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MBBS - Year 1 > Clinical skills - Soft Tissue > Flashcards

Clinical skills - Soft Tissue Flashcards

1
Q

Causes of pain in a leg

A

Anatomical structures involved e.g. skin, bursa, tendons, muscles, ligaments

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2
Q

Procceses that can cause pain

A

Injury
Infection
Inflammation
Insidious (Tumour)

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3
Q

Causes of leg pain - skin

A 
Cellulitis 
Bruise 
Bites 
Burns 
Haemosiderin 
Ingrowing nails 
Ulcers
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4
Q

Cellulitis

A

infection of staph or strep in the skin (gram +ve cocci or rods), draw black line on skin to see whether spreading

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5
Q

What is haemosiderin related to

A

Varicose veins

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6
Q

Bursa definition

A

Potential space w/ epithelial lining

Produces SF which reduces friction and trauma

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7
Q

Usual cause of bursitis

A

Overactivity - helped w/ physio (self-limited)

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8
Q

Common types of bursitis

A

Trochaneteric bursitis
Prepatellar bursitis
Anserine bursitis
Retrocalcaneal bursitis

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9
Q

Why does trocahnetic bursitis usually present in women

A

Shorter legs

DIff pelvis

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10
Q

Can be retrocalcaneal bursitis be treated w steroids

A

No as there is no tendon sheath

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11
Q

Tenosynovitis

A

Infl of tendon sheath

Local or part of a systemic illness such as RhA

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12
Q

Enthesiitis

A

Infl of the entheses, the sites where tendons or ligaments insert into the bone

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13
Q

Degenerative tendon conditions

A

Overuse of Achilles

Adductor tendinitis - tear

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14
Q

Cause of leg pain - muscles

A 
Overuse 
Viral infections e.g. flu 
Cramp 
Claudication 
Muscle rupture/ tear e.g. hamstrings 
Chronic pain e.g. fibromyalgia, myofascial pain syndromes 
Alcohol and other drugs e.g. statins 
Endocrine causes e.g. hypothyroidism 
Infl diseases of muscles e.g. polymyositis, PMR 
Compartment syndrome
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15
Q

Cause of claudication

A

Due to lack of blood flow

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16
Q

Main ligaments causing pain in the leg

A

MCL
LCL
Ankle ligaments - after injury points can be repositioned

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17
Q

Treatment of ligament pain

A

RICE
Analgesia
Physio

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18
Q

Grade I lateral ankle sprain

A

Stretching small tears

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19
Q

Grade II lateral ankle sprain

A

Larger, but incomplete tear

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20
Q

Grade III lateral ankle strain

A

Complete tear

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21
Q

Causes of leg pain - blood vessels

A

Veins -varicose, superficial thrombophlebitis, DVT

Arteries – aneurysm, atheroma, PVD (peripheral vascular disease)

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22
Q

Risk factors of DVT

A 
Sticky blood -  birth control, smokers 
Obesity 
Immobility 
Pregnancy 
Ortho pt – pelvic surgeries 
Varicose veins
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23
Q

Causes of leg pain - nerves

A

Referred e.g. sciatica
Peripheral neuropathy
Entrapment e.g. meralgia paraesthetica

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24
Q

Causes of leg pain - lymph

A

Lymphoedema

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25
Approach to limb pain
History Examination Investigations Management of the problem
26
Leg pain hx
``` Localisation and nature Duration Onset e.g. trauma Pain history Relieving and exacerbating history ```
27
Leg pain examination
Look how the pt moves Look at how ill the pt is e.g. systemically unwell ``` Look at the area Feel for tenderness around the joint Move joint Get pt to move Check for numbness and weakness ```
28
Hernia
Weakness of abdominal wall so bowel pushes through
29
Shoulder exam - look
Positioning – undress (vest top), standing, space Anteriorly, posteriorly, laterally: Skin Posture and symmetry Bony structure – clavicle, sternoclavicular joint, acromioclavicular joint, acromion, acromion process, scapula Joint swelling Muscle bulk – supraspinatus, infraspinatus, deltoid
30
Shoulder exam - feel
``` Ask if it hurts? Standing behind pt: Sternoclavicular joint Clavicle Acromioclavicular joint Acromion Coracoid process Greater tuberosity Scapula: spine, medial border, inferior angle ```
31
External rotation pain of shoulder - ddx
Usually OA
32
High painful arc (shoulder) - ddx
Pain in acromioclavicular joint - subacromial bursitis
33
Mid painful arc (shoulder) - ddx
Pain in sub acromion space - sulbcromial bursitis
34
Shoulder exam - feel
``` Ask if it hurts? Standing behind pt: Sternoclavicular joint Clavicle Acromioclavicular joint Acromion Coracoid process Greater tuberosity Scapula: spine, medial border, inferior angle ```
35
Shoulder exam - move
Compare both sides ``` Flexion Extension Adduction Adduction Internal and external rotation ``` If any active movement is reduced, test passive movements
36
Abduction - shoulder exam
Ask pt to lift arm out to side | Normal is 90 degrees w/out scapula or 180 w/ scapula
37
Adduction - shoulder exam
Ask pt to move arm across front of body | Normal is 40 degrees
38
Pain in resisted shoulder movements
Infraspinatus (external rotation) Subscapularis (internal rotation) Supraspinatus (abduction) Deltoid (abduction)
39
Causes of olecranon bursitis
Trauma Rheumatoid Gout
40
Elbow exam - look
``` Positioning – undress, seated, space Anteriorly, posteriorly, laterally Skin/ soft tissue – olecranon bursa/ nodules Bone Joint swelling Muscle bulk ```
41
Elbow exam - feel
``` Olecranon process Lateral epicondyle of humerus Medial epicondyle of humerus Ulna Head of radius ```
42
Elbow exam - move
Flexion - ask pt to bend elbow Extension - ask pt to straighten Ptonation Supination
43
Elbow exam - pronation
Ask the pt to bend elbow to 90 degrees of flexion and then turn arm over so palm faces the floor
44
Elbow exam - supination
Ask the pt to bend elbow to 90 degrees of flexion and then turn arm over so palm faces upwards
45
Pain in resisted elbow movements
Flexion (biceps) Extension (biceps) Supination (supinator) Pronation (pronator)
46
Wrist exam - look
``` Positioning, undress, space Dorsal and palmar aspects: Skin – colour, scars, bruising, nails Posture and symmetry Bony structures Joint swelling Muscle bulk ```
47
Wrist exam - feel
``` Ask if it hurts? Temperature/ tenderness Feel: Head of ulnar Its styloid process Radius base Its styloid process ```
48
Wrist exam - move
Flexion Extension – prayer sign Abduction (radial) – 20 degrees Adduction (ulnar) – 50 degrees
49
Hand exam - look
``` Skin Muscle Joints Posture Nails ```
50
Hand exam - skin
Erythema, redness, scars
51
Hand exam - muscle
Wasting in dorsal aspects
52
Hand exam - joints
Ulnar deviation, Z thumbs, subluxation of wrist, boutonnieres, swan neck deformity
53
Hand exam - nails
Oncolysis, pitting (PsA)
54
Hand exam - feel
``` Bimanually - soft tissue (synovitis) or. bony Pisiform bone Scaphoid (in anatomical snuffbox) MCP squeeze MCP joints PIP joints DIP joints ```
55
Condns to recognise from examination
Carpal tunnel Ulnar nerve entrapment Medial nerve entrapment Radial nerve entrapment
56
Hand exam - move (fingers)
MCPs – flexion/ extension DIPs – flexion/ extension PIPs – flexion/ extension Abduction/ adduction of fingers
57
Hand exam - move (thumb)
``` Flexion Extension Abduction Adduction Opposition ```
58
Pain in restricted movements - hand
Opposition – T1 (median nerve) Finger abductions – T1 (median nerve) Wrist extension – C8, T1 (radial nerve) Power – make a fist
59
Examination of nerve function
Motor component and sensory component
60
Masses can be ...
Origination or acquired
61
Where could potential lumps and bumps come from
``` Skin Fat Connective Tissue Muscles Bones Joints Nerve Blood vessels Lymphatic system Organs Metastases ```
62
Types of acquired masses
Neoplastic Infl Infective
63
Infective masses
Rubor Calor Tumor Dolor
64
Infl masses
``` Hx of infl condns e.g RhA etc Pain Tenderness Symmetry Other lesions ```
65
Benign neoplastic masses
A mass of cells that grows in an uncontrolled manner but does not have the ability to invade local structures or spread to other parts pf the body
66
Malignant neoplastic masses
A mass of cells that grows in an uncontrolled manner that has the ability to invade the local structures and has the ability to spread to other parts of the body. Also has the ability to kill the host is growth and spread is not controlled Cancer
67
Name of benign neoplastic growths in skin
Papilloma
68
Name of benign neoplastic growths in fat
Lipoma
69
Name of benign neoplastic growths in bone
Osteotoma
70
Name of benign neoplastic growths in joints
Endochondroma
71
Name of benign neoplastic growths in organisms
Adenoma
72
Name of malignant neoplastic growths in skin
Squamous cell carcinoma
73
Name of malignant neoplastic growths in fat
Liposarcoma
74
Name of malignant neoplastic growths in bone
Osteosarcoma
75
Name of malignant neoplastic growths in joints
Chondrosarcoma
76
Name of malignant neoplastic growths in organs
Adenocarcinoma
77
Hx of masses - benign tumours
Slow rate of growth Other long-term masses Painless Local pressure effects
78
Hx of masses - malignant tumours
``` Fast rate of growth Other new masses/ lesions Painful Local invasive effects Associated lumps Associated symptoms of metastasis/ systemic spread ```
79
Examination for lumps
Site Size Shape Surface Substance – consistency, soft, firm, hard Surrounding structures – local tissue, lymph nodes, nerves, blood vessels, other organs
80
Examination findings - benign masses
``` Well defined Mobile Smooth Soft No associated masses ```
81
Examination findings - malignant masses
``` Ill defined Immobile Irregular Hard Associated masses Associated organomegaly Associated reduce function of muscle, nerve ```
82
Investigations that can be used for lumps and bumps
MRI CT Autopsy
83
Investigation findings - benign masses
Well defined Capsule No invasion Homogenous signal pattern
84
Investigation findings - malignant masses
``` Ill defined No capsule Invasion of local tissue Heterogenous signal pattern Metastases in organs or lymph nodes ```
85
Significance of a bump having hard edges
Likely to be metastatic
86
Describing lumps and bumps
``` Position Colour Temp Shape/size/ surface Edge Consistency Fluctuation Translucency/ pulsability/ reducibility/ relation to other structures Bruits – noise Lymph node proximity ```
87
Mechanisms of soft tissue injury
Direct Injury Long term wear and tear Unclear? Infl Repetitive injury
88
Examples of upper limb soft tissue injury
``` Shoulder ACI dislocation Shoulder dislocation Shoulder rotator cuff tear Long head of biceps tear Elbow dislocation Distal biceps tendon tear Skiers thumb Small joint dislocation Other ligament and tendon ruptures, flexor/ extensor tendons ```
89
Example of lower limb soft tissue injury
``` Knee ACL tear Knee collateral ligaments and menisci Quadriceps tendon rupture Patellar tendon rupture Tenoacchilles rupture Ankle sprain ```
90
Assessment of a soft tissue injury
``` HPC PMH Personal, social and occupation hx Examination Investigations Treatment ```
91
Clinical examination for soft tissue injury
Look for deformity/ signs of injury Feel for tenderness, swelling Move to assess,
92
Investigations of a soft tissue injury
X-rays Ultrasound scan CT scan (to investigate associated fracture) MRI scan
93
Treatment for soft tissue injuries
``` Analgesia RICE Immobilise (splint, sling, brace) PT Surgical repair Education/ info ```
94
Treatment for acromioclavicular joint issues
Sling for 6 weeks Physiotherapy Surgery in severe cases Must fix grades 4 & 5 injuries
95
Hook test
Poke finger in distal biceps tendon - test for distal bicep ruptures
96
Presentation of distal biceps rupture
Usually men in late 40s/ early 50s Seen in bodybuilders as anabolic steroid makes tendons easier to tear Struggle to supinate
97
Testing for ACL tear
Anterior draw test Lachman's test MRI
98
Secondary condn associated with ACL tear
Post traumatic OA due to changed biomechanics of the knee
99
Clinical examination for Achilles Tendon rupture
Calf squeeze test and measure angle of declination
100
Treatment for Achilles Tendon Rupture
Walking boot for 3 months (tendons proximate) | Surgical repair
101
What does nerve compression result in
Ischaemia and demyelination of the nerve affecting its ability to conduct
102
Most common compression neuropathies in upper limb
Carpal tunnel syndrome | Cubital tunnel syndrome
103
Most common site of compression of peripheral nerves in lower limb
Common peroneal (fibular) nerve
104
Carpal tunnel
Complex of symptoms Pain, numbness and tingling in the distribution of median nerve Caused by compression within carpal tunnel Affects 0.1 – 10% of pop
105
Risk factors for carpal tunnel syndrome
Traumatic (post wrist fracture/ lunate dislocation) Pregnancy (common) Hypothyroid (rare) RhA (synovitis) Chronic Renal Failure Space occupying lesion (ganglion, tumour)
106
Who does carpal tunnel usually present in
Women 35-55
107
Typical symptoms and signs of carpal tunnel syndrome
Nocturnal dysesthesias Paraesthesia on driving, using telephone, reading Reduced dexterity (buttons, coins, sewing) Thenar wasting – late sign, irreversible
108
Tests for carpal tunnel
Tinel’s Phalen’s <60 secs Flexion-compression – press on nerve and flex wrist, best test to use
109
The use of nerve conduction studies in compression neuropathies
Diagnostic uncertainty Quantify degree of severity Persistence of symptoms post CTD Recurrence of symptoms post CTD
110
Ddx of carpal tunnel
C6 radiculopathy (get MRI) Proximal site compression (rare) – flexor dystrophy syndrome, pronator syndrome Non-organic/ non-anatomical cause
111
Non-operative treatment for carpal tunnel
Observation (may settle – e.g. pregnancy) Splints (night symptoms) Steroid injections
112
Steroid injection for carpal tunnel
Useful to confirm diagnosis | Injected in 30-degree angle, ulnar side of Palmaris Longus tendon
113
Surgery - carpal tunnel decompression
Performed under local anaesthetic (+/- tourniquet) – take 10 mins Good at relieving pain, numbness recovery less consistent
114
Healing from carpal tunnel decompression
Performed under local anaesthetic (+/- tourniquet) – take 10 mins Wound takes 2 weeks to heal Most pts go back to work within 2-4 weeks Expectation of outcome – depends on severity
115
Complications of surgery
``` Infection (rare) Bleeding and haematoma (rare) Scar pain/ tenderness – common/ last several weeks Pillar pain – may last several weeks Recurrence (<1%) Chronic Regional Pain Syndrome (rare) Incomplete relief of symptoms ```
116
Pillar pain
Pain over bony borders
117
Open vs endoscopic CTD
W/ endoscopic: Quicker return to work Higher rate nerve injury
118
Similarities in open and endoscopic CTD
No difference in symptomatic relief, revision rates and grip strength
119
Recurrent carpal tunnel
True recurrence <1% Exclude other causes of symptoms e.g. double crush – C6 nerve root (MRI), peripheral neuropathy, consider Neurology Re-operation about 70% successful Non-structural cause
120
Cubital Tunnel syndrome
Ulnar nerve compression at the elbow
121
Ddx for cubital tunnel
Thoracic outlet syndrome Pan coasts tumour C8/ T1 radiculopathy
122
Symptoms of cubital tunnel
Postural – leaning on elbow/ night symptoms | Established compression – numbness and weakness
123
Signs of cubital tunnel syndrome
``` Altered sensation – ulnar side of ring finger and pinky Wartenberg Wasting first dorsal interosseous Clawing – hyperextension of DIP Froments Tinel’s at epicondyle ```
124
Investigations for cubital tunnel
NCS | X-ray - look for elbow arthritis
125
Non-operative treatment for cubital tunnel
Postural advice Nocturnal splints Surgery consideration Surgery consideration in any numbness/ weakness and +ve NCS
126
Surgical indications for cubital tunnel
Failure of non-operative management | Motor weakness/ loss sensation
127
Types of nerve damage
Neurotmesis Neuropraxia Axonotmesis
128
Neurotmesis
Complete disruption of never and sheath, chronic
129
Neuropraxia
Transient nerve dysfunction, no damage to nerve or sheath, will recover fully
130
Axonotmesis
Disruption of axon but Schwann cell myelin sheath intact, recovery could occur if insulting force removed in timely fashion
131
Associated condns. w/ carpal tunnel
``` Diabetes mellitus Hypothyroidism Rheumatoid arthritis Pregnancy Acromegaly Trauma e.g. wrist fracture ```
132
Common causes of bursitis
``` Repetitive motion or position Injury Trauma Inflammatory arthritis Gout Infection ```
133
Epidemiology of bursitis
Equal incidence in males and females | Immunocompromised, diabetic, rheumatoid, alcoholism and HIV patients are at greater risk of septic bursitis
134
Presentation of bursitis
``` Sudden inability to move the joint Swelling Redness Bruising Rash Sharp or shooting pain Fever ```
135
Investigations for bursitis
X-ray cannot identify bursitis, however ican rule out other conditions Physical examination Ultrasound or MRI when diagnosis cannot be done through physical examination alone
136
Management of bursitis
Medication - abx if infection Injections Assistive walking aid Surgery - drainage or removed if necessary
137
Prognosis of bursitis
Not a fatal disorder, with most patients having a good outcome Pts who don’t avoid the causative mechanism will be more likely to develop recurrence
138
Fibromyalgia
Long-term condition that causes pain all over the body | Disorder of sensory processing of non-nociceptive input.
139
What causes FM to occur
Sensitisation of the CNS, as a result of abnormal temporal summation, altered pain thresholds, increased substance P levels, and blood flow abnormalities in pain processing centres in the brain
140
Presentation of FM
``` Increased Sensitivity to Pain Extreme Tiredness (fatigue) Muscle Stiffness Paraesthaesia Difficulty Sleeping Cognitive Problems Headaches Irritable Bowel Syndrome (IBS) Anxiety and Depression Cold Hands Hair Loss Allodynia ```
141
Epidemiology of FM
The prevalence of fibromyalgia is estimated at 2-5% 7x more common in women than men Prevalence increases with age and peaks in the 50s and 60s.
142
Causes of FM
``` Unknown but could be: Genetics Trauma Giving Birth Surgery Infection Psychological Factors (such as bereavement) Also strong link with deopression ```
143
Dx of FM
Usually be based on the symptoms in the patient history and you may also examine the patient for tender points
144
Potential complications of FM
``` Extreme allodynia with high levels of distress. Opioid or alcohol dependence. Marked functional impairment. Severe depression and anxiety. Obesity and physical deconditioning. Metabolic syndrome. ```
145
Allodynia
Pain felt in response to non-painful stimuli
146
Presentation of chronic fatigue syndrome
Chronic fatigue lasting longer than six months that is NOT alleviated by rest Muscle pains and aches Problems with thinking or memory (brain frog) Frequent headaches Joint pain
147
Post-exertional malaise (PEM)
Pts symptoms become worse after physical/mental activity that previously would not have been an issue with them Can lead to worse symptoms and longer recovery time Often associated with headaches, dizziness, and extreme fatigue
148
Some causes of myopathy
``` Vit D deficiency Diabetes Thyrotoxicosis Cushing's disease HIV ```
149
Causes of muscle pain
``` Chronic compartment syndrome Viral infections Anaerobic conditions Sprains/ trauma Cramps CTDs e.g. lupus, myositis Fibromyalgia Toxins e.g. drugs Metabolic e.g. hypothyroidism ```
150
Preventing DVT
``` LMWH (prophylactic) Stockings Exercise Aspirin Stop smoking Keep calf pump contracting ```
151
DVT presentation
Leg is very swollen
152
Presentation of arterial thrombosis
Leg is pale, pulseless, cold | Medical emergency
153
Signs that there is a metastasis
Lymphadenopathy
154
Treatment for Ruptured Achilles tendon
Equinus cast (similar to plaster of Paris)

MBBS - Year 1 (93 decks)

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