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Oishi's Final year flashcards > MSK > Flashcards

MSK Flashcards

1
Q

Mx of rheumatoid arthritis?

Flare Mx?

A
  1. DMARD monotherapy +/- a short-course of bridging prednisolone
  2. TNF-inhibitor if inadequate response to at least two DMARDs including methotrexate

Flare - steroids PO/IM

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2
Q

How to monitor response to Tx in RA? Score?

A

CRP + disease activity

DAS28

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3
Q

ESR and CRP in SLE with no flare up?

A

High ESR

Normal CRP

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4
Q

Mx of grade I-II Acromioclavicular joint injuries?

A

Conservative with sling + immobilisation

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5
Q

Which nerve does a Morton’s neuroma affect and where does it present clinically?

A

intermetatarsal plantar nerve

3rd inter-MTP space

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6
Q

2 main fractures which carry risk of compartment syndrome?

A

supracondylar fracture

tibial shaft injury

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7
Q

Which joint do Heberden’s nodes affect?

A

DIP

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8
Q

Which joint to Bouchard’s nodes affect?

A

PIP

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9
Q

What disease are Heberden’s and Bouchard’s nodes commonly seen in?

A

Osteoarthritis

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10
Q

What does a positive McMurray’s test suggest?

A

Meniscal tear

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11
Q

Allergy to which drugs is a caution for sulfasalazine in RA?

A

Aspirin or sulphonamides

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12
Q

When are symptoms in lumbar spinal stenosis usually improved?

A

On sitting vs standing

Walking uphill vs downhill

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13
Q

Typical bloods in polymyalgia rheumatica?

A

Raised ESR

Normal CK

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14
Q

When to offer bone protection to patients on long term steroids?

A

If over 65 y/o
<65 but previous fragility fracture

Offer bone density scan if <66 y/o
T score

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15
Q

What effect does carpal tunnel syndrome have on sensory and motor axons?

A

action potential prolongation

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16
Q

Examination findings in carpal tunnel?

A

weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms

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17
Q

Which muscles are involved in shoulder abduction?

A

Supraspinatous - first 15 degrees

Deltoid after that

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18
Q

What is the nerve supply of the deltoid?

A

Axillary nerve

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19
Q

How should alignment of vertebral bodies be checked?

A

Using 3 longitudinal lines

Anterior, posterior and spinolaminar lines

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20
Q

Max thickness of prevertebral soft tissue from C1-C4/5 and C4/5-T1?

A

C1 - C4/5: 7mm

C4/5-T1: 21mm (1 vertebral body width)

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21
Q

3 views needed to assess C spine in trauma?

A

Lateral view: whole spine + cervicothoracic junction
Open mouth view: odontoid peg
AP view

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22
Q

Presence of which fat pad is always abnormal?

A

Posterior

Anterior is normal if it lies adjacent to anterior humerus

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23
Q

What is a Hill-Sachs lesion?

A

posterolateral humeral fracture occurring when the soft head impacts against hard anterior glenoid during an anterior dislocation

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24
Q

Most commonly injured carpal bones?

A

Scaphoid

Then triquetral

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25
Q

What is a Colle’s fracture?

A

fracture of the distal radius with dorsal angulation (posterior displacement) of the distal fragment

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26
Q

What is a Smith’s fracture?

A

fracture of the distal radius with palmar angulation (anterior displacement) of the distal fragment

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27
Q

How do Colle’s fractures occur?

A

Fall onto an outstretched hand

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28
Q

Xray changes indicative of infection in hip replacement?

A

Wideband of radiolucency at the cement-bone interface (in the case of cemented prostheses) or at the metal-bone interface (in uncemented prostheses)
Bone destruction

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29
Q

Which tendons are affected in De Quervain’s tenosynovitis?

A

extensor pollicis brevis and abductor pollicis longus

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30
Q

What is Finkelstein’s test? What does a positive test suggest?

A

the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction
pain over radial styloid process and along tendons suggests De Quervain’s tenosynovitis

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31
Q

Which meds increase risk of marrow aplasia if prescribed alongside methotrexate?

A

Trimethoprim

Co-trimoxazole

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32
Q

Which drug increases risk of methotrexate toxicity?

A

high dose aspirin

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33
Q

How does psoriatic arthritis affect the hands? What might you see on xray?

A

Asymmetrical inflammation of DIPs
Plantar spur
Pencil in cup

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34
Q

How does RA affect the hands?

A

Symmetrical inflammation of several small joints (usually MCPs) but sparing DIPs

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35
Q

what does morning stiffness indicate?

A

Few mins = osteoarthritis

Long time = RA

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36
Q

What examination signs suggest a non impacted NOF fracture?

A

External rotation and leg shortening

Unable to straight leg rise

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37
Q

What classification system is used for NOF fractures?

A

Garden system:

Stage I: Incomplete fracture of the neck (so-called abducted or impacted)
Stage II : Complete without displacement
Stage III: Complete with partial displacement. Fragments are still connected by posterior retinacular attachment and there is malalignment of the femoral trabeculae
Stage IV : This is a complete femoral neck fracture with full displacement, the proximal fragment is free and lies correctly in the acetabulum so that the trabeculae appear normally aligned.

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38
Q

What is the definitive tx for intercapsular NOF fractures?

A

Total hip replacement

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39
Q

3 types of NOF fractures?

A

subcapital: femoral head/neck junction
transcervical: midportion of femoral neck
basicervical: base of femoral neck

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40
Q

How are extracapsular NOF fractures treated?

A

Dynamic hip screw

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41
Q

How are femoral shaft fractures treated?

A

Operative fixation with an intramedullary nail

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42
Q

Initial mx of displaced tibial fracture?

A

Analgesia and splintage

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43
Q

What is Simmond’s test?

A

Test for Achilles’ tendon rupture. The test is most easily performed by asking the patient to kneel on a chair/bed in front of you, squeezing both calves, and observing the feet for plantar flexion. If the Achilles tendon is ruptured, less plantar flexion will be seen on the affected side.

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44
Q

Tx of an Achilles’ tendon rupture?

A

Equinus cast

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45
Q

What is the anterior draw test for?

A

Anterior cruciate ligament

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46
Q

What is the Lachman test for?

A

Anterior cruciate ligament

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47
Q

What is the primary function of the anterior cruciate ligament?

A

Preventing anterior translocation of the tibia at the knee

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48
Q

What does a periosteal reaction suggest?

A

A stress fracture

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49
Q

Blood supply to femoral head?

A

Medial and lateral circumflex femoral arteries (from profunda femoris)
Ligamentum teres artery

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50
Q

Classical features o/e in osteoarthritis?

A

Joint crepitus
Abnormal gait
Limited movement

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51
Q

What 2 signs might be positive in OA of hip?

A

Trendelenburg’s (due to secondary gluteal weakness)

Thomas’ (fixed flexion deformity)

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52
Q

X-ray findings in OA?

A

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts and chondrocalcinosis

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53
Q

RFs for OA?

A 
FH
Metabolic:
- Obesity
- Acromegaly
- Alkaptonuria
Bone issues:
- Trauma
- Paget's
Neuropathic joints:
- DM
- syphilis
Inflammation:
- Gout
- RA
- infection
Haematological:
- SCD
- Haemophilia
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54
Q

Which nerve is affected in carpal tunnel syndrome?

A

Median nerve

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55
Q

What is the motor and sensory innervation of the median nerve?

A

The median nerve is a mixed nerve, supplies the skin of the thumb, index, and the middle half of the ring finger on the palmar side and up to the terminal joint of the index and middle half of the ring finger on dorsal side.

It supplies the thenar muscles.

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56
Q

RFs for carpal tunnel syndrome?

A 
COCP
Hypothyroidism
RA
Pregnancy
HF
Previous wrist trauma
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57
Q

Which test and sign are positive in carpal tunnel syndrome?

A

Tinel’s sign

Phalen’s test

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58
Q

Tx of carpal tunnel?

A

rest, splintage, anti-inflammatory medication and steroid injection
surgical release of carpal tunnel (flexor retinaculum)

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59
Q

Describe claw hand deformity

A

extension of the 4th and 5th fingers at the metacarpophalangeal joints and flexion at the interphalangeal joints

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60
Q

Damage to which nerve is associated with claw hand deformity? What is the ulnar paradox?

A

Ulnar

The ulnar paradox: proximal lesions of the ulnar nerve produce a less prominent deformity than distal lesions

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61
Q

What sign is positive in claw hand?

A

Froment’s paper sign, where on holding a piece of paper between thumb and index finger there is flexion of the terminal phalanx of the thumb on trying to pull paper away

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62
Q

Injury to which nerve causes wrist drop?

A

Radial nerve

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63
Q

What are the nerve roots for median, ulnar and radial nerves?

A

Medial cord brachial plexus C8 – T1 = ulnar nerve
Medial and lateral cords, C5 – T1 roots = median nerve
Posterior cord of the brachial plexus C5 – T1 = radial nerve

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64
Q

What is the most common cause of wrist drop?

A

Humeral fracture

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65
Q

What is Saturday night palsy?

A

Compression of radial nerve e.g. falling asleep with arm draped over a firm object directly compressing the nerve in the spiral groove causes neuropraxia

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66
Q

How is Thomas’ test carried out? What does it rule out?

A

the examiner feels over the lumbar spine for a lordosis on the side of the suspected abnormality and then flexes the normal hip. This abolishes the lordosis and makes the flexion deformity of the affected side obvious
used to rule out hip flexion contracture and and psoas syndrome

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67
Q

Main cause of fixed flexion contracture of the hip?

A

OA

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68
Q

What does Tinel’s test involve?

A

involves tapping the median nerve at the wrist to reproduce symptoms of carpal tunnel syndrome (numbness and tingling of the thumb, index and middle fingers)

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69
Q

Causes of positive Tinel’s test?

A 
Fluid retention
Previous fracture
Pregnancy
HF
RA
70
Q

When is pain worse in carpal tunnel? How can it be alleviated?

A

At night

Shaking the wrist

71
Q

Criteria for polymyalgia rheumatics dx?

A

ESR >40 mm/hr

72
Q

Tx of GCA initially?

A

IV Methylprednisolone or oral Prednisone 1 mg/kg/d

73
Q

Tx of polymyalgia rheumatica initially and then maintenance?

A

20mg prednisone po
azathioprine/methotrexate may help lower maintenance dose of steroid
Usually a course of 1-2 years is needed

74
Q

What are Polymyositis and dermatomyositis associated with?

A

Malignancy

75
Q

What is bamboo spine on xray and what does it suggest?

A

spinous ligament fusion

ankylosing spondylitis

76
Q

Tx for sarcoidosis?

A

prednisolone 40mg od

77
Q

Extra-articular manifestations of RA?

A

Episcleritis
Splenomegaly
Subcut nodules
Pericarditis

78
Q

What is felty syndrome characterised by?

A

RA
splenomegaly
neutropenia

79
Q

Characteristic xray findings in RA?

A

periarticular erosive changes

80
Q

What causes a dinner fork deformity?

A

Colles fracture

81
Q

What is a boxer’s fracture?

A

Fracture of neck of 5th metacarpal

82
Q

Classical Colles’ fractures have which 3 features?

A

Transverse fracture of the radius
1 inch proximal to the radio-carpal joint
Dorsal displacement and angulation

83
Q

Mx of scaphoid pole fracture?

A

Surgical fixation due to risk of avascular necrosis

84
Q

Blood supply to scaphoid bone?

A

Around 80% of the blood supply is derived from the dorsal carpal branch (branch of the radial artery), in a retrograde manner

85
Q

What signs are elicited in scaphoid fractures o/e?

A
  1. Maximum tenderness over anatomical snuffbox
  2. Wrist joint effusion
  3. Pain elicited by telescoping of the thumb (pain on longitudinal compression)
  4. Tenderness of the scaphoid tubercle (on the volar aspect of the wrist)
  5. Pain on ulnar deviation of the wrist
86
Q

Xray views of wrist needed for ?scaphoid fracture?

A 
AP
PA
Lateral
Oblique (with wrist pronated at 45º) 
Ziter (PA view with the wrist in ulnar deviation and beam angulated at 20º)
87
Q

Common cause of bilateral carpal tunnel syndrome?

A

RA in <50y/o

Acromegaly in >50y/o

88
Q

What are the Ottawa ankle rules for xray in ?ankle fracture?

A

Pain in malleolar zone + any of the following:

  1. Inability to weight bear for 4 steps
  2. Tenderness over the distal tibia
  3. Bone tenderness over the distal fibula
89
Q

Weber classification of ankle fracture and tx?

A

Type A is below (distal) to the syndesmosis - CAM boot for 6 weeks, weight bear as tolerated
Type B fractures are at the level of the syndesmosis
Type C is above (proximal) the syndesmosis which may itself be damaged - surgical repair open reduction, external fixation

90
Q

What is the medical term for frozen shoulder?

Who is it commonly found in?

A

Adhesive capsulitis

Diabetics

91
Q

Features of adhesive capsulitis in shoulder?

A

Reduced range of active and passive movement in all directions - loss of external rotation and abduction in about 50% of patients

92
Q

O/E of rotator cuff tear or supraspinatus tendonitis what would you find?
Who are they common in?

A 
Limited abduction (painful arc between 60 and 120 degrees) on active movement
Elderly
93
Q

O/E of subacromial bursitis what would you find?

A

Limited abduction but not internal rotation

94
Q

Where does the spinal cord end?

95
Q

Triceps reflex nerve root?

A

Radial nerve C7

96
Q

What is a Baker’s cyst?

A

distension of the gastrocnemius-semimembranosus bursa

97
Q

Mx for undisplaced fracture of scaphoid waist?

A

Cast for 6-8 weeks

98
Q

Common cause of acromioclavicular joint injury and what is seen?

A

Contact sports

Widening of joint space

99
Q

What is cubital tunnel syndrome and what are the symptoms?

A

ulnar nerve entrapment at the elbow

sensory symptoms affecting the 4th and 5th fingers

100
Q

Analgesia for NOF fracture?

A

iliofascial nerve block

101
Q

Management of intertrochanteric (extracapsular) proximal femoral fracture?

A

Dynamic hip screw

102
Q

Gustilo and Anderson classification of open fractures?

A

Grade1: Low energy wound <1cm
Grade 2: Greater than 1cm wound with moderate soft tissue damage
Grade 3: High energy wound > 1cm with extensive soft tissue damage

103
Q

Mx of any open fracture?

A

Emergency! Get into theatre to debride and lavage within 6 hours! Mean time:

  • Analgesia
  • Assessment: NV status, soft tissues and photograph.
  • Antisepsis: wound swab, copious irrigation, cover with betadine-soaked dressing.
  • Alignment: Align # and splint
  • Anti-tetanus: Check status (Booster lasts 10 years)
  • Abx: Fluclox IV/IM + Benpen IV/IM OR Augmentin.
104
Q

What is a straight leg rise used to test and when is it positive?

A

Sciatica

Pain in distribution of sciatic nerve

105
Q

L3 nerve root compression features?

A

Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

106
Q

L4 nerve root compression features?

A

Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test

107
Q

L5 nerve root compression features?

A

Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test

108
Q

S1 nerve root compression features?

A

Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test (straight leg rise)

109
Q

Tennis elbow affects which tendons?

A

The common attachment of the extensor muscles of the forearm to the lateral epicondyle of the humerus

110
Q

Tennis elbow findings?

A
  • localised point tenderness on palpation over and/or distal to the lateral epicondyle
    – Painful Resisted Middle Finger Extension Muscle Test
    – Painful resisted wrist extension
    – Painful resisted forearm supination
    – Weakened Grip Strength
    – Full Active and Passive Elbow ROM
111
Q

Key findings in Sub Acromial Impingement syndrome?

A 
Painful abduction and painful arc between 60-120 degrees (not painful above or below this) 
Painful elevation
Painful internal rotation
External rotation not painful
Tenderness over anterior acromion
112
Q

What does knee locked in flexion suggest?

A

Meniscal injury

113
Q

What does knee giving way suggest?

A

Ligament damage

114
Q

Ankylosing spondylitis xray findings?

A

sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis

115
Q

What position does the humeral head usually lie in anterior dislocation?

A

subcoracoid position

116
Q

Poor prognostic features in RA?

A

anti-CCP antibodies
high disease activity
X-ray: early erosions (e.g. after < 2 years)

poor functional status at presentation
extra articular features e.g. nodules
HLA DR4
insidious onset
rheumatoid factor positive
117
Q

Which antibodies are associated with drug-induced lupus?

A

Antihistone antibodies

118
Q

How to differentiate pseudogout from gout?

A

Chondrocalcinosis

119
Q

What to do in ED for suspected scaphoid fracture?

A

immobilisation using a Futuro splint or standard below-elbow backslab before specialist review
Xray

120
Q

Criteria for starting anti-TNF alpha inhibitors in axial ankylosing spondylitis? Which drugs are typically used?

A

failure on 2 different NSAIDS and meets criteria for active disease on 2 occasions 12 weeks apart
infliximab and etanercept

121
Q

Pott’s fracture?

A

Bimalleolar fracture

Forced foot eversion

122
Q

Bennett’s fracture?

What would you see on xray?

A

Intra-articular fracture of the first carpometacarpal joint
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at ulnar base of metacarpal

123
Q

Barton’s fracture?

A

Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist

124
Q

Features of femoral nerve damage?

A

Weakness in knee extension, loss of the patella reflex, numbness of the thigh

125
Q

Features of lumbosacral trunk damage?

A

Weakness in ankle dorsiflexion, numbness of the calf and foot

126
Q

Features of sciatic nerve palsy?

A

Paralysis of hamstrings and all muscles of leg and foot - Weakness in knee flexion and foot movements
Loss of sensation below knee (except medial leg and upper calf)

127
Q

Features of obturator nerve damage?

A

Weakness in hip adduction, numbness over the medial thigh

128
Q

most common site of metatarsal stress fractures?

A

2nd metatarsal shaft

129
Q

PRessures in compartment syndrome?

A

Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic

130
Q

Galeazzi fracture?

A

dislocation of the distal radioulnar joint with an associated fracture of the radius

131
Q

Monteggia fracture?

A

fracture of the proximal ulna, with an associated dislocation of the proximal radioulnar joint

132
Q

Mx of reverse oblique, transverse or subtrochanteric NOF fractures?

A

Intramedullary device

133
Q

Most common causes of drug induced lupus?

A

procainamide

hydralazine

134
Q

What is parsonage turner syndrome?

A

a peripheral neuropathy that may complicate viral illnesses

135
Q

Features of fracture of radial head?

A

FOOSH
marked local tenderness over the head of the radius
restricted supination and pronation
sharp pain on movement

136
Q

Ix for Achilles tendon rupture?

137
Q

Features of posterior shoulder dislocation? What would you see on xray

A

Arm is internally rotated and adducted
Resistance to external rotation
Humeral head palpable posteriorly below acromion
X ray: Lightbulb sign

138
Q

Features of anterior shoulder dislocation?

A

Arm is externally rotated and abducted
Humeral head is felt anteriorly below the clavicle
May be reduced sensation over regimental badge

139
Q

What is Sudek atrophy and what fracture is it common in?

A

Reflex sympathetic dystrophy which occurs after fracture of a limb
Presents with persistent burning pain + redness, swelling and warmth - progresses to pale atrophy
Common in Colles fracture

140
Q

Where does the biceps insert and where does typically rupture?
What movement is compromised as a result?

A

Radial tuberosity
Commonly ruptures proximally (long head)
Elbow flexion
Forearm supination

141
Q

Rheumatoid arthritis joint aspiration findings?

A

High WBCs - neutrophils
Yellow/cloudy
No crystals

142
Q

Risks of supracondylar fracture?

A

Radial artery damage - compartment syndrome
Radial nerve damage
+/- median nerve damage

143
Q

Posterior hip dislocation features?

A

‘clunk’, leg shortening and internal rotation

144
Q

Features of a fat embolus?

A

Triad:
Resp: Fever, breathlessness
Neuro: confusion
Petechial rash & retinal haemorrhages

145
Q

management for subluxation of the radial head?

A

Passive supination of the elbow joint whilst flexed to 90 degrees

146
Q

Features of ruptured pcl?

A

tibia lies back on the femur

Mechanism: hyperextension injuries

147
Q

What score can be used to assess hypermobility?

A

Beighton score

148
Q

Findings O/E of ankylosing spondylitis?

A

reduced lateral flexion
reduced forward flexion - Schober’s test <5cm
reduced chest expansion

149
Q

What is the weight bearing status of patients post hip fracture surgery?

A

Full weight bearing immediately post-op

150
Q

Where does meralgia paraesthetica affect?

A

pain in the lateral cutaneous nerve of the thigh distribution

151
Q

In children and adults where is the most common site where osteomyelitis occurs?

A 
Children = Minors = Metaphysis
Adults = Elders = Epiphysis
152
Q

1st line tx for lower back pain?

153
Q

Hallmark sign of compartment syndrome?

A

Pain on passive stretch

154
Q

Osteosarcoma Xray findings?

A

Metaphysis
Codman’s triangle
Sunburst pattern

155
Q

What gene is osteosarcoma associated with?

A

Retinoblastoma

156
Q

Ewing’s tumour Xray findings?

A

Pelvis and long bones

Onion skinning

157
Q

What gene is Ewing’s tumour associated with?

A

t(11;22) translocation which results in an EWS-FLI1 gene product

158
Q

Best ix for ankylosing spondylitis?

A

sacro-ilitis on a pelvic X-ray

159
Q

How do bisphosphonates work and what can they be used to treat?

A

Inhibit osteoclasts by reducing recruitment and promoting apoptosis

  • prevention and treatment of osteoporosis
  • hypercalcaemia
  • Paget’s disease
  • pain from bone metatases
160
Q

What needs to be done before starting biologics in RA tx?

A

CXR - look for TB (can reactivate)

161
Q

What distribution of pathology does a radiculopathy present with?

A

Dermatomal

162
Q

Biggest risk of posterior hip dislocation?

A

Sciatic nerve damage

163
Q

What type of ankle sprain is most common and which ligament is affected?

A

Lateral ligament sprain (inversion) - low ankle sprain
• Anterior talofibular - most important
• Calcaneofibular
• Posterior talofibular

164
Q

Damage to which ligaments contributes to chronic ankle instability?

A

Syndesmotic sprain (high ankle sprain)

165
Q

When would you MRI an ankle sprain?

A

If it is still painful after 6-8 weeks

166
Q

Fall onto thumb and pain over base - unable to make pinching movement?

A

Ulnar collateral ligament injury

167
Q

What type of lesion typically causes a “cotton wool calcification”

A

Paget’s

Chondrosarcoma

168
Q

Weakness of first 30 degrees of shoulder abduction but no pain?

A

Suprascapular nerve pathology

169
Q

Mx of undisplaced patella fractures, particularly vertical fractures with an intact extensor mechanism?

A

Hinged knee brace for 6 weeks and patients allowed to fully weight bear

170
Q

Mx of displaced patella fracture with loss of extensore mechanism?

A

Operative management with either tension band wire, inter-fragmentary screws or cerclage wires
Then placed in a hinged knee brace for 4 to 6 weeks and allowed to fully weight bear

Oishi's Final year flashcards (10 decks)

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