Lecture 1.2: Clinical Overview of the MSK Flashcards
How many adults consult their GP with musculoskeletal problems each year?
1 in 5
20%
What increases risk of MSK problems?
- Trauma
- Ageing
- Underlying Pathology
Clinical Assessment in MSK
80% History
15% Clinical Examination
5% Investigations
History Taking
SQUITARS
Occupation
Dominant hand?
Possible symptoms with MSK presentation
- Pain
- Swelling
- Bleeding
- Stiffness
- Loss of function
- Weakness
- Instability
- Change in sensation
- Weight bearing
What could suggest infection or malignancy as underlying cause for MSK presentation?
- Fever
- Unexplained weight loss
- History of malignancy
- Night sweats
Surgical Sieve: MIND IT
M: metabolic I: inflammation N: neoplastic D: degenerative I: infection T: trauma
Surgical Sieve: VINDICATE
V: vascular I: infection N: neoplasm D: degenerative or drugs I: iatrogenic or intoxication C: congenital A: autoimmune T: trauma E: endocrine/metabolic
Family History in MSK presentation
Inflammatory Arthritis
Degenerative Diseases
Social History in MSK presentation
- Mobility
- Walking aids
- Home situation
- Carers
Principles of an Orthopaedic Examination (4)
- Look
- Feel
- Move
- Special Tests
Principles of an Orthopaedic Examination: Look (12)
- Gait
- Look around the bed!
- Colour
- Scars
- Muscle wasting
- Deformity
- Swelling
- Bruising
- Puncture or skin wounds
- Joint fluid
- Asymmetry
- Varus + Valgus
Principles of an Orthopaedic Examination: Feel (7)
Look at the patient’s face! • Pain • Effusion • Temperature • Laxity • Crepitus • Pulses
Principles of an Orthopaedic Examination: Move (10)
- Active and Passive
- Flexion and Extension
- Pronation and Supination
- Abduction and Adduction
- Eversion and Inversion
Principles of an Orthopaedic Examination: Special Tests for Hip
- Trendelenburg
- Thomas’ test
- Hip impingement sign
Principles of an Orthopaedic Examination: Special Tests for Knee
- Collateral ligaments
- ACL/PCL
- Mc Murray’s test (menisci)
Principles of an Orthopaedic Examination: Special Tests for Foot
- Mulder Click (Morton’s neuroma)
- Silverskoild test
…and many more
Varus vs Valgus
Varus is knees wider than they should be
Valgus is Knock Knees, knees point inwards
Key things to remember when examining the patient (5)
- Introduce yourself
- Ask permission!
- Expose the patient appropriately whilst maintaining patient dignity
- Warm hands!
- Don’t cause pain
Rule of 2’s
- 2 joints
- 2 limbs
- 2 views (for X rays)
Examine joint above and below
Examine both limbs (for comparison)
Investigations (5)
- Xrays
- CT
- MRI
- Ultrasound
- Bone Scan
CT Pros vs Cons
Pros:
• 3D imaging/ X-sectional imaging
• Can help with interventional procedures
• Excellent for BONE
Cons:
• Significant radiation dose
• Not as good as MRI for assessing soft tissues
How does an MRI work?
- Magnetic field
- Radiofrequency pulse
- Hydrogen nuclei in water
MRI Pros vs Cons
Pros:
• Multi-planar imaging
• Non ionising radiation
• Good for picking up infection, tumours, soft tissue
Cons:
• Strict contraindications- Pacemaker, Metal/ FB
• Claustrophobia (1 in 3)
• Slow
How does an Ultrasound work?
High frequency sound waves (3-50MHz)
What is good about Ultrasounds and what can they be used for?
- Dynamic
- Safe (no radiation)
- Assessing tendons
- Assessing masses
- Joint effusions
- Screening DDH
Osteoarthritis
- Condition that causes joints to become painful and stiff
- Live long enough = OA
- Big impact on ADL
- Treat with Analgesia
- Joint replacement
Rheumatoid Arthritis
Autoimmune condition that causes pain, swelling and stiffness in the joints
Infections
- Erythema (redness)
- Swelling
- Decreased ROM
Tumours
Primary: Lymphomas or Myelomas
Secondary: Lung, Breast, Prostate…etc
Types of Joint Injury (6)
- Sprains
- Fractures
- Subluxations
- Dislocations
- Fracture dislocation/subluxation
- Open/closed injury
Methods of Treatment (10)
- Conservative & support
- Manipulation & cast
- Manipulate & insert wires
- Open Reduction Internal Fixation (ORIF) screws, plates, wires, combinations
- External fixation
- Arthroplasty (replace)
- Excision (remove)
- Osteotomy (re-align)
- Amputation
- Arthrodesis (restrict)
What is a sprain? Where do they commonly occur?
It is damage to a ligament
Can be complete, partial or damaged fibres with continuity intact
Commonly occur in ankle, knee, hand joints (thumb)
RICE for Sprains
R: rest
I: ice
C: compression
E: elevation
What is a Dislocation?
A complete loss of continuity of the articulating surfaces of the joint
What is Subluxation?
A partial loss of continuity of the articulating surfaces of the joint
What is a Fracture?
A break in the continuity of the bone
Causes of Fractures? (4)
- Stress
- Trauma
- Deficiency (osteoporosis, osteomalacia)
- Pathological (tumour, infection)
Classification of Fractures (4)
Displaced
Non-displaced ()
Open ()
Closed ()
What happens in a Displaced Fracture?
The bone snaps into two or more parts and moves so that the two ends are not lined up straight
What is a Comminuted Fracture?
It is when the bone is in many pieces
What happens in a Non-Displaced Fracture?
The bone cracks either part or all of the way through, but does move and maintains its proper alignment
What happens in an Open Fracture?
The bone breaks through the skin
It may then recede back into the wound and not be visible through the skin
This is an important difference from a closed fracture because with an open fracture there is a risk of a deep bone infection
What happens in a Closed Fracture?
When the bone breaks but there is no puncture or open wound in the skin
Treatment of Open Fractures
- Immediate cleaning
- irrigation and reduction
- IV antibiotics
- Tetanus status
- Subsequent surgical debridement/washout and fixation
Causes and Treatment of Neck of Femur Fractures
Typically caused either by low energy injuries (the most common type), such as a fall in frail older patient,
High energy injuries, such as a road traffic collision or fall from height and are often associated with other significant injuries
Cannulated Screw Fixation
Aims of Treatment of Fractures
• Pain relief (acute)
• Prevent infection (open wounds)
• Restoration of normal joint anatomy as far as possible (function and
aesthetics)
• Maintenance of position (function)
• Rehabilitate- reduce risk loss of function
• Reduce risk of chronic pain
