MSK Flashcards
Which of the following is of greatest concern following a posterior hip dislocation?
sciatic nerve injury -> foot drop
common feature of clinical injury indicating avascular necrosis?
acetabular #
The affected leg is shortened, adducted, and internally rotated. what type of hip injury is described?
posterior dislocation
The affected leg is usually abducted and externally rotated. No leg shortening. type of hip injury described?
anterior dislocation
27-year-old woman presents with painful genital ulceration. She has had recurrent attacks for the past four years. Oral aciclovir has had little effect on the duration of her symptoms. She has also noticed for the past year almost weekly attacks of mouth ulcers which again are slow to heal. Her only past medical history of note is being treated for thrombophlebitis two years ago. What is the most likely diagnosis?
behcets syndrome
oral ulcers, genital ulcers and anterior uveitis triad points to?
behcets syndrome
also thrombophlebitis and DVT, erythema nodosum
man presents to the emergency department 30 minutes after falling onto his left hand during a social basketball game. He complains of swelling and significant pain on the radial side of his left wrist. On examination, the man describes the pain as unbearable when asked to squeeze the examiner’s finger with his left hand no x-ray changes. dx?
scaphoid # after FOOSH
In the emergency department, suspected scaphoid fractures should be managed..???
immobilisation using a Futuro splint or standard below-elbow backslab before specialist review
refer to ortho for 7-10/7 rv. also XR
history and examination together, previous trauma to a limb, with paraesthesia (an early sign), disproportionate pain on assessment of tone (passive rather than active movements) and normal x-ray findings should raise suspicion of??????
compartment syndrome -> refer to orthopaedic surgeons
subcapital fracture of the femur with partial displacement. What is the most likely surgical treatment option for this type of fracture? in patient with cognitive impairment ->
hemiarthroplasty
Intracapsular femoral fracture -
hemiarthroplasty
intracapsular = subcapital
extracapsular femoral # ->
dynamic hip screw
34-year-old man visits his GP due to worsening weakness and pain in his arms and hands, and increasing fatigue, especially on exertion. On examination there are faint fine crackles audible in the lower-mid zones. The GP also notices thickened and cracked skin on the patient’s hands, as well as difficulty when the patient moves up from the chair onto the examination couch. dx?
antisynthetase syndrome
myositis
which Ab ix for antisynthetase syndrome?
anti-jo1 Abs
first line pharma mx for Raynaud’s syndrome:
nifedipine (CCB)
rugby -> shoulder injury - commonly?
AC jt injury
ankle XR: A minimally displaced, transverse fracture is seen distally through the lateral malleolus, below the level of the talar dome. No talar shift is seen. The medial malleolus is not involved. classification and mx?
weber A - stable
discharge from ED with walking boot and analgesia for f/u r/v to check healing
what is the most common cardiac manifestation of SLE and is included in many classification criteria including those outlined by the British Society for Rheumatology in their 2018 guidelines for SLE?
pericarditis
25-year-old man with a history of Crohn’s disease presents asking for advice. He currently takes methotrexate and asks if it is alright for him and his partner to try for a baby.
What is the most appropriate advice?
wait 6 months from finishing tx with MTX before trying
extremely painful joint at the base of his thumb which came on suddenly overnight. The 1st metacarpal-phalangeal (MCP) joint is swollen and erythematous. dx?
gout
bone pain for the past few weeks. He has also had a reduction in his hearing recently. His blood results show an isolated rise in alkaline phosphate.
Given the likely diagnosis, which bone is most likely to be in pain?
pelvis - pagets disease of bone
granulomatosis with polyangiitis: which antibodies?
wegener’s
cANCA
eosinophilic granulomatosis with polyangiitis (aka churg-strauss) + others - which antibodies to ix?
pANCA
78-year-old man is investigated for headaches. A routine blood screen is normal other than an elevated ALP. A skull x-ray is ordered: likely dx even without seeing XR:
Pagets disease of bone
septic arthritis: which abx?
IV flucloxacillin
what is first line tx in ankylosing spondylitis?
physio + NSAIDS
what should be used to manage the acute flares of rheumatoid arthritis in patients on chronic treatment?
IM Methylprednisolone
what bloods are normally seen in Osteogenesis imperfecta ?
normal adjusted Ca, PTH, ALP, P04
32-year-old woman presents with recurrent deep vein thromboses and pulmonary embolisms. She has a past medical history of recurrent miscarriages. Blood results reveal low platelets and a prolonged APTT. dx?
antiphospholipid syndrome
antiphospholipid syndrome: which antibody is investigated?
anti-Cardiolipin Ab
upwards lens dislocation, tall stature, high arch palate, pectus excavatum are all signs of ?
marfans syndrome
basketballers. mutation in fibrillin-1 protein (AD)
78-year-old man presents with symptoms of headaches and deteriorating vision. He notices that there is marked pain on the right hand side of his face when he combs his hair. dx?
GCA
needs pred and vision test
diagnostic angiogram is performed which shows an abrupt cut off at the level of the anterior tibial artery, together with the formation of corkscrew shaped collateral vessels distally.
Buergers disease
common in young male smokers
lady is referred to the vascular clinic. She has been feeling generally unwell for the past six weeks. She works as a typist and has noticed increasing pain in her forearms whilst working. On examination she has absent upper limb pulses. Her ESR is measured and mildly elevated. dx?
takayasu’s arteritis
what is an effective and commonly used method of analgesia for patients with a neck of femur fracture?
iliofascial nerve block
the classic signs are a shortened and externally rotated leg???
hip #. nof
undisplaced nof # mx?
internal fixation, or hemiarthroplasty if unfit.
displaced nof # in fit <70yo mx?
Reduction and internal fixation (if possible)
displaced nof # in older unfit pt mx?
hemiarthroplasty or total hip replacement
extracapsular hip # mx?
dynamic hip screw
if reverse oblique, transverse, subtrochanteric - intramedullary device
classification system for hip #?
garden system
what is Foucher’s sign?
increase in tension of the Baker’s cyst on extension of the knee
history of diabetes, osteoarthritis and hypertension. She twisted her leg whilst getting out of a car and developed increasing pain weight bearing which has eased with simple analgesia. She also tells you she has a lump under her knee. On examination, she has a 4cm non-tender lump just below the popliteal fossa which becomes tense on extending the leg. dx?
bakers cyst
40-year-old woman presents with new onset dull lower back pain since moving home. She is normally fit and well. She has a normal examination with no neurology or concerning features. What would be the first-line treatment for her pain?
naproxen
nsaids first line for lower back pain
+PPI
lower back pain analgesia if cannot tolerate NSAIDS?
co-codamol / codeine
lower back pain analgesia if spasm is a feature?
short course benzos
if have to ix lower back pain, which ix should ya use?
MRI
A patient with a subtrochanteric femoral fracture fixed with intramedullary nail should be given what advice re weight bearing after post-op?
weight bear immediately post op
Carpometacarpal and distal interphalangeal joint involvement is characteristic of??
hand OA
PIP involvement and joint effusions are typical of?
RA
Pencil in cup appearance is pathognomonic of
psoriatic arthritis
also plantar spurring
thumb squaring in which arthritis typically?
OA
how is avascular necrosis ix in scaphoid injury?
mri
blood supply to scaphoid???
80% dorsal carpal branch of the radial artery
public health terms for anatomical snuff box tenderness in ?scaphoid #?
highly sensitive >90%
poorly specific <40%
scaphoid # - how long cast on?
6-8/52 (only this if confirmed undisplaced - no f/u)
proximal scaphoid pole fractures
mx?
surgical fixation
Which one of the following pathologies does a positive straight leg raise suggest?
sciatic nerve pain
also need loss of ankle jerk and plantar response for this
IVDU R flank pain -> lower back pain
in pain. tender over l1,2
cannot weight bear
X-R no abnormalities. likely dx?
psoas abscess
likely organisms for psoas abscess?
saureus
ix psoas abscess?
CT abdo
mx psoas abscess?
abx
drainage percutaneous
surgery
weber A # mx?
weight bear as tolerable in a CAM boot for 6 weeks
regimental badge area nerve?
axillary
commonly injured in shoulder dislocations
(anterior - >95%)
Twisting knee injury - dx?
?meniscus tear - MRI
direct blow to knee ->?
patella dislocation
Falling hard onto a bent knee can injure the?
PCL
positive posterior drawer test =
PCL injury
Hyperextension knee injury most commonly results in ?
ACL rupture
positive anterior drawer test =
ACL injury
Repeated jumping and landing on hard surfaces causes?
patella tendinopathy or jumpers knee
McMurray’s test would also be positive (painful click).
meniscal tear
plus/minus MCL injury
knee pain worse on crouching ->
meniscal tear
Thessaly’s test 20degree flexion
cauda equina ix?
MRI urgent
what is a common cause of knee pain, particularly in runners
ITBS
in discitis caused by stapholococcus, what do you need to rule out and how?
ECHO endocarditis
All proximal scaphoid pole fractures require ?
surgical fixation
what predisposes to the development of a Charcot joint?
alcoholic neuropathy
non-tender, swollen, erythematous and hot foot are pathognomonic?
acute charcot joint
XR - extensive bone remodelling in midfoot
what are cx of discitis?
epidural abscess
changing lower limb neurology
sepsis
27-year-old man was admitted to hospital 6 hours previously following a fractured right tibia while playing a football match. His pain has been well controlled until 30 minutes ago, but he is now complaining of intense pain in his right lower leg. On examination he is in severe pain, worsened by passive movement of the foot. You are able to palpate the dorsalis pedis and posterior tibial pulse on the right foot. His heart rate and respiratory rate are both raised + sweating - dx?
compartment syndrome
DO NOT GIVE ANTICOAGULANTS - WORSENS
differentiate between vertebral OM and psoas abscess?
position ext rotation and lack of hip extension will help psoas abscess as it does not stretch the muscle
in OM these will make 0 difference
Fracture involving the physis, metaphysis and epiphysis. grade?
salter-harris 4
Finkelstein test positive?
pain over her radial styloid on forced abduction/flexion of the thumb
finkelstein test + indicates?
de quervain’s tenosynovitis
4-year-old girl with a three month history of a limp. Her parents report that she has ‘not been right’ for a few weeks now. She typically complains of pain in her left hip and right knee in the morning which gets better during the day.
dx?
JIA
7-year-old boy is brought in by his mother. For the past day he has felt generally unwell with a headache and nausea. This morning he complained of pain in his right hip and now just able to walk with a limp. On examination flexion, extension and rotation of the hip is painful and limited. Examination of the ears, throat and chest is normal. His temperature is 38.2ºC dx?
septic arthritis
6-year-old boy with a limp. His parents report that this has been getting steadily worse over the past few weeks. He complains of pain in the right groin/hip region. An x-ray shows widening of the right hip joint space with flattening of the femoral head.dx?
perthes disease
tenderness over the medial epicondyle and medial wrist pain on resisted wrist pronation.?
golfers elbow
tenderness over the lateral epicondyle and lateral elbow pain on resisted wrist extension.
tennis elbow
Management of a grade 1-2 AC joint injury:
conservative with resting and a sling
The Stimson Maneuver is used for?
reduction of disloacted shoulders
A 63-year-old lady undergoes an axillary clearance for breast cancer. She makes steady progress. However, 8 weeks post operatively she still suffers from severe shoulder pain. On examination she has reduced active movements in all planes and loss of passive external rotation.
dx?
adhesive capsulitis
DM is a RF
A 78-year-old man complains of a long history of shoulder pain and more recently weakness. On examination active attempts at abduction are impaired. Passive movements are normal.
dx?
rotator cuff tear
A 28-year-old man complains of pain and weakness in the shoulder. He has recently been unwell with glandular fever from which he is fully recovered. On examination there is some evidence of muscle wasting and a degree of winging of the scapula. Power during active movements is impaired.
dx?
parsonage-turner syndrome
what is parsonage-turner syndrome?
post-viral peripheral neuropathy
spontaneously resolves
which organism are sickle cell patients prone to getting which gives them OM?
salmonella
OM ix?
MRI
71F diagnosed with polymyalgia rheumatica. On prednisolone 15mg od. What is the most appropriate approach to bone protection?
start alendronate + ca + vitD replacement
over 65 or previous fragility # start asap
when would you not start someone on bone protection if they have been started on pred for rheum condition?
if under 65 - offer a bone density scan first and that dictates further mx
if going to be on long term - start immediately
T score interpretation:
> 0 fine
0 - -1.5: rescan 1-3 yrs
lower than -1.5 - offer bone protection without rescan
63F urticaria and difficulty breathing after a recent medication change. PMH osteoporosis, hypertension, refractory rheumatoid arthritis and GORD. Allergic to pollen, aspirin. what drug caused this reax?
sulfasalazine can cause reaction in those allergic to aspirin
Azathioprine is another DMARD that can be used in the management of refractory rheumatoid arthritis. Its use is contraindicated in patients with hypersensitivity to which drug?
metaclopramide
sulfasalazine adverse effects and caution:
caution G6PD deficiency, aspirin and sulfonamides
adverse effects: oligospermia
if adverse reax to co-trimoxazole - CI
which RA DMARD safe to use in pregnancy?
sulfasalazine
hydroxychloroquine safe too
etanercept for flare during preg
Patients with anti-phospholipid syndrome who haven’t had a thrombosis previously are generally given what for prophylaxis?
low dose aspirin
if previous clot LMWH
warfarin INR target for antiphospholipid syndrome?
2-3
pagets disease of bone tx:
IV Bisphosphonates
Radiolucency of subarticular region suggestive of osteolysis. Some areas of patchy sclerosis
on X-ray of right femur, with normal bloods except a raised ALP:
pagets disease of bone
low calcium and phosphate combined with the raised alkaline phosphatase point towards?
osteomalacia
what is osteomalacia called if growing still?
Rickets
tx osteomalacia?
ca+vitD
Hand XR: (mainly metacarpophalangeal and proximal interphalangeal joints) and changes seen (erosions, subluxation and loss of joint space) points to a diagnosis of ?
RA
which syndrome is a condition characterized by splenomegaly and neutropenia in a patient with rheumatoid arthritis?
Felty’s syndrome
63-year-old male presents to emergency department with acute monoarthritis waking him from sleep. He reports he has never experienced this in the past. Joint aspiration reveals negatively birefringent urate crystals under polarised light. dx?
GOUT
13M 3-month history of a growing lump on the posterior aspect of his right arm, extremely painful over the last two weeks. A shoulder XR: lytic lesion in the diaphysis of the right humerus with an ‘onion skin’ appearance. Fine-needle aspiration of the lesion is subsequently undertaken, analysis of which identifies the presence of EWS-FLI1 protein. dx?
ewing’s sarcoma
where does Ewing’s sarcoma commonly present?
diaphysis of pelvis or long bones
where does chondrosarcoma present and which demographic?
axial skeleton or diaphysis of long bones
middle age
commonest benign bone tumour?
osteochondroma - 20yo males
what is the most common primary malignant bone tumour?
osteosarcoma
which tumour typically metaphyseal region of long bones prior to epiphyseal closure. It also shows a ‘sunburst’ pattern on x-ray and is most commonly associated with mutations in the retinoblastoma gene (and hence retinoblastoma tumours).???
osteosarcoma
affects young people
bone mets in woman with CKD 4. which tx for bone protection from pathological #?
denosumab
as egfr<30
gout prevention but patient on azathioprine - which prophylactic agent?
febuxostat
azathioprine: sfx, preg?
pancreatitis, bone marrow suppression when given with allopurinol
safe in preg
56F referred to rheumatology clinic due to severe Raynaud’s phenomenon associated with arthralgia of the fingers. On examination you note shiny and tight skin of the fingers with a number of telangiectasia on the upper torso and face. She is also currently awaiting a gastroscopy to investigate heartburn. Which one of the following antibodies is most specific for the underlying condition? dx?
limited (central, cutaneous) systemic sclerosis
features of CREST
anti-centromere abs
which abs associated with diffuse cutaneous systemic sclerosis?
anti-scl-70
35F multiple spontaneous miscarriages, recurrent DVT / PEs review appointment. Purpuric rashes, splinter haemorrhages and livedo reticularis. Given the likely diagnosis, which of the following would be the most appropriate auto-immune antibody test to perform?
Anti-phospholipid syndrome
ANti-cardiolipin Abs
Lupus Anticoagulant Abs too
antibodies in SLE?
anti-double stranded DNA Abs (spec)
anti-ANA*** (sens)
Anti-CCP (cyclic citrullinated peptide) Abs for?
RA
anti-Jo-1 and anti-Mi-2 Abs for?
polymyositis
Anti-Ro and Anti-La abs for?
Sjogren’s syndrome
Urethritis + arthritis + conjunctivitis =
reactive arthritis
which organism likely caused reactive arthritis in young male?
chlamydia trachomatis
reactive arthritis mx?
symptomatic: analgesia, NSAIDS, intra-articular steroids
The x-ray demonstrates juxta-articular erosive changes around the 1st MTP joint with overhanging edges and associated with a moderate soft tissue swelling. The joint space is maintained. These findings are consistent with:
gout
signs of asymmetrical inflammation of peripheral joints, with a background of inflammatory bowel disease. This points towards a diagnosis of?
enteropathic arthritis
HLA-B27
HLA-B51 is associated with ?
behcet’s disease
reactive arthritis: synovial fluid aspiration interpretation:
develops after an infection where the organism cannot be recovered from the joint
would be yellow colour, culture negative, crystal negative, WCC 20,000ish
29M -> GP recent onset of low back pain. Worse at night and often radiates to the hips. It improves with exercise. He is also suffering from sensitivity to light in both eyes and reduced vision in his right eye. Oral NSAIDs have failed to improve his symptoms. Which of the following drugs would be most appropriate in the next step of management?
Ank spond
Etanercept (TNF-a blocker, others: Infliximab)
use these when 2 drugs have failed
31F 4 week history of joint pain, a pink, bumpy rash on arms, legs, and trunk, and fevers that spike in the evenings. On examination, there is bilateral cervical lymphadenopathy and the spleen is palpable. Blood tests are ordered, which show a marked leucocytosis (≥ 10,000/µL) and high serum ferritin (350ng/mL) levels but negative tests for antinuclear antibody and rheumatoid factor. dx?
adult onset of Still’s disease
salmon rash
joint pain, spiking fevers, and a pink bumpy rash is very characteristic of
(also high ferritin, leucocytosis)
adult onset of Still’s disease
Renal impairment, respiratory symptoms, joint pain, systemic features → consider ?
ANCA - associated vasculitis
