MSK clinical 1 Flashcards
(181 cards)
1
Q
why is the humeral head retroverted
A
increases the range of movement at the glenohumeral joint (30degrees on average)
2
Q
what condition commonly affects the trapezium
A
osteoarthritis - the commonest site in the hand
3
Q
what type of accident is associated with trauma to he midcarpal joint
A
dislocation due to high energy injury
- (peri) lunate dislocation with or without fracture
4
Q
what type of joint is the 1st carpometacarpal joint
A
saddle
5
Q
what disease commonly occurs at the first carpometacarpal joint
A
osteoarthritis
6
Q
what is the position of safe splinting
A
collateral ligaments of MCPs are at full stretch when fingers 90 degrees flexed
collateral ligements of the IPJs are at full stretch when fully extended
7
Q
what condition commonly affects the metacarpophalangeal joints
A
swelling due to rheumatoid arthritis
8
Q
what clinical sign is seen at the metacarpophalyngeal joints in rheumatoid arthritis
A
ulnar drift
9
Q
what type of joints are the interpharyngeal joinrs
A
hinge
10
Q
where would you find heberden’s nodes
A
the distal interphalangeal joints
11
Q
where would you find bouchards nodes
A
at the proximal interphalangeal joints
12
Q
Flexor muscles of the thumb
A
flexor pollicis longus and brevis
13
Q
extensor muscles of the thumb
A
extensor pollicis longus and brevis
14
Q
abduction muscles of the thumb
A
adductor pollicis longus and brevis
15
Q
adduction muscles of the thumb
A
adductor pollicis
16
Q
what is the muscle of the thumb responsible for opposition
A
opponens pollicis
17
Q
nerve supply to the muscles of the thumb in the thenar eminence
A
flexor pollicis brevis, abductor pollicis brevis and opponens pollicis
– median nerve
18
Q
nerve supply to the muscle of the thumb in the palm of the hand
A
opponens pollicis
– ulnar
19
Q
Allens test
A
how to test for patency of the radial and ulnar nerves
- hand is ellevated and patient is asked to make a fist for about 30 seconds
pressure is applied over the ulnar and radial nerves as to occlude them both
still elevated the hand is then opened and it should appear blanched (pallor at the finger nails)
ulnar pressure is released and the colour should return in 7 seconds
20
Q
what is the palmar aponeurosis
A
fibrous sheet of fascia which blends with palmaris longus
21
Q
what condition can occur in the palmar aponeurosis
A
dupuytren’s contracture
22
Q
what is a dermatome
A
sensory area of skin supplied by a single spinal nerve
23
Q
what is a myotome
A
group of muscles supplied by one segment of the spinal cord
24
Q
where on its course is the axillary nerve at risk
A
surgical neck of the humerus
25
what injuries can affect the axillary nerve
- fracture of humeral neck (surgical neck particularly)
- shoulder dislocation
- pressure on posterior cord of the brachial plexus
26
what is the motor deficit in an axillary nerve lesion
loss of shoulder abduction (deltoid)
27
sensory deficit in an axillary nerve lesion
badge area
28
during its course where is the radial nerve most at risk
spiral neck of the humerus - humeral shaft/radial groove
29
sensory deficit in a radial nerve palsy
1st web space dorsally (thumb and index)
30
nerve roots of the sciatic nerve
L4-S3
31
when is the sciatic nerve at risk
posterior dislocation of the hip
| IM injections
32
what are the criteria for rheumatoid arthritis
morning stiffness
arthritis in 3 or more joint areas
arthritis of hand joints
symmetric arthritis
rheumatoid nodules (subcut over bony prominences, extensor surfaces and juxta-articular regions
serum rheumatoid factor
radiographic chanfes (erosions or definite bone decalcification
33
what is pannus
abnormal layer of fibrovascular tissue or granulation tissue
34
symptoms of arthritis
```
pain
stiffness
swelling
functional impairment
systemic symptoms
```
35
what are the signs of arthritis
```
tenderness
swelling
restriction of movement
(heat)
(redness)
systemic features
```
36
systemic features of rheumatoid arthritis (non-specific)
fatigue
weight loss
anaemia
37
specific systemic features of rheumatoid arthritis
```
eyes
lungs
nerves
skin
kidneys
```
38
investigations for rheumatoid arthritis
immunology - rheumatoid factor - IgG, IgM
anti cyclic citrullinated antibodies (antiCCP, ACPA) - very specific
Xray
USS to show inflammation
39
how is rheymatoid arthritis assessed
using the disease activity score
40
how is the disease activity score for rheumatoid arthritis calculated
number of swollen joints/28
number of tender joints/28
ESR
CRP
41
what does a DAS28 score of 2.4 represent
clinical remission
42
what does a DAS28 score of >5.1 indicate
eligibility for biologic therapy
43
Aetiology of hallux valgus
```
Genetic
Foot wear (particularly female)
```
44
Symptoms of hallux valgus
Pressure symptoms from show wear
Pain - particularly in ball of foot and over bunion and when crossing toes
Metatarsalalgia = pain in ball of foot
45
Management of hallux valgus
```
Change shoes!
Give insoles
Activity modification
Analgesia
Operative - release soft tissuers, osteotomy of 1st metatarsal (+/- proximal phalynx)
```
46
Hallux rigidus - what is it and what is the cause
Stiff big toe - osteoarthritis of the 1st metatarsophalangeal joint
Unknown aetiology potentially genetics or microtrauma
47
Symptoms of halux rigidus
Many assymptomatic
Pain at extreme of dorsiflexion
Limited range of movement
48
Treatment for a ganglion
Arise from joint or tendon sheath
- hit with a bible!
- aspiration
49
What are the risks for developmental dysplasia of the hip ?
```
Being the first born
Oligohydramnios (underlying kidney and bladder problems)
Breach presentation
Family history
Being more than 10lbs at birth
```
50
Clinical features of congenital dysplasia of the hip
Orltolani's sign
| ...
51
Screening for developmental dysplasia of the hip
Selective ultrasound screening
| - for breech presentations, family history, >10lbs and thought to have abnormal hip
52
Presentation of perthes disease
```
Usually male (10:1)
Primary school age
Short stature
Limp
KNEE PAIN ON EXERCISE
Stiff hip joint
Systemically well
```
53
Aetiology of developmental dysplasia of the hip
Idiopathic
Avascular necrosis of the hip
Possible relationship to minor trauma or coagulation tendency
54
Treatment of developmental hip dysplasia
Maintain hip motion and analgesia
Restrict painful activity; "supervised neglect"
Consider osteotomy in selected groups of older children
55
Presentation of slipped upper femoral epiphyses
- teenage boys> girls
- mainly overweight
- pain in hip or knee
- externally rotated posture and gait
- reduced internal rotation, especially in flexion
56
Mimics of multisystem connective tissue disease
Drugs - cocaine, PTU
Infection - HIV, endocarditis, hepatitis,TB
Malignancy - lymphoma
Cardiac myxoma
Cholesterol emboli
Scurvy
57
Does SLE affect men or women more?
Women 9:1
58
Age of presentation of SLE
15-50
59
Criteria for SLE
```
S= serositis (pleurisy, pericarditis)
O= oral ulcers
A= arthritis (2+ joints)
P= photosensitivity
```
```
B= blood (haemolytic anaemia, leukopenia, thrombocytopenia
R= renal (high blood and protein)
A= ANA positive
I = immunologic (anti-Sm, anti-dsDNA
N= neuropsych (unexplained seizures and psychosis)
```
```
M= malar rash = butterfly
N = discoid rash (-->alopecia)
```
60
Complications of scleroderma
Pulmonary hypertension
Pulmonary fibrosis
Renal crisis
Small bowel bacterial overgrowth
61
Investigations if suspect SLE
Urine dipstick - haematuria and proteinuria
Blood - anaemia, thrombocytopenia, raised CRP and ESR
ANA testing - positive for 90%
Antibodies to double stranded DNA - highly specific for SLE
62
Complications of SLE
Increased incidence of atherosclerosis
Increased thrombosis risk
Increased infection risk due to immunosuppressive treatment
63
Presentation of scleroderma
```
C - calcinosis of subcut tissues
R - raynaud's
E - oesophageal and gut dysmotility
S - sclerodactyly (swollen tight digits)
T - telangiectasia
```
64
Features of sjorgren's syndrome
Dry eyes and mouth
Parotid gland enlargement
1/3 have systemic upset
- fever, fatigue, myalgia, arthalgia
65
Giant cell arteritis classification criteria
```
Age at onset 50+ years old
New headache
Temporal artery tenderness
ESR 50+
Abnormal temporal biopsy
```
66
Treatment for mild multisystem autoimmune diseases
Hydroxychloroquine
67
Treamtent for moderate multi-system autoimmune diseases
Azathioprine
Methotrexate
Mycophenolate
68
Treatment for severe multi-system autoimmune disease
Cyclophosphamide
| Rituximab
69
Causes of raised plasma urate
Malignancy (Leukaemia), inborn errors of metabolism, cytotoxuc drugs --> overproduction
Under-excretion
- renal impairment
- hypothyroid
- exercise, starvation, dehydration
- drugs - ALCOHOL, ASPIRIN, DIURETICS (thiazide commonly)
70
Presentation of gout
Severe monoarthropathy with joint inflammation
| - commonly MTP joint of big toe
71
Treatment of acute gout episode
- NSAIDS
- colchicine
- steroids
- Ice and elevation
72
Long term management of gout
LIFESTYLE - less purine rich meat and alcohol; lose weight and avoud prolonged starvation
Allopurinol - prevents urate acid synthesis by blocking xanthine oxidase
feboxiostat if allopurinol not tolerated
Uricosuric agents to increase secretion - sulphinpryazone
73
Basis of psuedogout
Pyrophospate dehydrate crystals --> monoarthritis of the elderly
74
Management of pseudogout
Intra-articular steroid injections
| NSAIDs not as effective
75
Presentation of polymyalgia rheumatica
Sudden onset of shoulder +/- pelvic girdle stiffness
Systemic - anaemia, malaise, weight loss, fever, depression
76
Who is commonly affected by polymyalgia rheumatica
Elderly females
(>50 but more commonly 70)
Females (2:1Males)
Common if have giant cell arteritis
77
ESR levels of someone with polymylagia rheumatica
>40
78
Treatment of polymyalgia rheumatica
18-24 month course of prednisolone
- will need bone prophylaxis
79
Drugs which can cause gout
```
Cytotoxic drugs (used in chemo)
Ethanol
Aspirin
Diuretics
Cyclosporin antibiotics
```
80
Which condition commonly has high levels of antinuclear antibodies (ANA)
Systemic lupus erythematosis
Drug induced LE
Reumatoid arthritis
Sjorgen's
Scleroderma
Old age
Chronic inflammation
81
How accurate is antinuclear antibody levels for SLE
High sensitivity for SLE
Low specificity for SLE
IF ANA TEST IS NEGATIVE SLE IS EXTREMELY UNLIKELY
82
ANCA stands for
Antinuclear cytoplasmic antibodies
83
risen levels of ANCA may indicate
```
Infection
Inflammation
Drugs
Connective tissue disorders
Inflammatory bowel disease
```
84
Secondary anti-phospholipid syndrome
Connective tissue disorders - SLE, RA, systemic sclerosis, sjorgen's
Chronic infection - HIV, hep C, malaria
Drugs - phenytoin, phenothiazines, anti-hypertensives
Lymphoproliferative disease
85
Features of anti-phospholipid syndrome
- vascular thrombosis
- recurrent fetal loss
- livedo reticularis
- thrombocytopenia
86
Functions of complement
Phagocyte chemotaxis
Opsonisation
Lysis of micro-organisms
Maintaining solubility of immune complexes
87
Name for a malignant tumour arising from connective tissue
Sarcoma
88
How do sarcomas spread
Along fascial planes
| Haematogenous spread to lungs
89
Are malignant tumours of the skeleton common or rare
RARE
90
Osteosarcoma
Malignant bone-forming tumour
91
Osteoid osteoma
Benign bone-forming tumour
Can be excruciatingly painful but are sensitive to aspirin
92
Endochondroma
Benign cartilage forming tumours
93
Chondrosarcoma
Malignant cartilage forming tumour
| - tend to be very aggressive
94
Fibroma
Benign fibrous tissue tumours
95
Malignant fibrous tissue tumours
Fibrosarcoma
96
Haemangioma
Vascular tissue tumour
97
Malignant vascular tissue tumours
Angiosarcoma
98
Benign tissue tumours
Lipoma (fatty lumps)
99
Malignant adipose tissue tumour
Liposarcoma
100
Marrow tissue tumours
Malignant: ewing's sarcoma, lymphoma, myeloma
101
Tumour like lesions
Benign - simple bone cysts and fibrous cortical defect
102
Commonest primary malignant bone tumour in younger patient
Osteosarcoma (still very rare)
103
Commonest primary malignant bone tumour in older patient
Myeloma
| Still very rare
104
Presentation of bone tumours
PAIN - activity related if large enough to weaken bone, unexplained, progressive pain at rest and night
Mass
Abnormal x-rays - incidental
105
First line investigation for suspected bone tumour
XRAY
106
Red flags regarding pain that may suggest bone tumour
Worsening, activity related pain, unexplained pain at rest and at night
107
Xray findings for an inactive bone lesion
Clear margins
Surrouding rim of reactive bone
Cortical expansion can occur with aggressive benign lesions
108
Xray findings for aggressive bone lesion
Less well defined zone of transition between lesion and normal bone
Cortical destruction = malignancy
Periosteal reactive new bone occurs when lesion destroys the cortex
Codman's triangle, onion skinning (layering of new bone) or sunburst patterns
109
Best investigation for bone and soft tissue tumours
MRI
| - accurate for limits of disease both within and outside bone
110
Investigations for bone or soft tissue tumour suspect
```
Xray
CT (sarcoma spread to lungs/haematogenous spread)
Bloods
MRI of lesion
Bone scan
CT, chest, abdo and pelvis
```
BIOPSY (needle core or open)
111
Cardinal features of malignant primary bone tumour
```
Increasing pain
Unexplained pain
Deep-seated boring nature
Night pain
Difficulty weight bearing
Deep swelling
```
112
Clinical features of bone tumour
Pain - increasing, analgesics (eventually ineffective), not related to exercise, deep boring ache, worse at night
Loss of function - limp, reduced movement, stiff back
Swelling - diggise in malignancy, near end of long bone, warm over swelling and venous congestion, pressure effects
Pathological fracture - more commonly caused by osteoporosis
Joint effusion
Deformity
Neurovascular effects
Systemic effects of neoplasia
113
Treatment of bone tumours
Chemo
Surgery - limb salvage usually possible
Radio
114
Soft tissue tumour features of malignancy
```
Painless
Deep tumours of any size
Subcutaneous tumours >5cm
Fixed, hard or indurated mass
Rapid growth, hard, craggy, non-tender
```
115
Most common cancers to cause bone metastasis
```
LUNG
BREAST!!
PROSTATE
KIDNEY
THYROID
GI TRACT
MELANOMA
--> vertebrae > proximal femur > pelvis > ribs >sternum > skull
```
116
Imaging of choice for soft tissue tumour
MRI
117
Peak age incidence of osteosarcoma
10-25 years
118
Peak age incidence for ewing's sarcoma
E10-18
119
Peak incidence for chondrosarcoma
45-60 years
120
Treatment of hallux rigidus
Activity modification
Shoewear with rigid sole
Analgesia
Surgery - chielectomy to remove dorsal impingement
121
Joint affected by
Claw toe
Hammer toe
Mallet toe
Claw - extended MTP, flexed PIP and DIP
Hammer - extended MTP flexed PIP and extended DIP
Mallet - flexed DIP rest neutral
122
Aetiology of lesser toe deformities
Imbalance between flexors/extensors
Shoewear
Neurological
Rheumatoid arthritis
123
Symptoms of lesser toe deformities
Deformity
Pain from dorsum or plantar side
124
Most common site for morton's neuroma
Middle metatarsophalyngeal joint
125
Where does a dorsal foot ganglia arise from
Tendon or joint sheath
126
Symptoms of dorsal foot ganglia
Pain from pressure from shoe wear
Pain from underlying problem (arthritis or tendon pathology)
127
Rate of return for dorsal foot ganglia
50%
128
Presentation of plantar fasciitis
Pain on weight bearing after rest - early morning
Common condition that takes 2 years to resolve
Common in theatre nurses and the overweight
129
Treatment for plantar fasciitis
Rest, cross training
Stretching - achilles tendon
Ice
NSAIDs
Orthoses
Weight loss
Corticosteroid
Night splinting
130
If someone presents with ankle arthritis under 50 with no known trauma what should you investigate for
Haemochromatosis
131
Presentation of posterior tibial tendon dysfunction
Acquired adult flat foot
Stages:
1. Medial pain, no deformity
2. Flat foot, flexible deformity
3. Flat foot, fixed deformity
4. Flat foot, fixed deformity and ankle involvement
132
Diabetic feet commonly have what feet deformities
Ulceration
| Charcot foot
133
Aetiology of diabetic foot ulcer
Diabetic neuropathy - patient unaware of trauma
Diabetic autonomic neuropathy - lack of swearing/normal sebum production so skin is dry and cracked and more sensitive to minor trauma
Poor vascular supply
Lack of patient education
134
Treatment of diabetic foot ulcer
```
Prevention!
Modify detriments to healing
- diabetic control
- smoking
- vascular supply
- external pressure
- internal pressure (deformity)
- infection
- nutrition
```
135
Cause of charcot arthropathy
Any cause of neuropathy of which diabetes is most common cause
Historically common with syphilis
? Neurotrauma - lack of proprioception and protective pain sensation
? Neurovascular - abnormal autonomic nervous system results in increased vascular supply and bone resorption
136
Charcot arthropathy is characterised by...
Rapid bone destruction
- fragmentation
- coalescence
- remodelling
137
Complications of charcot's foot
Deformity leads to ulceration leads to infection leads to amputation
138
Foot manifestations of rheumatoid arthritis
Swollen and painful joints due to synovitis and erosions
Tendon or ligament ruptures
Stress fractures
Avascular necrosis of bones
May involve hallux and lesser toes
139
Tarsal tunnel syndrome
Pressure on tibial nerve in tarsal tunnel
--> vague symptoms of pain (neuralgic) and altered sensation
140
Treatment of tarsal tunnel syndrome
Decompression
141
Effects of peroneal tendon disorders
Subluxation or dislocation
Injury or degeneration
142
Most common direction of hip dislocation
Posterior
143
Typical position of the leg in a posterior dislocation
Holds leg in a flexed, adducted, internally rotated position with some shortening of the leg
144
Most common associated injuries in a posterior hip dislocation due to a head on collision
Fractures of patella or femur
Posterior force on the tibia may result in rupture of the posterior cruciate ligament
Posterior wall acetabelar fractures and fractures of the femoral head
Sciatic nerve injury (suspect if patient has weakness of plantarflexion and dorsiflexion with sensory disturbance below the knee
145
Potential problems associated with fracture of a growth plate
Premature growth arrest resulting in an angular deformity
Limb length discrepancy may also result
146
Presentation of a hip fracture on examination
Leg shortened and externally rotated on examination
147
Complications associated with a hip fracture
Non union
Failure of fixation
Avascular necrosis
148
What is the blood supply to the hip
Majority is derived from capsular vessels which are formed from the anastomoses of the medial and lateral femoral circumflex vessels - these vessels are branches of the profunda femoris
149
What are the ALTS steps
Primary survey - airway, breathing circulation to detect and rectify immediately life-threatening injury (airway obstruction, major thoracic trauma causing serious respiratory compromise and hypovolaemic shock); this will include airway management and fluid resuscitation
Secondary survey - head to toe examination to detect any important but not life-threatening injury
A limited history is obtained from the patient, relatives or paramedical staff
Lateral cervical spine, chest and pelvic radiographs are obtained in all patients
150
Which injuries are associated with haemarthrosis of the knee
Tear of the anterior cruciate ligament
Fractures of the tibial plateau or osteochondral fractures of the femoral condyle
Dislocation of the patella
Meniscal tears if there is a peripheral detachment
Rupture of patellar of quadriceps tendon causes a lot of bleeding but there is no contained haemarthrosis because the capsule is disrupted
151
Investigation of choice in a suspected ruptures anterior cruciate ligament
MRI
152
Management of ligament injury - ACL
Non-operative in the acute setting
ACL tears or ACL and MCL tears often associated with marked swelling and stiffness of the knee in the weeks after injury
Physiotherapy is the initial management to allow time for swelling and stiffness to resolve
Surgical reconstruction once the swelling has resolved
153
Presentation of a posterior shoulder dislocation
Shoulder fixed in internal rotation
If the elbow is flexed to 90 it will be apparent that the shoulder is internally rotated and no external rotation is possible
154
What can cause an achilles tendon rupture
Dorsiflexing force applied suddenly to the forefoot that is resisted by powerful plantarflexion of the gastrocnemius and soleus muscles
155
What is genu recurvatum
When both knees are extended at rest --> hypermobility
156
Empiric antibiotic treatment in a septic arthritis
Suspect staph aureus or strep pyogenes so give IV flucloxacillin and benzylpenicillin or amoxicillin for 2 weeks
Then oral antibiotics for 4 weeks
157
What must you consider before starting someone on biologic therapy such as anti-TNF
Careful history to rule out current infection; check past history for infection with tuberculosis (do chest Xray at baseline)
Patients should not have a malignancy or have had a malignancy in the previous 10 yrs
Those with MS and heart failure are excluded
158
Antibodies to screen for coeliac disease
Anti-endomysial antibodies
159
If suspecting gout what investigation would you do
Polarised light microscopy of joint contents - will show negatively birefringent crystals
160
Antibody findings that are suggestive of SLE
Anti-nuclear antibodies and antibodies to double stranded DNA
161
Which blood products are associated with increased risk of thrombotic complications
Anti-phospholipid antibody and lupus anticoagulant
162
Management of anti-phospholipid syndrome
Lifelong anticoagulation - aspirin and heparin should be given throughout all future pregnancies and thereafter given warfarin
163
What is the difference between subluxation and dislocation
Subluxation is partial dislocation of the bone from its normal position so that some of the articular surfaces are still in contact
Dislocation is complete dislocation of the bone from its normal position so that the articular surfaces are no longer in contact
164
Which lobe of the lungs is most commonly affected by aspiration pneumonia
Right lower lobe
165
Are calf DVTs more or less likely to thrombose to the lungs
Less
166
What is the cause of webbing of fingers and toes
Failure of programmed cell death
167
What do you call webbing of the fingers
Syndactylyl
168
What do you call too many fingers
Polydactylyl
169
Which embryonic component is responsible for muscle development
Myotome
170
When does the pubic symphysis become mobile
Childbirth
171
Which fracture can lead to carpal tunnel syndrome
Colles fracture
172
Where is hip pain commonly referred to
Groin and knee
| Sometimes thigh laterally
173
Main nerve supply to the hip joint
Obturator
174
Damage to the sciatic nerve would cause
Drop foot
175
Nerve supply to sartorius
Femoral
176
What is a locked knee
A knee that cannot be fully extended - can flex fully
177
Most common associated problem with juvenille idiopathic arthritis
Uveitis
178
What is a bursa
Sac lined with synovial membrane, filled with a small amount of synovial fluid that provides cushioning to allow muscles to move over each other
179
Medical term for knock knees; bow legs
Genu valgrum
Genu varum
180
Neuropraxia
Transient damage to a nerve such as compression, stretching
| - have good prognosis
181
Neurotmesis
Partial or complete severance of a nerve, with disruption of the axon and its myelin sheath and the connective tissue elements
