Locomotor Flashcards
Nerve roots Biceps
C5-C6
Nerve roots triceps
Triceps C7-C8
Nerve roots Knee
L3-L4
Nerve roots ankle
Ankle S1-S2
Nerve roots Deltoid
C5
Nerve roots Triceps
C7
Quarreceps Nerve roots
L3
Nerve roots Long Flexor
L8
Nerve roots Gastrocnemius
Gastrocnemius S1
Deltoid muscle:
Supplied by the axillary nerve (C5,C6)
* Actions: mainly shoulder abduction
Lateral epicondylitis (tennis elbow) features
Pain and tenderness localized to the lateral epicondyle
* Pain worse on resisted wrist extension with the elbow extended or
supination of the forearm with the elbow extended also there is pain on
middle finger extension
* Episodes typically last between 6 months and 2 years. Patients tend to
have acute pain for 6-12 weeks
Medial epicondylitis (golfer’s elbow) features
Pain and tenderness localized to the medial epicondyle
* Pain is aggravated by wrist flexion and pronation
* Symptoms may be accompanied by numbness / tingling in the 4th and
5th finger due to ulnar nerve involvement
Radial tunnel syndrome
Most commonly due to compression of the posterior interosseous branch of the radial nerve. It is thought to be a result of overuse.
Features
* Symptoms are similar to lateral epicondylitis making it difficult to
diagnose
* However, the pain tends to be around 4-5 cm distal to the lateral
epicondyle
* Symptoms may be worsened by extending the elbow and pronating the
forearm, not like tennis elbow where supinating is the problem
Cubital tunnel syndrome
Due to the compression of the ulnar nerve.
Features
* Initially intermittent tingling in the 4th and 5th finger
* May be worse when the elbow is resting on a firm surface or flexed for
extended periods
* Later numbness in the 4th and 5th finger with associated weakness
De Quervain’s Tenosynoviti
is a common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged 30 - 50 years old
Features
* Pain on the radial side of the wrist
* Tenderness over the radial styloid process
* Abduction of the thumb against resistance is painful
* Finkelstein’s test: with the thumb is flexed across the palm of the hand, pain is reproduced by
movement of the wrist into flexion and ulnar deviation
Carpal Tunnel Syndrome
is caused by compression of MEDIAN NERVE in the carpal tunnel
Examination Carpal Tunnel Syndrome
Weakness of thumb abduction
* Wasting of thenar eminence (NOT
HYPOTHENAR)
* Tinel’s sign: tapping causes paraesthesia
* Phalen’s sign: flexion of wrist causes symptoms
eleectrophysiology Carpal Tunnel Syndrome
Electrophysiology
* Motor + sensory: prolongation of the action potential
Median Nerve: Arm:
The median nerve has no voluntary motor or cutaneous function in the (upper) arm. It gives vascular branches to the wall of the brachial artery. These vascular branches carry sympathetic fibers.
Median Nerve: Forearm:
nnervates all of the flexor ( except flexor carpi ulnaris and that part of flexor digitorum profundus that supplies the medial two digits)
The main portion of the median nerve supplies the following muscles:
uperficial group:
o Pronator teres
o Flexor carpi radialis o Palmaris longus
Intermediate group:
o Flexor digitorum superficialis muscle
The anterior interosseus branch of the median nerve supplies the following muscles:
Deep group:
o Flexor digitorum profundus (only the lateral half) o Flexor pollicis longus
o Pronator quadratus
median nerve Hand:
motor innervation to the 1st and 2nd lumbrical muscles.
innervates the skin of the palmar side of the thumb, the index and middle finger, half the ring finger, and the nail bed of these fingers.
LOAF”
Lumbricals 1 & 2, Opponens pollicis, Abductor pollicis brevis and Flexor pollicis brevis.
MEDIAN
median Injury of this nerve at a level above the elbow
loss of pronation and a reduction in
flexion of the hand at the wrist.
Injury to the anterior interosseous branch in the forearm (median
causes the anterior interosseous
syndrome.
Severing the median nerve causes
median claw hand.
Anterior Interosseous Nerve brach of?
largest branch of the median nerve arising distal to the lateral epicondyl.
Anterior Interosseous Nerve It supplies:
It supplies:
* Flexor pollicis longus
* Felxer digtorium profundus to the index and sometimes middle finger
* Pronator quadrates
Anterior Interosseous Nerve lesion The typical symptoms:
- Inability to oppose the thumb and index finger
- Inability to flex the thumb IP joint
- Inability to flex the distal IP joint of the index
- Pronator quadrates paralyzed
Radial Nerve motor and sensory
Motor to
* Extensor muscles (forearm, wrist, fingers, thumb)
Sensory to
* Dorsal aspect of lateral 3 1/2 fingers
* However, only small area between the dorsal aspect of the 1st and 2nd metacarpals is
exclusively by the radial nerve
Patterns of damage Radial Nerve
Patterns of damage
* Wrist drop
* Sensory loss to small area between the dorsal aspect of the 1st and 2nd metacarpals
Axillary damage
* As above
* Paralysis of triceps
Ulnar Nerve:arrises to
arises from medial cord of brachial plexus (C8, T1)
Radial Nerve: arises from
posterior cord of the brachial plexus (C5-8)
Ulnar Nerve motor and sensory
Motor to
* Medial two lumbricals
* ADductor pollicis
* Interossei
* Hypothenar muscles: ABductor digiti minimi, flexor digiti minimi * Flexor carpi ulnaris
Sensory to
* Medial 1 1/2 fingers (palmar and dorsal aspects)
dammage at the wrist Ulnar Nerve
Damage at wrist
* ‘Claw hand’
* Wasting and paralysis of intrinsic hand muscles (except lateral two
lumbricals)
* Wasting and paralysis of hypothenar muscles
* Sensory loss to the medial 1 1/2 fingers (palmar and dorsal aspects)
dammage at the elbow Ulnar Nerve
Damage at elbow
* As the wrist
* Radial deviation of
wrist
Adhesive Capsulitis (frozen shoulder) has a known association with
diabetes
Adhesive Capsulitis features
Patients typically
have a painful freezing phase, an adhesive phase and a recovery phase. The episode typically lasts 2-3
years.
Red flags for lower back pain
Age<20yearsor>50years
* History of previous malignancy
* Night pain
* History of trauma
* Systemically unwell e.g. Weight loss, fever
Spinal stenosis features
Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis
Ankylosing spondylitis back pain
Typically a young man who presents with lower back pain and stiffness Stiffness is usually worse in morning and improves with activity Peripheral arthritis (25%, more common if ♀)
Peripheral arterial disease back pain
Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischemia Past history may include smoking and other vascular diseases
Spinal Cord Compression
Features
* Back pain: may be worse on lying down and coughing
* Neurological signs depend on the level of the lesion. Tendon reflexes tend to be increased
below the level of the lesion and absent at the level of the lesion
Management
* High-dose oral dexamethasone
* Urgent oncological assessment for consideration of radiotherapy or surgery
L3 nerve root compression
Sensory loss from anterior thigh to medial aspect of lower leg Weak quadriceps
↓ knee reflex
Positive femoral stretch test
L4 nerve root compression
L4 nerve root compression
Sensory loss anterior aspect of knee Weak quadriceps
↓ knee reflex
Positive femoral stretch test
L5 nerve root compression
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion Reflexes intact
Positive sciatic nerve stretch test
S1 nerve root compressio
S1 nerve root compression
Sensory loss posterolateral aspect of leg and lateral aspect of foot Weakness in plantar flexion of foot
↓ ankle reflex
Positive sciatic nerve stretch tes
Common Peroneal Nerve Lesion
The sciatic nerve divides into the tibial and common peroneal nerves. Injury often occurs at the neck of the fibula
The most characteristic feature of a common peroneal nerve lesion is foot drop
Other features include: Common Peroneal Nerve Lesion
- Weakness of foot dorsiflexion
- Weakness of foot eversion
- Weakness of extensor hallucis longus
- Sensory loss over the dorsum of the foot and the lower lateral part of the leg
- Wasting of the anterior tibial and peroneal muscles
Baker Cyst (Popliteal Cyst)
- Most common mass in the popliteal fossa
- Since the cyst is an extension from the knee joint, it is lined by synovium.
- Ultrasound is the investigation of choice in the evaluation of a popliteal mass.
- Complication: most common is rupture or dissection of fluid into the adjacent proximal
gastrocnemius muscle belly which results in a syndrome mimicking the symptoms of a deep vein thrombosis. Doppler ultrasound will, however, show the vascular lumen to be compressible (the lumen is not compressible in DVT due to the presence of the thrombus).
Conditions associated with popliteal cysts, in descending order of frequency, are as follows:
- Arthritides
- Osteoarthritis
- Rheumatoid arthritis
- Juvenile arthritis
- Gout
- Reiter’s syndrome
- Psoriasis
- Systemic lupus erythematosus
- Internal derangement (meniscal tears, anterior cruciate ligamaent (ACL) tears, osteochondral
fractures) - Infection (septic arthritis, tuberculosis)
- Chronic dialysis
- Hemophilia
- Hypothryroidism
- Pigmented villonodular synovitis
- Sarcoidosis
he Ottawa Rules with for ankle x-rays
any pain in the malleolar zone and + 1 of the following findings:
* Bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the
lower 6 cm of posterior border of the fibular)
* Bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower
6 cm of the posterior border of the tibia)
* Inability to walk four weight bearing steps immediately after the injury and in the emergency
department
Osteomalacia:
The low calcium and phosphate combined with the raised alkaline phosphatase point towards
osteomalacia
- Low Ca2, PO34-, 25(OH) vitamin D
- Raised ALP
- X-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser’s
zones or pseudofractures)
Osteoporosis: Risk factors:
Family history
* ♀ sex
* Increasing age
* Deficient diet
Low body weight
Smoking
Diseases which predispose Osteoporosis:
- Endocrine: glucocorticoid excess (e.g. Cushing’s, steroid therapy), hyperthyroidism, hyperparathyroidism, hypoGonadism (e.g. Turner’s), Growth hormone deficiency, diabetes mellitus (Glucose)
- Multiple myeloma, lymphoma
- GI problems: malabsorption (e.g. Celiac), gastrectomy, liver disease
- Rheumatoid arthritis
- Long term heparin therapy*
- Chronic renal failure
- Osteogenesis imperfecta, homocystinuria
Treatment is indicated Osteoporosis:
Following osteoporotic fragility fractures in postmenopausal women who are confirmed to have osteoporosis (a T-score of – 2.5 SD or below).
Vitamin D and calcium supplementation should be offered to all women unless the clinician is confident they have adequate calcium intake and are vitamin D replete
osteoporosis first line
Alendronate is first-line
Bisphosphonates osteoporosis
lendronate, risedronate and etidronate are all licensed for the prevention and treatment of post- menopausal and glucocorticoid-induced osteoporosis
* All three have been shown to ↓ the risk of both vertebral and non-vertebral fractures although alendronate, risedronate may be superior to etidronate in preventing hip fractures
* Ibandronate is a once-monthly oral bisphosphonate
Vitamin D and calcium osteoporosis
Poor evidence base to suggest ↓ fracture rates in the general population at risk of osteoporotic fractures - may ↓ rates in frail, housebound patients
osteoporosis Raloxifene - selective estrogen receptor modulator (SERM)
Has been shown to prevent bone loss and to ↓ the risk of vertebral fractures, but has not yet
been shown to ↓ the risk of non-vertebral fractures
* Has been shown to ↑ bone density in the spine and proximal femur
* May worsen menopausal symptoms
* ↑ risk of thromboembolic events
* May ↓ risk of breast cancer
Strontium ranelate osteoporosis
‘Dual action bone agent’ - ↑ deposition of new bone by osteoblasts and ↓ the resorption of bone by osteoclasts
* Strong evidence base, may be second-line treatment in near future
* ↑ risk of thromboembolic events
osteoporosis teriparatide
Recombinant form of parathyroid hormone
* Very effective at increasing bone mineral density but role in the management of osteoporosis
yet to be clearly defined
Hormone replacement therapy osteoporosis
Has been shown to ↓ the incidence of vertebral fracture and non-vertebral fractures
* Due to concerns about ↑ rates of cardiovascular disease and breast cancer it is no longer recommended for primary or secondary prevention of osteoporosis unless the woman is
suffering from vasomotor symptoms
Osteomalacia:Types
- Vitamin D deficiency e.g. Malabsorption, lack of sunlight, diet
- Renal failure
- Drug induced e.g. Anticonvulsants
- Vitamin D resistant; inherited
- Liver disease, e.g. Cirrhosis
Osteomalacia: features
Features
* Rickets: knock-knee, bow leg, features of hypocalcemia
* Osteomalacia: bone pain, fractures, muscle tenderness, proximal myopathy
Osteomalacia:Treatment
Treatment
* Calcium with vitamin D tablets
Diseases which predispose Osteoporosis:
Diseases which predispose
* Endocrine: glucocorticoid excess (e.g. Cushing’s, steroid therapy), hyperthyroidism, hyperparathyroidism, hypoGonadism (e.g. Turner’s), Growth hormone deficiency, diabetes mellitus (Glucose)
* Multiple myeloma, lymphoma
* GI problems: malabsorption (e.g. Celiac), gastrectomy, liver disease
* Rheumatoid arthritis
* Long term heparin therapy*
* Chronic renal failure
* Osteogenesis imperfecta, homocystinuria
Osteoporosis: Treatment is indicated following
osteoporotic fragility fractures in postmenopausal women who are confirmed to have osteoporosis (a T-score of – 2.5 SD or below).
Alendronate is first-line
risks of not taking / tolerating alendronate
Risk factors
* Parental history of hip fracture
* Alcohol intake of 4 or more units
* Rheumatoid arthritis
Bisphosphonates
Alendronate, risedronate and etidronate are all licensed for the prevention and treatment of post- menopausal and glucocorticoid-induced osteoporosis
* All three have been shown to ↓ the risk of both vertebral and non-vertebral fractures although alendronate, risedronate may be superior to etidronate in preventing hip fractures
* Ibandronate is a once-monthly oral bisphosphonate
Vitamin D and calcium
Poor evidence base to suggest ↓ fracture rates in the general population at risk of osteoporotic fractures - may ↓ rates in frail, housebound patients
Raloxifene
- Has been shown to prevent bone loss and to ↓ the risk of vertebral fractures, but has not yet
been shown to ↓ the risk of non-vertebral fractures
The Only MRCP Notes You’ll Ever Need
279 / 546 www.sudamedica.com - Has been shown to ↑ bone density in the spine and proximal femur
- May worsen menopausal symptoms
- ↑ risk of thromboembolic events
- May ↓ risk of breast cancer
Strontium ranelate
- ‘Dual action bone agent’ - ↑ deposition of new bone by osteoblasts and ↓ the resorption of bone by osteoclasts
- Strong evidence base, may be second-line treatment in near future
- ↑ risk of thromboembolic events
Teriparatide
Recombinant form of parathyroid hormone
* Very effective at increasing bone mineral density but role in the management of osteoporosis
yet to be clearly defined
Hormone replacement therapy osteoporosis
Has been shown to ↓ the incidence of vertebral fracture and non-vertebral fractures
* Due to concerns about ↑ rates of cardiovascular disease and breast cancer it is no longer recommended for primary or secondary prevention of osteoporosis unless the woman is
suffering from vasomotor symptoms
Assessment for treatment - patients taking the equivalent of prednisolone 7.5 mg or more each day for 3 months, and one of the following
Are over the age of 65 years
* Have a history of a fragility fracture
* Have a T-score less than - 1.5 SD
First-line: oral bisphosphonate
* Second-line: alfacalcidol or calcitriol
Paget’s Disease
disease of ↑ but uncontrolled bone turnover. It is thought to be primarily a disorder of osteoclasts, with excessive osteoclastic resorption followed by ↑ osteoblastic activity. Paget’s disease is common (UK prevalence 5%) and symptomatic in only 5%.
Paget’s Disease Predisposing factors
Predisposing factors
* Increasing age
* ♂sex
* Northern latitude
* Family history
Paget’s Disease Clinical features -
only 5% of patients are symptomatic
Normal calcium and phosphate combined with a raised alkaline phosphate
* Bone pain (e.g. Pelvis, lumbar spine, femur)
* Classical, untreated features: bowing of tibia, bossing of skull
* Raised alkaline phosphatase (ALP) - calcium* and phosphate are typically normal
* Skull x-ray: thickened vault, osteoporosis circumscripta
Paget’s Disease Indications for treatment
include bone pain, skull or long bone deformity, fracture, periarticular Paget’s
* Bisphosphonate (either oral risedronate or IV zoledronate)
* Calcitonin is less commonly used now
paget’s Disease Complications
- Deafness (cranial nerve entrapment)
- Bone sarcoma (1% if affected for > 10 years)
- Fractures
- Skull thickening
- High-output cardiac failure
Osteopetrosis
AKA marble bone disease
* Rare disorder of defective osteoclast
function resulting in failure of normal
bone resorption
* Stem cell transplant and interferon-gamma
have been used for treatment
Osteopetrosis Overview
Autosomal dominant
* Abnormality in type 1 collagen due to ↓ synthesis of pro-α 1 or pro-α 2 collagen polypeptides
- Presents in childhood
- Fractures
- Blue sclera
- Deafness secondary to otosclerosis
Rhabdomyolysis features
Features
* Acute renal failure with disproportionately raised creatinine
* Elevated CK
* Myoglobinuria
* Hypocalcemia (myoglobin binds calcium)
* Elevated phosphate (released from myocytes)
Rhabdomyolysis causes
Causes
* Seizure
* Collapse/coma (e.g. Elderly patients collapses at home, found 8 hours later)
* Ecstasy
* Crush injury
* Mcardle’s syndrome
* Drugs: statins
Multiple Myeloma Clinical features
Bone pain, osteoporosis + pathological fractures (typically vertebral), osteolytic lesions
* Lethargy
* Infection
* Hypercalcemia (see below)
* Renal failure
* Other features: amyloidosis e.g. Macroglossia, carpal tunnel syndrome; neuropathy;
hyperviscosity
Multiple Myeloma diagnosis is based on:
- Monoclonal proteins in the serum and urine (Bence Jones proteins)
- ↑ plasma cells in the bone marrow
- Bone lesions on the skeletal survey
- Other findings on investigations:
o Rouleaux formation of RBCs on blood film
Rouleaux formation of RBCs
Rouleaux are stacks of RBCs which form because of the unique discoid shape of the cells in vertebrate body. The flat surface of the discoid RBCs give them a large surface area to make contact and stick to each other; thus, forming a rouleau. They occur when the plasma protein concentration is high, and because of them the ESR is also increased. This is a non-specific indicator of the presence of disease.
Conditions which cause rouleaux formation include infections, Multiple myeloma, inflammatory and connective tissue disorders, and cancers. It also occurs in DM and i
Hypercalcemia in myeloma
Due primarily to ↑ osteoclastic bone resorption caused by local cytokines released by the myeloma cells
* Other contributing factors include impaired renal function, ↑ renal tubular calcium reabsorption and elevated PTH-rP levels
Diagnostic criteria: for symptomatic myeloma, asymptomatic myeloma and MGUS
- Symptomatic myeloma:
* Clonal plasma cells >10% on bone marrow biopsy or (in any quantity) in a biopsy from other tissues (plasmacytoma)
* A monoclonal protein (paraprotein) in either serum or urine(except in cases of true non- secretory myeloma)
* Evidence of end-organ damage felt related to the plasma cell disorder (related organ or tissue impairment, ROTI, commonly referred to by the acronym “CRAB”):
o HyperCalcemia (corrected calcium >2.75 mmol/L)
o Renal insufficiency attributable to myeloma
* Anemia (hemoglobin <10 g/dL)
* Bone lesions (lytic lesions or osteoporosis with compression fractures)
- Asymptomatic myeloma: diagnosis
- Serum paraprotein >30 g/L AND/OR
- Clonal plasma cells >10% on bone marrow biopsy AND
- NO myeloma-related organ or tissue impairment
monoclonal gammopathy of undetermined significance (MGUS): diagnosis
- Serum paraprotein <30 g/L AND
- Clonal plasma cells <10% on bone marrow biopsy AND
- NO myeloma-related organ or tissue impairment
B2-microglobulin in myeloma
useful marker of prognosis - raised levels imply poor prognosis. Low levels of albumin are also associated with a poor prognosis
treatment myeloma < 65 years of age:
Initial treatment depends on the patient’s age and comorbidities:
High-dose chemotherapy with hematopoietic stem-cell transplantation
* Prior to stem-cell transplantation, these patients receive an initial course of induction chemotherapy (thalidomide–dexamethasone, bortezomib and lenalidomide–
dexamethasone.
* Autologous stem cell transplantation (ASCT), (patient’s own stem cells after
chemotherapy), is the most common type of stem cell transplantation for multiple
myeloma. It is not curative, but does prolong overall survival.
* Allogeneic stem cell transplantation, (transplantation of a healthy person’s stem cells into
the affected patient), has the potential for a cure, but is only available to a small percentage of patients.
> 65 years old and patients with significant concurrent illness treatment myeloma
Chemotherapy (Bortezomib) with melphalan and pred
Renal failure in multiple myeloma
can be acute (reversible) or chronic (irreversible). Acute renal failure typically resolves when the calcium and paraprotein levels are brought under control. Treatment of chronic renal failure is dependent on the type of renal failure and may involve dialysis.
Ewing’s Sarcoma
lethal malignant primary bone tumor derived from the red bone marrow. It is most common in children and adolescents and rare after the age of 30 years. It has a ♂:♀= 3:2.
Ewing’s Sarcoma Presentation:
earliest symptom is pain, which is usually intermittent but becomes increasingly intense. Delay in the diagnosis can occur due to the fact that the clinical picture may be similar to that of acute or chronic osteomyelitis. However, eventually most patients have a large palpable rapidly growing mass, which is tense and tender.
Ewing’s Sarcoma Poor prognostic features:
*♂
* Age > 12 years
* ↑LDH
* Anemia
* Poor response to chemotherapy.
