MSK Flashcards

Question

compression of which nerves causes loss of knee jerk and ankle jerk reflex?

Answer 1

major: joints, new cardiac murmur, nodules, erythema, sydenhams chorea minor: long PR, increased ESR, athralgias, increased CRP, increased temp need 2 major, or 1 major and 2 minor, plus evidence recent GAS infection

Answer 2

buffalo hump, easy brusing, cataracts, larger appetite, obesity, moonface, euphoria, thin arms and legs, hypertension, hyperglycemia, avascular necrosis of femoral head, skin thinning, osteoporosis, negative nitrogen balance, emotional liability

Answer 3

Site What is the pattern of joint involvement? i.e. Which joints are affected? Small or large joints? One or more than one joint? What was the speed of onset like? Is the condition bilateral? If so, is it symmetrical or asymmetrical? Onset When did it start? What was the onset like? (Acute e.g. gout; Subacute e.g. septic arthritis, rheumatoid arthritis (RA); Chronic e.g. osteoarthritis (OA)) Has it been constant since the onset? If episodic, what are the frequency, regularity and duration of the episodes? Character e.g. ache, sharp pain, throbbing Radiation e.g. neck pain to upper limb; lower back pain (LBP) to buttocks/ lower limb; hip pain to knee Associated symptoms Stiffness and/or swelling, crepitus (grating of surfaces against each other) Erythema, increased local temperature Fatigue, malaise, depression Systemic temperature (e.g. gout, sepsis) Rashes/skin conditions (e.g. psoriasis, erythema nodosum) Nodules (e.g. rheumatoid nodules, gouty tophi) Fever, abdominal pain, weight loss (e.g. systemic symptoms of vasculitis/connective tissue disease or symptoms suggestive of associated inflammatory bowel disease) Dry mouth and gritty eyes Timing Is there a relationship with the time of day? Ask: ‘What do your joints feel like on rising; How do you feel at the end of the day? How do you sleep?’ e.g. RA – significant early morning stiffness (>60 mins usually) & joints stiffen up again after period of rest/ in evening OA – minimal to moderate early morning stiffness (<30 mins usually) & joints made worse by activity. Also stiffen up in evening. Exacerbating factors Exercise in mechanical/ degenerative conditions; Rest in inflammatory conditions. Alleviating Factors NSAIDs. Exercise / Rest as above. Severity Very severe – acute gout +/- sepsis Slightly less severe – RA/ OA (usually) Any movements that are particularly painful? Is function limited by pain?

Answer 4

Occupation. Does the problem affect their employment? • Sports and hobbies • Home circumstances (type of dwelling e.g. house, bungalow; dependents, carers, social support) • Ability to carry out activities of daily living – a detailed history is likely to be needed here. For example, a patient with osteoarthritis of the hip may have difficulty getting in and out of a car or bath, picking up objects from the floor, putting on their shoes and socks, cutting their toenails etc. • Smoking • Alcohol consumption

Answer 5

Is there a family history of RA, OA, psoriasis, gout, Ulcerative Colitis, Crohn’s disease, connective tissue disease or any other autoimmune disease?

Answer 6

Do you have any pain or stiffness in your muscles, joints or back? • Are you able to completely dress and undress yourself without any difficulty? • Are you able to climb up and down stairs without any difficulty?

Answer 7

Position the patient with the knee flexed to 90° and the foot flat on the bed. Inspect from the side. A posterior sag of the upper tibia, with a ‘step’ visible below the patellar, is suggestive of posterior cruciate ligament (PCL) damage.

Answer 8

Position the patient with the knee flexed to 90° and the foot flat on the bed. Stabilise the leg using your own forearm – for infection control reasons you should not sit on the patient’s bed. With the fingers of both hands behind the knee and the patients hamstrings relaxed, place your thumbs over the tibial tuberosity and apply a forward pull. Significant movement indicates a positive draw test and suggests anterior cruciate ligament (ACL) damage.

Answer 9

Flex the knee to 20°. Grasp the patient's heel with one hand while exerting pressure against the inside of the knee with the other hand. The varus stress applied will cause lateral gaping in the laterally unstable knee. A small amount of lateral joint gaping is physiological and is the asymmetry of the gaping that constitutes the abnormal finding.

Answer 10

As above but apply a valgus stress against the lateral | aspect of the knee and assess for medial gaping.

Answer 11

This test has higher sensitivity and specificity than the anterior draw test for detecting ACL laxity. However, the REMS national curriculum specifies that the anterior draw should be taught to medical students (1). Many orthopaedic surgeons will ask you to perform the Lachman’s test instead and in the OSCE, you may perform either test, depending on your personal preference. Flex the knee to 20°. Place one hand behind the tibia with your thumb on the tibial tuberosity. Grasp the patient’s thigh with your other hand and pull anteriorly on the tibia. You should feel a firm end-point as the anterior cruciate ligament (ACL) prevents forward translocation of the tibia on the femur. A soft end-point suggests ACL damage. If the patient’s thigh is too large, or your hand is too small, to stabilise the limb adequately, you may perform Lachman’s test with the patient’s thigh supported by the edge of the examination couch.

Answer 12

. The test is designed to trap or catch a torn meniscus between the femoral condyle and the tibial plateau and should only be performed if the patient’s history is suggestive of a torn meniscus (In the OSCE, if you need to perform this test, you will be instructed to do so). Flex the patient’s hip to 90° and maximally flex the knee. Externally rotate the knee and, maintaining this rotation, move the knee gradually from the fully flexed position to the fully extended position. The test is repeated using internal rotation. A palpable, audible, or painful click over the medial or lateral joint line indicates a meniscal tear. The test is useful when positive but is unreliable when negative. It is difficult to perform on an acutely painful knee.

Answer 13

quantitative evaluation of flexion of the lumbar spine. Mark a 15cm length of the lumbar spine with the patient in the erect position), measuring 10cm above and 5cm below the posterior superior iliac spines (Dimples of Venus). Instruct the patient to flex his or her spine maximally. Re-measure the distance between the marks. Normal flexion increases the distance by at least 5 cm.

Answer 14

Ask the patient to lie flat on the couch. Passively flex their thigh with their leg extended. If the patient complains of back or leg pain the test is positive (hamstring tightness is not relevant). Paraesthesiae or pain in a nerve root distribution [64] indicates nerve root irritation. Back pain suggests, but is not indicative of, a central disc prolapse, and leg pain suggests a lateral protrusion. Lower the leg gradually until the pain disappears then dorsiflex the foot. This increases tension on the nerve roots, aggravating any pain or paraesthesiae (Lasegue’s sign)

Answer 15

. Perform a straight leg raise. If the patient experiences pain, flex the knee slightly then apply firm pressure with the thumb in the popliteal fossa to stretch the tibial nerve. Radiating pain and paraesthesiae suggest nerve root irritation.

Answer 16

With the patient prone and the anterior thigh fixed to the couch, flex each knee in turn. This causes pain in the skin overlying the anterior compartment of the thigh by stretching the femoral nerve roots in L2-L4. The pain produced is normally aggravated by extension of the hip.

Answer 17

Resisted active abduction (supraspinatus) initiates abduction - first 15 degrees, deltoid abducts up to 90 degrees; trapezius and serratus anterior cause scapular rotation for abduction beyond 90 degrees). o Resisted active external rotation (infraspinatus, teres minor) o Resisted active internal rotation – “lift off” test (subscapularis). Ask the patient to place their hand behind their back with the dorsum of their hand resting over their mid-lumbar spine. The dorsum of the hand is then raised off the back by maintaining or increasing internal rotation of the humerus and extension at the shoulder. To perform this test the patient must have full passive internal rotation so that it is physically possible to place the arm in the desired position and pain cannot be a limiting factor during the manoeuvre. The ability to actively lift the dorsum of the hand off the back constitutes a normal lift-off test. Inability to move the dorsum off the back constitutes an abnormal lift-off test and indicates subscapularis rupture or dysfunction

Answer 18

Place the arm into forced adduction across the body at 90° of flexion at the shoulder = “scarf test”. Note any pain or tenderness over the ACJ

Answer 19

In the supinated position, ask the patient to make a fist and flex their wrist against resistance. Pain will be felt at the medial epicondyle.

Answer 20

In the pronated position, ask the patient to extend their wrist against resistance. This will re-produce pain at the origin of the extensor muscles (lateral epicondyle).

Answer 21

Bouchard’s nodes at PIPJs in osteoarthritis (OA) | • Heberden’s nodes at DIPJs in O

Answer 22

``` Swan neck and Boutonniere deformities of IPJs in rheumatoid (RA Windswept deformity (ulnar deviation at MCPJ in RA) ```

Answer 23

Sensory - Test light touch in the median nerve distribution. o Motor - Test palmar abduction against resistance (with the patient’s palm supinated and held out flat, ask them to point their thumb vertically up to the ceiling. Apply resistance by pushing the thumb back towards the palm with your own thumb). o Provocation – • Tinel’s test - tap strongly over the median nerve as it goes through the carpal tunnel. Reproduction of pain, numbness or tingling in the cutaneous distribution of the median nerve is a positive test. • Phalen’s test – ask the patient to hold both wrists in palmar flexion for one minute. Reproduction of pain, numbness or tingling in the cutaneous distribution of the median nerve is a positive test. • Compression test – di

Answer 24

Sensory - Test sensation in the ulnar nerve distribution o Motor – • Ask the patient to cross their index and middle fingers • to grip a piece of paper between their thumb and index finger without flexing their thumb IP joint (Froment’s sign). You will need to demonstrate to the patient what you are asking them to do. • To abduct their fingers against resistance

Answer 25

o Sensory - Test sensation in the anatomical snuffbox | o Motor - Test wrist and finger dorsiflexion against resistance.