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Year 4/5 Revision > MSK > Flashcards

MSK Flashcards

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1
Q

Two main types of persistant pain disorders - fibromyalgia and CRPS. Define ACR criteria for FIbromyalgia:

A

Pain in >=9/18 joint pairs
Chronic pain >3 mo

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2
Q

Phyiscal (3) and mental sx (2) of fibromyalgia

A

Joint stiffness
Feeling of joint swelling
Fatigue
“fibro fog”
sleep disturbance

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3
Q

Strongest evidence based mx for fibromyalgia

A

Aerobic exercise

other mx - medical (Duloxetine/Pregabalin), analgesia, acupuncutre, CBT

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4
Q

Complex regional pain syndrome - what does the Budapest criteria involve?

A

Symptoms (1+) and signs (1+) - vasomotor (e.g. temperature asymmetry), sensory (allodynia/hyperaesthesia), motor (reduced range of motion) and oedema (asymmetry)

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5
Q

CRPS: distinguish type 1 and 2

A

Type 1 - absence of previous nerve injury
Type 2 - develops in presence of nerve injury, e.g. post #

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6
Q

Aims:
Reduction
Fixation

A

Reduction - acheive mechanical alignment of joint
Fixation - provide stability
General - 6-9 weeks of joint in fixed position to allow healing

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7
Q

Principles of # mx
* Initial assessment
* Managed in A&E or need admission?
* Mx of long bone # (3)
* General principle overall

A

Initial:
* Primary survey (A-E) –> Resus –> secondary survey
* Pain management
* XR (/CT)
* Manage in A&E (simple) or admitted (complex) - refer to trauma & ortho
Mx
* Reduction (closed or open) - alignment
* Fixation (conservative or operative) - stability & time for bone healing
* Rehab

Joint immobilisation for 6-weeks

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8
Q

Acute MSK pain mx

A

Ix - rule out #, dislocation, bleeding, neurovascular compromise (pulses, sensory, motor supply)
Mx - # (splint) , soft tissue (POLICE) + pain mx

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9
Q

Rotator cuff injury - a partial or full tear in one of the 4 muscles of shoulder. List the muscles & their main functions:

A
  • Supraspinatus - abduction
  • Subscapular - internal rotation
  • Infraspinatus & teres minor - external rotation

but all have multiple functions

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10
Q

“Painful arc syndrome”: where is the pain for
- impingement syndrome (supraspinatus tendonitis)
- Acromio-clavicular joint arthritis

A
  • 60-120, 170-180
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11
Q

Rotator cuff tear
Ex
Ix
Mx

A

Ex - E.g.
* supraspinatus: empty can test.
* drop arm test positive
* May also have impingement syndrome (painful arc between 60 - 120).
Ix -
* U/S is diagnostic
Mx -
* conservative (rest/adaptation/NSAIDs/physio), surgery (arthroscopic rotator cuff repair)

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12
Q

Shoulder: Capsule pathologies = OA and frozen shoulder.
30% of patients with frozen shoulder have which condition?
What is it also linked to?
F or M affected more?
It affects all active/passive movements but which the most?

A

DMT1
& metabolic syndrome
F>M, middle/old age
External rotation

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13
Q

Progression of frozen shoulder

A
  • 6 mo per phase
  • freezing –> frozen (stiff) –> thawing (reduced pain)
  • Can take years to resolve
  • May reqs referral for surgery if severe
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14
Q

Shoulder: Capsule pathologies = OA and frozen shoulder.
Joints affected by OA = acromio-clavicular and gleno-humeral.
Describe test for AC joint?

A

Scarf test

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15
Q

Shoulder dislocation
* Special test for shoulder instability?
* Associated defects (2)?
* Nerve damage causing reduced sensation in the regimental badge area?

A
  • Apprehension test (crank) - supine, arm abduction –> apprehension on external rotation
  • Hill Sachs defect (proximal humerus #) and the Bankart lesion - anterior labral tear
  • Axillary nerve
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16
Q

Shoulder dislocation - glenohumeral joint
* Special test?
* Associated defects (2)?
* Nerve damage causing reduced sensation in the regimental badge area?

A
  • Apprehension test (crank) - supine, arm abduction –> apprehension on external rotation
  • Hill Sachs defect (proximal humerus #) and the Bankart lesion - anterior labral tear
  • Axillary nerve
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17
Q

Ix & Mx shoulder dislocation
Lightbulb sign is indicative of?

A
  • XR / MRI for other lesions
  • Analgesia (Entonox), Reduction, Immobilisation
  • Posterior
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18
Q

Humeral fractures: - neurovascular risks for each
* surgical neck of humerus
* midshaft
* distal humerus (supracondylar) - most common elbow fracture in children

A
  • axillary nerve damage, and AVN if >1cm displaced
  • radial nerve damage
  • brachial artery injury (absent radial pulse), compartment syndrome (elbow swelling)
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19
Q

Olecranon bursitis = “student’s elbow”: swollen, warm and tender elbow joint.
What would you do if infection suspected?
How could you manage it?

A
  • Aspiration –> MC&S, crystals, gram staining
  • Aspirate fluid & abx if infected, or steroid injections, or conservative
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20
Q

Distal radius #s
Need to check if neurovascular compromised (median, ulnar, radial nerve)
distinguish Colle’s, Smith’s and Barton’s

A

1. Colles = FOOSH; dorsally (posterior) displaced distal radius; dinner fork, extra-articular
2. Smiths= fall backwards; garden spade, extra-articular
3. Barton’s= intra-articular # + disloation of radio-carpal joint

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21
Q

General mx distal radius #:
* Colles’
* Smith’s
* Barton’s / either if unstable:

A
  • Non-surgical; immobilise in case
  • Surgery
  • Surgery
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22
Q

Scaphoid # is most common wrist fracture, causing swelling & tenderness in anatomical snuff box, pain on movement and thumb telescoping.
Ix - scaphoid series.
If x-ray shows no injury what is the next step and why?
Mx for confirmed scaphoid fractures - if undisplaced or if displaced/affects proximal pole rather than waist ?

A
  • Splint
  • Re-xray after 10 days
  • risk of AVN due to disrupted radial artery blood flow(evident at later stage)

Mx
- Immobilisation with splint/back-slab and refer to ortho
- Cast 6-8weeks if undisplaced
- surgical fixation if displaced or proximal scaphoid pole

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23
Q

What are
Monteggias
Galaezzi’s
#s

GRUM

A

Fractures of the foream, with dislocations of the radio-ulnar joint
Galaezzi = distal radial #, FOOSH
Moteggias = proximal ulnar #

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24
Q

Classify #NOF into two categories:

A
  • Intracapsular = subcapital, transcervical, basicervical
  • Extracapsular = interotrochanteric, subtrochanteric up to 5cm distal
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25
Presentation and examination findings of #NOF
* Hip pain --> knee, unable to weight bear * O/E: **shortened, externally rotated & abducted leg**
26
What sign can be seen on XR for #NOF (intracpaulsar) & hip dislocation?
Disruption of Shenton's line ## Footnote Curved line between medial side neck of femur and inferior side of pubic ramus
27
Garden Classification for **intracapsular #NOF** (1-4)
1. Undisplaced; partial # 2. ", full 3. Displaced, partial 4. ", full
28
Mx of #NOF varies depending on type of # - what are the general principles? * Extracapsular (intero and subtrochanteric) * Undisplaced intracapsular (Garden I-II) * Displaced intracapsular (Garden III-IV)
* Extracapsular: internal fixation (intero - dynamic hip screw, sub - intramedullary nail) * Garden I-II: internal fixation * Garden III-IV: hemiarthroplasty (hip replacement) or total hip replacement **NICE RECOMMEND ARTHROPLASTY FOR ALL PATIENTS WITH DISPLACED INTRACEPSULAR FRACTURES - GARDEN III AND IV** ## Footnote Risk of **AVN with intracapsular #s**
29
Distiguish THR from hemiarthroplasty
THR - replacement of femoral head with prosthetic head **and acetabulum** (ball & socket) Hemi - just ball
30
3 complications of #NOF
* Hip dislocation * Peri-prosthetic # * Infection
31
O/E: Hip dislocation
Shortened, internally rotated and flexed leg
32
Trochanteric bursitits presents with gradual onset lateral hip pain that is worsened by activity. What examination findings would you expect?
* Positive Trendelenberg' sign (*hip dips on unaffected side*) * Pain on **resisted movement** - abduction and int/ext. rotation
33
Pelvic #s (pelvic ring/pelvic ramus) have a bimodal presentation - in young with high energy impacts or in elderly with low energy impacts. What sx must you be aware of, suggestive of an internal # or haematoma?
* Haematuria * PV bleeding * Loin eccyhmosis * Shock - hypovolaemia
34
List the Ottowa Knee Rules. | For XR
1945 - Knee-ver again! * Unable to flex knee to **9**0 degrees * * Isolated **Ten**derness of **patella** or **head of fibula* * Unable to walk 4 steps immediately after injury or in ED * >55
35
List the Ottowa Ankle Rules. Exclusions include - | For XR
Pain (in malleolar area) + bony tenderness (in medial/lateral mallelous or posterior edge of tibia) **or** inability to walk 4 steps/WB immediately after/in ED. Exclusions - >10 days injury, pregnancy, skin injury, <18.
36
Ottowa rules for Foot X-ray
Same as for ankle x-ray but with different anatomy. Pain in midfoot area + 1 of - bony tenderness in navicular bone or 5th metatarsal base - inability to wlk 4 steps or weight bear immediately/ in ED
37
Patella # - 2 types? - common MOI? - Mx?
* extra-articular or partial/full articular# * dashboard injury --> avulsion # * ORIF
38
Tibial plateu # MOI Schatzer classification (1-6) general
Knee forced into valgus or varum - bone breaks before ligmaent breaks 1-3 generally from low-energy impact 4-6 higher-energy except for Schatzer 4 = split fracture of medial condyle or osteoporotic fracture ## Footnote 1= #, 2= depressed, 3= both, 4= split, 5= bicondylar, 6 = dislocation
39
Ankle fracture - Dans Weber Classification - from most stable to least stable (aka requiring ORIF); * A * B * C Initial mx ## Footnote Other #s can have conservative mx - cast 4-6wks, serial X-rays and physio
A: below joint, tibiofindibular syndesmosis (TFS) intact B: at level of joint, TFS partially torn C: above joint, TFS disrupted Initial mx: Prompt reduction (reduce pressure on overlying skin + subsequent necrosis) - surgical or conservative mx
40
Metatarsal stress # - also known as March # - MOI - RF - Px - Most common metatarsal affected - Sign on x-ray - Mx options
* overuse injury & prolonged standing * female, eg. runners * dull ache that eases during exercise, but painful at beginning and afterwards (e.g. maintain ability to go on runs despite pain) * Grey cortex and periosteal erosion * conservative (avoid aggrevating activity) or cast * **2nd**
41
Lisfranc joint complex injuries * Can affect which areas of the foot? * MOI * x-ray findings (3) * Mx options (2)
* Lisfranc ligament, tarsal or metatarsal bones, other ligaments of the midfoot. Fracture or strain/tear. * Rotation whilst plantarflexed, strapping (think snowboarder/horse-rider in stirrups) * Widening between 1st and 2nd metatarsal, displacement of 2nd TMT joint, associated #s (Fleck) * Cast or ORIF
42
Achilles tendon injuries - distinguish * Tendinitis * Tendinosis * Tendinopathy
* inflammation of the tendon * microtears * general damage/swelling/reduced function
43
Risk factors for Achilles tendon rupture / tendinopathy (4)
Quinolones - *Ciprofloxacin, Levofloxacin* Inf. - RA/ank spond Diabetes Raised cholesterol
44
**Achilles tendon rupture** * example patient * triad of clinical findings * gold standard inv * mx
* middle aged man unaccostomed to exercise, sprinting, felt as if they were hit on calves + popping sound * (MR) Simmonds triad - Simmond's test +ve (x plantarflexion), Rests in dorsiflexion, palpable gap in heel * U/S * Cast with alteration from plantar flexion to neutral + rehab (or surgery)
45
Brachial plexus originates from which nerve roots? Roots -->
C5-T1 Roots, Trunks, Divisions, Cords, Branches
46
**Mononeuropathies - upper limb** Signs + cause of the following neuropathies: * Axillary: sensory, motor deficits (2)
**Axillary** * Loss of sensation in regimental badge, * X shoulder adduction * deltoid wasting * Shoulder dislocation, surgical neck of humerus #
47
Median neuropathy - name of pathology caused by compression to medial nerve - findings (motor, sensory) - causes of compression to extensor retinaculum - Ix (1) - mx (cons, medical, surgical) - cause of bilateral CTS
* Carpal Tunnel syndrome * motor: wasting of thenar eminence, weakness of thumb and 4/5th fingers; specifically **2LOAF** (lateral 2 lumbricals, opponens policis brevis, abducens policis, flexor policis) * sensory - paraesthesia of thenar eminence, palm --> 1/2 of 4th finger, dorsal 2-3rd finger tips * compression to the extensor retinaculum - oedema, pregnancy, obesity, diabetes. Wrist #. * Ix - nerve conduction studies * Mx - conservative (wrist splint, weight loss, physio); medical (CS injections); surgical: **flexor retinaculum division** * bilateral = RA
48
Radial neuropathy - Findings (sensory, motor) - Causes
* Dorsal paraesthesia (webbing); * Wrist drop; weakness in forearm extensors (triceps) * Midshaft # of humerus, wrist #
49
Ulnar neuropathy * Motor, sensory findings * Froment's test shows what? * Ulnar claw = * Cause
* Motor: Weakness of majority of muscles of the hand (Except 2LOAF) muscles; hypothenar eminence wasting * Paraesthesia of 1/2 ring finger and 5th and outer dorsum * Froment's - compensation for inability to adduct thumb - flexor policis longus causes hyperflexion of the DIP joint - check with removing piece of paper from grip * Ulnar claw = unable to extend 4/5th fingers * Cause - Klumpke's paralysis (C5-T1), wrist #
50
Musculocutaneous neuropathy (rare) typical cause
Axilla stabbing
51
The sciatic nerve branches into: 1. Common peroneal (fibular) nerve (--> superficial/deep branches) 2. Tibial nerve **Common peroneal nerve neuropathy** - supply from which spinal cord levels? - motor findings (for deep PNN and superficial) - sensory findings
supplied by L4, L5, S1 Foot drop: - Deep = x dorsiflex - Superfical = x eversion sensory loss over dorsum & lower lateral part of leg
52
The other branch off the sciatic nerve is the tibial nerve. **Tibial neuropathy** - Supplied by which spinal cord levels? - Motor findings - Sensory findings - Cause -
* L4, L5, S1, S2, S3 * Cant stand on tiptoes (x plantarflex); pes planus, pronated foot, abnormal gait * sensory = leg, foot * Tibial tunnel syndrome - pain of median ankle
53
**Meralgia paraesthetica **is lateral thigh pain & paraesthesia, caused by compression of which nerve? * From which nerve roots does it originate? * Sx can be ellicited on examination by compression of ? and extension of? * Important negative in MP * Mx - medical (2) * surgical (3)
* Lateral Femoral Cutaneous Nerve (LFCN) * L2, L3 * ASIS compression & Hip extension * No motor weakness; sensation symptoms only * Medical = Amitryptiline, CS injections * Surgical = 1. Decompression 2. Transection 3. Resection
54
Two types of Brachial Plexus injury 1. Affects superior trunk (C5,C6) 2. Affects inferior trunk (C8, T1)
* Erb's: causes wrist flexion and elbow pronation. Post shoulder distocia. * Klumpke's - causes ulnar claw and Horner's (if T1 affected). birth injury/difficult delivery.
55
Risk factors for AVNFH Findings on xray (3)
Long term steroid use , Alcohol abuse. Flattening of femoral head & irregular borders, osteopenia (reduced bone density), sclerosis.
56
Plantar fascitis - most common cause of adult heel pain Initial mx (3) And then refer to...
Rest, stretching & weight loss (if overweight) Orthotics - insoles/heel pads
57
**Back Pain Red Flags** * Cauda Equina * Spinal mets * Spinal infection * Ank spond
* urinary retenion/incontinece, faecal incontience, saddle anaesthesia, reduced anal tone * weight loss, localised bony tenderness, thoracic back pain * fever, IVDU * <40, M, progressive lower back pain, morning stiffness & pain at night
58
General mx for backpain **Conservative** - low/high risk **Medical** What drugs are specifically *not* recommended by NICE for lower back pain?
* Low severity - self help, exercise, reassurance * High severity - CBT, group exercise, physio. * Medical - NSAIDs --> Codeine --> Benzos short couse. * Not advised: neuropathic agents, opioids, antidepressants
59
**Sciatica - ** shooting pain down back of the leg Nerve roots affected? Causes? First line mx? If above fails after 4-6 weeks? Screen for?
* L3/L4 * disc prolapse, spinal stenosis, spondylosithesis * NSAID and physio * Referral - ?neuropathic agents or specialist treatment (e.g. CS/local anaesthetic injections) * bilateral sciatica - sign of cauda equina
60
**Name of disease & cause** Isolated rise in ALP. XR = osteoporosis circumstripta (lytic lesions), cotton wool spots, V shaped defects.
**Paget's disease of bone** Excessive bone turnover- but disordered bone modelling (uncoordinated activity of osteoblasts/osteoclasts resulting in patches of lysis and sclerosis)
61
Which bones does Paget's particularly affect? Mx?
* Axial skeleton - head (skull enlargement, hearing loss if bones of skull affected), spine (back pain) * Bisphosphonates, NSAIDs for pain & monitoring
62
2 main complications for Pagets
* Osteosarcoma * Spinal stenosis --> spinal cord compression
63
Cancers most likely to metastasize to bone (5)
Prostate Renal Thryoid Breast Lung | PoRTaBLe
64
Key presenting sx for central spinal stenosis ## Footnote stenosis = compression of the spinal cord (central), nerve root (lateral) or foramina (of the vertebral foramina)
Intermittent neurogenic claudication (presents like PVD but ABPI normal & pulses present)
65
Osteomyelitis * 2 modes of spread * Ix (2) * Mx (acute osteo & chronic)
* hematogenous (blood inf) & direct (op/open #) * XR (subtle changes) --> MRI (dx) * Acute - surgical debridement & abx (Fluclox +/- Rifampicin 2 week). Chronic - abx 3 mo.
66
XR changes for osteomyleitis (however may not be obvious for several weeks)
* Periosteal reaction * Localised osteopenia * Destruction of bone
67
Fever & back/flank pain & IVDU
Iliopsoas abscess
68
**Bone tumours** Malignant: * Osteosarcoma * Chondrosarcoma * Ewing's sarcoma *Which is the most common primary malignant bone tumour? * Benign: * Osteoma * Osteochondroma * Giant cell tumour
Key points/demographics for each: * Ewing's - pelvis/long bones, severe pain, onion skin (XR) * Chondrosarcoma - cartilage, axial skeleton, middle age * Osteosarcoma - **most common**, children/teens, long bones prior to epiphyseal closure. Codman triangle & Sunburst (XR). Rb mutation, radioX and Paget's (RF).

Year 4/5 Revision (21 decks)

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