MSK Flashcards
A patient presents with lower back pain. Give 5 differentials for each age:
15-30:
30-50:
>50:
Other:
15-30:
1) Postural/mechanical
2) Prolapsed disk
3) Trauma/fracture
4) Ankylosing spondylitis + Reactive arthritis
5) Spondylolisthesis
6) Pregnancy
30-50:
1) Postural
2) Prolapsed disc
3) Discitis
4) Spondyloarthropathies (Ankylosing spondylitis, psoriatic arthritis, Reactive arthritis)
5) Degenerative bone disease (OA, Spondylosis, Osteoporosis)
> 50:
1) Postural
2) Prolapsed disc
3) Malignancy
4) Myeloma
5) Degenerative joint disease (OA, spondylosis, osteoporosis)
6) Paget’s disease
Other:
1) Spinal stenosis
2) Spinal infection (Osteomyelitis, septic arthritis)
3) Cauda Equina
4) AAA
What is the difference between spinal stenosis and spinal compression
Spinal Stenosis is the narrowing of the spinal canal which can lead to nerve compression.
Spinal Compression involves direct pressure on the nerves or spinal cord, and can be a result of stenosis or other conditions like disc herniation or tumours.
What is encompassed within Spondyloarthropathies?
What do they all share?
Spondyloarthropathies are a group of HLA-B27 disorders that primarily affect the spine and are characterised by Enthesitis. They include:
Ankylosing spondylitis (15-30+30-50)
Psoriatic arthritis (30-50)
Reactive arthritis (15-30 + 30-50)
What organisms primarily cause reactive arthritis
Chlamydia
Food borne (Shigella campylobacter)
State 3 degenerative bone diseases
OsteoArthritis
Spondylosis (OA but for spine)
Osteoporosis (typically 50+)
What are the most common malignancies found on a bone scan
the vast majority of tumours found in bone scans are not primary but metastasis from another tumour (Prostate, breast, thyroid, kidney)
What is Paget’s disease of the bone?
What age group does it primarily affect?
Paget’s disease of the bone is a disease characterized by high turnover bone remodelling in a mosaic pattern leading to mis-shaped, fragile bones and bone pain
3 phases: (extra info)
1) Increased osteoclast activity => abnormal breakdown
2) Abnormal excessively increased osteoblast activity leading to disorganised, thickened bone
3) Cycle repeats leading to the high turnover bone remodelling
Go over the Dermatomes yourself (image in answer)
State the myotomes and the reflexes they are involved in if applicable
L2 - Hip flexion + adduction
L3 - Knee extension
L4 - Knee extension + Foot dorsiflexion
L5 - Knee flex + foot inversion + Big tow dorsiflexion
S1 - Knee flexion + Foor plantar flexion
Knee reflex (L3,L4)
Ankle reflex (S1,S2)
A joint that moves with ease suggests?
Inflammation as the cause (think RA for example which eases with movement)
How would you structure and hx and exam in MSK?
Hx
Pain (Socrates)
Deformity
Loss of function/Impact on QoL
Neurology
Exam
Look
Feel
Move
Special tests
+/- neuro
When conducting an examination in MSK, what routine neuro should you perform?
1) SLR (if backpain)
2) Sensory loss
3) Muscle weakness (power)
You are asked to conduct a focused examination of the spine. Go through what you will do and what you are looking for
Important to note that the lower limb must be examined along with the spine
Look: Deformity such as kyphosis (ank.spon), lumbar lordosis, scoliosis
Feel: Spine and paraspinal muscles for tenderness !stepdeformity, muscle spasm
Move: Flexion, extension, !!!lateral rotation and flexion.
Special tests: Straight leg raise (ipsilateral sciatica) + Schober test
Neuro:
Inspection: LL Muscle wasting
Palpation: LL Muscle wasting and LL sensory
Motor: Power + Reflexes!!
How is Schober test performed?
Mark at L5 and another 10cm above. Ask the patient to flex forward. If <+5 cm (total 15cm) => Ankylosing spondylitis
What are the red flags in MSK
!!!Saddle Anaesthesia
!!!Urinary incontinence
!!! Night time pain
Weight loss/past hx of cancer
Ages <20, >55
Non-mechanical pain/pain at rest
Pain that worsens when supine
Immunosuppression (Drugs, transplant, HIV, IVDU)
Systemically unwell
What screening tool is used in the evaluation of back pain? How would you explain what it involves?
How are the results interpreted?
The Keele STarT Back Screening Tool is a validated questionnaire used to classify patients with low back pain into categories of low, medium, or high risk for chronicity, based on their physical and psychosocial risk factors, to guide appropriate treatment strategies.
3 or less -> Avoid rest, advise on self-help and exercise
If 4+ -> we should look at questions 5-9
=> 3 or less => Physical therapy after 4 weeks
=> 4+ => Specialist referral
What is the general workup of a patient presenting with lower back pain in primary care including relevant general management
-> means If present then do
1) Triage with hx and exam
2) Rule out fracture -> Xray -> manage (cast, external/internal fixation)
3) Rule out Cauda Equina? -> Immediate admission
4) Rule out Red flags? -> Conduct bloods (ESR, Ca2+, PO4, Alk Phos, PSA, CA125) + Xray
5) Neurological signs? -> Referral if not resolving within 4 weeks
6) Keele STarT Back Pain Scoring Tool
Final management based on score
In all: NSAID + Omeprazole or Codeine + Paracetamol
3 or less -> Avoid rest, advise on self-help and exercise
If 4+ -> we should look at questions 5-9
=> 3 or less => Physical therapy after 4 weeks
=> 4+ => Specialist referral
What does physical therapy entail? Give 3 examples
Physiotherapy
Back exercises
Chiropractic
Osteopathy
Acupuncture
What is Cauda Equina?
How does it present?
How is it managed?
Compression below L2 e.g. disc protrusion at L4/L5
This is a lower motor neuron lesion (upper motor neuron lesion) =>
Perianal anaesthesia
Asymmetrical LL weakness (Dorsiflexion-L4, Plantar flexion-S1, Eversion-S1)
Hypoflexion
Bowel/Bladder incontinence (sphincter)
Loss of ankle reflex (S1)
Immediate admission to A&E and surgical intervention
A patient presents with a hx of thyroid cancer and new onset backpain worse on movement.
What is the most likely diagnosis?
Based on this what neurological symptoms may accompany this?
What imaging technique is best for this?
How is this managed?
If a patient is in the final stages of the disease, how is it managed?
Worse on backpain indicates that this isn’t due to inflammation
This is most likely spinal cord compression
Neurological signs:
In any case: LL weakness, urinary incontinence, constipation
Above L1 - UMN => increased tone and reflexes
Below L1 - LMN => reduced tone and reflexes
MRI (saggital view)
Management: Oral dexamethasone and referral for same-day assessment, surgery, and radiotherapy.
If final stage of disease, palliative care
What is Scoliosis?
Give 5 causes
Give 3 specific examination findings
How would you manage in primary care?
Scoliosis is the lateral curvature of the spine
Causes:
1) Congenital (butterfly vertebra)
2) TB of spine
3) Neoplasm
4) Trauma
5) Neuromuscular (Cerebral palsy, neurofibromatosis)
6) Metabolic (bone dysplasia)
Exam:
1) Asymmetrical shoulder height
2) lateral curvature of spine
3) !!Unequal space between the trunk and the upper limb
Management: Referral to ortho. If pain then urgent referral
What is postural scoliosis?
Scoliosis that disappears on bending.
It is not clinically significant
What joints are you feeling during a shoulder exam? what would you be looking for?
Sternoclavicular joint
Acromioclavicular joint
Glenohumeral joint
Looking for crepitus, numbness, paraesthesia, swelling, tenderness, muscle wasting, ridges
A patient presents with pain beginning at the shoulder and radiating down the arm anteriorly. Where is the pathology?
Shoulder joint
Sources of shoulder tip pain?
Acromioclavicular joint
Cervical spine disorder
Irritation of the phrenic nerve/diaphragm => Referred pain(MI or inflammation e.g. cholecystitis, ectopic pregnancy, splenic rupture peritonitis)
In a hx of shoulder problems, how would you assess for loss of function?
Inability to wear clothes, brushing hair, doing up bra
What is the drop arm test and what does it test for?
Abduct arm to 90 degrees and ask patient to slowly bring down to their sides. Tests for rotator cuff tear
What special tests should you perform in the shoulder test section. What does each test for
Empty can test (supraspinatus)
Drop arm test (Rotator cuff tear)
Lift off test (w/ resistance) (Subscapularis)
Scarf Test (AC joint pathologies such as arthritis)
Sulcus test (inferior instability)
Apprehension test (Shoulder/anterior stability)
A patient presents with painful limitation of movement in all directions. The pathology is likely to be caused by
Intraarticular disease
A patient presents with painful limitation of movement in one plane. The pathology is likely to be caused by
Tendonitis
A patient presents with painful weakness. The pathology is likely to be caused by
Tendon rupture or neurological signs
A patient presents with a stiff, painful shoulder joint. What are your differentials
Rotator cuff injury/Tendonitis
Shoulder osteoarthritis
Adhesive capsulitis
Prolonged immobilisation
Polymyalgia rheumatica
How does acute tendonitis present?
Holding shoulder immobile
Unable to lie on affected side
You suspect rotator cuff tear. What special test will you perform?
Drop arm test
You suspect subacromial impingement. On examination, what would help you reach a diagnosis?
Painful arc test
or internal rotation
What is the painful arc?
Abduction from 60-120 degrees as this is the range that the rotator cuffs are responsible for
How can a rotator cuff injury present (3)?
What is the pathophysiology behind them all?
What investigations will you perform?
How are these managed in primary care + escalations
Rotator Cuff injury can present as either to all 3 of the folllowing:
1) Acute tendonitis: Due to excessive use/trauma in <40yo. Patient would be holding shoulder immobile and cannot sleep on that side
2) Rotator cuff tear: From trauma, Drop arm test +ve
3) Subacromial impingement: Painful arc +ve or pain on internal rotation
Pathophysiology: Excessive use/trauma of the shoulder joint (controlled by the rotator cuff muscles) leads to acute tendonitis or tear which results in reduced space within the joint ending up with nerve impingement or subacromial impingement
Investigations: X-ray, Dynamic USS, MRI
Management: Rest->NSAIDs (+PPI) -> Physiotherapy -> Subacromial steroid injection -> Refer to Ortho
A 55 year old with no history of trauma presents holding his shoulder immobile. He complains of being unable to sleep on that side lately. What could be the likely cause of this presentation?
How is it treated?
With no history of trauma, it is more likely to be caused by inflammation around calcific deposits.
Tx = Steroid injection
What findings on X-ray would be consistent with rotator cuff injury?
What findings on Dynamic USS?
X-ray -> calcification (of Supraspinatous), Glenohumeral joint cysts
USS -> Impingement, tendonitis tears
Remember what X-ray can see and what USS can see better
Give 3 benefits and risks of steroid injections in joints
Benefits:
- Reduce inflammation
- Pain relief
- Joint function (mobility)
Risks:
- Site infection or even septic arthritis
- Cartilage damage and joint degradation
- Increased blood sugar levels
- Tendon weakening or rupture
- Bleeding/haemorrhage (US-guided may help)
What is the typical aetiology(ies) of shoulder osteoarthritis?
Trauma > chronic
Or Crystal-induced inflammation (Gout/Haemochromatosis)
What is the presentation of adhesive capsulitis?
What pathologies are associated with adhesive capsulitis?
Give the management escalations
Painfull stiff shoulder with global limitation of movement (intraarticular pathology that is !worse at night
DM, Intrathoracic pathologies (Lung disease, Ischaemic heart disease, cervical pathologies)
Management: Check HbA1c -> NSAIDs (+ppi) + Physiotherapy -> Local steroid injection -> Orthopaedic referral
What is the typical aetiology of anterior dislocation
What are complications of this?
What examination findings are associated with this?
How is this managed?
Fall on arm/shoulder in contact sports on an outstretched hand with !extended elbows (as opposed to Elbow dislocation)
Complications:
1) Labral tear-> Apprehension test, Sulcus test +ve
2) Axillary nerve damage -> reduced sensation over regimental patch
Management: Referral to A&E for Xray and reduction. Refer to ortho/physio if recurrent
What is the typical aetiology and presentation of rupture of the head of the biceps.
Lifting -> pop -> Swelling and discomforty -> bulge on elbow flexion (Popeye’s sign)
Acromioclavicular joint problems present as
Shoulder tip pain
Just a note, if you dont know how to treat something in ortho just say NSAIDs + PPI +/- steroid injection -> Refer to ortho
What is cleidocranial dystosis
AD condition characterised by missing part or all of clavicle, delayed ossification of the skull, a/w short stature.
No tx
You perform a clinical exam on a patient coming with elbow pain. You note nodules over the olecranon. What are your ddx
1) Psoriasis
2) RA nodule
3) Gouty Tophus
4) Olecranon bursa
5) Trauma
Note: When performing an elbow exam, dont forget to test for supination and pronation
Define Epicondylitis and then Go through epicondylitis you already know it
Extensor tendon inflammation at the epicondyles due to repeated strain
Tennis elbow = Lateral epicondylitis = pain on resisted wrist extension. Tenderness over lateral epicondyle
Golfer’s elbow = medial epicondyle = pain on resisted wrist pronation!!!. Tenderness over medial epicondyle
Management: Rest and stop triggering movements +/- NSAIDs (+ppi) +/- Steroid injections (speeds up recovery but increased risk of recurrence) + physiotherapy
What is the aetiology of olecranon bursa?
Management?
Traumatic bursitis due to repeated pressure on elbow => pain and swelling over olecranon which may become infected => abscess
Management:
Conservative: Rest + Ice + analgesia
Large/unresolving: Aspiration of fluid or steroid injection -> referral
Infected -> antibiotics
What is the aetiology of a pulled elbow?
If you are looking at a child with a pulled elbow, what will you see?
Would you do an Xray?
How is this managed?
Children <5 due to traction injury causing subluxation of the radial head. Occurs when child is pulled up suddenly by the head.
Child not using arm, elbow held in !extension + pronation (in contrast to elbow dislocation)
X-ray is unhelpful. Reduce arm in clinic using
What X-ray findings would indicate Osteoarthritis?
Joint space narrowing
Subchondral sclerosis
Subchondral cysts
Osteophytes (bony growths)
Where are rheumatoid nodules found?
Extensor surfaces of arms (typically elbow)
Give 15 exam findings and other features associated with Rheumatoid arthritis
Hands:
1) Involvement (swelling + tenderness) of MCP and PIP and NOT DIP (OA)
2) Ulnar deviation of fingers
3) Z-deformity of the thumb
4) Boutonnier’s deformity (EM,FP)
5) Swan neck deformity (EP,FD)
6) Reduced grip strength
7) Bilateral carpal tunnel due to nerve entrapment
8) Palmer Erythema
Extra-articular:
1) Anemia (Microcytic)
2) Felty Syndrome (RA + Splenomegaly + Leucopenia)
Arms: Rheumatoid nodules (extensor surfaces)
Eyes: Scleritis + Episcleritis
Heart:
1) Pericarditis
2) Mitral regurgitation
Lungs: Pleural effusions
Shoulder: Adhesive capsulitis
Spine: (Risk of cord compression)
1) Cervical spine subluxation
2) Atlantoaxial instability
Legs and Feet:
1) Subluxation of metatarsal heads
2) Claw toes (pain walking => ask to walk for gait)
3) Baker’s cyst
4) Patellar tap => Swelling over joint
What relevant investigations would you conduct for RA? For each, state the findings you are looking for
FBC - looking for microcytic anemia and leucopenia (Felty)
Serology: Anti CCP, RF, ANA titre (+ve in RA)
Xray:
1) Periarticular soft tissue swelling
2) Joint space narrowing
3) Erosions (From infl. of socket +/- collapsed head)
4) Juxtaarticular osteopenia (black in bones = reduced density)
What is the full management protocol for Gout starting from presentation with a painful swollen 1st metatarsal with confirmed sodium monourate crystals under polarised light.
