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Year 4/5 Revision > MSK > Flashcards

MSK Flashcards

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
Q

Presentation and examination findings of #NOF

A
  • Hip pain –> knee, unable to weight bear
  • O/E: shortened, externally rotated & abducted leg
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26
Q

What sign can be seen on XR for #NOF (intracpaulsar) & hip dislocation?

A

Disruption of Shenton’s line

Curved line between medial side neck of femur and inferior side of pubic ramus

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27
Q

Garden Classification for intracapsular #NOF (1-4)

A
  1. Undisplaced; partial #
  2. ”, full
  3. Displaced, partial
  4. ”, full
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28
Q

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)

A
  • 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

Risk of AVN with intracapsular #s

29
Q

Distiguish THR from hemiarthroplasty

A

THR - replacement of femoral head with prosthetic head and acetabulum (ball & socket)
Hemi - just ball

30
Q

3 complications of #NOF

A
  • Hip dislocation
  • Peri-prosthetic #
  • Infection
31
Q

O/E: Hip dislocation

A

Shortened, internally rotated and flexed leg

32
Q

Trochanteric bursitits presents with gradual onset lateral hip pain that is worsened by activity. What examination findings would you expect?

A
  • Positive Trendelenberg’ sign (hip dips on unaffected side)
  • Pain on resisted movement - abduction and int/ext. rotation
33
Q

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?

A
  • Haematuria
  • PV bleeding
  • Loin eccyhmosis
  • Shock - hypovolaemia
34
Q

List the Ottowa Knee Rules.

For XR

A

1945 - Knee-ver again!
* Unable to flex knee to 90 degrees
* * Isolated Tenderness of patella or **head of fibula*
* Unable to walk 4 steps immediately after injury or in ED
* >55

35
Q

List the Ottowa Ankle Rules.
Exclusions include -

For XR

A

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
Q

Ottowa rules for Foot X-ray

A

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
Q

Patella #
- 2 types?
- common MOI?
- Mx?

A
  • extra-articular or partial/full articular#
  • dashboard injury –> avulsion #
  • ORIF
38
Q

Tibial plateu #
MOI
Schatzer classification (1-6) general

A

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

1= #, 2= depressed, 3= both, 4= split, 5= bicondylar, 6 = dislocation

39
Q

Ankle fracture - Dans Weber Classification - from most stable to least stable (aka requiring ORIF);
* A
* B
* C
Initial mx

Other #s can have conservative mx - cast 4-6wks, serial X-rays and physio

A

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
Q

Metatarsal stress # - also known as March #
- MOI
- RF
- Px
- Most common metatarsal affected
- Sign on x-ray
- Mx options

A
  • 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
Q

Lisfranc joint complex injuries
* Can affect which areas of the foot?
* MOI
* x-ray findings (3)
* Mx options (2)

A
  • 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
Q

Achilles tendon injuries - distinguish
* Tendinitis
* Tendinosis
* Tendinopathy

A
  • inflammation of the tendon
  • microtears
  • general damage/swelling/reduced function
43
Q

Risk factors for Achilles tendon rupture / tendinopathy (4)

A

Quinolones - Ciprofloxacin, Levofloxacin
Inf. - RA/ank spond
Diabetes
Raised cholesterol

44
Q

Achilles tendon rupture
* example patient
* triad of clinical findings
* gold standard inv
* mx

A
  • 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
Q

Brachial plexus originates from which nerve roots?
Roots –>

A

C5-T1
Roots, Trunks, Divisions, Cords, Branches

46
Q

Mononeuropathies - upper limb
Signs + cause of the following neuropathies:
* Axillary: sensory, motor deficits (2)

A

Axillary
* Loss of sensation in regimental badge,
* X shoulder adduction
* deltoid wasting
* Shoulder dislocation, surgical neck of humerus #

47
Q

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

A
  • 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
Q

Radial neuropathy
- Findings (sensory, motor)
- Causes

A
  • Dorsal paraesthesia (webbing);
  • Wrist drop; weakness in forearm extensors (triceps)
  • Midshaft # of humerus, wrist #
49
Q

Ulnar neuropathy
* Motor, sensory findings
* Froment’s test shows what?
* Ulnar claw =
* Cause

A
  • 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
Q

Musculocutaneous neuropathy (rare)
typical cause

A

Axilla stabbing

51
Q

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

A

supplied by L4, L5, S1
Foot drop:
- Deep = x dorsiflex
- Superfical = x eversion
sensory loss over dorsum & lower lateral part of leg

52
Q

The other branch off the sciatic nerve is the tibial nerve.
Tibial neuropathy
- Supplied by which spinal cord levels?
- Motor findings
- Sensory findings
- Cause
-

A
  • 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
Q

**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)

A
  • 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
Q

Two types of Brachial Plexus injury
1. Affects superior trunk (C5,C6)
2. Affects inferior trunk (C8, T1)

A
  • 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
Q

Risk factors for AVNFH
Findings on xray (3)

A

Long term steroid use , Alcohol abuse.
Flattening of femoral head & irregular borders, osteopenia (reduced bone density), sclerosis.

56
Q

Plantar fascitis - most common cause of adult heel pain
Initial mx (3)
And then refer to…

A

Rest, stretching & weight loss (if overweight)
Orthotics - insoles/heel pads

57
Q

Back Pain Red Flags
* Cauda Equina
* Spinal mets
* Spinal infection
* Ank spond

A
  • 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
Q

General mx for backpain
Conservative - low/high risk
Medical
What drugs are specifically not recommended by NICE for lower back pain?

A
  • 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
Q

**Sciatica - ** shooting pain down back of the leg
Nerve roots affected?
Causes?
First line mx?
If above fails after 4-6 weeks?
Screen for?

A
  • 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
Q

Name of disease & cause
Isolated rise in ALP.
XR = osteoporosis circumstripta (lytic lesions), cotton wool spots, V shaped defects.

A

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
Q

Which bones does Paget’s particularly affect?
Mx?

A
  • Axial skeleton - head (skull enlargement, hearing loss if bones of skull affected), spine (back pain)
  • Bisphosphonates, NSAIDs for pain & monitoring
62
Q

2 main complications for Pagets

A
  • Osteosarcoma
  • Spinal stenosis –> spinal cord compression
63
Q

Cancers most likely to metastasize to bone (5)

A

Prostate
Renal
Thryoid
Breast
Lung

PoRTaBLe

64
Q

Key presenting sx for central spinal stenosis

stenosis = compression of the spinal cord (central), nerve root (lateral) or foramina (of the vertebral foramina)

A

Intermittent neurogenic claudication (presents like PVD but ABPI normal & pulses present)

65
Q

Osteomyelitis
* 2 modes of spread
* Ix (2)
* Mx (acute osteo & chronic)

A
  • hematogenous (blood inf) & direct (op/open #)
  • XR (subtle changes) –> MRI (dx)
  • Acute - surgical debridement & abx (Fluclox +/- Rifampicin 2 week). Chronic - abx 3 mo.
66
Q

XR changes for osteomyleitis (however may not be obvious for several weeks)

A
  • Periosteal reaction
  • Localised osteopenia
  • Destruction of bone
67
Q

Fever & back/flank pain & IVDU

A

Iliopsoas abscess

68
Q

Bone tumours
Malignant:
* Osteosarcoma
* Chondrosarcoma
* Ewing’s sarcoma

*Which is the most common primary malignant bone tumour?
*
Benign:
* Osteoma
* Osteochondroma
* Giant cell tumour

A

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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