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YR2 Clinical Skills SEM 2 > Block 8 - Musculoskeletal > Flashcards

Block 8 - Musculoskeletal Flashcards

1
Q

How should you approach pelvic x-rays?

A

Pelvic X-Rays

  • 1) Trace the three rings:
    • main pelvic ring and two obturator foramen
    • consider fracture if there is a disruption
    • if you find one fracture always look for a second
  • 2) Look at the joint spaces:
    • sacroiliac joints: symmetrical ~2-4mm
    • symphysis pubis: =5mm
    • if widened consider pelvic fracture
  • 3) Acetabulum
  • 4) Sacral foramina
  • 5) Proximal femur
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2
Q

What are 2 types of pelvic fractures?

A

Open book pelvic fractures:

  • ligamentous rupture or fracture of both:
    • 1) anterior arch-e.g. pubic diastasis/ pubic rami #
    • 2) posterior arch-e.g. SI joint widening or diastasis/ posterior ilium #
  • Unstable fracture, can lose large volume of blood in a trauma case.

Pubic rami fractures:

  • Always look for a second # in the same ring and also check the other side.
  • Bilateral pubic rami # + L SI joint dislocation
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3
Q

How should you approach hip x-rays?

A

Hip X-Rays

  1. Joint space-access joint space for narrowing or osteophytes e.g osteoarthritis
  2. Look at femoral head and neck-compare symmetry and length to other side, look for breaches in cortex-may be #
  3. Look for normal smooth Shenton’s line-disruption may mean #
  4. In any musculoskeletal X-Rays assess two views
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4
Q

How should you approach knee x-rays?

A

Knee X-Rays

  1. Assess the joint lines - look for asymmetry or narrowing - e.g. osteoarthritis
  2. Look closely at tibial plateaus and intercondylar eminence- fractures here are often subtle
  3. Look for an effusion or a lipohaemarthrosis (fat & blood in the joint) on horizontal lateral view-may be the only sign of fracture.
  4. Look at main bones: tibia, fibula, distal femur, patella
  5. Sometimes skyline view requested for patella
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5
Q

What is one type of knee fracture?

A

Tibial plateau fractures

  • Require discussion with ortho/ORIF as intra-articular
  • Note the fluid:fat level (lipohaemarthrosis) on the lateral view
  • Fat is less dense so floats on top of the blood
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6
Q

Approach to an ankle x-ray?

A

Ankle X-Ray

  1. Assess ankle joint (mortise) - should be nice and even on all sides, and talar dome smooth
  2. Assess tibia and fibula especially malleoli, look for spiral fibula fractures on lateral view
  3. If there is one fracture look for another - especially trimalleolar fracture
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7
Q

Type of ankle fracture?

A
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8
Q

Approach to a foot x-ray?

A

Foot X-Ray

  1. Review bones - check around cortex, look for disruptions, anything not attached (??avulsion/ ossicle or bone fragment)
  2. Assess joints for normal joint space/ deformity, signs arthritis
  3. Look for Lisfranc injury (disruption of Lisfranc ligament between base 2nd MT and 2nd cuneiform
  4. Look for Chopart injury (fracture-dislocation mid-tarsal joint)
  5. Look for base 5th metatarsal fracture or avulsion (common)
  6. Look for calcaneal fractures
  7. Look for stress # (2nd and 3rd MT)
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9
Q

3 types of foot fractures?

A
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10
Q

How do malignant bone lesions appear on x-ray?

A
  1. Primary e.g. osteosarcoma - usually lytic lesions
  2. Secondary - far more common
    1. lytic (osteoclastic) → looks moth-eaten e.g. lung ca, melanoma, renal cell ca, thyroid
    2. sclerotic (osteoblastic) → looks like crazy paving e.g. prostate ca, breast ca (may be mixed)
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11
Q

Musculoskeletal history protocol?

A
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12
Q

Shoulder examination protocol?

A
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13
Q

Elbow examination protocol?

A
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14
Q

Hand & Wrist examination protocol?

A
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15
Q

Hip history protocol?

A
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16
Q

Hip examination protocol?

A
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17
Q

Knee history protocol?

A
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18
Q

Knee Examination Protocol?

A
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19
Q

Low back pain history protocol?

A
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20
Q

Low back pain examination protocol?

A

Slump or SLR test?

The Slump test was found to be more sensitive (0.84) than the SLR (0.52) in the patients with lumbar disc herniation. However, the SLR was found to be a slightly more specific test (0.89) than the Slump test (0.83). (Clinical Journal of Rheumatology, April 2008).

Both the Slump and the SLR tests elicit pain in the presence of lumbar disc herniation due to the traction of the involved nerve root. The SLR applies traction primarily to L5 and S1 roots. The Slump test in contrast, may apply further traction to all the lumbar roots. The examiner applies traction during the SLR test by hip flexion and knee extension. During the Slump test, further traction is applied by additional hip flexion and spinal flexion.

Positive SLR: straight leg raising, by itself, can produce pain from a variety of sources, including myogenic pain, ischial bursitis, annular tear, and hamstring tightness, as well as herniated disc.

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21
Q

Identify the major bones in the radiograph below:

A
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22
Q

RADL:H:14 Lateral view of the human knee

On the juvenile radiograph note:

  1. The distal femur
  2. The epiphysis on the tibial plateau
  3. The epiphysis on the proximal fibula
  4. The growth plate forming the tibial tuberosity
A

YELLOW = The epiphysis on the tibial plateau

ORANGE = The epiphysis on the proximal fibula

BLUE = The growth plate forming the tibial tuberosity

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23
Q

RADL:H:14 Lateral view of the human knee

On the adult radiograph note:

  1. Femoral condyles
  2. Patella
  3. Tibia
  4. Fibula
  5. Tibial tuberosity
A
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24
Q

*Additional radiographic: Frontal (AP) view of the knee

Patient data: 58 year old female

Identify the bones on the radiograph below:

A
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25
Q
A
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26
Q
A
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27
Q
A

10 - patella

15 - medial patella joint

16 - lateral patella joint

28
Q

RADL:H:5 Lateral and frontal view of the human tarsus (ankle)

On the lateral radiograph note:

  • The articulation between the tibia-talus and the talus –calcaneus
  • The trabecular patterns align with the principal lines of stress
A
29
Q

RADL:H:5 Lateral and frontal view of the human tarsus (ankle)

On the frontal radiograph note:

  1. The joint spaces
  2. The articulations of the tibia and fibula with the talus
  3. How the overlap of the medial and lateral malleoli over the joint prevents lateral displacement of the joint
A
30
Q

RADL:H:6 The human foot

Identify the following bones:

  • Calcaneus
  • Cuboid
  • Metatarsals 1-5
  • Navicular
  • The cuneiforms
  • The phalanges

Note:

  • The articulation of the cuboid with the calcaneus and with the 4th and 5th metatarsals
  • The articulation of the navicular with the distal row of the tarsal bones; the cuneiforms
  • The sesamoid bones adjacent to the distal first metatarsal and the distal aspect of the first phalanges
A
31
Q

RADL:H:6 The human foot

Identify the following bones:

  • Calcaneus
  • Cuboid
  • Metatarsals 1-5
  • Navicular
  • The cuneiforms
  • The phalanges

Note:

  • The articulation of the cuboid with the calcaneus and with the 4th and 5th metatarsals
  • The articulation of the navicular with the distal row of the tarsal bones; the cuneiforms
  • The sesamoid bones adjacent to the distal first metatarsal and the distal aspect of the first phalanges
A
32
Q
A
33
Q

Identify the following bones:

  • Calcaneus
  • Navicular
  • Talus
  • Metatarsals
  • Phalanges

Note:

  • The longitudinal arches
  • The sesamoid bones of the hallux under the distal aspect of the first metatarsal
  • The articulations of the navicular
A
34
Q
A
35
Q
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36
Q

Which bone pathology is this?

A
37
Q

Red flags in back pain - 6 Clinical Features?

A

Red Flags in Back Pain

Features, signs and symptoms in a patient with back pain which indicate serious spinal pathology.

Features

  1. Previous history malignancy (however long ago)
  2. Age 16< or >50 with NEW onset pain
  3. Weight loss (unexplained)
  4. Previous longstanding steroid use
  5. Recent serious illness
  6. Recent significant infection
38
Q

Red flags in back pain - 6 Signs?

A

Red Flags in Back Pain

Signs

  1. Saddle anaesthesia
  2. Reduced anal tone
  3. Hip or knee weakness
  4. Generalised neurological deficit
  5. Progressive spinal deformity
  6. Urinary retention
39
Q

Red flags in back pain - 5 Symptoms?

A

Red Flags in Back Pain

Symptoms

  1. Non-mechanical pain (worse at rest)
  2. Thoracic pain
  3. Fevers/ rigors
  4. General malaise
  5. Urinary retention
40
Q

Red Flags in Back Pain - 5 ways to Identify?

A

Red Flags in Back Pain

How to Identify

  1. High index of suspicion
  2. Majority of information in history
  3. Simple inspection of back with movement
  4. Simple neurological examination
  5. Heel/ toe walk, squat
41
Q

Red Flags in Back Pain - 8 Signs & Symptoms of Cord Compression?

A

Red Flags in Back Pain - Cord Compression

  1. Back pain
  2. Leg weakness
  3. Limb numbness
  4. Ataxia
  5. Urinary retention (with overflow)
  6. Hyper-reflexia
  7. Extensor plantars
  8. Clonus
42
Q

Red Flags in Back Pain - 6 Signs & Symptoms of Cauda Equina?

A

Red Flags in Back Pain - Cauda Equina

  1. Bilateral leg pain
  2. Back pain
  3. Urinary retention
  4. Perianal sensory loss
  5. Erectile dysfunction
  6. Reduced anal tone
43
Q

When to investigate red flags in back pain? What to include?

A

When to investigate red flags

  • Urgent when red flags present
  • To include:
    • Myeloma screen
    • ESR, CRP, FBC, U+E, Ca2+
    • Plain xray particularly osteoporosis / infection
    • Consider MRI
44
Q

What is the distribution of different polyarthralgias?

  • Rheumatoid?
  • Seronegative psoriatic arthritis?
  • Seronegative spondyloarthritis?
  • Osteoarthritis?
A
45
Q

What are 6 features of Rheumatoid Arthritis on X-Ray?

A

Features RA on X-Ray

  1. Joint space narrowing
  2. Periarticular osteoporosi
  3. Marginal erosions
  4. Ulnar deviation/ joint deformity
  5. Subluxations
  6. Soft tissue swelling
46
Q

Features of Rheumatoid Arthritis on X-Ray?

A
47
Q

Features of Osteoarthritis on X-Ray - Shoulder?

A
48
Q

Features of Osteoarthritis on X-Ray - Knee?

A
49
Q

Compare the radiographical features of osteoarthritis (4) with rheumatoid arthritis (6)?

A

Radiological features:

Osteoarthritis

  1. Joint space narrowing
  2. Subchondral sclerosis
  3. Osteophytes
  4. Cysts

Rheumatoid Arthritis

  1. Joint space narrowing
  2. Periarticular osteoporosis
  3. Marginal erosions
  4. Subluxations
  5. Soft tissue swelling
  6. Ulnar deviation/ deformities
50
Q

Which joints do Heberden’s nodes affect?

Which joints do Bouchard’s nodes affect?

A
51
Q

How is the Slump test performed?

A

LOW BACK EXAMINATION

Slump Test

The patient sits in a relaxed position on the couch and then slumps forward placing the chin on the chest. The unaffected leg is straightened and then restored. The affected leg is straightened and then restored. Both legs are straightened together. The foot of the affected leg is dorsiflexed (toes to patient). If the above movements elicit pain deflex the neck and if necessary extend it. Pain of spinal origin will be relieved by deflexing the neck. Pain that persists is likely hamstring in origin.

52
Q

How is the straight leg raise special test performed?

A

LOW BACK EXAMINATION

Straight Leg Raise

The leg is grasped, slightly internally rotated and passively, slowly raised with the knee extended. Keep raising the leg until you reach 90 degrees or need to stop due to pain. If forced dorsiflexion increases pain this indicates dural irritation. Normal raise is 80-90 degrees. In disc prolapse 60 degrees or less may be achieved and it will often be asymmetrical.

53
Q

How is the Thomas Test performed?

A

HIP EXAMINATION

Thomas test

For detecting fixed flexion deformity of hip joint. Thomas’ test is a reliable means of assessing such deformity even when both hips are affected. The patient is laid on their back and both hips flexed simultaneously to their limit. This position obliterates any excessive lordosis. One leg is then extended. If there is a fixed flexion deformity the hip will be prevented from straightening.

54
Q

How is the Trendelenburg Test performed?

A

HIP EXAMINATION

Trendelenburg Test

In normal movement when you raise one foot off the ground the abductors of the other leg are activated. Even though the grounded leg seems straight it is, in fact, adbucted from the midline. If you have a full length mirror lift your leg and watch the opposite hip to see this in action. A diseased hip, such as in osteoarthritis, will very often have weak abductors. In normal function, the hip is held stable by gluteus medius acting as an abductor in the supporting leg. If the pelvis drops on the unsupported side – positive Trendelenburg sign – the hip on which the patient is standing is painful or has a weak or mechanically-disadvantaged gluteus medius. When conducting the Trendelenburg test ask your patient to lift the opposite foot off the ground and watch the hip in question.

55
Q

What are 2 special tests in the shoulder exam?

A

SHOULDER EXAMINATION

Test for painful arc – pain between 60-120 degrees when the arm is abducted.

Apprehension test

Standing behind the patient – abduct, extend and externally rotate the shoulder while pushing the head of the humerus forwards with the thumb. The patient strongly resists this if there is impending dislocation. This tests for joint stability.

56
Q

What is the Lachman’s sign and how is it performed?

A

KNEE EXAMINATION

Lachman’s sign
(Detects anterior crutiate ligament (ACL) injury)
The knee is flexed at 20–30 degrees with the patient supine. The examiner should place one hand behind the tibia and the other grasping the patient’s thigh. It is important that the examiner’s thumb be on the tibial tuberosity. The tibia is pulled forward to assess the amount of anterior motion of the tibia in comparison to the femur. An intact ACL should prevent forward translational movement (“firm endpoint”) while an ACL-deficient knee will demonstrate increased forward translation without a decisive ‘end-point’ - a soft endpoint indicative of a positive test. More than about 2 mm of anterior translation compared to the uninvolved knee suggests a torn ACL (“soft endpoint”), as does 10 mm of total anterior translation. This test can be done in either an on-field evaluation in acute injury, or in a clinical setting when a patient presents for follow-up with knee pain.

57
Q

What is the McMurray’s test and how is it performed?

A

McMurray’s test
(Detects meniscal injury)
Patient lies supine. Hold the ankle with opposite hand on medial side of the knee. Push to apply valgus force (outward), then extend the leg from the flexed position and internally and externally rotate it. A positive test is when there is a popping sensation which may be followed by an inability to extend the knee.

58
Q

What is the Apley’s grind test and how is it performed?

A

Apley’s grind test (Detects meniscal injury)

Patient lies prone. Flex leg to 90 degrees. Stabilise the thigh and press down on the foot (hard) Rotate the leg backward and forwards. A positive test is when pain or clicking is elicited.

59
Q

What is the Thessaly test and how is it performed?

A
  • Thessaly test*
  • (Detects meniscal injury)*

The clinician holds the patient’s outstretched hands for support, while the patient stands flat-footed with their knees flexed to 20 degrees and rotates their body and knee three times, internally and externally. The test is positive if symptoms are reproduced on rotation.

The above two tests (Apley’s & Thessaly ) are becoming out of favour if not obsolete. With the MRI era, such tests deemed unnessessary as they cause more damage to the menisci during establishing the diagnosis, while MRI does not!
It seems within few years McMurray’s test will be out of favour too. It is no longer part of the NICE guidelines, however, still widley used.

60
Q
A
61
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A
62
Q

What pathology is this?

A

Ulnar Drift of Metacarpals

63
Q

What pathology is this?

On the above right image, identify the proximal interphalangeal (PIP) joint and distal interphalangeal (DIP) joint on the extended digit. In this swan neck deformity what is the position of these joints (i.e. flexed, extended, hyperextended etc)? The swan neck deformity in the patient above was caused by trauma, can you name another cause of Swan neck deformities?

A
64
Q

What pathology is this?

A

Boutonniere deformity is one of the musculoskeletal manifestations of rheumatoid arthritis in the hand with:

  • Flexion contracture of the proximal interphalangeal (PIP) joints
  • Extension of the distal interphalangeal (DIP) joints
  • Boutonniere is French for buttonhole.
  • The “buttonhole” appears in the tendon which splays open.
65
Q

What pathology is this?

A

Boxer’s Fracture

66
Q

Identify the fracture in the X-rays below:

A

YR2 Clinical Skills SEM 2 (4 decks)

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