MSK Flashcards
1
Q
What type of crystals are seen in aspiration of pseudogout? What are they made from?
A
Positively birefringent rhomboid crystals
Made from calcium pyrophosphate dehydrate crystals
2
Q
Which conditions pre-dispose to pseudogout, how do you image it?
A
Hyperparathyroidism, hemochromatosis and acromegaly
XR will show chondrocalcinosis
3
Q
Which blood test most accurately diagnoses RA?
A
Raised anti-CCP
4
Q
What is club foot? How do you correct it?
A
Inverted and plantar flexed foot which is not passively correctable.
Mx = manipulation and casting from birth
5
Q
What is a Colle’s fracture? Which nerve is commonly damaged and what motor function does this affect?
A
Dinner fork deformity due to a fall onto an outstretched hand
Affects the median nerve => inability to flex the thumb and index finger
6
Q
What is the most important complication of temporal arteritis? How do you visualise this?
A
Anterior ischaemic optic neuropathy. Fundoscopy will reveal a swollen pale disc with blurred margins
7
Q
How do you manage temporal arteritis?
A
If visual changes IV methylprednisolone
If no visual changes high dose oral prednisolone
8
Q
What is trigger finger? How do you manage?
A
Stiffness and snapping on extending the finger from flexed
A nodule may be felt at the base of the finger
Mx = steroid injection
9
Q
When should you suspect discitis?
A
With fever, severe lumbar spine pain restricting movement in an IVDU
10
Q
How does colchicine affect the bowels?
A
It can cause diarrhoea
11
Q
What is seen in a scaphoid #?
A
Swelling and tenderness of the anatomical snuff box, pain on wrist movement and on longitudinal compression of the thumb
12
Q
What is a Smith’s #?
A
Reverse Colle’s #, caused by falling backwards onto an outstretched hand or falling with a flexed wrist
13
Q
What is the initial management of a displaced #?
A
Closed reduction
14
Q
What is Felty’s syndrome?
A
RA, splenomegaly and a low WCC
15
Q
Sx of Polyarteritis Nodosa?
A
Fever, malaise, arthralgia, weight loss, HTN, haematuria, renal failure and livedo reticuaris
Often associated with hep B infection
16
Q
What should you do if you suspect spinal cord compression?
A
Urgent MRI vertebrae and spinal cord and give high dose dexamethasone
17
Q
What should you consider in a patient who is septic with a developing lower limb neurological defect?
A
Epidural abscess
18
Q
What is Charcot’s joint?
A
A swollen, red and warm weight bearing joint which is not as painful as you would expect.
XR will show osteolysis and joint dislocation
19
Q
Which conditions is Charcot’s joint associated with?
A
DM, alcoholic neuropathy, syphilis and cerebral palsy
20
Q
Which bone is most commonly affected in stress #s?
A
The 2nd metatarsal shaft
21
Q
What is the most commonly # metatarsal? What type of injury causes it?
A
The proximal 5th metatarsal
Caused by inversion of the ankle
22
Q
Which bug is the most common cause of discitis?
A
Staph. aureus
23
Q
What is pneuomnitis?
A
Cough, dyspnoea and fever associated with methotrexate
24
Q
Sx of spinal stenosis?
A
Gradual onset leg pain +/- back pain with numbness and weakness which is worse on walking and is resolved by sitting, crouching or leaning forward
25
What investigation is important to do if you suspect spinal stenosis?
MRI to confirm the diagnosis and exclude malignancy
26
What is the Webber classification of ankle #s? How does it affect management?
A = below the syndesmosis
B = at the syndesmosis
C = above the syndesmosis
A/B require a cast/boot and weight bear as tolerated
C open reduction and internal fixation
27
Should you continue steroids if the temporal artery biopsy is normal?
Yes
There can be skip lesions
28
When should you suspect avascular necrosis?
Anterior groin/hip pain which is worse on weight bearing but no morning stiffness in the presence of long term steroid use, chemotherapy or alcohol excess
29
Mx of an intracapsular hip #?
Undisplaced (Garden Grade 1/2) = internal fixation
Displaced (Garden Grade 3/4)= total hip replacement or hemiarthroplasty (do id patient was unable to walk independently with no more than 1 stick before #, if cognitive impairment or not medically fit for the anaesthetic or op)
30
Mx of an extracapsular hip #?
If intertrochanteric = dynamic hip screw
If reverse oblique, transverse or subtrochanteric = intramedullary device
31
Sx Ankylosing Spondylitis?
Reduced lateral and forward flexion of the spine
Reduced chest expansion
Anterior uveitis, Aortic regurg, Achilles tendonitis and AV node block
32
What will be grown on aspiration of a joint affected by reactive arthritis?
Nothing! Reactive arthritis joints are sterile
33
How does Giant cell arteritis most commonly present?
As temporal arteritis.
Unilateral severe headache, jaw claudication, scalp tenderness on light touch, blurred/double vision
34
What is seen on Ix of Giant cell Arteritis? What are some important SEs to be aware of?
Ix = Raised ESR and multinucleated giant cells on temporal artery biopsy
Important complications are aortic dissection and aortic aneurysm
35
What should you always suspect in an acutely red, hot and swollen joint with fever or sepsis Sx? Which joint is most commonly affected?
Septic arthritis!
Most commonly affects the knee joint!
36
Sx and Mx of compartment syndrome? Which type of fractures are highest risk?
Sx = pain on movement (even on passive movement e.g. when assessing tone) which is out of proportion with clinical findings, paraesthesia, pallor and normal X-ray
Mx = urgent fasciotomies and aggressive IV fluids
Supracondylar and tibial fractures are the highest risk
37
What are the common knee injuries, how do they present?
ACL injury = high twisting force applied to a bent knee, loud crack with pain and rapid joint swelling
PCL injury = hyperextension injuries
MCL = leg forced into a valgus position from a force outside the leg
Meniscus = rotational sports injuries, delayed knee swelling with joint locking
38
Describe the Sx of L3 nerve root compression?
Sensory loss of the anterior thigh
Weak quadriceps, reduced knee reflex and positive femoral stretch test
39
Describe the Sx of L4 nerve root compression?
Sensory loss on the anterior knee and medial malleolus
Weak knee extension and hip adduction, reduced knee reflex and positive femoral stretch test
40
Describe the Sx of L5 nerve root compression?
Sensory loss on the dorsum of the foot
Weak foot and big toe dorsiflexion, normal reflexes and a positive sciatic nerve stretch test
41
Describe the Sx of S1 nerve root compression?
Sensory loss on the posterolateral aspect of the leg and lateral foot, weak plantarflexion of the foot, reduced ankle reflex and a positive sciatic nerve stretch test
42
How should you manage a nerve root compression?
NSAIDs +/- PPIs
If symptoms persist beyond 4-6 weeks consider referring to neuro for consideration of MRI
43
Describe PMR?
Aching and morning stiffness of the proximal muscles but NO true weakness.
Ix = raised ESR and CRP, CK and EMG are normal
Mx = prednisolone, if this fails to dramatically improve Sx consider an alternative diagnosis
44
Ix and Mx of osteomyelitis? What is the most common causative organism?
Ix = MRI
Mx = Flucloxacillin for 6 weeks (Clindamycin if penicillin allergic)
Staph aureus is the most common causative organism except in those with sickle cell, then it is Salmonella
45
Mx of SLE?
Hydroxychloroquine, NSAIDs and sun cream
46
How does a posterior hip dislocation present?
A shortened and internally rotated leg, often secondary to RTA
47
What are Gottron's papules? What condition can they be seen in, describe it?
Gottron's papules are roughened red papules over the extensor surfaces of the fingers seen in dermatomyositis.
Other symptoms include rash, photosensitivity and muscle weakness/tenderness
Once diagnosed screen for underlying malignancy
48
What are some important blood tests used in SLE?
ANA is highly sensitive but not very specific
Anti-dsDNA is highly specific but not very sensitive
Complement C3/C4 are low in active disease
Raised CRP may indicate underlying infection
49
Mx of RA flares?
Corticosteroids (may be oral or IM)
50
Mx Septic Arthritis?
IV flucloxacillin 1st line, IV clindamycin if pen allergic.
Give 2/52 IV and then 2-4/52 PO
51
Mx of acute reactive arthritis?
NSAIDs. If these fail consider steroid injections
52
Describe osteomalacia?
Bone pain/tenderness, muscle tenderness, proximal myopathy which may cause a waddling gait.
Ix = low vitamin D, calcium and phosphate, raised ALP and PTH. X-ray will show translucent bands
Mx = vitamin D supplements +/- calcium supplements
53
What will the bone profile of osteoporosis look like? How do you treat?
Normal ALP, calcium, phosphate and PTH
Mx = bisphosphonates
54
Do women >75 with fragility fractures need a DEXA scan?
No, start immediately on bisphosphonates
55
Describe osteoarthritis?
Asymmetrical arthritis commonly affecting joints inc. the DIPJs and Carpometacarpal joints (can lead to squaring of the thumbs keeping them in fixed adduction)
XR = Loss of joint space, Osteophytes, Subchondral sclerosis and Subchondral cysts
56
Sx of Antiphospholipid syndrome?
Often occurs secondary to SLE
Sx = venous/arterial thrombosis, recurrent miscarriages, pre-eclampsia, pulmonary HTN and livedo reticularis
57
Ix and Mx of Antiphospholipid syndrome?
Ix = raised APTT and thrombocytopenia
Anticardiolipin antibodies, anti Beta2 GPI antibodies and lupus anticoagulant
Mx = low dose aspirin, after 1st clot switch to life long warfarin
58
Which T score is an indication for bisphosphonates?
<-1.5
59
Describe the joint aspirate in RA?
Yellow/cloudy joint fluid with no crystals, increased WCC (mainly neutrophils).
The aspirate in septic arthritis is very similar except the patient will be systemically unwell
60
How can compartment syndrome lead to AKI?
Raised myoglobin secondary to rhabdomyolysis becomes stuck in the kidneys and causes AKI
61
Describe osteogenesis imperfecta?
AD condition causing brittle bones which # after minor trauma, blue sclaera, deafness and dental imperfections.
Presents in childhood.
Bone profile is fully normal
62
Name a late sign of cauda equina which may indicate irreversible damage?
Incontinence
63
How does synovitis present?
A tender, erythematous and boggy joint swelling
64
What test should you do on all patients with ?septic arthritis?
Synovial fluid sampling
65
What movement is mainly impaired in adhesive capsulitis?
External rotation (passive and active)
66
What is seen in diffuse systemic sclerosis?
Scleroderma (tightening and fibrosis of the skin), Raynaud's and respiratory symptoms
It is associated with anti-SCL-70 and anti-topoisomerase antibodies
Start patients on an ACEi
67
What is seen in CREST syndrome?
Calcinosis (hard calcified nodules under the skin), Raynaud's, oEsophageal dysmotility, Sclerodactyly (tightening of the skin over the fingers causing them to curl inwards) and Telangiectasia (dilated prominent capillaries especially in the cheeks)
Associated with anti-centromere antibodies
68
What are the commonest type of intracapsular hip #s?
Subcapital hip #
69
Describe Paget's disease of bone?
Excessive bone turnover resulting in bone pain/deformity, #s and hearing loss
X-ray shows V shaped deformities of the long bones, cotton wool appearance of the skull and osteoporosis circumscripta
Normal calcium, phosphate and PTH but raised ALP
Mx = bisphosphonates, NSAIDs and calcium/vitamin D supplements
70
How should you manage rib # pain which is not controlled by IV morphine?
Regional nerve block
If there is a flail segment urgently offer surgical fixation and invasive ventilation
71
Describe Sjogren's syndrome?
Presents with dry eyes/mouth, arthralgia and Raynaud's
Ix = Rheumatoid factor and ANA positive, Perform Schirmer's test
Mx = artificial tears and pilocarpine
There is a marked increased risk of developing lymphoma
72
Describe a baker's cyst?
An asymptomatic fluctuating swelling behind the knee - often seen in children
73
Describe Type 1 hypersensitivity reaction?
Anaphylactic
IgE mediated
Anaphylaxis, Asthma, Eczema and Hayfever
74
Describe Type 2 hypersensitivity reaction?
Cell bound
IgG/IgM mediated
Pernicious Anaemia, ITP, Goodpasture's, Rheumatic Fever and Autoimmune Haemolytic Anaemia
75
Describe Type 3 hypersensitivity reaction?
Immune complex
IgG and IgA mediated
SLE, Post-Streptococcal Glomerulonephritis, Serum Sickness and Extrinsic Allergic Alveolitis
76
Describe Type 4 hypersensitivity reaction?
Delayed Hyper-Sensitivity
T cell mediated
TB, MS, GBS, Contact Dermatitis and Scabies
77
Describe Type 5 hypersensitivity reaction?
Stimulatory Hypersensitivity
MG and Grave's
78
What should you do with a child presenting with unexplained bony pain/swelling?
Very urgent X-ray to look for bony sarcoma
79
How do we investigate cruciate ligament/meniscal injuries?
MRI
80
A patient presents with a knee injury, they describe hearing a popping sound and are now unable to fully extend their knee (it is locked in flexion) what is the likely injury?
Meniscal tear
81
What may be seen in a posterior hip dislocation?
Adducted hip with a shortened limb which is internally rotated
There may also be damage to the sciatic nerve
82
Which drug commonly can cause pulmonary fibrosis?
Methotrexate
83
What should you do before starting a biologic drug e.g. in RA?
Do a CXR to exclude TB (biologics can cause its reactivation)
84
Describes the signs of biceps rupture?
Sudden pop/tear at the shoulder or antecubital fossa followed by pain, bruising and swelling. Bulge in the middle of the arm (Popeye deformity) and shoulder/elbow weakness (particularly in supination) are seen
85
True or false, definitive Mx of an open # should be delayed until the soft tissues have recovered?
TRUE
86
Early and late x-ray findings in RA?
Early = loss of joint space, juxta-articular osteopenia/osteoporosis and soft tissue swellings
Late = joint erosions and subluxation
87
What is seen on X-ray in osteosarcoma?
Codman triangle (triangle of new periosteal bone formation) with sunburst appearance
88
True or false, osteosarcoma is associated with retinoblastoma?
True
89
What is De Quervain's Tendonitis?
Pain at the base of the thumb without squaring of the thumb (squaring would point more to OA)
90
What should you consider in all housebound patients?
Daily vitamin D
91
What condition is PMR strongly associated with?
GCA. They can occur concurrently
92
What is seen in sciatic neuropathy?
Loss of knee flexion and power below the knee, loss of ankle jerk and the plantar response
93
What is the most common cardiac manifestation of SLE?
Pericarditis
94
Sx of Lateral epicodylitis?
AKA tennis elbow
Pain worse on extension of the wrist against resistance and pain on supination of the wrist whilst the elbow is extended
95
What is Plantar fascitis?
The most common cause of heel pain in adults
Mx = rest, stretching and weight loss
96
What is a marker of poor prognosis in RA?
Anti-CCP
97
What is iliotibial band syndrome?
A common cause of knee pain in runners - tenderness is seen above the lateral joint line (e.g. the lateral femoral epicondyl)
98
Name 2 complications of systemic sclerosis? How do you treat the condition?
HTN and AKI
Mx = ACEi
99
What is osteochondritis dessecans?
Knee pain and swelling in young people after exercise, knee catches/locks/gives way. There is a painful clunk on extension/flexion of the knee with joint effusion
100
How does spinal stenosis affect walking?
Symptoms mimic claudication on walking, patients find it easier to walk down hill but difficult to walk up hill
101
How are ANA and anti-dsDNA used in diagnosing SLE?
ANA is highly sensitive, if it is negative the patient does NOT have SLE
Anti-dsDNA is highly specific, if it is positive the patient DOES have SLE
102
What are sensitive/specific tests best for doing?
Sensitive tests are best for ruling things out
Specific tests are good for ruling things in
103
What is meant by 'dorsally displaced distal radius'?
Dinner fork deformity, seen in colles #
104
You should use sulfasalazine with caution in patients allergic to what drug?
Aspirin - they are often reactive to both
105
What is cubital tunnel syndrome?
Compression of the ulnar nerve as it runs through the cubital tunnel (on the inside of the elbow)
Tingling and numbness in the 4th and 5th fingers, over time weakness and muscle wasting may occur.
Pain is worse on leaning on the effected elbow
106
What most commonly causes septic arthritis?
Staph. aureus
In young sexually active adults it is often caused by N. gonorrhoea
107
What should you do with patients who suffer GI side effects on alendronate?
Switch to risedronate or etidronate
108
Mx of prolapsed disc?
Analgesia and physio. If no improvement after 4 weeks consider sending for an MRI
109
What happens if you give trimethoprim to someone on methotrexate?
Pancytopenia - this can be fatal
110
What antibodies are seen in dermatomyositis?
Anti-Jo-1-antibodies, anti-M2-antibodies and SRP antibodies
Also ANA however this is not very specific
111
What is the bone profile like in primary, secondary and tertiary hyperparathyroidism?
Primary = raised calcium, low phosphate, raised PTH and raised ALP
Secondary = low/normal calcium, raised phosphate, raised PTH and raised ALP - low vitamin D
Tertiary = raised/normal calcium, low/normal phosphate, raised PTH and raised ALP - low/normal vitamin D
112
Which fingers are most commonly affected in Dupuytren's contracture? When should you consider surgical management?
Most commonly affects the ring or little finger. Consider surgical management when the MCP joints cant be straightened (the hand can not be placed flat on a table)
