MSK Flashcards
Which artery is at risk with a femoral neck fracture?
Medial circumflex femoral artery
Which nerve is at risk with humeral shaft fracture?
Radial nerve
Which nerve and artery is at risk with a humeral neck fracture?
Axillary nerve
Posterior humeral circumflex artery
What fracture is suggestive of cancer rather than osteoporosis?
Vertebral above T4
What does the cystic artery branch from?
Right hepatic artery
What is Behcet’s disease?
Complex inflammatory condition characteristically presents with recurrent oral and genital ulcers.
Link with HLA B51 gene
What are the features of Behcet’s disease?
Mouth ulcers (red halo) at least 3/year
Genital ulcers
Skin: erythema nodosum, papules and pustules and vasculitic type rash
Eyes: anterior or posterior uvetitis, retinal vasculitis and retinal haemorrhages
MSK: morning stiffness, arthralgia
GI
CNS: memory impairment, headaches, aseptic meningitis
Veins: Budd-chiari syndrome, DVT
What are the investigations of Behcet’s disease?
Clinical diagnosis based on features
Pathergy test
What is the management of Behcet’s disease?
Topical steroids to mouth ulcers (soluble betamethasone)
Prednisolone
Colchicine
Topical anesthetics e.g. lidocaine
Immunosuppressants
Infliximab
What are the four key changes on xray in osteoarthritis?
LOSS
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
What is the management of osteoarthritis?
- Paracetamol and topical NSAIDs
- Oral NSAIDs and PPI
- Opiates
- Intra-articular steroid injections
- Joint replacement
What are the genetic associations of rheumatoid arthritis?
HLA DR4
HLA DR1
Which antibodies are linked to rheumatoid arthritis?
Rheumatoid factor
Cyclic citrullinated peptide antibotides (anti-CCP)
What are the xray changes in rheumatoid arthritis?
Joint destruction and deformity
Soft tissue swelling
Periarticular osteopenia
Boney erosions
What is the management of rheumatoid arthritis?
- NSAIDs and PPI
- one off: methotrexate, lefllunomide or sulfasalazine.
- Combination of these two
- Methotrexate + biological therapy
- Methotrexate + rituximab
Hydroxychloroquinine is the midlest anti-rheumatic drug
What are the signs of psoriatic arthritis?
Plaques of psoriasis on the skin
Pitting of nails
Onycholysis
Enthesitis
What are the xray changes seen in psoriatic arthritis?
Periostitis Ankylosis Osteolysis Dactylitis Pencil-in-cup appearance
What is the management of psoriatic arthritis?
NSAIDs
DMARDs
Anti-TNF meds
Ustekinumab
What is reactive arthritis?
Where synovitis occurs as a reaction to recent infection.
Known as Reiter Syndrome.
Acute monoarthritis, affecting a single joint.
No infection present
Most common triggers are gastroenteritis and chlamydia
What are the features of reactive arthritis?
Bilateral conjunctivitis
Anterior uveitis
Circinate balanitis
Can’t see, pee or climb a tree.
What is the management of reactive arthritis?
Aspirate and send for gram staining, C+S
NSAIDs
Steroid injections
Systemic steroids
Most resolve within 6 months
What is ankylosing spondylitis?
Inflammatory condition affecting spine that causes progressive stiffness and pain
Linked to HLA-B27
Bamboo spine on xray
What is the presentation of ankylosing spondylitis?
Young adult malle in late teens or 20s
Slow onset >3months Lower back pain and stiffness Sacroiliac pain Worse with rest and improves with movement Pain worse at night and in the morning Takes 30mins for stiffness to improve
Vertebral fractures
What are the investigations in ankylosing spondylitis?
Inflammatory markers (CRP, ESR)
HLA B27 genetic test
Xray of spine and sacrum
MRI of spine shows bone marrow oedema
What are the Xray changes seen in akylosing spondylitis?
Bamboo spine
Squaring Subchondral sclerosis Syndesmophytes Ossification Fusion of the facet, sacroiliac and costovertebral joints
What is the management of ankylosing spondylitis?
NSAIDs
Steroids
Anti-TNF
Secukinumab
Where does the trachea bifurcate? (carina)
T4-T5, at the angle of louis
What is the action of the parotid gland?
Secretomotor action via glossopharygeal and auricotemporal nerves
Which fracture gives dinner form deformity?
Colle’s fracture
What is osteomalacia?
Condition where there is defective bone mineralisation causing “soft” bones.
This is due to a lack of vitamin D
What is the presentation of osteomalacia?
Fatigue Bone pain Muscle weakness Muscle aches Pathological or abnormal fracture
What are looser zones in relation to osteomalacia?
Fragility fractures that go partially through the bone
What are the investigations in osteomalacia?
Serum 25-hydroxyvitamin D
<25 - Vit D deficiency
25-50 - Vit D insufficiency
>75 - Optimal
Low calcium
Low phosphate
High PTH
Osteopenia on xray
What is the treatment for osteomalacia>
Supplementary vit D (calciferol)
Maintenance dose should be continued lifelong after treatment
If insufficient vit D, can be started on maintenance without treatment
What is osteoporosis?
Condition where there is reduction in the density of the bones
What are the risk factors for osteoporosis?
Older age Female Reduced mobility and activity Low BMI Rheumatoid arthritis Alcohol and smoking Long term corticosteroids Post menopausal women
What is a FRAX tool?
Prediction of the risk of a fragility fracture over the next 10 years
A score of 10% or more warrants a DEXA scan
What is the management of osteoporosis?
Lifestyle changes
Vitamin D and calcium (calciferol)
Bisphosphonates - 1st line
What is polymyalgia rheumatica?
Inflammatory condition that causes pain and stiffness in the shoulder, pelvic girdle and neck.
Strong association to giant cell arteritis
What are the core features of polymyalgia rheumatica?
Following present for at least 2 weeks:
Bilateral shoulder pain that may radiate to the elbow
Bilateral pelvic girdle pain
Worse with movement
Interferes with sleep
Stiffness for at least 45 minutes in the morning
What is the diagnosis of polymyalgia rheumatica?
Diagnosis based on clinical presentation and response to steroids.
Inflammatory markers raised
Bloods and tests to rule out other conditions
What is the treatment of polymyalgia rheumatica?
Steroids
- Prednisolone 15mg/day
After 1 week, if poor response consider alterantive diagnosis
After 3-4 weeks would expect 70% improvement. If so, reduce regime to get patient off steroids
What is sjogren’s syndrome and give the different types
Autoimmune condition that affects the exocrine glands.
Leads to dry mucous membranes: dry eyes, mouth and vagina
Primary sjogren’s: where the condition is in isolation
Secondary sjogren’s where it occurs related to SLE or rheumatoid arthritis
What are the antibodies associated with sjogren’s?
anti-Ro and anti-La
What is the schrimer test?
Diagnostic test for sjogrens
If tears travel <10mm is significant (15mm is normal)
What is the management of sjogren’s?
Artificial tears
Artificial saliva
Vaginal lubricants
Hydroxychloroquine is to used to halt the progression of the disease
What is carpal tunnel syndrome?
Caused by compression of the median nerve in the carpal tunnel
What is the presentation of carpal tunnel syndrome?
Pain/Pins/needles in thumb, index and middle finger
Shakes hand for relief at night
What is the examination in carpal tunnel syndrome?
Weakness of thumb abduction
Wasting of thenar eminence
Tinel’s sign (tapping causes paraesthesia)
Phalen’s sign (flexion of wrist causes symptoms)
What is the management of carpal tunnel syndrome?
Corticosteroid injection
Wrist splints at night
Surgical decompression
What is chronic fatigue syndrome?
Diagnosed after at least 4 months of disabling fatigue affecting mental and physical function more than 50% of the time.
What is gout?
A type of crystal arthropathy associated with high uric acid levels
Which are the typical joints affected in gout?
Base of big toe
Wrists
Base of thumb
What is the diagnosis of gout?
Clinically or by aspiration of fluid from joint
Aspirated fluid will show: No bacterial growth Needle shaped crystals Negatively birefringent of polarised light Monosodium urate crystals
What is seen on joint x-ray in gout?
Space between joint maintained
Lytic lesions in bone
Punched out erosions
Erosions can have sclerotic borders with overhanging edges
What is the management of gout?
Acute:
- NSAIDs
- Colchicine
- Steroids
Prophylaxis:
Allopurinol (can be continued during attack)
Lifestyle changes
What are the features of fibromyalgia?
Chronic pain
Lethargy
Cognitive impairment
Sleep disturbance, headache, dizziness are common
What is the diagnosis and management of fibromyalgia?
Clinical
CBT
Pregabalin, duloxetine, amitriptyline
What is osteomyelitis?
Infection in the bone and bone marrow
Staph aureus
What is the presentation of osteomyelitis
More common in boys <10yr
Refusing to weight bear
Pain
Swelling
Tenderness
What are the investigations in osteomyelitis?
Xrays = initial investigation MRI = best imaging
Blood tests: high CRP and ESR
Blood culture
What is the management of osteomyelitis?
Extensive and prolonged antibiotic therapy.
Maybe drainage and debridement of infected bone
What is osteogenesis imperfecta?
Genetic condition that results in brittle bones that are prone to fractures.
Affects the formation of collagen.
What is the presentation of osteogenesis imperfecta?
Recurrent and inappropriate fractures
Hypermobility
Blue/grey sclera
Triangular face Short stature Deafness Dental problems Bone deformities Joint and bone pain
What is the diagnosis and management of osteogenesis imperfecta?
Clinical diagnosis
Bisphosphonates
Vitamin D supplementation
No cure
What is the management of septic arthritis?
Empirical IV antibiotics until sensitivities are known
3-6weeks in total
Depending on local guidelines but e.g.
- Flucloxacillin + rifampicin
2 Vancomycin + rifampicin
What is SLE?
Inflammatory autoimmune connective tissue disease
Often relapsing-remitting
What is the presentation of SLE?
Photosensitive malar rash (butterfly shaped) - worse with sunlight
Fatigue Weight loss Myalgia Lymphadenopathy + splenomegaly SOB Mouth ulcers Hair loss
What are the antibodies associated with SLE?
anti-nuclear antibodies = DIAGNOSTIC
anti-double stranded DNA
What is the treatment of SLE?
First line: NSAIDs Steroids (prednisolone) Hydroxychloroquine Suncream and sun avoidance
More Immunosuppressants in more severe lupus
Biological therapies
What is slipped upper femoral epiphysis (SUFE)?
Where the head of the femur is displaced along the growth plate
Common in boys 8-15yrs
What is the presentation of SUFE?
Hip, groin, thigh or knee pain
Restricted range of hip movement
Painful limp
Restricted movement in the hip
What is the diagnosis of SUFE?
Initial = Xray
Blood tests
Technetium bone scan
CT scan
MRI scan
What is the management of SUFE?
In situ screw fixation
Which nerve is at risk in sacrospinous fixation of vault prolapse?
Sciatic
What are the functions of the facial nerve?
Carries secretomotor fibres to lacrimal gland through greater petrosal nerves
Associated developmentally with 2nd brachial arch
Supplies muscles of facial expression
Anterior 2/3 taste via chorda tympani
Secretomotor to submandibular and sublinguial glands
Which nerve and muscle causes winging of the scapula?
Long thoracic nerve
Serratus anterior
Name of amputation at ankle joint?
Syme’s amputation
Which artery supplies the lesser curvature of the stomach?
Left gastric artery
Most common cause of varicose veins?
Long saphenous vein
What is meralgia parasthetica?
Entrapment of the lateral cutaneous nerve of thigh (L2, L3)
What is the nerve supply for the medial and anterior aspects of the thigh?
Medial: Obturator nerve
Anterior: Femoral nerve
Which nerve is damaged in a supracondylar fracture and how does it present?
Anterior interosseous nerve
Presents with weakness to the R index finger
What is Bennett’s fracture caused by>
Boxer’s injury
What is the preferred management of an intertrochanteric (extracapsular) proximal femoral fracture?
Dynamic hip screws
What is the preferred management of an intracapsular femoral fracture?
hemiarthroplasty or total hip replacement
Hemi preferred if frail or if no history of osteoarthritis
What is given for rheumatoid flares?
IM methylprednisolone
What is used to monitor SLE flares?
Complement levels, levels are usually low during active disease
Which score is used to test for hypermobility?
Beighton score
Patients with temporal arteritis would most likely have a history of which other condition?
Polymyalgia rheumatica
Describe the location of an indirect hernia?
Traverses the inguinal canal through both the superficial and deep rings
What is the characteristic feature of hand osteoarthritis?
Squaring
Which dermatological condition is associated with rhuematoid arthritis?
Pyoderma gangrenosum
