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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
Q

Approach to limb pain

A

History
Examination
Investigations
Management of the problem

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26
Q

Leg pain hx

A 
Localisation and nature 
Duration 
Onset e.g. trauma 
Pain history 
Relieving and exacerbating history
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27
Q

Leg pain examination

A

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
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28
Q

Hernia

A

Weakness of abdominal wall so bowel pushes through

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29
Q

Shoulder exam - look

A

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

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30
Q

Shoulder exam - feel

A 
Ask if it hurts? 
Standing behind pt:
Sternoclavicular joint 
Clavicle 
Acromioclavicular joint 
Acromion 
Coracoid process 
Greater tuberosity
Scapula: spine, medial border, inferior angle
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31
Q

External rotation pain of shoulder - ddx

A

Usually OA

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32
Q

High painful arc (shoulder) - ddx

A

Pain in acromioclavicular joint - subacromial bursitis

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33
Q

Mid painful arc (shoulder) - ddx

A

Pain in sub acromion space - sulbcromial bursitis

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34
Q

Shoulder exam - feel

A 
Ask if it hurts? 
Standing behind pt:
Sternoclavicular joint 
Clavicle 
Acromioclavicular joint 
Acromion 
Coracoid process 
Greater tuberosity
Scapula: spine, medial border, inferior angle
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35
Q

Shoulder exam - move

A

Compare both sides

Flexion 
Extension 
Adduction 
Adduction 
Internal and external rotation

If any active movement is reduced, test passive movements

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36
Q

Abduction - shoulder exam

A

Ask pt to lift arm out to side

Normal is 90 degrees w/out scapula or 180 w/ scapula

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37
Q

Adduction - shoulder exam

A

Ask pt to move arm across front of body

Normal is 40 degrees

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38
Q

Pain in resisted shoulder movements

A

Infraspinatus (external rotation)
Subscapularis (internal rotation)
Supraspinatus (abduction)
Deltoid (abduction)

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39
Q

Causes of olecranon bursitis

A

Trauma
Rheumatoid
Gout

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40
Q

Elbow exam - look

A 
Positioning – undress, seated, space 
Anteriorly, posteriorly, laterally 
Skin/ soft tissue – olecranon bursa/ nodules
Bone 
Joint swelling 
Muscle bulk
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41
Q

Elbow exam - feel

A 
Olecranon process 
Lateral epicondyle of humerus 
Medial epicondyle of humerus
Ulna
Head of radius
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42
Q

Elbow exam - move

A

Flexion - ask pt to bend elbow
Extension - ask pt to straighten
Ptonation
Supination

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43
Q

Elbow exam - pronation

A

Ask the pt to bend elbow to 90 degrees of flexion and then turn arm over so palm faces the floor

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44
Q

Elbow exam - supination

A

Ask the pt to bend elbow to 90 degrees of flexion and then turn arm over so palm faces upwards

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45
Q

Pain in resisted elbow movements

A

Flexion (biceps)
Extension (biceps)
Supination (supinator)
Pronation (pronator)

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46
Q

Wrist exam - look

A 
Positioning, undress, space 
Dorsal and palmar aspects:
Skin – colour, scars, bruising, nails 
Posture and symmetry 
Bony structures 
Joint swelling 
Muscle bulk
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47
Q

Wrist exam - feel

A 
Ask if it hurts? Temperature/ tenderness 
Feel:
Head of ulnar 
Its styloid process
Radius base 
Its styloid process
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48
Q

Wrist exam - move

A

Flexion
Extension – prayer sign
Abduction (radial) – 20 degrees
Adduction (ulnar) – 50 degrees

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49
Q

Hand exam - look

A 
Skin 
Muscle 
Joints 
Posture 
Nails
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50
Q

Hand exam - skin

A

Erythema, redness, scars

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51
Q

Hand exam - muscle

A

Wasting in dorsal aspects

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52
Q

Hand exam - joints

A

Ulnar deviation, Z thumbs, subluxation of wrist, boutonnieres, swan neck deformity

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53
Q

Hand exam - nails

A

Oncolysis, pitting (PsA)

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54
Q

Hand exam - feel

A 
Bimanually - soft tissue (synovitis) or. bony 
Pisiform bone 
Scaphoid (in anatomical snuffbox)
MCP squeeze 
MCP joints 
PIP joints 
DIP joints
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55
Q

Condns to recognise from examination

A

Carpal tunnel
Ulnar nerve entrapment
Medial nerve entrapment
Radial nerve entrapment

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56
Q

Hand exam - move (fingers)

A

MCPs – flexion/ extension
DIPs – flexion/ extension
PIPs – flexion/ extension
Abduction/ adduction of fingers

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57
Q

Hand exam - move (thumb)

A 
Flexion 
Extension 
Abduction
Adduction 
Opposition
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58
Q

Pain in restricted movements - hand

A

Opposition – T1 (median nerve)
Finger abductions – T1 (median nerve)
Wrist extension – C8, T1 (radial nerve)
Power – make a fist

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59
Q

Examination of nerve function

A

Motor component and sensory component

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60
Q

Masses can be …

A

Origination or acquired

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61
Q

Where could potential lumps and bumps come from

A 
Skin 
Fat 
Connective Tissue 
Muscles 
Bones 
Joints 
Nerve 
Blood vessels 
Lymphatic system 
Organs
Metastases
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62
Q

Types of acquired masses

A

Neoplastic
Infl
Infective

63
Q

Infective masses

A

Rubor
Calor
Tumor
Dolor

64
Q

Infl masses

A 
Hx of infl condns e.g RhA etc
Pain 
Tenderness 
Symmetry 
Other lesions
65
Q

Benign neoplastic masses

A

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
Q

Malignant neoplastic masses

A

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
Q

Name of benign neoplastic growths in skin

A

Papilloma

68
Q

Name of benign neoplastic growths in fat

A

Lipoma

69
Q

Name of benign neoplastic growths in bone

A

Osteotoma

70
Q

Name of benign neoplastic growths in joints

A

Endochondroma

71
Q

Name of benign neoplastic growths in organisms

A

Adenoma

72
Q

Name of malignant neoplastic growths in skin

A

Squamous cell carcinoma

73
Q

Name of malignant neoplastic growths in fat

A

Liposarcoma

74
Q

Name of malignant neoplastic growths in bone

A

Osteosarcoma

75
Q

Name of malignant neoplastic growths in joints

A

Chondrosarcoma

76
Q

Name of malignant neoplastic growths in organs

A

Adenocarcinoma

77
Q

Hx of masses - benign tumours

A

Slow rate of growth
Other long-term masses
Painless
Local pressure effects

78
Q

Hx of masses - malignant tumours

A 
Fast rate of growth 
Other new masses/ lesions 
Painful Local invasive effects 
Associated lumps 
Associated symptoms of metastasis/ systemic spread
79
Q

Examination for lumps

A

Site
Size
Shape
Surface
Substance – consistency, soft, firm, hard
Surrounding structures – local tissue, lymph nodes, nerves, blood vessels, other organs

80
Q

Examination findings - benign masses

A 
Well defined 
Mobile 
Smooth
Soft 
No associated masses
81
Q

Examination findings - malignant masses

A 
Ill defined 
Immobile 
Irregular 
Hard 
Associated masses 
Associated organomegaly 
Associated reduce function of muscle, nerve
82
Q

Investigations that can be used for lumps and bumps

A

MRI
CT
Autopsy

83
Q

Investigation findings - benign masses

A

Well defined
Capsule
No invasion
Homogenous signal pattern

84
Q

Investigation findings - malignant masses

A 
Ill defined 
No capsule 
Invasion of local tissue 
Heterogenous signal pattern 
Metastases in organs or lymph nodes
85
Q

Significance of a bump having hard edges

A

Likely to be metastatic

86
Q

Describing lumps and bumps

A 
Position 
Colour 
Temp 
Shape/size/ surface 
Edge 
Consistency 
Fluctuation 
Translucency/ pulsability/ reducibility/ relation to other structures 
Bruits – noise 
Lymph node proximity
87
Q

Mechanisms of soft tissue injury

A

Direct Injury
Long term wear and tear
Unclear? Infl
Repetitive injury

88
Q

Examples of upper limb soft tissue injury

A 
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
Q

Example of lower limb soft tissue injury

A 
Knee ACL tear 
Knee collateral ligaments and menisci 
Quadriceps tendon rupture 
Patellar tendon rupture 
Tenoacchilles rupture
Ankle sprain
90
Q

Assessment of a soft tissue injury

A 
HPC
PMH 
Personal, social and occupation hx
Examination 
Investigations 
Treatment
91
Q

Clinical examination for soft tissue injury

A

Look for deformity/ signs of injury
Feel for tenderness, swelling
Move to assess,

92
Q

Investigations of a soft tissue injury

A

X-rays
Ultrasound scan
CT scan (to investigate associated fracture)
MRI scan

93
Q

Treatment for soft tissue injuries

A 
Analgesia 
RICE 
Immobilise (splint, sling, brace)
PT
Surgical repair
Education/ info
94
Q

Treatment for acromioclavicular joint issues

A

Sling for 6 weeks
Physiotherapy
Surgery in severe cases
Must fix grades 4 & 5 injuries

95
Q

Hook test

A

Poke finger in distal biceps tendon - test for distal bicep ruptures

96
Q

Presentation of distal biceps rupture

A

Usually men in late 40s/ early 50s
Seen in bodybuilders as anabolic steroid makes tendons easier to tear
Struggle to supinate

97
Q

Testing for ACL tear

A

Anterior draw test
Lachman’s test
MRI

98
Q

Secondary condn associated with ACL tear

A

Post traumatic OA due to changed biomechanics of the knee

99
Q

Clinical examination for Achilles Tendon rupture

A

Calf squeeze test and measure angle of declination

100
Q

Treatment for Achilles Tendon Rupture

A

Walking boot for 3 months (tendons proximate)

Surgical repair

101
Q

What does nerve compression result in

A

Ischaemia and demyelination of the nerve affecting its ability to conduct

102
Q

Most common compression neuropathies in upper limb

A

Carpal tunnel syndrome

Cubital tunnel syndrome

103
Q

Most common site of compression of peripheral nerves in lower limb

A

Common peroneal (fibular) nerve

104
Q

Carpal tunnel

A

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
Q

Risk factors for carpal tunnel syndrome

A

Traumatic (post wrist fracture/ lunate dislocation)
Pregnancy (common)
Hypothyroid (rare)
RhA (synovitis)
Chronic Renal Failure
Space occupying lesion (ganglion, tumour)

106
Q

Who does carpal tunnel usually present in

A

Women 35-55

107
Q

Typical symptoms and signs of carpal tunnel syndrome

A

Nocturnal dysesthesias
Paraesthesia on driving, using telephone, reading
Reduced dexterity (buttons, coins, sewing)
Thenar wasting – late sign, irreversible

108
Q

Tests for carpal tunnel

A

Tinel’s
Phalen’s <60 secs
Flexion-compression – press on nerve and flex wrist, best test to use

109
Q

The use of nerve conduction studies in compression neuropathies

A

Diagnostic uncertainty
Quantify degree of severity
Persistence of symptoms post CTD
Recurrence of symptoms post CTD

110
Q

Ddx of carpal tunnel

A

C6 radiculopathy (get MRI)
Proximal site compression (rare) – flexor dystrophy syndrome, pronator syndrome
Non-organic/ non-anatomical cause

111
Q

Non-operative treatment for carpal tunnel

A

Observation (may settle – e.g. pregnancy)
Splints (night symptoms)
Steroid injections

112
Q

Steroid injection for carpal tunnel

A

Useful to confirm diagnosis

Injected in 30-degree angle, ulnar side of Palmaris Longus tendon

113
Q

Surgery - carpal tunnel decompression

A

Performed under local anaesthetic (+/- tourniquet) – take 10 mins
Good at relieving pain, numbness recovery less consistent

114
Q

Healing from carpal tunnel decompression

A

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
Q

Complications of surgery

A 
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
Q

Pillar pain

A

Pain over bony borders

117
Q

Open vs endoscopic CTD

A

W/ endoscopic:
Quicker return to work
Higher rate nerve injury

118
Q

Similarities in open and endoscopic CTD

A

No difference in symptomatic relief, revision rates and grip strength

119
Q

Recurrent carpal tunnel

A

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
Q

Cubital Tunnel syndrome

A

Ulnar nerve compression at the elbow

121
Q

Ddx for cubital tunnel

A

Thoracic outlet syndrome
Pan coasts tumour
C8/ T1 radiculopathy

122
Q

Symptoms of cubital tunnel

A

Postural – leaning on elbow/ night symptoms

Established compression – numbness and weakness

123
Q

Signs of cubital tunnel syndrome

A 
Altered sensation – ulnar side of ring finger and pinky
Wartenberg 
Wasting first dorsal interosseous 
Clawing – hyperextension of DIP
Froments
Tinel’s at epicondyle
124
Q

Investigations for cubital tunnel

A

NCS

X-ray - look for elbow arthritis

125
Q

Non-operative treatment for cubital tunnel

A

Postural advice
Nocturnal splints
Surgery consideration
Surgery consideration in any numbness/ weakness and +ve NCS

126
Q

Surgical indications for cubital tunnel

A

Failure of non-operative management

Motor weakness/ loss sensation

127
Q

Types of nerve damage

A

Neurotmesis
Neuropraxia
Axonotmesis

128
Q

Neurotmesis

A

Complete disruption of never and sheath, chronic

129
Q

Neuropraxia

A

Transient nerve dysfunction, no damage to nerve or sheath, will recover fully

130
Q

Axonotmesis

A

Disruption of axon but Schwann cell myelin sheath intact, recovery could occur if insulting force removed in timely fashion

131
Q

Associated condns. w/ carpal tunnel

A 
Diabetes mellitus
Hypothyroidism
Rheumatoid arthritis
Pregnancy
Acromegaly
Trauma e.g. wrist fracture
132
Q

Common causes of bursitis

A 
Repetitive motion or position
Injury 
Trauma 
Inflammatory arthritis 
Gout 
Infection
133
Q

Epidemiology of bursitis

A

Equal incidence in males and females

Immunocompromised, diabetic, rheumatoid, alcoholism and HIV patients are at greater risk of septic bursitis

134
Q

Presentation of bursitis

A 
Sudden inability to move the joint 
Swelling 
Redness 
Bruising 
Rash
Sharp or shooting pain
Fever
135
Q

Investigations for bursitis

A

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
Q

Management of bursitis

A

Medication - abx if infection
Injections
Assistive walking aid
Surgery - drainage or removed if necessary

137
Q

Prognosis of bursitis

A

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
Q

Fibromyalgia

A

Long-term condition that causes pain all over the body

Disorder of sensory processing of non-nociceptive input.

139
Q

What causes FM to occur

A

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
Q

Presentation of FM

A 
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
Q

Epidemiology of FM

A

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
Q

Causes of FM

A 
Unknown but could be:
Genetics
Trauma
Giving Birth
Surgery
Infection
Psychological Factors (such as bereavement)
Also strong link with deopression
143
Q

Dx of FM

A

Usually be based on the symptoms in the patient history and you may also examine the patient for tender points

144
Q

Potential complications of FM

A 
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
Q

Allodynia

A

Pain felt in response to non-painful stimuli

146
Q

Presentation of chronic fatigue syndrome

A

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
Q

Post-exertional malaise (PEM)

A

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
Q

Some causes of myopathy

A 
Vit D deficiency
Diabetes 
Thyrotoxicosis 
Cushing's disease 
HIV
149
Q

Causes of muscle pain

A 
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
Q

Preventing DVT

A 
LMWH (prophylactic)
Stockings 
Exercise 
Aspirin 
Stop smoking 
Keep calf pump contracting
151
Q

DVT presentation

A

Leg is very swollen

152
Q

Presentation of arterial thrombosis

A

Leg is pale, pulseless, cold

Medical emergency

153
Q

Signs that there is a metastasis

A

Lymphadenopathy

154
Q

Treatment for Ruptured Achilles tendon

A

Equinus cast (similar to plaster of Paris)

MBBS - Year 1 (93 decks)

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