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RACGP Exams Complete Deck > MSK3 > Flashcards

MSK3 Flashcards

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1
Q
A
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2
Q

What’s the management of lateral epicondylitis?

A

BASIC:

  • Rest from offending activity
  • IF acute - RICE and oral NSAID
  • Exercises - stretching and strengthening

example is dumbell exercise with palm facing down (lex luthor is Down)

ADDITIONAL (if refractory)

  • Corticosteroid/LA injection (max two)

Manipulation

Surgery

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3
Q

How does medial epicondylitis present?

A
  1. Pain over the medial epicondyle on Resisted flexion of the wrist
  2. TENDERNESS over medial epicondyle
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4
Q

What is the management of medial epicondylitis?

A

BASIC:

  • Rest from offending activity
  • IF acute - RICE and oral NSAID
  • Exercises - stretching and strengthening

example is dumbell exercise with palm facing UP (lex luthor is Down so the opposite is UP)

ADDITIONAL (if refractory)

  • Corticosteroid/LA injection (max two)

Manipulation

Surgery

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5
Q

What’s the differential diagnosis of an epicondylitis?

A

Elbow OA

Posterior interosseus nerve entrapment

Cervical radiculopathy

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6
Q

How does posterior interosseus nerve syndrom present? What is the management?

A

Weakness and/or paralysis of the wrist and digital extensors

Pain is not the primary symptom

Attempts at active wrist extension often result in weak dorso-radial deviation due to preservation of the radial wrist extensors.

1, Rest from offendng activity

  1. Wrist and elbow splint
  2. NSAID
  3. Corticosteroid injection
  4. If not settled in three months. Surgery
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7
Q

What are the types of femoral neck fractures?

A

Femoral neck fractures are intracapsular - therefore a tenuous blood supply which can be disrupted by fracture and cause AVN

Subcapital - most common = TREATED BY Reduction and PINNING usually (and/or prosthesis in elderly)

In ederly risk of AVN - a prosthetic replacement of femoral head in elderly

(A partially impacted subcapital fracture can allow partial weight bearing - so need to xray, if fracture not evident but suspicion high - then Bone scan )

Stress fractures in the young

(Beware of teenage athlete complaining of hip pain after running- exclude a) SUFE and then b) fracture - 99 technetium bone scan will detect the fracture. Need prophylactic reduction to prevent AVN from spontaneous displacement

Extracapsular fractures:

Intratrochanteric - pin and plate - good blood supply so good prognosis after reduction

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8
Q

A teenage athlete complains of hip pain after running - Management approach?

A

exclude a) SUFE and then b) stress fracture - Xray first and then 99 technetium bone scan will detect the fracture.

A stress fracture can displace without warning - serious threat of AVN!

Therefore consideration for prophylactic pinning with ortho

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9
Q

Elderly person presents with hip pain - can still partially weight bear. Management approach?

A

Xray - consider subcapital fracture

If no evidence of fracture on the xray

99 technetium bone scan.

These need pin and/or prosthetic femoral head replacement due to the high risk of Avascular necrosis in a greatly displaced subcapital fracture

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10
Q

Why is it important to diagnose a femoral neck fracture?

A

Femoral neck fractures are intracapsular - therefore a tenuous blood supply which can be disrupted by fracture and cause AVN

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11
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A
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12
Q

How would you treat a femoral shaft fracture?

A

Intramedullary nail

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13
Q

How do you treat a supracondylar fracture?

A

Internal fixation

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14
Q

How would you treat a condylar fracture? a) undisplaced b) displaced?

A

a) full limb plaster cylinder or internal fixation for undisplaced
b) internal fixation for displaced

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15
Q

How would you investigate a patient with a suspected hip fracture?

A
  1. Plain radiographs of the hip - including a) an AP view with maximal internal rotation and b) lateral view
  2. AP radiograph of pelvis to compare with unaffected hip can be useful
  3. If Xray is unrevealing but clinical suspicion is high - then MRI is best (otherwise bone scan)
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16
Q

Initial management of patient with hip fracture?

A

Xrays - AP and Lateral of affected side

+/- AP pelvis to view unaffected side.

Provide adequate analgesia (may need regional nerve block)

Refer urgently to emergency department with orthopaedic services.

Consider prophylaxis against VTE and infection

IF the patient has a peritrochanteric fracture - and age over 75 and or they have HB less than 120 - obtain blood for group and crossmatch

Falls workup in elderly patients

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17
Q

Presenting symptoms of fibromyalgia?

A
  1. Cognitive clouding (Fibro fog)
  2. Fatigue
  3. Impaired concentration
  4. Sleep dysfunction
  5. Depression
  6. Gastrointestinal and urogenital dysfunction

(irritable bowel and irritable bladder)

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18
Q

How do you confirm the diagnosis of fibromyalgia?

A

Clinical.

Investigations do not confirm diagnosis.

However normal CRP and ESR reassure that its not inflammatory.

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19
Q

When would you refer a patient with fibromyalgia?

A

If diagnosis is unclear or patients presentation is atypical

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20
Q

What would you discuss with a newly diagnosed fibromyalgia patient?

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A

Pain experienced by patient is real but is not cuased by tissue damage.

Fibro is not a progressive or deforming disease

Fibro is frustrating- and because symptoms fluctate it feels like two steps forward, one step back

Chronic pain in fibro can affect the way the patient feels - this does not necessarily indicate a problem with their mental health

Overarching goal of management - not to achieve a pain free state but to help patient manage their pain so that it does not limit their funciton

21
Q

Treatment of fibromyalgia (pharmocotherapy)

Study These Flashcards
A

Amitryptilline 10 to 25mg nocte, increasing dose every 2 to 4 weeks up to max dose of 50mg nocte

OR

Duloxetine 30mg once daily

Increase to 60mg daily after one month

22
Q

What are the two tendons that pass underneath the lateral malleolus?

Study These Flashcards
A

Peroneus longus and brevis

23
Q

What do the pernoeal muscles in the lateral leg do?

Study These Flashcards
A

Evert the foot

24
Q

Which three lateral ankle ligaments are commonly involved in ankle sprains?

Study These Flashcards
A

Anterior Talofibular ligament

Calcaneofibular Fibular lIgament

Posterior talofibular ligament

25
How would you test the integrity of the anterior talofibular ligament?
Anterior draw test
26
How would you test the integrity of the calcaneofibular ligament?
Talar tilt
27
What clinical features would you expect in a sprained lateral ligament?
Ankle gives way Diffculty weight bearing Discomfort - mod -sev Bruising can take 12-24 hrs Can have functional instability - gives way on uneven ground
28
Clinical examination signs of sprained lateral ligaments in ankle?
Inspect for swelling and bruising Palpate over bony landmarks and three lateral ligaments Test joint laxity and range of motion Common finding is rounded swelling in front of the lateral mallelolus - Signe de la coquille d'oeuf Tests of stability - Anterior draw (for ATFL) and talar tilt for (CFL)
29
What are important causes of heel pain in adults?
1. Achilles tendon disorders (u/s useful to differentiate) - tendonopathy/pertendonitis - bursitis - postcalcaneal (Superficial), retrocalcaneal (deep) - tendone tear - partial or complete. 2. bruised heel 3. tender heel pad - usually atrophy - also inflammation 4. Peripheral neuropathy (DM, ETOH) 5. Tenosynovitis (FHL, FDL) 6. Plantar fasciitis 7. Periostitis 8. Calcaneal apophysitis (Severs disorder) 9. Peroneal tendon dislocation at the lateral malleolus 10. Nerve entrapments - tarsal tunnel, medial calcaneal nerve, nerve to abductor digiti minimi
30
31
How does achilles tendon bursitis present?
Often in young females with shoe pressure 1. Can occur between skin and tendon - postcalcaneal (Superficial) (mainly in women with heel pressure) or between tendon and calcaneus (Deep) - Retrocalcaneal 2. elicit tenderness in the deep bursa by squeezing with thumb and index finger in front of tendon - swelling can be visualised on either side of the tendon in bursitis (retrocalcaneal).
32
How would you treat achilles tendon bursitis?
1. Avoid shoe pressure (eg wear sandals) 2. 1-2 cm heel raise in shoe 3. Apply local heat and u/s 4. NSAIDS 5. INject corticsteroid into bursa with a 25 guage needle
33
What clinical features would you expect for a patient with partial tear of achilles tendon?
Sudden onset pain in achilles tendon Sharp pain with stepping off on the affected leg (Doesnt fall) Usually men over 30 (sporadic sporting engagmenet) Hx of running, jumping or hurrying up stairs Tender swelling about 2.5 cm above insertion of achilles tendon THESE PATIENTS NEED U/S FOR DDX exclusion On Examination - palpate for gap in achilles tendon If 'gap' - surgery If no gap - Rest and Ice initially 1-2cm heel raise in shoe Physiotherapy for supervised graduate exercise program with stretching for rehab Ultrasound and deep friction massage Takes three months to settle
34
What are the clinical features of a complete achilles tendon rupture?
Common in athletes Possible degenerated tendon subject to sudden increase in load - Sudden onset intense pain - pt falls over usually - feels more comfortable after acute phase passed - difficulty walking, especially rising onto tip toes ON EXAMINATION palpation of gap in tendon (after 2-4 hours haematoma can fill gap) Positive Simon Thompson test (no plantar flexion of foot on squeezing of calf)
35
How would a patient with achilles tendonopathy present?
Mainly due to *repetitive activity causing inflammation + longstanding degenerative change* eg marathon runner Clinically - Presents with **PAIN after weight bearing** activity Examination - **tender thick achilles tendon,** with **crepitations** on movement **US is very important** to rule out other causes of achilles tendon pain
36
How can a patient prevent achilles tendonopathy?
Warm up and stretchin exercises in athletes Good quality shoes 1cm heel raise
37
Treatment of achilles tendonopathy?
Rest Crutches may be needed in acute phase, plaster cast if severe Cool with ice in acute phase, then heat NSAIDS 1-2 cm heel raise inside shoe Ultrasound and deep friction massage Mobilisation, then graduated stretching exercises
38
A child presents (between 7 -15) with limp and pain at the calcaneal insertion of the achilles tendon? What is the most likely diagnosis? What is your managment
**Calcaneal apophysitis -** Severs disease caused by inflammation of the growth plate Can be visualised as an irregular calcaneal growth plate on *lateral Xray* **Management:** Reassure Avoid flat foot wear - use foot wear with slightly raised heels Avoid strenuous sports for 3 months stretching exercises
39
How does fat pad disorder of the heel present? Management?
Dull throbbing pain under the heel More proximal than plantar fasciitis Fat pad acts as shock absorber - can atrophy esp in elderly and also become inflamed Pain on prolonged standing (whereas PF is pain on first few steps after rest) **Management:** Reduction of aggravating activity Weight loss (if applicable) Simple analgesia Orthotic (cushioning heel cup) + or - foam insert Good foot wear
40
What fractures of the 5th Metatarsal exist?
1. Avulsion fracture of the base 2. Stress fracture of metaphysis or diaphysis (jones) 3. spiral fracture (undisplaced - cast for 6/52, displaced - needs ortho opinion re: reduction) Spiral fracture and stress require referal to orthopaedics Avulsion fracture - usually NWB - PWB -FWB over 3 to 4 weeks - immobilisation not essential but would provide pain relief - refferal if significant displacement or if greater than 30% articulation with cuboid.
41
How does a peroneal tendon subluxation present? Peroneal tendonopathy?
Pain or tenderness posterior to the lateral malleolus Audible snap or sound +/- bruising/swelling may be stiffness **Peroneal tendonopathy** These guys are behind the LATERAL malleolus RED is lateral pain on resisted dorsiflexion and pain on extension.
42
Common cause of Lateral foot pain in a 11-15 year old - bony fleck at 5th Metatarsal on xray
Traction Apophysitis of 5th metatarsal is common
43
Features of a syndesmotic ankle sprain?
High ankle sprain Usually from eversion/dorsiflexion injury Less swelling but longer lasting pain Contribute to chronic ankle instability Examination: **Hopkins test - squeeze** tibia to fibula at level of mid calf - causes syndesmotic pain **External rotation test** - pain in syndesmosis Also can PALPATE syndesmotic ligament
44
A middle aged woman presents with abnormal flat foot. There is gross eversion of the foot. Diagnosis?
Rupture of posterior tibialis tendon. Flat foot - grossly everted "Too many toes sign" Rupture of tib post after trauma, inflammation or degeneration (esp common in middle aged females) causes collapse of longitutidinal arch of the foot - patient presents with flat foot. Uncommon to feel pain at moment of rupture Tib the postie has too many toes
45
How does tibialis posterior tendonopathy present?
Pain and weakness of midfoot. Pes planus (flat foot) PAIN in the medial malleolus and posterior to the medial malleolus PAIN ON PALPATION ANTERIOR AND INFERIOR TO MEDIAL MALLEOLUS MPTTTTTTTTT (if it ruptures - too many toes with gross eversion) RIP - PAIN on Resisted plantar flexion and INVERSION Pain on **inversion and resisted plantar flexion** of the foot. Pain aggravated by standing and walking Diagnosis is by U/S or MRI Management: Graduated activity under physiotherapy guidance orthotics to support arch Remedial massage If conservative mx fails - for corticosteroid injection +/- surg
46
How does a flexor hallicus long (FHL) tendonopathy present?
- ballet dancers, runners, soccer players, athletes. ***Ballet dancer saying "FML" next to RFG*** - Pain in the POSTEROMEDIAL ankle - worse on REPETITIVE PUSH OFF Pain BEHIND the medial malleolus Can radiate distally along medial arch and be worse on weightbearing o/e - Pain on palpation of the tendon behind the medial malleolus and crepitations Pain on resisted FLEXION of the GREAT TOE (RFG) Management - **Rest/modification** of agravating activity **Physiotherapy** for supervised graduated activity and stretching **Shoe implant eg orthotic** **NSAIDs** If refractory - may need surgical review
47
What is the differential diagnosis for a sprain of the lateral ligament of the ankle?
Syndesmotic sprain (high ankle sprain) Osteochondral defect of talus Anterior process of calcanues fracture
48
What investigations would you order if you were concerned about a sprain of the lateral ankle ligaments?
Xray - to exclude fracture U/S
49
What is the management of an acute tear of the ATFL?
1. Initially Rest, Ice and Elevation 2. NSAIDS 3. Initially crutches then wean off 3. Physio review for graduated activity/exercise program 4. Use lace up shoes 5. Commence low impact activities such as cycling and swimming after acute phase has passed. 6. Review in 6 weeks - if minimal improvement - MRI

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