scan to assess bone mineral density (BMD): if T-score of - 2.5 SD or below start bisphosphinates
- A postmenopausal woman, or a man age ≥50 has a symptomatic osteoporotic vertebral fracture: above
start treatment straight away - oral bisphosphonates are used first-line e.g. alendronate or risedronate
- following a fragility fracture in women ≥ 75 years, a DEXA scan is not necessary to diagnose osteoporosis and hence commence a bisphosphonate

Question 9

Which groups are bisphosphinates CI in? [3]

Answer 9

Severe renal impairment (renally excreted)
Hypocalcaemia
Upper GI disorders

Smokers and dental disease should be cautioned because of jaw necrosis risk

Question 10

In which patient groups is raloxifene CI In? [1]

Answer 10

history of venous thromboembolism or if a patient has prolonged immobilisation due to risk of VTE

Question 11

Name three side effects of raloxifene [3]

Answer 11

Side effects include hot flushes, vaginal dryness and leg cramps.

NB: Raloxifene is a selective oestrogen receptor modulato

Question 12

Name two side effects of denosumab [2]

In which patient populations is it CI In? [3]

Answer 12

Side effects include cellulitis and hypocalcaemia

CI in hypocalcaemia and hypersensitivity and avoided in pregnancy.

Question 13

Name the clinical presentation of the hand signs of OA [5]

Answer 13

Heberden’s nodes (in the DIP joints)
Bouchard’s nodes (in the PIP joints)
Squaring at the base of the thumb (CMC joint)
Weak grip
Reduced range of motion

Question 14

Describe the medical management of OA

Answer 14

First line:
- NSAIDS (topical); w/ PPI. Hand: topical; Knee - topical; Hip - oral

Second line:
- oral NSAIDS

Third line - Intra-articular injections:
- corticosteroid injections for short-term pain relief in patients with moderate-to-severe knee OA and signs of local inflammation
- Hyaluronic acid (HA)

Surgery:
- Hip or knee replacement (Arthroplasty)
- Osteotomy (realignment)

NB: NICE guidance (NG 226) advise against hyaluronan injections (due to lack of evidence of efficacy), though some clinicians do use them, typically the patient must buy the medication privately.

Question 15

Answer 15

Phenytoin

Question 16

Management of Pagets? [+]

Answer 16

First line: Bisphosphinates
- Alendronic acid: This is often the first choice due to its favourable side effect profile and cost-effectiveness. It is typically given orally.
- Pamidronate and Zoledronic acid: These intravenous bisphosphonates may be used in patients who cannot tolerate oral bisphosphonates

Analgesics:
- Over-the-counter analgesics like paracetamol may be sufficient for some patients, but others may require stronger analgesics such as opioids.
- Nonsteroidal anti-inflammatory drugs (NSAIDs) may be beneficial for those with associated inflammatory arthritis.

Surgery:
- Pathological fractures: These may require surgical fixation to allow for proper healing and to reduce pain.
- Severe osteoarthritis or joint destruction: Joint replacement surgery may be considered in patients with severe joint damage.
- Neurological complications: For patients with nerve compression syndromes, such as spinal stenosis, decompressive surgery may be required.

Question 17

What are the non-musculoskeletal features of Paget’s disease? [3]

Answer 17

Skull enlargement can lead to complications such as hearing loss (most commonly), thought to be due to cochlear damage. They may also develop tinnitus because of nerve compression.

Rarely patients can develop osteosarcoma which might be suspected if their pain levels suddenly and significantly worsens.

From a cardiac perspective, patients are more likely to develop congestive heart failure, particularly if more than 40% of their skeleton is affected by the condition.

Question 18

What is the rare malignant complication of Paget’s disease? [1]

Answer 18

Osteosarcoma

Question 19

Neer impingment test assess which muscle

Supraspinatous
Teres minor
Teres major
Subscapularis
Infraspinatous

Answer 19

indicative of impingement of rotator cuff tendon/bursa against the coracoacromial arch: most commonly supraspinatous

Question 20

Jobe’s Test / Empty can test assesses

Supraspinatous
Teres minor
Teres major
Subscapularis
Infraspinatous

Answer 20

Supraspinatous

Question 21

A in this picture assesses which muscle? [1]

Supraspinatous
Teres minor
Teres major
Subscapularis
Infraspinatous

Answer 21

Subscapularis

Question 22

Resisted arm external rotation tests which muscle

Supraspinatous
Teres minor
Teres major
Subscapularis
Infraspinatous

Answer 22

Infraspinatous
Teres minor

Question 23

Which cancers that met to bone are sclerotic / lytic? [5]

Answer 23

PB KTL

Sclerotic —-> Lytic

NB: ProState = Sclerotic; Lung = Lytic

Question 24

What are the primary investigation for establishing the diagnosis of carpal tunnel syndrome? [1]

Answer 24

Nerve conduction studies (EMG) are the primary investigation for establishing the diagnosis:
- A small electrical current is applied by an electrode (nerve stimulator) to the median nerve on one side of the carpal tunnel
- Recording electrodes over the median nerve on the other side of the carpal tunnel record the electrical current that reaches them.

Question 25

# * What are the four rotator cuff muscles? [4] What movements do they cause? [4]

Answer 25

**S** – Supraspinatus – abducts the arm (first 20/30 degrees) **I**– Infraspinatus – externally rotates the arm **T** – Teres minor – externally rotates the arm **S** – Subscapularis – internally rotates the arm

Question 26

Describe the difference between intrinsic tendon degeneration versus impingement syndrome in rotator cuff injuries

Answer 26

**Intrinsic tendon degeneration** * Tendon hypo-perfusion of a watershed area * Repetitive micro-trauma **Impingement syndrome** can be classified as external, internal or secondary: **External** * **Compression** of **rotator cuff tendons** as they pass underneath the **coracoacromial arch** * Narrowing of this space can occur due to **osteophyte** formation, **bony** **spurs** or **malunion** after **fractures** **Internal** * Associated with **overhead** and **throwing** sports **activities** causing **small repetitive injuries** * **Under** surface **fraying** of **infraspinatus tendon** on the **posterior glenoid** * Increased association with **labral** **disorders** **Secondary** * **Glenohumeral** **instability** leads to **slight humeral head subluxation** * This **narrows** the **acromiohumeral interval**

Question 27

In those with suspected SAIS, two common examination signs can be elicited What are they? [2]

Answer 27

**Neer's impingement test** * Anterolateral shoulder pain reported during forward flexion with arm internally rotated **Hawkin's test** Forced internal rotation of an arm held at shoulder height and elbow bent at 90º causes anterolateral shoulder pain

Question 28

In those with suspected rotator cuff tendon tears, three common examination signs can be elicited What are they? [3]

Answer 28

**'Empty can test'** * Evaluates supraspinatus * Patient's raise their arm to 90º in the scapular plane * The arm is internally rotated (thumbs down) * Downward pressure is applied to their arm * Presence of weakness or pain indicates a tear **Posterior cuff test** * Evaluates infraspinatus * Weakness or pain on resisted external rotation suggests a tear **Gerber's lift-off test** * Evaluates subscapularis * Patient attempts to lift a hand from small of the back, while resistance is applied * Weakness or pain suggests a subscapularis tear

Question 29

Describe the managment plan for rotator cuff injuries

Answer 29

**Non-operative:** * **Rest** in the acute phase * Offer **paracetamol** as 1st line analgesia. If no benefit consider oral NSAID * Referral for a course (usually 6 weeks) of **physiotherapy** * Consider **subacromial corticosteroid injection** **Operative**: **Acromioplasty**: - Aims to increase the volume of the subacromial space, preventing mechanical irritation of the rotator cuff tendons **Rotator cuff repair**: - Aims to reattach the cuff tendons to the bone

Question 30

Describe the clinical presentation of adhesive capsulitis [4]

Answer 30

**Course of symptoms:** **Painful phase** – shoulder **pain** is often the first symptom and often **worse at night** **Stiff phase** – shoulder **stiffness** develops and affects both active and passive movement (external rotation is the most affected) – the pain settles during this phase **Thawing phase** – there is a gradual improvement in stiffness and a return to normal **Symptoms** * **external rotation is affected** more than internal rotation or abduction * both **active and passive movement** are **affected** * the episode typically **lasts between 6 months and 2 years**

Question 31

The main differentials in a patient presenting with shoulder pain not preceded by trauma or an acute injury are [3] Shoulder pain preceded by trauma or an acute injury may be due to [3]

Answer 31

**Pain with no trauma:** * **Supraspinatus tendinopathy** * **Acromioclavicular joint arthritis** * **Glenohumeral joint arthritis** **Pain** preceded by **trauma**: * **Shoulder** **dislocation** * **Fractures** (e.g., proximal humerus, clavicle or rarely the scapula) * **Rotator cuff tear**

Question 32

Describe shoulder anatomy that prediposes impingement syndrome [3]

Answer 32

**Impingement syndrome** is caused by **rotator cuff tendonitis** as the **tendons** pass **beneath** the **acromion**. The **supraspinatus** muscle’s tendon is most commonly affected. Patients with impingement syndrome often complain of pain when their arms are raised (this is particularly common in mechanics and manual labourers who work with their arms overhead). When the **arm** is **raised**, the **subacromial space narrows**, which can result in **impingement of the supraspinatus muscle tendon** leading to an **inflammatory** **response**.

Question 33

Typical findings on clinical examination in supraspinatus impingement syndrome include: [2]

Answer 33

* **Pain** **experienced** between **60-120°** of shoulder abduction (known as a ‘**painful arc**’). * **Weakness** and **pain** experienced when the supraspinatus muscle is isolated using the ‘**Empty can/Jobe’s test**

Question 34

What is the difference in treatment plan for displaced and undisplaced Boxer's fractures? [2]

Answer 34

Undisplaced, non-communicated: - **Ulnar gutter splint** Displaced: - **closed reduction, then plaster cast**

Question 35

Describe how you distinguish between supraspinatous tendonitis and adhesive capsulitis [2]

Answer 35

**Adhesive capsulitis** * Common in middle-age and diabetics * Characterised by painful, stiff movement * Limited movement in all directions, with loss of external rotation and abduction in about 50% of patients **Supraspinatus tendonitis** * (Subacromial impingement, * painful arc) Rotator cuff injury * Painful arc of abduction between 60 and 120 degrees * Tenderness over anterior acromion

Question 36

Describe the sensory [4] and motor [3] symptoms of radiculopathies

Answer 36

**Sensory**: - **Pain**: sharp, shooting, or electric-like and follows a dermatomal distribution - hallmark symptom - **Paresthesia** - **Numbness** - **Hypersensitivity** **Motor Symptoms**L: - **Muscle Weakness:** Depending on which nerve root is compressed, patients may experience weakness in specific muscle groups - **Muscle Atrophy:** In chronic cases where there has been ongoing nerve compression - **Fasciculations/Twitching**

Question 37

Describe the presentation for each lumbosacral radiculopathy (L1; L2-4; L5; S1)

Answer 37

**L1**: - sensory changes in the inguinal region **L2-4**: - **acute back pain** that radiates around the **anterior** **thigh** - **sensory** **changes** may be present over the **anterior thigh and medial lower leg** **L5**: - **acute back pain** that radiates down the **lateral aspect of the leg to the foot** - **sensory** **changes** may be present over the **lateral aspect of the lower leg and dorsum of the foot.** - **Motor** **weakness** is seen in f**oot dorsiflexion, big toe extension, and foot inversion/eversion** S1: - **acute back pain** that **radiates** down the **posterior aspect of the leg into the foot**. - **sensory** **changes** may be present over the **posterior leg and lateral foot**. - weakness may be present in **hip extension** and **knee** **flexion**. There may be a loss of the ankle reflex

Question 38

Several manoeuvres can be completed to determine whether the pain is radicular in origin (L1-S1), which includes [2]

Answer 38

**Straight leg raise for L5/S1 radiculopathy:** - worsening radicular pain on raising the leg with the knee extended. Pain should be relieved if the knee is flexed **Reverse straight leg raise for L2-4** **radiculopathy**: - worsening radicular pain on extending the leg with the patient prone ## Footnote NB: helps to differentiate between these and common peroneal nerve injuries

Question 39

Describe the classic presentation of C5-C8 radiculopathie

Answer 39

**C5 radiculopathy**: - associated with **pain in the neck, shoulder, and scapula**. - **sensory loss** is usually seen in the **lateral aspect of the upper arm** - **weakness** in **shoulder** **abduction**. *Biceps and brachioradialis reflexes may be affected* **C6 radiculopathy:** - associated with **pain** in the **neck, shoulder, scapula, and lateral arm, forearm, and hand**. - **Sensory loss** in the **lateral forearm, thumb, and finger** (pointing a gun). - Weakness may be seen in **elbow flexion and supination/pronation**. *Biceps and brachioradialis reflexes may be affected* **C7 radiculopathy**: - associated with **pain in the neck, shoulder, hand, and middle finger**. - sensory loss in the **palm**, **middle**, and **index** **finger**. - weakness is usually seen in **elbow and wrist extension**. *Triceps reflex may be affected* **C8 radiculopathy:** - associated with **pain in the neck, shoulder, medial forearm, hand, and 4th/5th fingers.** - **sensory** **loss** in the **medial** **forearm, hand, and 4th/5th digits** - **weak finger movements**

Question 40

There are several important signs may be present that are suggestive of the involvement of the cervical cord (i.e. cervical myelopathy). What are they? [4]

Answer 40

**Lhermitte phenomenon:** - shock-like paraesthesia radiating down the spine and towards the legs that occur on neck flexion **Gait disturbance** **Upper motor neuron signs in the lower limbs** (e.g. increased tone, weakness, clonus, upgoing plantar) **Bladder/bowel dysfunction**

Question 41

How do you investigate radiculopathies? [+]

Answer 41

**Imaging**: - **MRI**: first line as gives high-resolution images of the spinal cord, nerve roots, and surrounding structures - **CT** - **X-ray** - can reveal osteophytes causing compression **Nerve conduction**: assess the speed at which nerves transmit signals. **EMG**: measures electrical activity within muscle fibres, providing insights into how well muscles respond to nerve stimulation. **Lab tests:** - **Serology** - if vasculitis or Lyme disease the cause - **CSF analysis**

Question 42

Describe the management plan for radiculopathies

Answer 42

**Pharmalogical treatment:** * **NSAIDs** are the first-line treatment for pain relief * **Corticosteroids** may be used orally or via epidural injections in cases resistant to NSAIDs - **this is both diagnostic and therapeutic. If this works to relieve pain, then know its the correct cause of pain** * **Gabapentinoids, tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs)** can be considered for neuropathic pain **Physical Therapy** **Lifestyle Modifications** **Surgical Interventions**: * Open discectomy or microdiscectomy * Disc fusion * Laminectomy

Question 43

The spinal nerves **[] – []** come together to form the **sciatic nerve.** Describe the path of sciatic nerve [3]

Answer 43

The spinal nerves **L4 – S3** come together to form the **sciatic nerve.** Pathway: - **sciatic nerve** exits the **posterior** part of the pelvis through the **greater sciatic foramen**, in the buttock area on either side - It travels **down the back of the leg**. - At the **knee**, it divides into the **tibial nerve and the common peroneal nerve**.

Question 44

Where does the sciatic nerve supply sensation to? [2] Where does the sciatic nerve supply motor function to? [3]

Answer 44

The sciatic nerve supplies sensation to the **lateral lower leg and the foot**. It supplies **motor function to the posterior thigh, lower leg and foot**.

Question 45

What are the three main causes of sciatica? [3]

Answer 45

**Herniated disc** **Spondylolisthesis** (anterior displacement of a vertebra out of line with the one below) **Spinal stenosis**

Question 46

Describe a test can perform to diagnose sciatica [1]

Answer 46

The **sciatic stretch test**: - The patient lies on their back with their leg straight. - The examiner lifts one leg from the ankle with the knee extended until the limit of hip flexion is reached (usually around 80-90 degrees). - Then the examiner dorsiflexes the patient’s ankle. - Sciatica-type pain in the buttock/posterior thigh indicates sciatic nerve root irritation. - Symptoms improve with flexing the knee.

Question 47

What is the STarT Back Screening Tool? [1] How does this tool inform management plans? [3]

Answer 47

**Tool used to stratify the risk of a patient presenting with acute back pain developing chronic back pain**. This helps guide the intensity of the initial interventions (e.g., referral for group exercises, physiotherapy and cognitive behavioural therapy). * **Low risk patients**: can be managed with reassurance and encouragement to remain active, early managed return to work and simple analgesia * **Medium risk patients**: should be managed as per low risk in addition to offering a referral to physiotherapy * **High risk patients**: should be referred to psychologically informed physiotherapy.

Question 48

How do you manage generalised back pain? [+]

Answer 48

**First line analgesia**: - NSAIDS (+PPI) - Codeine / dihydrocodeine/ tramadol **Other management strategies** For patients at higher risk of poor outcome, NICE recommends considering the following: * Referral to a group exercise programme * Referral to physiotherapy for manual therapy * Referral for CBT as part of a treatment package including exercise +/- manual therapy **Radiofrequency denervation** NICE advises consider referral for radiofrequency denervation in patients with chronic back pain where: * The patient has failed to respond to non-surgical treatment * The main source of pain is thought to be related to structures supplied by the medial branch nerve * The pain is rated as 5 or more on a visual analogue scale or equivalent

Question 49

What is the managment plan if muscle spasms are thought to be the primary issue causing back pain? [1]

Answer 49

A short course (2-5 days) of **diazepam** may be used. Initially this should be 2mg diazepam to be taken as required up to three times a day. The dose can be titrated up to 5mg tds if required.

Question 50

Describe the management plan of sciatica [3]

Answer 50

**NSAIDS** first line **Codeine** / **dihydocodeine** **Amitriptyline** or **Duloxetine** (but not gabapentin or pregabalin)

Question 51

Describe the anatomy of the cauda equina [1]

Answer 51

The **cauda equina** is a collection of nerve roots that travel through the spinal canal after the spinal cord **terminates** around **L2/L3.** The spinal cord tapers down at the end in a section called the **conus medullaris.**

Question 52

**Conus medullaris syndrome (CMS)**: The conus medullaris is the tapered end of the spinal cord which spans from T12-L2. Injuries to the lumbar vertebrae may result in compression of the conus medullaris, resulting in symptoms. How would you differentiate this to CES? [2]

Answer 52

**CMS** differences: **Sudden onset** (typically after injury to the back); **Patients have a mix of upper and lower motor neurone signs** with hyperreflexia, weakness and fasciculations often being present. - More **lower** **back** **pain** - **motor** **strengh** **loss** is more **symmetrical** **CES** is **slower** **onset** - - **motor** **strengh** **loss** is more **asymmetrical** **Big differentiator:** - **CMS**: **Reflexes** are **mixed** - **brisk** **below** the **level** of lesion; **reduced** **above** the **level** of lesion - **CES**: **diminshed**

Question 53

Which patients with CES would not be suitable for sugery? [3] How would you treat them instead? [3]

Answer 53

Inflammatory disease such as **late stage ankylosing spondylitis** * These patients may benefit from **steroids** **Infection** * These patients will be treated with **antibiotics** **Spinal neoplastic disease** which is not suitable for surgical removal or where surgical removal was incomplete * These patients should be given **IV** **dexamethasone** and be evaluated for chemo-radiotherapy

Question 54

What are the three types of spinal stenosis [3]

Answer 54

**Central stenosis** – narrowing of the central spinal canal **Lateral stenosis** – narrowing of the nerve root canals **Foramina stenosis** – narrowing of the intervertebral foramina

Question 55

How does central lumbar stenosis differ to lateral and foramina stenosis [1]

Answer 55

**Lateral stenosis and foramina stenosis in** the lumbar spine tends to cause symptoms of **sciatica** (*unilateral pain from the buttock radiating down the back of the thigh to below the knee or feet.*) **Intermittent neurogenic claudication** is a key presenting feature of lumbar spinal stenosis with central stenosis. It is sometimes referred to as pseudoclaudication. Typical symptoms are:

Question 56

Describe the management of LSS [3]

Answer 56

**Conservative management:** - NSAIDS; paracetamol; opoids - Physio - Epidural injections - temporary pain relief **Decompression surgery**: removing bone or ligament tissue and relieving nerves **Spinal fusion**: This procedure stabilises the spine by fusing two or more vertebrae together using grafts or hardware.

Question 57

The most common location for sarcoma to metastasise to is the **[]**.

Answer 57

The most common location for sarcoma to metastasise to is the **lungs**.

Question 58

What nerve roots are affected in saddle anaesthesia? [1]

Answer 58

Saddle anaesthesia is a loss of sensation of the perineal area. This is due to cauda equina syndrome, where **L2-L5 nerve roots** coming off the spinal cord (cauda equina) are compressed. This is also an emergency.

Question 59

What is the most common non-haematological malignancy in children?

Answer 59

Osteosarcoma

Question 60

Which form of cancer typically shows a **moth-eaten pattern of bone destruction**? [1]

Answer 60

**Chondrosarcoma**

Question 61

Giant cell tumours: - what x-ray changes? [1] - Which population? [1]

Answer 61

Bubble wrap / soap bubble signs 20-40 yr olds

Question 62

Describe the clinical features of olecranon bursitis

Answer 62

**non-septic olecranon bursitis**: - **swelling over the olecranon process**; tenderness and erytheme also common **Septic bursitis:** - tenderness over the bursa (92-100%) -fever (40%) **TOMTIP**: Movement at the elbow joint should be painless until the swollen bursa is compressed in full flexion.

Question 63

How do you investigate for CS?

Answer 63

Clinical findings **ICP measurement** - is performed using a specialised device that measures the pressure within the muscle compartment. - The normal resting pressure in a relaxed muscle compartment **should be less than 10 mmHg.** - A differential diagnosis can be made if **ICP is >30 mmHg** or if there is a **delta pressure (diastolic blood pressure - ICP) of < 20-30 mmHg.** **Creatine kinase** - elevated (but not specific) **Urinalysis**: **Myoglobinuria**

Question 64

Describe what is meant by Volkmann's contracture [1]

Answer 64

A permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers. The persistent ischaemia leads to necrosis of muscle tissue resulting in shortening and fibrosis, hence causing a claw-like deformity.

Question 65

Why do CS patients require aggressive IV fluids? [1]

Answer 65

**Myoglobinuria** may occur following fasciotomy and result in **renal failure** and for this reason these patients require aggressive IV fluids

Question 66

Why might compartment syndrome lead to a patient having low Na? [1]

Answer 66

**Syndrome of inappropriate antidiuretic hormone secretion (SIADH)**: - Although rare, SIADH has been reported in patients with severe compartment syndrome. - It results from an abnormal response to stress causing excessive release of antidiuretic hormone leading to hyponatraemia.

Question 67

Describe where trochanteric bursitis occurs [1]

Answer 67

Trochanteric bursitis refers to inflammation of a **bursa** over the **greater trochanter on the outer hip.**

Question 68

How do you test for trochanteric bursitis?

Answer 68

**Trendelenburg test** - Ask to stand on affected side - Otherside drops down = positive **Resisted abduction, internal and external rotation of hip**

Question 69

Describe the presentation of trochanteric bursitis [3]

Answer 69

Lateral (outer hip) thigh pain that may radiate down outer thigh Aching or burning pain - worse with activity, standing after sitting or sitting crossed legged Tenderness over greater trochanter but NO swelling Often painful when sleeping on them

Question 70

The popliteal fossa is the diamond-shaped hollow area formed by the [4]

Answer 70

**Semimembranosus and semitendinosus** tendons (superior and medial) **Biceps femoris tendon** (superior and lateral) **Medial head of the gastrocnemiu**s (inferior and medial) **Lateral head of the gastrocnemius** (inferior and lateral)

Question 71

What is the underlying pathophysiology of Baker's cysts? [4]

Answer 71

In adults, Baker’s cysts are usually **secondary to degenerative changes** in the knee joint. They can be associated with: * **Meniscal tears** (an important underlying cause) * **Osteoarthritis** * **Knee injuries** * **Inflammatory arthritis** (e.g., rheumatoid arthritis) **Synovial fluid** is **squeezed** out of the knee joint into the **popliteal** **fossa**

Question 72

Describe what is meant by **Foucher’s sign** [1]

Answer 72

When knee fully extended (standing) - the fossa pops out When flexed to 45degrees - the cyst dissapears

Question 73

A ruptured Baker’s cyst can rarely cause **[]**

Answer 73

A ruptured Baker’s cyst can rarely cause **compartment syndrome.**

Question 74

Define what is meant by a **Baker's cyst** [1]

Answer 74

A Baker’s cyst is an **extension of the knee synovium** that develops between the **medial head of gastrocnemius and the semi-membranosus muscle**