Common Musculoskeletal swellings Flashcards
Generalised or discreet swelling?
Ill defined / well defined
What type of swelling is cellulitis?
Generalised
Which organisms cause cellulitis?
Beta haemolytic strep and staphylococci
Presentation of cellulitis?
Pain, swelling, erythema
Spectrum: Minor problem – septic
Presentation of abscess
Defined and fluctuant swelling
Erythema, pain
History of trauma (eg. bite, IVDU)
Spectrum: Minor problem – septic
Organisms causing spetic arthritis?
Staph aureus/strep/E. coli
Bacterial infection of a joint e.g. septic arthritis
Traumatic (joint penetration)
Haematoginous spread
Presentation of septic arthritis
Acute monoarthropathy
↓↓ ROM +/- swelling
Systemic upset
Raised WCC + inflam markers
Acute monoarthropathy
↓↓ ROM +/- swelling
Systemic upset
Raised WCC + inflam markers
Septic arthritis
Management of septic arthritis
Urgent orthopaedic review
Aspiration; M,C & S
Urgent Open / arthoscopic washout + debridement
What are ganglion?
Outpouchings of synovium lining of joints and filled with synovial fluid
Appearance of ganglia
Discreet, round swellings Non-tender <10mm – several cms Skin mobile, fixed to underlying structures Wrists, feet, knees
Management of ganglia
Nothing
NOT aspiration
Percutaneous rupture
Surgical excision
Where would you find a baker’s cyst?
Popliteal fossa
Presentation of baker’s cyts
Can appear as general fullness of the popliteal fossa
Soft and non-tender
Associated with OA
Painful rupture
Which type of cyst may be associated with OA?
Baker’s cyst
Bursitis
Inflammation of the synovium lined sacs
Management of bursitis
NSAIDs / Analgesia
Antibiotics
Incision and drainage (secondary infection)
V. rarely excision (chronic cases)
Symptoms of bursitis
Symptoms of bursitis may include localized tenderness, pain, edema, erythema, or reduced movement. Pain is aggravated by movement of the specific joint, tendon, or both.
Which condition is associated with purine rich food, alcohol, dairy?
Gout
What may rheumatoid nodules be associated with?
Repetitive trauma
Do rheumatoid nodules respond to DMARDs?
No :(
Management of rheumatoid nodules
Excision if problematic but recurrence high
Histology of rheumatoid nodules
Intense inflammatory changes
Rheumatoid factor positive in rheumatoid nodule presentation?
Yesh
What causes Bouchards/Heberden’s nodes?
Bony spurs due to chronic trauma
Which are more common, Bouchards or Heberdens?
Heberdens
Which conditions would you fins bouchards and heberdens nodes in?
Bouchards: OA/RA
Heberdens: OA
Excessive myofibroblast proliferation and altered collagen matrix composition lead to thickened and contracted palmar fascia
Dupuytren’s disease
Which type of collagen makes up the bands in Dupuytren’s disease?
Collagen type III
Dupuytren’s disease
Progressive disease resulting in digital flexion contractures
Excessive myofibroblast proliferation and altered collagen matrix composition lead to thickened and contracted palmar fascia
Bands are primarily collagen type III
Avascular process involving O2 free radicals
It is NOT a disease of the flexor tendons
Avascular process involving O2 free radicals?
Dupuytren’s disease
Excessive MYOFIBROBLAST proliferation and altered collagen matrix composition leading to thickened and contracted PALMAR FASCIA?
Dupuytren’s disease
Which 3 factors contribute to Dupuytrens?
- Genetic predispostion
- Environmental factors
- Local and global protein expression
Method of inheritance of Dupuytrens
Autosomal dominant with variable penetration
Environmental factors contributing to Dupuytren’s disease
Alchohol, diabetes, trauma
Factors predisposing to Dupuytren’s disease
Genetic predisposition:
Autosomal dominant with variable penetration
Common in northern Europe; men > women
Environmental factors:
Alcohol, diabetes and trauma
Local and global protein expression:
Multiple protein expression enzymes up-regulated and down-regulated
Traeatment for Dupuytren’s disease
Needle fasciotomy
Collaginase injection
Limited fasciectomy
Dermofasciectomy + graft
PVNS
Pigmented villonodular synovitis (PVNS) is a joint disease characterized by inflammation and overgrowth of the joint lining
Associated with diffuse giant cell tumours of the tendon sheath
Giant Cell Tumour of the Tendon Sheath
2 types: Localised (common) Diffuse (uncommon; assoc. with PVNS)
Regenerative hyperplasia with inflammatory process
Benign
Presentation:
Firm, discreet swelling, usually on volar aspect of digits
Can occur in toes
May or may not be tender
Management of giant cell tumour of the tendon sheath
Leave alone if no functional issue!
Surgical excision:
Usually marginal excision, i.e. not complete as adherent to tendon sheath
Incidence of recurrence
Where would an osteochonroma most likely occur?
Near the knee
Distal femur / proximal tibia metaphyseal regions
Presentation of osteochondroma
Painless, hard lump
Symptoms with activity (pain from tendons; numbness from nerve compression)
Why might you feel numbness during activity if you have an osteochondroma?
Osteochondroma might compress nerves
Managment of osteochondroma
Management:
Close observation
Surgical excision
Which cells does a Ewings sarcoma originate from?
Endothelial cells (E for Ewings, E for endothelial)
Ages affected by Ewings sarcoma?
10-20
Ewing’s Sarcoma
Malignant primary bone tumour of the endothelial cells in the marrow
2nd most common bone tumour
Worst prognosis
Most common age 10 – 20 years
Ewing’s Sarcoma Presentation
The great mimic: Hot, swollen, tender joint or limb with raised inflammatory markers
Can mimic infection
Be suspicious; ask about night pain and duration of symptoms; investigate early
Should you be suspicious of night pain in bone?
Yes, investigate early and ask about duration of symptoms
Could be Ewing’s sarcoma :(
Management for Ewing’s sarcoma
Management:
Poor prognosis
Surgical excision problematic
Often radio- and chemo-sensitive
Why is Ewing’s sarcoma called the great mimc?
Can present as a hot, swollen, tender joint/limb with raised inflammatory markers
- Can mimic infection
- Be suspicious of night pain and duration of symptoms, investigate early
Lipoma
Can be discreet or less well defined Slow growing and painless/non-tender Can be large (several cms) Characteristic consistency No overlying skin changes
What is a lipoma?
Benign neoplastic proliferation of fat
Often subcutaneous
Management of lipomas
Based on symptoms
Can be left alone
Surgical excision is causing symptoms
Balance of removal vs scarring
Where do sebaceous cysts occur?
Head, neck, trunk
Strictly speaking this is a dermatological condition
Mentioned only for completeness
Originate at hair follicles and fill with caseous material (keratin)
Presentation:
Slow growing, painless, mobile discreet swellings
Can become infected
Management: Excision if required
Where do sebaceous cysts occur?
Hair follicles
Think head, neck, trunk
Myositis ossificans?
Abnormal calcification of a muscle haematoma
is a benign process characterised by heterotopic ossification usually within large muscles. Its importance stems in large part from its ability to mimic more aggressive pathological processes.
Abnormal calcification of a muscle haematoma?
Myositis ossificans
is a benign process characterised by heterotopic ossification usually within large muscles. Its importance stems in large part from its ability to mimic more aggressive pathological processes.
If you are going to intervene in myositis ossificans, e.g. with surgery, how long to you have to wait and why?
Must wait until maturity of ossification otherwise risk of recurrence 6-12 months
