MSK Flashcards
chronic pain at multiple sites - 'pain all over' lethargy cognitive impairment sleep disturbance dizziness headache
fibromyalgia
diagnosis of fibromyalgia
11/18 tender points
management of fibromyalgia
aerobic exercise, CBT
medication = pregabalin, duloxetine and amitriptyline
severe pain
erythema
swelling
usually the 1st MTP joint affected
hx of high purine diet, thiazide use and excessive alcohol/dehydration
gout
investigation for gout
joint aspiration and crystal analysis
negatively birefringent crystals
management for gout
acute = NSAIDs (& appropriate gastroprotection)
colchicine can be given but slower to act
chronic = allopurinol, might start with colchicine
second line = febuxostat
pain mainly in the hip and shoulder pain/aching in the morning stiffness in the proximal limbs polyarthralgia lethargy depression low grade fever
polymyalgia rheumatica
Ix for PMR
ESR/CRP
management of PMR
prednisolone
hot, swollen, episodic attacks of joints
knee, wrist and shoulders mainly affected
pseudogout
investigation of pseudogout
aspiration = positively birefringent crystals
(exclude septic arthritis)
calcium pyrophosphate
management of pseudogout
IA steroid injection
NSAIDs
arthritis uveitis urethritis fever dactylitis
hx of GI/GU infection 1-4 weeks prior
usually male and HLA-B27
reactive arthritis/reiter’s syndrome
management of reactive arthritis/reiter’s syndrome
NSAIDs first line
steroid second line
usually in 20-30s , more common in females
multiple, peripheral joins - MCPs and PIPs
symmterical, joint pain and stiffness
stiffness worse in the morning - improves with as the day goes on
positive squeeze test
rheumatoid arthritis
Diagnosis of rheumatoid arthritis
anti-CCP
X - rays = erosions
management of rheumatoid arthritis
DMARDs - methotrexate/sulfasalazine
- usually taken with folic acid
start with bridging steroids
give steroids IM/PO in acute flares
TNF-a/biologics in inadequate responses
Fever, malaise and arthralgia HTN peripheral motor neuropathy livedo reticularis weight loss
commonly with 40-60yrs old and Hep B infections
polyarteritis nodosa
Ix for polyarteritis nodosa
biopsy = full thickness necrotizing inflammation
raised ESR/CRP
normocytic, normochromic anaemia
management of polyarteritis nodosa
steroids
+/- DMARDs
common in knee and DIPs
usually mono/oligoarthritis - asymmetrical
dactylitis
pitting nails
swelling of associated tendons - enthesis
dry erythematous skin
psoriatic arthritis
Ix of psoriatic arthritis
X-ray hands and feet = pencil in cup deformity
ESR/CRP raised
management for psoriatic arthritis
mild cases = NSAIDs
DMARDs and immunosuppressants - TNFa inhibitors
severe dry eyes and dry mouth fatigue arthralgia Raynauds phenomenon vaginal dryness recurrent parotitis positive schimer's test
Sjogren’s syndrome
Ix for sjogren’s
diagnostic = parotid gland biopsy
+SSRA/Ro, +SSA/La antibodies
treatment for sjogren’s
symptomatic relief from eye drops
sialogogues
punctal plugs
C= calcinosis R = raynauds E = esophageal dysmotility S = sclerodactyly T = telangiectasia
scleroderma (fibrosis of skin)
Ix for scleroderma
Scl-70, anti-topoisomerase I
management of scleroderma
relieve symptoms
steroids, immunosuppressants
fatigue, fever and mouth ulcers lympahdenopathy malar/butterfly discoid rash - spares nose raynaud's phenomenon livedo reticularis arthralgia pericarditis glomerulonephritis
systemic lupus erythematous
Ix for SLE
anti-dsDNA, anti-smith
complement C3/4
management of SLE
hydroxychloroquine (anti-malarial) - retinal toxicity
NSAIDs and steroids
weakness in the proximal muscles
weakness>pain
complains of trouble getting out of chair, trouble brushing hair
usually age >40
polymyositis
Ix for polymyositis
CK massively elevated
EMG
definitive dx = muscle biopsy
management of polymyositis
steroids
aged under 16 with arthritis for over 6 weeks
more common in women
joint pain and swelling, commonly in the knee
intermittebn spiking fevers (1-2 a day)
extra articular - uveitis
juvenile rheumatoid arthritis
Ix for JRA
elevated CRP/ESR
possibly positive for RF/ANA
management of JRA
NSAIDs first line
DMARDs second line
joint pain following use, improves with rest
DIPs and PIPs joints - herberden and bouchard nodes
joint crepitus
affects mainly the weight bearing joints
older age
Osteoarthritis
Ix for OA
X-ray = loss of joint space, subchondral sclerosis and osteophyte formation
Management of OA
pt ed, weight loss, exercise
pain control - analgesia, joint aspirations/steroid injection
replace joint as last resort
Osteoporosis risk factors
menopausal women increased age smoking steroid use (long term) low BMI
Diagnosis for osteoporosis
T-score on DEXA scan = - 2.5 SD or below
presentation of osteoporosis
usually asymptomatic until a fracture appears
management of osteoporosis
bisphosphonates - osteonecrosis of the jaw/atypical femoral fractures
give a ‘drug holiday’ = come off medication every 3-5yrs
older male with bone pain
isolated ALP elevation
bowing of tibia, bossing of skull
Paget’s disease
skull x-ray: thickened vault, osteoporosis circumscripta
paget’s disease
management for paget’s disease
bisphosphonate (either oral risedronate or IV zoledronate)
usually a single area non-specific pain fever malaise/fatigue inflammation swelling
hx of IC drug use, HIV and penetrating injuries
acute osteomyelitis
management of osteomyelitis
high dose antibiotics - flucloxacillin
screening of choice for osteomyelitis
MRI
acute hot swollen and erythematous swelling of joint
tender
restricted ROM
systemically unwell with a fever
septic arthritis
diagnosis of septic arthritis
Aspirate - culture and gram stain
if prosthetic joint - refer to ortho specialist
management of septic arthritis
IV vancomycin
typically elderly frail hx of osteoporosis pain in groin shortened and externally rotated leg unable to bear weight
femoral neck fracture
Ix for femoral neck fracture
X-ray
MRI
looking for shenton’s line
management of femoral neck fracture
intramedullary screws/dynamic hip screws
major trauma hip pain inability to bear weight obvious deformity leg shorter internal rotation
hip dislocation
Diagnosis of hip dislocation
X-Ray
management of hip dislocation
reduce, stabilise and analgesia
thick cord-like strand forming in the palm of hand
closer to the ring finger
finger ‘gets caught on things’
no pain typically
commonly in men, 40-60s
diabetics and smokers often affected
positive tabletop test
dupuytren’s contracture
management for dupuytren’s contracture
monitor in early cases
corticosteroid injection for certain cases
surgery in later stages
fracture in the 5th metatarsal joint after punching someone or something
boxer’s fracture
unable to straighten finger - can lead to avulsion fracture
often referred to as basketball fracture
mallet finger
management of mallet finger
splint & surgery
more common in the thumb, middle, or ring finger
initially stiffness and snapping when extending
nodule may be felt at the base of the affected finger
trigger finger
management of trigger finger
<3months = steroid injection and hand therapy 2-4 weeks >3months = inject and consider surgical referral
pain in anatomical snuffbox
hx of FOOSH
scaphoid fracture
Scaphoid fracture diagnosis
normal X-ray
MRI better
Management of scaphoid fracture
immobilise/splint ASAP to avoid risk of AVN
dinner fork deformity
dorsal displacement of distal radius
hx of FOOSH
colles fracture
management of colles fracture
straighten deformity & immobilise in 6 weeks
pain/pins and needles in thumb, index, middle finger
unusually the symptoms may ‘ascend’ proximally
patient shakes his hand to obtain relief, classically at night
carpal tunnel
tests for carpal tunnel
phalen’s and tinel’s test
diagnostic = nerve conduction studies
management of carpal tunnel
NSAIDs, splints and steroid injections
surgical decompression
discomfort and pain everytime the patient turns wrist, grasps anything or makes fist
Finkelsteins test positive
de Quervain’s tenosynovitis
management of de Quervain’s tenosynovitis
analgesia, splint, steroid injection and surgery
opposite to colles fracture but less common
distal radius displaced vetrally
caused by falling on flexed wrists
smiths fracture
common in 5yrs and most often from swinging by the arm
usually child will not use the affected arm
distressed only on elbow movement
marked resistance and pain with supination of the forearm
pulled/nursemaid’s elbow
Ix of pulled/nursemaid’s elbow
X-ray
management of nursemaid’s/pulled
reduction and mobilisation
point tenderness on the lateral aspect of the elbow
lateral epicondylitis
point tenderness on the medial aspect of the elbow
medial epicondylitis
epicondylitis management
Rest, physio and NSAIDs
shoulder pain
painful arc abduction from 60-120°
tenderness over anterior acromion
sub-acromial impingement
other rotator cuff injuries
calcific tendonitis
rotator cuff tears
rotator cuff arthropathy
most commonly after FOOSH
affected arm externally rotated and close to body
loss of round and greater fullness
anterior dislocation of shoulder
which nerve should be checked in anterior dislocation
axillary nerve - sensation of deltoid checked
usually due to seizures of electrocution
affected arm medially rotated and locked
shoulder looks flat
swollen
prominent coracoid process
Posterior dislocation of shoulder
management of shoulder dislocations
check neurovascular status before and after and do a closed reduction.
slow progressive passive loss of ROM of shoulder joint
affects adls
severe stiffness in shoulder
+ve coracoid pain test
can be a complication of shoulder injury/surgery
more common in women compared to men, typically in 40-70yr olds
RFs = DM, thyroid disease
adhesive capsulitis (aka frozen capsulitis)
management of adhesive capsulitis
first line = NSAIDS and physio
second line = IA steroid injection
back pain red flags
significant injury/trauma bowel or bladder incontinence history of metastatic cancer major neuro deficit saddle anaesthesia suspected spinal infection
management of back pain
patient ed, NSAIDs, paracetamol, muscle relaxants
avoid bed rest, most cases resolve
insidious morning stiffness
relieved by exercise
positive schober’s test
typically in young (~25), caucasian male, HLA-B27
ankylosing spondylitis
Ix for ankylosing spondylitis
sacroiliitis, squaring of lumbar vertebrae, ‘bamboo spine’
syndesmophytes
CXR = apical fibrosis
saddle anaesthesia/paresthesia
recent onset of bladder or faecal incontinence
progressive/severe neurodeficit in the lower limbs
cauda equina
Ix for cauda equina
immediate MRI
management for cauda equine
Urgent surgical decompression
what is compressed in cauda equina
nerves L1-S5
management for ankylosing spondylitis
NSAIDs and regular exercise & physio
DMARDs - peripheral joint involvement
groin pain radiating to the leg
pain despite analgesia
RFs = alcoholism, steroid/chemo and sickle cell anaemia
Investigation
avascular necrosis in the hip
AVN in hip Ix
MRI and orthopaedic referral for 6 weeks of pain with normal X-rays
management of AVN in hip
hip replacement
limp, externally rotated leg
knee pain
groin pain
restricted ROM
typically boys aged 10-17, obese and hypogonadism
Slipped Capped femoral epiphysis (SCFE)
Ix for SCFE
X-ray
management for SCFE
surgical fixation with screws
done on both side prophylactically
painless limp complains of hip and knee pain sometimes painful after activity but relieved by rest reduced ROM typically presents unilaterally
legg calve perthes
legg calves perthes
X-rays
management of legg calves perthes
cast/braces and surgical management
localised pinpoint tenderness on the outside of the hip (laterally)
pain on movement
moves down the thigh
pain on palpating the greater trochanter
typically on women aged 50-70yrs
trochanteric bursitis
management of trochanteric bursitis
exercises
steroid injection into the affected site/bursa
insidious back pain bilateral leg pain better when leaning forward relieved lying supine paresthesia on ambulation - worse standing /walking
spinal stenosis
Ix for spinal stenosis
MRI scanning
management of spinal stenosis
laminectomy (surgery in which a surgeon removes part or all of the vertebral bone (lamina)).
kyphosis
hunchback - usually seen in osteoporotic/elderly
scoliosis
the spine twists and curves to the side
lordosis
usually seen in pregnancy - spine protrudes forwards
management of spinal deformities
dependent on the degree of curvature - <20° = exercise and monitoring
21-45° = exercise and monitoring
>45 = surgery
hypermobile patella with significant crepitus
pain aggravated by deep bending
typically >50 years and overweight
chondromalacia patella
loss of cartilage under the patella
Ix for chondromalacia patella
bone on bone patella and femur
twisting injuries transient locking of knee severe knee pain knee effusion/swelling knee giving way
meniscal injuries
special tests for meniscal injury
McMurray and Apley
MRI definitive
management of meniscal injury
conservative management = ICE, analgesia, physio and rest
If torn = open or arthroscopic surgery
loss of anterior or posterior stability
swollen and painful knee
audible ‘pop’ at the time of injury
instability on ambulation
anterior is usually more common
positive draw tests
cruciate injury
ortolani test = characteristic clunk that is felt as the femoral head slides over the posterior rim of the acetabulum and is reduced.
barlow test = mild adduction and applying a slight forward pressure with the thumb. If the hip is unstable, the femoral head will slip over the posterior rim of the acetabulum, again producing a palpable sensation of subluxation or dislocation.
RF = fist born girls, breech baby, oligohydromnios, L>R hip and a family history
developmental hip dysplasia
diagnosis of developmental hip dysplasia
<6months = ultrasound >6months = X-ray
management of developmental hip dysplasia
observe and consider splinting
if hip dislocated = reduce and then splint
pain and swelling over the tibial tuberosity
point tenderness
pain usually aggravated by loaded knee extension
typically in growing teenagers aged 10-14years
usually active/play football
osgood sclater
tibial tuberosity opophysitis
management of osgood sclater
modification of exercises, physio and NSAIDs
recent trauma + ankle pain and swelling
inability to bear weight
swollen malleolus
tender on palpation
ankle fractures
what rules are used to decide is X-ray is indicated in ankle injuries
bony tenderness on either to medial or lateral malleolus
unable to bear weight for 4 steps
management for ankle fractures
open fracture = surgical fixation
closed fracture = reduce and splint
swelling, bruising and pain after injury around an ankle
ottawa rules don’t apply
ankle sprain/strain
Investigation for ankle sprain/strain
no fracture seen on X-ray
MRI/US = better for soft tissue
heel pain with a gradual onset - worse following activity
morning pain and stiffness common
RFs = quinolone use & hypercholesterolemia
Aschilles tendinitis
management of achilles tendinitis
simple analgesia, calf, msucle eccentric exercises
audible pop in the ankle with sudden onset of significant pain
uanble to tiptoe
positive simmons test/thompson’s test
absence plantar reflec on calf squeeze
achilles tendon rupture
stabbing heel pain and on pressure point under foot
most painful in the first few steps in the mornign
typically in runners and also in obese, aged 40-60yrs
plantar fascitis
plantar fascitis management
heel padding, insoles, exercises
physiotherapy
NSAIDs
pain between the 3rd and 4th toes
described to be like walking on a marble
elicit pain by squeezing toes from the side
palpate web space
more common in women more than men
mortons neuroma
rocker foot deformity swelling pain redness altered shape in the foot
hx of severe peripheral neuropathy = diabetes, peripheral
charcot’s joint
unilateral leg pain back pain leg pain > back pain usually radiates to foot/toes worse on sitting down numbness and paresthesia
herniated nucleus pulposus
Ix for herniated nucleus pulposus
MRI
