MSK 2 Flashcards
1
Q
Vertebral column organisation?
A
33 vertebrae organised in 5 sections
- 7 cervical
- 12 thoracic
- 5 lumbar
- 5 sacral (fused)
- 4 coccygeal (fused)
2
Q
C1 and C2 vertebrae? C7?
A
- C1 = atlas, no vertebral body
- C2 = axis, dens
- C7 = vertebral prominens, (vertebral artery does not pass through transverse foramen)
3
Q
Intervertebral disc cartilage?
A
Secondary cartilaginous joint (fibrocartilage)
4
Q
Facet joints also known as? What kind of joint? How do facet joints affect mobility of spinal sections? (3)
A
Facet joints = zygapophysial joints
- Synovial joint
- Cervical = horizontal facet joints, allows greatest movement
- Thoracic = less flexion/extension due to constraint of ribs
- Lumbar = more movement than thoracic spine, due to more vertical facet joints
5
Q
Consequence of loss of intervertebral disc water with ageing? Tx?
A
Overload of facet joints and secondary OA
* If OA involves only 1 or 2 segments, can be treated with fusion
6
Q
Where does slipped disc usually affect? Dx?
A
L4/5
* MRI is not diagnostic unless symptoms are present as 60% of ASYMPTOMATIC people > 45 y/o have bulging discs on MRI
7
Q
Ax acute disc prolapse? s/s?
A
Lifting heavy object -> annulus tear -> “twang”
* pain on coughing
8
Q
Location motor neurones in spinal cord? Sensory neurons?
A
- Motor neurons = bodies in anterior grey horn
* Sensory = bodies in dorsal (posterior) root ganglion
9
Q
Where does spinal cord run?
A
Vertebral foramen
10
Q
Where does spinal cord end?
A
L1 - cauda equina
11
Q
Exiting and transverse nerve root?
A
- exiting nerve root i.e. outside the thecal sac passes under the pedicle of the corresponding vertebra (ie L4 root passes under L4 pedicle)
- traversing nerve root inside thecal sac (in lateral recess) prepares to penetrate thecal sac and become the next exiting nerve root more distally
(L5 nerve root is the traversing nerve root at the L4-L5 level, and is the exiting nerve root at the L5-S1 level)
12
Q
Which nerve root is often compressed in disc prolapse? Exception? Effects of nerve root compression? (3)
A
- Trasverse root
- In far lateral disc prolapse the exiting nerve root can be compressed
- RADICULOPATHY resulting in pain down the sensory distribution of the nerve root (dermatome), which in the lower leg is known as SCIATICA
- Weakness in muscle supplied (myotome)
- Absent reflexes
13
Q
Spinal stenosis? s/s?
A
Complication of OA
* Neurogenic claudication = leg pain on walking (relieved by rest)
14
Q
Babinski sign?
A
Can indicate spinal cord compression (when sole of foot is stimulated, big toe travels upwards instead of downwards)
15
Q
Cauda equina syndrome? S/s? (3)
A
caused by pressure (usually prolapsed disc) on all lumbosacral nerve roots resulting in loss of BLADDER and BOWEL control
- Bladder and bowel dysfunction
- Saddle anaesthesia
- Loss of anal tone - PR exam req!!!
16
Q
Erector spinae muscles? (3)
A
- Iliocostalis
- Longissimus thoracis
- Spinalis thoracis
(strengthen muscles to help back pain)
17
Q
Use complete anatomy to find supraspinous ligament, interspinous ligament, anterior + posterior longitudinal ligament, intertransverse ligaments
A
…
18
Q
Chance fracture? tx?
A
Highly unstable - can damage spinal ligaments
* May need surgical stabilisation
19
Q
At what level is lumbar puncture and spinal anaesthesia carried out?
A
- L4 - i.e. posterior iliac crest
side note, S2 is level of PSIS
20
Q
Mechanical back pain? s/s? Red flags?
A
Related to joints/muscles with no red flag features
* worse with activity, relieved by rest
Red flags
* red flags = weight loss, night sweats, bladder/bowel symptoms
21
Q
Tx for sciatica that doesn’t settle within 3 months? Difference between mechanical back pain and sciatica?
A
- Discectomy or decompression
* Mechanical back pain can radiate to buttock and thigh but will NEVER go below knee (sciatica should go below knee)
22
Q
How do bones grow?
A
Longitudinal from the growth plate (physis) by enchondral ossification
+
Circumferential from the periosteum by appositional growth
23
Q
Factors affecting growth plate in children? (5)
A
- Diet / Nutrition
- Sunshine, Vitamins (Vit D & A)
- Injury
- Illness
- Hormones (GH)
24
Q
Normal development milestones? (10)
A
- 1-6 months Loss of primitive reflexes – Moro, grasp , stepping, fencing
- 2 months head control
- 6-9 months - Sits alone, crawls
- 8-12 months – stands
- 9-12 months few words
- 14 months feeds self, uses spoon
- 14-17 months walks
- 18 months stacks 4 blocks, understands 200 words
- 24 months jumps
- 3 years manages stairs alone + potty trained
25
Knee alignment during ageing?
* infant = genu varum
* 1 year = neutral alignment
* ~2 years = genu valgus
* 4 years = neutral alignment
26
When is genu varum normal? When is it considered pathological? (4)
<2 y/o (however, persisting mild genu varum can run in families)
* Unilateral (asymmetry >5*)
* Severe >2SD from mean
* Short stature >2SD
* painful
27
Ax pathologic genu varum? (5)
* Skeletal dysplasia
* Rickets
* Tumour e.g. enchondroma
* Blounts disease
* Trauma (physeal injury)
28
Blounts disease? Dx?
Growth arrest of medial tibial physis of unknown aetiology
| * beak-like protrusion on x-ray
29
When is genu valgum normal?
When is genu valgum considered pathological?
Ax genu valgum? (4)
Tx?
Peaks at age 3.5
* Unilateral (asymmetry >5*)
* Severe >2SD from mean
* Short stature >2SD
* painful
Ax
* Tumours - enchondroma, osteochondroma
* Rickets
* Neurofibromatosis
* Idiopathic
Tx
>8cm intermalleolar distance at age 11 = consider surgery
30
Inteoing? Ax? (3)
| Femoral neck anteversion test?
Child walks with toes pointing in AKA pigeon-toed
* femoral neck anteversion
* Internal Tibial Torsion
* metatarsus adductus
Increased internal hip rotational range (tend to sit in W position)
31
Internal tibial torsion tx?
Usually seen in toddlers (1-3 yrs) and vast, vast majority resolve by 6 yrs!!
32
Metatarsus adductus?
Common, benign, resolves
33
Intoeing tx?
* Determine cause - femur, tibia, foot
| * Discharge unless persisting and severe
34
How to determine if flat feet flexible or fixed? Flexible Ax? Fixed Ax?
Ask patient to walk on tip-toes (if actively dorsiflex, arch will become visible)
* Ax = ligement laxity or tightness gastrocsoleus complex (can assess calf tightness by flexing knee)
* Rigid Ax (uncommon) = underlying bony connection known as tarsal coalition (may req surgery if painful!!)
35
Hypermobility assessment?
Beighton score (9/9)
36
Curly toes? Tx?
Very, very common - vast majority resolve by 6 yrs
* splinting or taping are ineffective!!!
* if very severe case, can consider flexor tenotomy
37
Anterior knee pain epidemiology? Ax? Dx? (2) Tx?
* Adults, females > males
* Ax = stairs/squats
* Dx = x-ray + ALWAYS CHECK HIPS!!
* Tx = physio
38
Causes of back pain? (5)
* Viscerogenic - abdominal viscera
* spondylogenic
* Discogenic
* Neurogenic
* Psychogenic
39
Viscerogenic causes of back pain? (7)
* AAA
* RENAL PAIN (COLIC)
* PANCREATITIS
* PEPTIC ULCER DISEASE
* GALL BLADDER
* UTERINE/OVARIAN
* COLONIC
40
Spinal pathologies leading to back pain? (4)
* Wedge fracture due to osteoporosis
* Tumours - metastatic i.e. bad boys pee through kidneys (breast, bronchus, prostate, thyroid, kidneys), primary tumour in spine is myeloma
* Infection
* Inflammatory - ankylosing spondylitis
41
Nerve root problems leading to back pain? Pathogenesis disc prolapse? Common consequence of disc prolapse?
* cauda equina syndrome
* L5 disc prolapse (will affect S1 nerve root)
Pathogenesis
* Impaired disc nutrition -> damage -> disc fissure -> protrusion/extrusion/sequestration
* Consequence = face joint arthropathy
42
Causes of mechanical back pain? Dx? Tx?
Ax: spondylolysis (linear crack) and spondylolisthesis (break allows vertebrae to slide on vertebrae above)
Dx: Scottie dog appearance on x-ray
Tx: usually non-surgical however occasionally requires stabilisation surgery
43
Neurological examination of spine consists of? (4)
* Myotomes
* Dermatomes
* Reflexes
* Nerve irritation
44
Nerve irritation tests? (2)
* Straight leg raise for sciatic nerve roots
| * Femoral stretch test for femoral roots
45
Myotomes? (4)
* Hip flexion = L1/L2
* Knee extension = L3/4
* Foot dorsiflexion + big toe = L5
* Ankle planterflexion = S1/2
46
What can restrict straight leg raise?
Hamstring tightness
47
What other examinations should be carried out when considering the spine? (2)
* Abdominal exam
| * PR exam
48
Ix back pain? (5)
* MRI
* Diagnostic facet injection
* Contrast enhanced CT
* Provocation discography
* Selective nerve block / ablation
(x-rays are pretty useless)
49
Thoracic outlet syndrome Ax?
Can be caused by cervical rib
50
Antalgic gait?
gait that develops as a way to avoid pain while walking
51
Developmental dysplasia of the hip?
| Epidemiology? (2)
abnormal development resulting in dysplasia and possible subluxation or dislocation of the hip
* Most common orthopaedic disorder in newborns (usually female, left hip)
* More commonly seen in Native Americans and Laplanders, rare in Africans
52
Pathophysiology DDH?
| Risk factors? (5)
* Genetic laxity, intrauterine/post-natal malpositioning
Risk factors
* Firstborns
* Female
* Breech birth
* Family history
* Oligohydraminos (not enough fluid)
53
Patient presentation DDH? (3)
| Dx? (3)
* Early = abnormality on screening
* Late = limping child (Trendelenburg gait)
* Too late = secondary arthritic changes
Dx: examination, USS, imaging
54
Clinical examination DDH? (3)
* Inspection = leg lengths, restricted abduction
* Ortalani ('o' for out = abduction)
* Barlows = pushing hip backwards to try and dislocate
55
Tx early DDH?
| Late DDH?
early
PAVLIK HARNESS - hold ships flexed + abducted
(USS to monitor improvement)
Late
SURGERY
* Closed reduction - tenotomies
* Open reduction - osteotomies
56
Reactive synovitis of the hip?
| s/s? (3)
Inflammation of the synovium, often secondary to a viral illness
* Limp, hip/groin pain (sometimes referred to knee)
* Hip flexed
* usually systemically well, apyrexial
57
Dx reactive synovitis?
| Tx?
Koshers criteria (distinguishes between RS and septic arthritis)
Tx = self-limiting (but analgesia and NSAIDs if req)
58
Septic arthritis of hip?
| S/s? (5)
SURGICAL EMERGENCY!
* Acute onset
* Unable to bear weight due to hip/groin pain
* hip flexed
* severe hip pain on passive movement
* Pyrexial (but usually haemodynamically stable i.e. normal HR)
59
(Legg-calve) Perthes disease? Ax?
Epidemiology?
Risk factors? (4)
Avascular necrosis of the hip
* Ax = Idiopathic
Epidemiology
* 4-8 y/o
* Males > females
* higher in lower socioeconomic classes
Risk factors
* Family history
* Low birth weight
* Second hand smoke
* Asian, inuit, European
60
Pathophysiology Perthes disease?
* osteonecrosis due to disruption of blood supply to femoral head
* revascularization then collapse
* creeping substitution provides pathway for remodeling after collapse
61
S/s Perthes disease? (2)
| Dx?
* Painless limp (sometimes intermittent groin pain)
* Hip stiff
Dx = x-ray, MRI
62
Tx Perthes disease?
* Restrict weight-bearing
* physiotherapy
* Surgery (osteotomy for young patients, arthroplasty for older patients)
63
Slipped upper femoral epiphysis (SUFE)?
| Epidemiology? (3)
condition affecting proximal femoral physis that leads to slippage of the metaphysis relative to the epiphysis
* Males (10-16)
* Obesity
* Endocrine disorders (GH deficiency, hypothyroidism)
64
S/s SUFE? (2)
Dx?
Tx?
S/s
* Groin pain
* Limp (antalgic)
Dx = X-ray, MRI ("ice cream falling off cone")
Tx = SURGERY (percutaneous pinning of hip or open reduction if v severe)
65
Straight leg raise significance?
Tx?
Risk factors for rupture? (3)
if can’t raise leg, ruptured extensor mechanism of leg i.e. quadriceps tendon/muscle (palpable gap)
* Tx = surgical repair (NEVER inject with steroids!!)
* Risk factors = chronic renal failure, steroids, previous tendonitis
66
What is the most common meniscal tear?
Dx?
Tx?
Medial meniscal
Dx = MRI
* Tx = bucket handle tears require urgent surgery, radial tears will not heal with surgery as only peripheral 1/3rd has blood supply
67
Degenerate tears? tx?
Often asymptomatic, surgery not useful
68
Function of MCL? LCL?
| Tx for injury?
* MCL = resists valgus stress
* LCL = resists varus stress
Tx = brace, physio (rarely reqs surgery)
69
PCL rupture presentation? (2)
Recurrent hyperextension + instability descending stairs
70
Ax ACL injury? Tx?
```
Ax = twisting
Tx = reconstruction
```
71
PCL rupture Ax?
Direct blow to anterior tibia
72
Knee dislocation?
| Tx?
NO NOT confuse with patellar dislocation
| * Tx = emergency reduction, check neurovascular status, vascular surgery
73
Patellar dislocation Ax? Tx?
Rapid turn or direct blow (females > males)
| * Surgical stabilisation
74
What anatomy do imaging tests show?
* X-rays only show bone outlines
* CT shows bone outlines in more detail and some soft tissue structures eg lumbar discs
* MRI shows bone outlines in less detail but shows bone marrow, discs, ligaments and the spinal cord and nerves
(i. e. all the soft tissue structures)
75
Describe structure of vertebrae? (2)
```
Vertebral body
Posterior arch made up of:
* 2 pedicles
* 2 laminae
* 1 spinous process
* 2 transverse processes
```
76
Vertebral neural foramen found?
Lies inferior to pedicle
77
Appearance of ligaments on MRI?
Ligaments are only seen by MRI
* Normal ligaments are BLACK on MRI
* Damaged ligaments are LIGHT on MRI
78
X-ray and CT findings of bony tumours in spine? (3) Unique MRI findings? (2)
X-ray + CT
* Bone destruction
* Vertebral collapse (pathological fracture)
* Bone sclerosis
Unique MRI findings
* Early - bone marrow infiltration
* Late - extradural mass + spinal cord compression
79
What imaging is used for intervertebral discs?
X-rays useless (cannot see discs)
| * CT and MRI show discs and disc prolapse but MRI is best
80
What imaging is used for spinal cord?
* Invisible on x-rays
* Poorly shown by CT
* Only adequately shown by MRI
81
Ax spinal cord disease? (4)
Trauma
Demyelination
Tumour
Ischaemia
82
Inflammatory myopathies? (2)
| s/s? (7)
Polymyositis + dermatomyositis
* MUSCLE WEAKNESS
* Stiffness
* Abnormal blood tests
* Fever
* Weight loss
* raynauds
* Polyarthritis
83
Ax polymyositis + dermatomyositis? Epidemiology? (2)
| Risks associated with inflammatory myopathies?
Idiopathic
* Ex = female>male, 40-50
* Risks = malignancy i.e. Ovarian, breast, stomach, lung, bladder and colon cancers (risk of malignancy greatest in men >45 years)
84
Ix polymyositis + dermatomyositis? (7)
* MUSCLE BIOPSY (definitive test) - necrosis, degeneration, inflammatory cells
* CXR (lung involvement - ILD + myocarditis)
* Electromyography - increased muscle fibrillations, abnormal motor potentials
* OGD - oseophageal dyphagia
* Blood tests (CK, CRP, calcium, electrolytes, AUTOANTIBODIES - ANA, anti-Jo)
* Confrontational testing + isotonic testing
* MRI muscles (inflammation, oedema, fibrosis, calcification)
85
Main feature of inflammatory myopathies?
MUSCLE WEAKNESS
* Insidious onset, worsening over months
* Usually symmetrical proximal muscles
* Specific problems = difficulty brushing hair, climbing stairs
86
Dermatomyositis skin manifestations? (3)
* Gottrons sign (hands)
* Heliotrope rash
* Shawl sign
87
Risk factors inflammatory myopathies? (4)
* Medical problems = diabetes, thyroid disease
* Drugs = steroids, statins
* FHx
* Social = alcohol, illicit drug use
88
Tx inflammatory myopathies?
* Glucocorticoids
* Azathioprine
* Methotrexate
* Ciclosporin
* IV immunoglobulin
* Rituximab
89
Polymyalgia rheumatica associated with? Epidemiology?
s/s? (6)
Difference between polymyalgia rheumatica and inflammatory myopathies?
GCA + temporal arteritis
* >50 years
s/s
* Symmetrical shoulder + hip pain
* Stiffness
* Fatigue
* Anorexia
* Weight loss
* Fever
MUSCLE STRENGTH IS NORMAL
90
Temporal arteritis/GCA? s/s? (5)
Granulomatous arteritis of large vessels
* Headache
* Scalp tenderness
* Jaw claudication
* Visual loss (amaurosis fugax)
* Tender, enlarged, non-pulsatile temporal arteries
91
Dx temporal arteritis? (2)
Tx for polymyalgia rheumatica?
Tx for temporal arteritis?
* Raised CRP, PV
* Temporal artery biopsy
Tx
* Poly = low dose steroids
* Temporal arteritis = HIGH DOSE STEROIDS
92
Fibromyalgia?
| Epidemiology?
Common cause of chronic MSK pain NOT associated with inflammation
* Females > males, 20-50 years
93
S/s fibromyalgia? (8)
* Diffuse pain
* Symptoms worse with exertion, stress
* Fatigue (poor sleep)
* Pins and needles/tingling
* Headaches
* Depression
* IBS
* Poor concentration + memory
94
O/E fibromyalgia?
| Tx?
* Excessive tenderness on palpation of soft tissues
* No other abnormality of MSK system
Tx
* Graded exercise programme, CBT, anti-depressants, analgesia (NON-OPIATE), gabapentin + pregabalin
95
Adult hip conditions? (5)
* Femoroacetabular impingement syndrome (FAI) +/- labral tears
* Avascular necrosis
* Idiopathic Transient Osteonecrosis of the Hip (ITOH) - uncommon
* Trochanteric bursitis
* OSTEOARTHRITIS
96
Femoroacetabular impingement syndrome (FAI)?
Effect?
Different forms of FAI? (3)
Altered morphology of femoral neck/acetabular
Inability to put on a shoe i.e. flex, abduct, internallt rotate
* CAM
* Pincer
* Mixed
97
Differences between CAM and Pincer?
| Consequences? (3)
CAM
* FEMORAL deformity
* Usually young athletic males
* Asymmetric femoral head with decreased head:neck ratio
* Can be related to previous SUFE
Pincer
* ACETABULAR deformity
* Usually seen in females
* Acetabular overhang
Both cause:
* damage to labrum + tears
* damage to cartilage
* OA
98
Patient presentation FAI? (4)
| Dx? (3)
* Activity related pain in groin (flexion + rotation)
* Difficulty sitting
* C sign positive
* FADIR (flexion, adduction, internal rotation) provocation test positive
Dx
* X-ray
* CT
MRI (better for labrum tear and bony oedema)
99
Tx FAI? (4)
If patient asymptomatic, do not treat!!
* CAM = athroscopic surgery
* Pincer = peri-acetabular osteotomy
* Arthroplasty in older patients w/ secondary OA
100
Avascular necrosis?
| Pathophysiology? (2)
Failure of the blood supply to femoral head
* Idiopathic - venous thrombosis
* Trauma (medial femoral circumflex)
101
AVN epidemiology?
| Risk factors? (7)
* Males > females, adults
Risk factors
* MOST CASES ARE IDIOPATHIC!!
* ALCOHOLISM
* STEROIDS
* radiation
* trauma
* haematologic diseases (leukaemia)
* dysbaric disorders (decompression sickness)
102
s/s AVN? (3)
| Dx?
S/s
* Insidious groin pain
* Worse on stairs/impact
* EXAMINATION IS USUALLY NORMAL!!! i.e. normal ROM, no tenderness
Dx
* X-ray (often normal in early disease - "hanging rope sign")
* MRI scan (oedema)
103
When is AVN reversible?
| Tx?
* Reversible = pre-subchondral collapse
* Irreversible = post-subchondral collapse
Tx
* Bisphosphonates (decreases reabsorption of bone)
* Core decompression
* Curettage and bone grafting
* Vascularised fibular bone graft (part of fibula along with arteries grafted into femoral head)
* Rotational osteotomy
* Total hip replacement
104
Idiopathic Transient Osteonecrosis of the Hip (ITOH)?
S/s? (2)
Epidemiology?
Local hyperaemia and impaired venous return with marrow oedema and increased intramedullary pressure
S/s (usually unilateral)
* Groin pain
* Difficulty weight bearing
Ex
* Males > females
* 2 GROUPS: middle aged men + pregnant women in 3rd trimester
105
Dx ITOH? (4)
* Raised CRP
* X-ray: osteopenia of head + neck, preserved joint space
* MRI (GOLD STANDARD) - will look like AVN oedema
* Bone scan
106
ITOH tx?
Self-limiting
| * Analgesia + protected weight bearing
107
Trochanteric bursitis?
| Epidemiology?
Repetitive trauma caused by iliotibial band tracking over trochanteric bursa - causes inflammation of bursa
Epidemiology
* Females
* Young runners + older patients
108
s/s trochanteric bursitis? (2)
Dx?
Tx? (4)
* Pain on the LATERAL ASPECT of the hip
* Pain on palpation of greater trochanter
Dx
* Clinical diagnosis!
```
Tx
* Analgesia
* NSAIDs
* Physiotherapy – strengthening surrounding muscles to off-load IT band
* Steroid injection
NO BENEFIT FROM SURGERY
```
109
Causes of secondary OA? (6)
* DDH
* SUFE
* Septic arthritis
* AVN
* FAI
* Trauma
110
Tx OA?(5)
* Analgesia
* Weight loss
* Physiotherapy
* Steroid injections
* Total hip arthroplasty
111
Thomas test?
Thomas test – test for fixed-flexion deformity in hip
* Hip that you are not examining – flex hip by flexing knee
* If other hip does not remain flat = FFD
* Dx = OA
112
What determines whether you do an open/closed reduction for DDH?
If catch very early = Pavlik harness (no reduction required)
* If later (12-18 months) = closed reduction, spica cast * If failure of hip reduction, carry out open reduction
* For an adult – adults present with dysplastic hips having previously had DDH
* In skeletally mature person with dysplastic hip, osteotomy or hip replacement
113
Are pins eventually removed in SUFE?
Not routinly
114
Are steroids used to treat both acute meniscal tears and degenerative tears?
* Acute = usually operable
| * Degenerative = steroids
115
Positive ortalani and barlow test?
DDH
116
Hanging rope sign?
* Perthes disease in children
| * AVN in adults
117
What is the first movement to go in Perthes?
Internal rotation
118
Why do older children with Perthes have worse prognosis?
Less remodelling potential than younger children
119
Is polymyalgia rheumatica inflammatory?
Inflammatory condition improved by steroids
120
Difference between physis and metaphysis?
Physis is the growth plate between epiphysis and metaphysis
121
What is sensory nerve supply to dorsum of foot?
Superficial fibular nerve except for webbing between big toe and second toe which is deep fibular nerve
122
Condyloid joints of the hand?
Condyloid joints are flexion, extention, abduction + adduction
So MCP joints
123
Most common type of shoulder dislocation?
Anterior
124
Methods for reducing shoulder dislocation? (3)
* Hippocratic method
* Stinson method
* Surgery - either arthroscopic or open repair
125
Associated injuries following shoulder dislocation? (4)
* Fracture humeral head
* Rotator cuff tear
* Blankart lesion
* Fracture of glenoid
126
What patients are at higher risk of recurrent dislocations?
Younger patients
127
What is shoulder impingement?
| Ax? (5)
pain originating from sub-acromial space
* Intrinsic = tendon vascularity, watershed area, tendon degeneration, cuff dysfunction
* Extrinsic = pressure
128
How is impingement staged?
Neer's classification
* Stage 1 = inflammation, oedema, haemorrhage (reversible)
* Stage 2 - fibrosis, tendonitis
* Stage 3 = full thickness
129
Tx shoulder impingement? (5)
* rest
* pain relief
* physio exercises,
* corticosteroid injections in subacromial space
If >6 months tx and no improvement = SURGERY (subacromial decompression)
130
Cuff tears generally affect what group of people?
S/s? (2)
Tx?
Cuff tears = grey hairs (50-60s)
* Weakness, pain
* Chronic (common) tx = steroid injections, physio
* Acute (rare) = rest, analgesia, sling
131
Drawbacks of surgery for cuff tears?
20-40% re-tear rate at 1 year following surgery + prolonged recovery period
132
Risk factors for frozen shoulder? (4)
| Features? (2)
* Females, association with diabetes, lipid + endocrine disease, Dupuytren's
* Usually bilateral but NOT simultaneous, gradual severe pain
133
Pathology frozen shoulder?
contracture and thickening of coraco-humeral ligament
| -> decrease in joint volume
134
S/s frozen shoulder? (4)
| Differential diagnoses? (2)
* pain at rest
* pain at night
* anterior pain
* stiffness (if <50% internal rotation = most likely frozen shoulder)
Lack of IR can also be = locked posterior dislocation + glenohumeral arthritis
However, if look at x-rays of frozen shoulder will be NORMAL
135
Tx frozen shoulder? (3)
* Analgesia
* Physio
* Steroid injections
136
Glenohumoral OA epidemiology? s/s? (5)
| Tx? (4)
>60 y/o
* Pain at rest
* pain at night
* Intermittent exacerbations
* Functional difficulties
* Passive ROM problems as well as active
Tx = analgesia, physio, steroid, surgery (shoulder replaceement, arthroplasty, resurfacing)
137
Upper limb nerve entrapments? (2)
| Risk factors carpal tunnel? (5)
Carpal tunnel + cubital tunnel
* Female > male
* diabetes
* Obesity
* RA
* Hypothyroidism
138
Tests for carpal tunnel? (3)
| Tx? (3)
* Durkin's test = compression
* Tinnels test = tapping
* Phalens test = volar flexion
Tx = physio, steroid, if severe SURGICAL DECOMPRESSION
139
Risk factors cubital tunnel? (4)
| Tx?
* >30
* Males > females
* Trauma
* Arthritis
Tx = decompression
140
What can mimic acute avulsion fractures? (3)
| How to distinguish?
* Sesamoid bones
* Accessory ossification centres
* Old non-unified fractures
Distinguishing factor = o all fracture mimics have a completely corticated contour (brighter white outline)
141
What is the x-ray sign for elbow effusion?
Posterior fat pad sign - darker area posterior to humerus
142
Unique fractures to children? (2)
* Buckle fractures = no smooth curvature, will be a sudden bump
* Greenstick fractures = only part of bone is fractured
143
Why is growth plate prone to injury? Complications?
| Classification?
Weakest part of developing bone
* Comps = limitation of growth
* Salter-Harris classification used to grade growth plate fractures
144
Appearance of growth plate fractures on x-ray?
| What can mimic growth plate fracture? (2)
In normal bones, growth plate always centred on metaphysis
* Fractures are not centred on metaphysis
Fracture of ulnar styloid and radial metaphysis can look similar to growth plate fracture
145
What are bony rings?
| Feature of bony ring fractures?
Bones and joints often form rings to help share transmission of force and increase strength e.g. spinal canal, pelvis forearm and lower leg
* Often not disrupted in only one place (think trying to fracture a polo mint in only one place – not possible)
* E.g. fracture of ulna can be accompanied by radial head dislocation
146
Whoch x-ray view should be obtained in posterior shoulder dislocation?
an oblique view should always be obtained, which shows that humeral head lies posterior to glenoid (difficult to appreciate on AP)
147
Appearance of scaphoid fractures on x-ray? Why are they important to catch?
very subtle lucency
| * important to catch! – due to retrograde blood supply, if untreated can cause AVN!!!!
148
Bennet's fracture?
| Complications?
involves thumb base, tendons pulling on thumb distal to fracture cause displacement
* if not treated can cause deformity and arthritis
149
What is used to Ix superficial soft tissue structures? Deep?
* Superficial = USS
| * Deep = MRI
150
Typical sites for impacted fractures? (3)
| Appearance on x-ray?
femoral neck, calcaneus, tibial plateau
| * Will see thickened sclerotic area (i.e. more dense because bones are squashed into each other)
151
Ax pelvic ring fractures? (2)
| Ix?
* High energy = often RTAs, young people
Ix = x-ray if pelvis only, CT if more than 1 injury
* Low energy = elderly patients with osteoporosis
Ix = x-rays often NORMAL - MRI most sensitive
(remember = expect multiple fractures due to ring)
152
Most common type of hip dislocation?
| Complications?
• Hip dislocations are typically posterior (unlike shoulder which is usually anterior)
* AVN due to retrograde blood supply
153
Intra-capsular vs extra-capsular femoral fracture?
| Tx? (2)
Intra
* Interferes with blood supply (AVN)
* Tx = haemarthroplasty
Extra
* doesn't affect blood supply (don't develop AVN)
* Tx = surgical fixation
154
Signs of knee effusion on x-ray?
Effusion fills suprapatellar space (which is normally occupied by fat)
* So will see lighter fluid-filled area as opposed to dark fatty area
155
What is lipohaemarthrosis of the knee joint? Indicative of?
blood and fat collect in suprapatellar recess
| * sign of intra-articular fracture
156
Common vascular injury in knee dislocation?
Popliteal artery
157
Ax tibial plateau fractures?
80% affect lateral condyle – following valgus force with foot planted (bumper injury)
158
Intra-articular soft tissue knee injuries best shown by?
| E.g? (4)
MRI
* meniscal tears
* Collaterals
* Cruciate ligaments
* Hyaline cartilage injury (thickest in body)
159
Ax calcaneal fracture?
| Appearance on x-ray?
Fall from height and smack into ground on heel
| * Fracture = loss of peak and increased bone density
160
What sesamoid bone can mimic knee fracture?
Fabella (Latin for little bean)
161
What sesamoid bone can mimic talar fracture?
Os trigonum
162
Lisfranc fracture?
| Dx?
Injury of the foot in which one (or more) of the metatarsal bones are displaced from the tarsus
* Shown best by CT – as can cause ligamentous avulsion
163
Mucous cyst of the hand?
S/s? (3)
Tx?
outpouching of synovial fluid from DIPjt OA
S/s
* Painful
* Discharge
* May deform nail
Tx
* May be left alone/excision
164
Ganglions of the hand?
S/s?
Tx? Exception?
Outpouchings of synovial cavity (filled with synovial fluid)
* Painless
Tx = usually resolve with time (however, large bore needle can be used for drainage - since fluid is v thicc)
* Exception - volar wrist ganglion NOT safe to aspirate!!! Too close to radial artery
165
Where do tendons of hand run within?
Flexor tendon sheath
166
Trigger finger?
Swelling of tendon = tendon caught on edge of A1 pulley
| * sticking of finger (usually in flexion)
167
Tx trigger finger?
Tx = often resolves on its own
* splint to prevent flexion
* steroid injection
* surgery to divide A1 pulley (NO OTHERS)
168
DeQuervain's tenosynovitis?
S/s?
Dx?
Irritation of tendon sheath causing pain in base of thumb
* Pain
* Redness
* Swelling
Dx = Finklestein's test - thumb folded under fingers then ulnar deviate
169
Tx dequervains tenosynovitis? (4)
* NSAIDS
* splint
* steroid injection
* surgery- decompression
170
Dupuytrens contracture?
S/s?
Ax? (6)
thickening and contracture of subdermal fascia leading to fixed flexion deformity of fingers (pathology is not the tendon - tendon is normal)
* Painless
* Gradual progression
Ax
* Genetics
* Diabetes
* Alcohol
* Smoking
* Epilepsy
* Trauma
171
Dx dupuytrens? (3)
* Feel cords
* MCP/PIP joint involvement - measure angles
* Table top test ("can you lie hand flat on table?")
172
Dupuytrens tx? (4)
* Stretches + activity modification
* Fasciotomy
* Collagenase injection
* Amputation
173
Why are zig-zag incisions made in dupuytrens fasciotomy?
To prevent scar contractures
174
Paronychia?
Ax?
Tx? (3)
```
Infection within nail fold
Ax = NAIL BITING
Tx
* elevate
* antibiotics
* drainage
```
175
Flexor tendon sheath infection?
S/s?
Tx?
Infection within sheath tracking up palm + arm (SURGICAL EMERGENCY!!!)
* Extremely painful
* Limited extension
* May have tracking lymphangitis
Tx = wash out tendon sheath
176
Nail injury can lead to?
| If pressure causes pain?
Subungal haematoma
| * Operate on with a trephine
177
Mallet fracture?
DIP unable to straighten
178
PIP dislocation tx?
| Why is it important to catch early?
Pull to reduce, buddy strap
| * Delayed presentation = impossible to reduce, may require fusion
179
Eschar?
| Tx?
Thick, leathery, inelastic skin which can form after burns
| * May require surgical release to allow movement
180
Tendinopathy? Tendonitis?
Tendonosis?
Tenosynovitis?
Enthesopathy?
* Tendinopathy - disease of a tendon
* Tendonitis - inflammation
* Tenosynovitis - inflammation of tendon sheath
* Enthesopathy - inflammation of tendon origin or insertion
181
Organisation of tendons?
What are the tendon fascicles surrounded by?
What is the outer connective tissue layer within the tendon sheath?
Microfibrils -> Subfibrils - > Fibrils -> Fascicles -> Tendon unit
* Fascicles surrounded by endotendon which contains nerves and blood vessels
* Epitendon is outer connective tissue layer in tendon sheath
182
Which drugs can cause tendinopathy? (2)
* Steroids
| * Antibiotics
183
Upper limb tendon problems? (7)
* Rotator cuff
* Biceps brachii rupture
* Tennis elbow
* Golfer's elbow
* Dequervain's tenosynovitis
* EPL rupture
* Trigger finger
184
Pathophysiology rotator cuff? (2)
S/s? (4)
Tx?
* Extrinsic compression + intrinsic degeneration
* Inflammation of subacromial bursa
S/s
* Achy pain down arm
* Difficulty sleeping on affected side
* Painful arc
* Positive impingement tests
Tx
* Physio
* Surgery = subacromial decompression
185
Biceps tendinopathy Ax?
S/s? (3)
Tx?
Overuse, instability, impingement or trauma
S/s
* Pain anterior shoulder radiating to elbow
* Aggravated by shoulder flexion, forearm pronation + elbow flexion
* Snapping with shoulder movements if subluxation
Tx
* Conservative vs surgical
186
Clinical signs of biceps rupture? (2)
| Tx? (3)
* Popeye sign
* Extensive bruising
Tx
* Rest
* Physio
* Surgical repairs
187
Lateral epicondylitis?
S/s?
Tx?
Tennis elbow - tendinosis and inflammation at extensor carpi radialis brevis origin (common extensor origin)
S/s
* Pain and tenderness over lateral epicondyle
* Pain with resisted extension of middle finger
* Non-inflammatory
Tx
* Self-limiting
* Steroid injections
* Surgical release of ECRB origin (only in persistent cases)
188
Medial epicondylitis?
S/s?
Tx? (3)
Golfer's elbow - origin of wrist flexors
* Medial elbow pain
Tx
* Self-limiting
* DO NOT INJECT STEROIDS (ulnar nerve)
* Surgery last resort
189
Most common hand tendon rupture?
Ax?
Tx?
Extensor pollicus longus rupture
* Occurs a few weeks after undisplaced distal radius fractures
Tx
* Loss of thumb extension but often doesn't impact daily life - however, tendon transfer can be offered (EIP)
190
Complication of trigger finger?
| Surgical release of A1 pulley contraindicated in?
Can lead to fixed flexion contracture esp in diabetics
| * Contraindicated in RA as may exacerbate ulnar drift - synovectomy instead
191
Tx for quadriceps and patellae tendon rupture?
Surgical repair (open)
192
Traction apophysitis?
Epidemiology?
S/s?
Osgood-Schlatter's disease
* inflammation of patellar ligament at tibial tuberosity
Epidemiology = adolescent active boys
S/s
* painful bump below knee that is worse with activity and better with rest
193
Tibialis posterior rupture leads to?
| Tx? (4)
Progressive flat foot + valgus hindfoot
* NSAIDs
* Cast
* Steroids
* Debride
194
Tx joint ganglia?
NOT aspiration = surgical excision
195
Features of bakers cyst? (3)
* Associated with OA
* Soft and non-tender
* Painful rupture
196
Why do children experience fractures differently from adults?
Thick periosteum
197
Osteogenesis imperfectica symptoms?
Blue sclera
198
Process of fracture healing?
* Primary bone healing: when <1mm fracture gap - bone bridges gap via osteoblasts (seen in hairline fractures + when fractures are fixed with screws and plates)
* Secondary bone healing: fracture -> inflammation -> WBCs and osteclats remove debris + bone -> granulation tissue from fibroblasts -> chondroblasts form cartilage (soft callus) -> osteoblasts begin enchondral ossification -> calcium mineralisation produced woven bone (hard callus) -> remodelling
199
At what stage in secondary bone healing is a soft callus formed? Hard callus?
* Soft = 2-3 weeks
| * Hard = 6-12 weeks
200
Fracture patterns? (5)
* Transverse = bending force (almost straight across)
* Oblique fractures = shearing force (e.g. fall from height/deceleration)
* Spiral fractures = torsional forces
* comminuted fractures = 3 or more fragments, need to be stabilised surgically
* Segmental = bone is fractured in 2 separate places, req stabilisation
201
Investigation of fractures? (5)
* X-rays
* Tomogram (moving x-ray) - used for mandibular fractures
* CT
* MRI
* Technetium bone scan - stress fractures as many fail to show up on x-ray until hard callus begins to appear
202
Management of long bone fractures
Tx of undisplaced/minimally displaced/minimally angulated fractures?
Displaced/angulated fractures?
Unstable extra-articular diaphyseal fractures?
Displaced intra-articular fractures?
* Splintage/immobilisation
* Closed reduction + cast (if unstable = surgical stabilisation via K-wires etc)
* Open reduction + internal fixation using plates and screws
* Reduction + internal fixation using wires, plates and screws
203
Complications of fractures? (13)
* Compartment syndrome
* Ischaemia
* Nerve injury
* Hypovolaemia
* Fat embolism
* ARDS
* Acute renal failure
* SIRS + MODS
* OA
* chronic regional pain syndrome
* Infection
* Volkmann's ischaemic contracture
* PE - occurs several days to weeks after injury
204
Signs of fracture non-union? (4)
* Ongoing pain
* Oedema
* Movement at fracture site
* Bridging callus on x-ray/CT
205
What are types of non-union? (2)
* hypertrophic non‐union - due to instability and excessive motion at fracture site
* atrophic non‐union - due to rigid fixation with a fracture gap, lack of blood supply, chronic disease
Both can also be caused by infection!!
206
What is fracture disease?
term used to describe stiffness and weakness due to the fracture and subsequent splintage in cast
207
Tx open fracture? (3)
* IV broad spectrum antibiotics
* Surgical debridement of non-viable soft tissue
* Internal/external fixation
208
What does delayed presentation of dislocation (e.g. in alcoholics) result in?
Increases risk of requiring open reduction and recurrent instability
209
How are ligament ruptures graded? (3)
* Grade 1 = sprain
* Grade 2 = partial tear
* Grade 3 = complete tear
210
Tx for most soft tissue injuries?
RICE
* Rest
* Ice
* Compression
* Elevation
(some complete ligament ruptures may need repair)
211
What kind of tendon tears require surgery? Conservative management?
Surgery
* Quadriceps and patellar tendon
Conservative (however may need repair)
* Achilles, rotator cuff, biceps brachii
212
Spinal chock?
| What is the test to signal the end of spinal shock?
physiologic response to injury with complete loss of sensation and motor function and loss of reflexes below the level of the injury (usually resolves in 24 hours)
* bulbocavernous reflex is absent in spinal shock and its return signals the end of spinal shock
213
Neurogenic shock?
| Tx?
occurs secondary to temporary shutdown of sympathetic outflow from T1 to L2, usually due to injury in the cervical or upper thoracic cord (causes hypotension and bradycardia which usually resolves within 24‐48 hours)
* Tx = IV fluid therapy
214
What does sacral sparing in spinal cord injury indicate?
Incomplete cord injury and better prognosis :)
215
Side effects of pain-killers? (4)
* peptic ulcers
* Renal impairment
* Increased cardio risk
* Exacerbation of asthma
216
Is methotrexate safe in pregnancy?
NO
| * If trying to concieve, must come off for at least 3 months (sub with sulphasalazine and use contraception)
217
Side effect of hydroxychloroquine?
Retinopathy (very rare!)
218
Side effects of biologics (anti-TNF)? (3)
* Infection
* Reactivation of latent TB
* Increases risk of skin cancer
219
Tx acute episode of gout? Side effect?
Colchicine
| * diarrhoea common
220
Gout prophylaxis? (3) Side effects?
* Allopurinol - allergic rash (very common) - stop if rash develops
* Febuxostat - contraindicated in patients with ischaemic heart disease
* Uricosurics (difficult to source)
221
What are allopurinol and febuxostat?
Xanthine oxidase inhibitors (used in tx of gout)
222
Dangerous drug interaction with allopurinol?
Azathioprine - causes irriversible bone marrow suppression!!
223
When should allopurinol dose be increased in gout?
If urate levels not <360
224
Corticosteroid side effects? (4)
* Loss of bone density
* Weight gain
* Muscle wasting
* Skin atrophy
225
Where are crackles heard in methotrexate pneumonitis?
Both lung bases
226
What is triple therapy for RA?
Methotrexate, sulphasalazine, hydroxychloroquine
