Common MSK Swellings

Question 1

Why are MSK swellings important?

Answer 1

Uncommon but may be presentation of malignancy

Question 2

What are questions to ask when taking a history of an MSK lump?

Answer 2

When did it appear (gradual/sudden), history of trauma, painful, size (changing/constant), other symptoms, other similar lumps, dose it impair function

Question 3

What should be considered when examining an MSK lump?

Answer 3

Site, size, shape, ill/well-defined, consistency of size, texture, mobile/fixed, temperature, transluminable, skin changes, local lymphadenopathy

Question 4

What would be the history and examination findings of a patient with an infection?

Answer 4

History = systemic upset, pyrexia, break in skin, co-morbidities
Examination = calor, dolor, rubor, tumor

Question 5

What is cellulitis?

Answer 5

Inflammation and infection of soft tissues = causes generalised swelling

Question 6

How does cellulitis present?

Answer 6

Pain, swelling, erythema, may be minor problem to full blown septic wound

Question 7

What causes cellulitis and how may it be treated?

Answer 7

Causes = Staph aureus, beta haemolytic strep
Treatment = rest, elevation, splint, oral/IV penicillin, NOT surgery

Question 8

What are abscesses?

Answer 8

Discrete collections of pus

Question 9

How do abscesses present?

Answer 9

Discrete and fluctuant swelling, pain, erythema, history of bite/IV drug use

Question 10

How are abscesses treated?

Answer 10

Surgical incision and drainage of pus

Rest, elevation, analgesia, splint, antibiotics

Question 11

What is septic arthritis?

Answer 11

Bacterial infection of joint = traumatic or haematogenous spread
Caused by staph aureus, strep and E.coli

Question 12

Why is septic arthritis a surgical emergency?

Answer 12

Causes irreversible damage to hyaline articular cartilage

Question 13

How does septic arthritis present?

Answer 13

Acute monoarthroplasty, decreased ROM +/- swelling, systemic upset, raised white cell count and inflammatory markers

Question 14

How is septic arthritis treated?

Answer 14

Urgent orthopaedic review = aspiration (less commonly), urgent arthroscopic/open washout and debridement

Question 15

What is a ganglion?

Answer 15

Outpouching of synovium lining of joints = filled with synovial fluid

Question 16

How do ganglia appear?

Answer 16

Discrete, round swellings, non-tender, <10mm to several cm, skin mobile, fixed to underlying structures
Occur at wrist, feet and ankles

Question 17

How are ganglia treated?

Answer 17

Do nothing, not aspiration, percutaneous rupture, surgical excision

Question 18

What is a Baker’s cyst?

Answer 18

Ganglion of the popliteal fossa

Question 19

How do Baker’s cysts appear and how are they treated?

Answer 19

Can appear as general fullness of popliteal fossa = soft and non-tender, associated with OA, painful rupture
Non-surgical management

Question 20

What is bursitis?

Answer 20

Inflammation of the synovium-lined sacs that protect bony prominences and joints = may become secondarily infected and form abscesses

Question 21

How is bursitis treated?

Answer 21

NSAIDs/analgesia, antibiotics, incision and drainage for secondary infection, very rarely excision in chronic cases

Question 22

What is gout?

Answer 22

Inflammatory arthritis most commonly affecting the great toe and knee = caused by uric acid crystal deposition in joints due to elevated serum urate

Question 23

How does gout present and how is it diagnosed?

Answer 23

Severe, red, hot swollen joint

Diagnosed by aspirate = negatively birefringent needle shaped crystals

Question 24

How is gout treated?

Answer 24

NSAIDs, steroids, allopurinol

Question 25

What are rheumatoid nodules associated with an how do they present?

Answer 25

Associated with repetitive trauma | Presentation = chronic, more severe RA patients, rheumatoid factor positive

Question 26

How are rheumatoid nodules treated?

Answer 26

Excision if problematic, otherwise leave alone

Question 27

What are Bouchard's and Heberden's nodes?

Answer 27

Bony swelling of the IP joints = caused by bony spurs (OA associated)

Question 28

What are some features of Bouchard's and Heberden's nodes?

Answer 28

``` Bouchard's = less common, PIP joints Heberden's = more common, OA associated, DIP joints ```

Question 29

What occurs in Dupuytren's disease?

Answer 29

Excessive myofibroblast proliferation and altered collagen matrix deposition = results in digital flexion contractures

Question 30

What are some features of Dupuytren's disease?

Answer 30

Chords of type three collagen, avascular process involving oxygen free radicals

Question 31

What are some associations of Dupuytren's disease?

Answer 31

Genetics = autosomal dominant, more common in males and Northern Europeans Linked to alcohol, diabetes and trauma

Question 32

How is Dupuytren's disease treated?

Answer 32

Needle fasciotomy = if single chord Collaginase fasciotomy = for mild cases Limited fasciectomy = chord removal Dermofasciectomy and graft

Question 33

What are the two types of giant cell tumour of the tendon sheath?

Answer 33

Localised (common) and diffuse (uncommon, PVNS associated)

Question 34

What occurs in giant cell tumours of the tendon sheath?

Answer 34

Benign regenerative hyperplasia with inflammatory process

Question 35

How do giant cell tumours of the tendon sheath present?

Answer 35

Firm, discrete swelling, usually on volar aspect of digits, can occur in toes, may be tender

Question 36

How are giant cell tumours of the tendon sheath treated?

Answer 36

Leave alone if no functional issue, surgical excision (usually marginal excision)

Question 37

What is a lipoma?

Answer 37

Benign neoplastic proliferation of the fat, normally subcutaneous

Question 38

How do lipomas present?

Answer 38

Presentation = can be discrete/less well defined, slow growing, painless, can be several cm, no overlying skin changes

Question 39

How are lipomas treated?

Answer 39

Leave alone or surgical excision (s-shaped incision)

Question 40

What is an osteochondroma?

Answer 40

Benign lesion derived from aberrant cartilage from perichondral ring = may be solitary or multiple hereditary exostosis (MHE)

Question 41

How do osteochondromas present?

Answer 41

Painless, hard lump, symptoms with activity, commonly occurs near knee, usually in adolescence, MHE carry higher risk of malignancy

Question 42

How are osteochondromas treated?

Answer 42

Close observation or surgical excision

Question 43

What is Ewing's sarcoma?

Answer 43

Malignant primary bone tumour of endothelial cells in marrow = most common in ages 10-20, poor prognosis

Question 44

How does Ewing's sarcoma present?

Answer 44

Hot, swollen, tender joint = mimics infection | Night pain and weight loss

Question 45

How are Ewing's sarcomas treated?

Answer 45

Chemo or radiotherapy, surgery is difficult

Question 46

How do sebaceous cysts form?

Answer 46

Originate at hair follicles and fill with caseous material (keratin)

Question 47

How do sebaceous cysts present and how are they treated?

Answer 47

Slow growing, painless, mobile, discrete swelling, can become infected Excise if necessary, otherwise leave alone

Question 48

What is myositis ossificans?

Answer 48

Abnormal calcification of muscle haematoma

Question 49

What is the history of myositis ossificans?

Answer 49

Trauma, initial soft swelling, hardness develops over several weeks

Question 50

What investigations can be done for myositis ossificans and how is it treated?

Answer 50

Image with MRI and x-rays | Treatment = observe, intervene only if symptoms demand

Question 51

Why must you wait for maturity of ossification before intervening surgically in myositis ossificans?

Answer 51

Otherwise risk recurrence