MSK Flashcards
Describe the presentation of an Iliopsoas Abscess?
Pain relieved by hip flexion
Pain worse on extension and internal rotation, can be lower back pain
Patient is sitting on back with knees flexed and hips externally rotated slightly.
What imaging is used in an Iliopsoas abscess?
CT is first line
What is the commonest organism causing an Iliopsoas Abscess?
S. Aureus
What is the managment of an Iliopsoas abscess?
Surgical drainage and IV abx for 4-6 weeks
How is a non displaced patellar fracture with no extensor mechanism issues managed?
Hinged knee brace with weight bearing. 6 weeks
How is a displaced patellar fracture or one with an affected extensor mechanism managed?
Surgically fixed then hinged knee brace with weight bearing.
Signs and Symptoms of Iliotibial Band Syndrome
Runner
Lateral Knee pain
Extension and Flexion can induce a snapping feeling
What imagining is used in SUFE?
AP and Lateral Frog Leg X-ray
Clinical sign of SUFE
Reduced internal rotation especially when leg is flexed . Leg is sitting externally rotate.
What fracture is likely to present following a FOOSH
Colles Fracture - Dinner Fork Deformity
Distal Dorsally Displaced Radius.
Falling onto a flexed wrist or backwards onto outstretched hand is likely to result in what kind of fracture?
Smiths Fracture - Garden Spade Deformity
Distal Volar displacement of Radius.
A painful thumb occurring after a fist fight is likely to be what?
Bennets Fracture
Interarticular fracture at he base of the thumb metacarpal
What is a Monteggia Fracture?
Ulnar Fracture
Radial Head Dislocation - pain at elbow
What is a Galeazzi Fracture?
Radial Fracture
Distal Radioulnar Dislocation
If a young person presents with pain over radial head after a FOOSH. What could it be?
Radial Head Fracture
McMurrays test is positive in what?
Meniscal Tear - Pain on crouching is also common
Extracapsular / Intertrochanteric - Stable Fracture
Dynamic Hip Screw
Extracapsular / Intertrochanteric - Oblique, Reverse or Sub-trochanteric
Intramedullary Device
Damage to the median nerve at the level of the wrist presents with.
Carpal Tunnel like syndrome
Damage to the median nerve at the level of the elbow present with.
Carpal Tunnel symptoms Reduced forearm pronation Weak wrist flexion Ulnar devotion of the arm sign of benediction
Damage to the Anterior Interosseus Nerve
Reduced pronation of the forearm
Cant make the OK sign due to reduced thumb and forefinger flexion.
What fracture is likely to damage the anterior interosseus nerve?
Supracondylar Fracture - paediatric - direct blow to elbow or falling on elbow
A tibial fracture is likely to be associated with what nerve being damaged?
Sural nerve - posteriolateral distal 1/3 lower leg
- lateral foot and ankle
Sural nerve damage will present like this.
Sensory loss only
Posterolateral distal 1/3 of lower leg
Lateral foot
Finger fixed in flexion + Fusiform swelling + Tenderness
Tendon Flexor Tenosynovitis
IV abx + elevation +/- surgical debridement
What is the commonest reason for a THR revision and how does it present?
Aseptic loosening
Pain radiating to the knee and on weight bearing
Still able to walk and weight bear.
What is affected in De Quervians Tenosynovitis?
Extensor Pollicus Brevis and Abdcutor Pollicus Longus tendon sheath
If a post menopausal women presents with a fracture do they require a DEXA scan?
No
Bisphosphonates are used and no need for a DEXA atm
What is gold standard for rib fractures but what is usually enough?
CT scan is gold standard but X ray is usually enough
Management of rib fractures
Adequate analgesia
12 weeks and no repair -> surgery
Who do you refer a patient to if they present with a flail chest?
Cardiothorasic surgeon
4-8 years Male Reduced ROM Limp Pain
Perthes
Perthes Management
X ray is diagnostic
<6 - monitor
>6 or severe disease - surgery
Describe the classification of Ankle fractures.
Webers A- below syndesmoses - generally stable = moon boot
Webers B - level of syndesmoses - can be unstable observe taller shift
Webers C - Above level of sydesmoses - requires open surgery and fixation
List two bad things that would indicate an unstable ankle fracture on X - ray ?
Bi malleolar fracture - observe medial malleolus
Talar Shift look for a widened gap
Tibial Shaft Fracture - describe
Open fracture are common
Risk of compartment syndrome
Tibial Shaft Fracture - Management
Above the knee cast - conservative
IM nailing, ORIF - surgical
Tibial Plateau # what nerve is at risk?
Common peroneal nerve
Sensory lateral lower leg and top of the foot
Dorsiflexion
Eversion
Tibial Plateau - Management
ORIF, External Fixator, Delayed Total Knee Replacement - surgical
Above Knee cast - conservative
What splint is used in a femoral shaft fracture ?
Thomas Splint
In an old patient with a suspected pelvic fracture, where is usually affected? and how does this affect management?
Inferior and superior Pubic rami fracture
Usually managed conservatively
How are most humeral shaft fractures managed?
Conservatively
Distal = cast
Proximal = Humeral brace sling
What nerve is at risk in a proximal humeral fracture?
Axillary Nerve - badge patch dermatome
What nerve is at risk in a humeral shaft fracture?
Radial nerve
Neuropraxia
Temporary block - symptoms last up to 28 days
Axonotmesis
Demyelination distal to injury
Takes a long time as nerve regenerates 1mm a day
Neurotmesis
Nerve transection - no recovery without surgical repair
What is you concern with a intracapsular fracture?
Risk of avascular necrosis
Retinacular arteries get torn
What vessel supplies the retinacular arteries
Medial circumflex femoral artery
Hip fracture - what X-ray and what are you looking for?
AP and Lateral
Loss of Shentons line and prominent lesser trochanter
What nerve is at risk in a Hip fracture
Sciatic nerve damage
Sciatic nerve damage will present with what?
Weak Knee flexion
Weak Ankle dorsiflexion and plantar flexion
Hip fracture - presentation
Acutely shortened and externally rotated leg
Hip dislocation - presentation
Pain and inability to bear weight
Posterior - Internally rotated
Anterior - Externally rotated
Posterior Dislocation - hip
Commonest type
Dashboard injury - leg internally rotated, adducted and flexed
Anterior Dislocation - hip
Less common - more likely if linked to motor bike accident
Hyperabducted and extended
What nerve is at risk during a posterior hip dislocation?
Sciatic
Point tenderness over greater trochanter
Generalised pain over lateral leg
Pain reproducible by resisting lateral abduction
Trochanteric Bursitis
Point tenderness over greater trochanter
Generalised pain over lateral leg
Pain reproducible by resisting lateral abduction
Trochanteric Bursitis
What is a major risk with femoral artery catheterisation?
Retroperitoneal bleed - posterior wall of common femoral or external iliac artery.
Surgery is only life saving method
What trauma is a femoral artery at risk of rupture?
Proximal femur fracture
What nerve is responsible for a trendelenburg gait?
Superior Gluteal Nerve - supplies gluteus minimus medius and tensor fascia lata
Describe a trendelenburg gait and how this can tell you what side is affected.
When standing on affected side the opposite leg and pelvis drop down
Body tilts towards affected side
What other non neuro causes of a Trendelenburg gait is there?
Muscle weakness
Perthes disease
osteonecrosis of the hip
Developmental dysplasia
What nerve is affected in meralgia parasthetica ?
Lateral Femoral cutaneous nerve
Obese pregnant Diabetic lady wearing tight jeans
Anterolateral thigh pain and paraesthesia
Meralgia Paraesthetica
A patient who cant sit on their wallet for along period of time without pain.
Pain tingling and numbness over buttocks and sciatica distribution
Piriformi syndrome
Muscle injury or hypertrophy
In a severe hamstring tear what fracture may occur?
Avulsion fracture of the ischial tuberosity
Where is the safe space to administer an IM injection in the buttocks?
Superiolateral quadrant
In a tibiofemoral dislocation what are you worried about?
Neurovascular compromise as displace bone compresses popliteal fossa and its contents
What is your management of a tibifemoral dislocation?
Immediate reduction
Neurovascular exam
ABPI
CT angiogram
Lateral epicondyle pain in a keen runner and cyclist
Knee pain on flexion extension
Iliotibial band syndrome
What artery supplies the ACL?
Distal Medial Geniculate Artery
Whats the unhappy triad?
MCL ACL Medial Meniscus
Whats the commonest combination of soft tissue injury in the knee?
ACL MCL and Lateral Meniscus
Pain Erythema Boginess over patella
Person kneels a lot
Prepattelar bursitis
Pain over distal patellar ligament
Kneels a lot
Superficial infrapatellar bursitis
Patient generally kneels a lot but with a more upright back
Pain over patellar ligament laying over tibial tuberosity
Deep infra patellar bursitis
Suprapatellar Bursitis
Supra patellar pain selling redness warmth and reduced ROM
Generally there will have been a preceding superficial wound and bacterial infection.
Ruptured Bakers Cyst
Calf pain, warmth, erythema and swelling.
USS required to rule out DVT
Anterior knee pain on stairs
Prolonged stiffness
Teenage girl
Chondromalacia Patellae
- patellar cartilage is softened
Pain after exercise with intermittent swelling and locking
Osteochondritis Dissecans
Septic Arthritis in young sexually acitve
N.Gonorrhoea
Septic arthritis in sickle cell patient
Salmonella
Commonest septic arthritis
S.Aureus
Septic arthritis <6 week joint replacement
Stap Epidermidis
Common in younger
Haemophilus
Strep. Pyogenes
A history of young child being pulled by the arm
Elbow pain
Limited supination and extension of the elbow
Radial Head subluxation
Management of a radial head subluxation
Anaelgasia
Passive supination of elbow joint whilst elbow is flexed
The tibial nerve is a branch of what nerve?
Sciatic -> common fibular -> tibial nerve
At what two levels can the tibial nerve be injured?
Popliteal fossa - posteror dislocations, trauma, surgery
Tarsal tunnel - Talus, calcaneus or medial malleolar fractures
- compression
How would damage to the tibial nerve at the level of the popliteal fossa present?
Inability to plantar flex, invert foot or toe flexion
Sensory loss to sole of the foot
Injury to the tibial nerve at the level of the tarsal tunnel will resent with?
Sensory loss to the sole of the foot
Motor function is preserved.
Where does the fibular nerve come from?
Divides from the sciatic nerve at the apex of the popliteal fossa.
Describe the branches of the femoral (peroneal) nerve
Superficial - sensory innervation to the lateral compartment of the lower leg and the dorsum of the foot.
Deep - Motor - dorsiflexes and everts the foot
- sensory - 1st web space
Where is the likely point of injury to the fibular nerve going to occur and how would this present?
At the head of the fibular - compression trauma
Foot drop and loss of foot eversion and sensory loss to lateral leg and whole dorsum of the foot.
Plantar flexion and inversion remain intact.
Commonest site of a tibial fracture
Distal 1/3
Where is the commonest compartment to be affected in lower leg compartment syndrome.
Anterior
Anterior Tibial Artery + Deep fibular nerve
How will anterior compartment syndrome in the lower leg present.
Compartment syndrome symptoms +
Foot drop and loss of first webspace sensation
Lateral Compartment syndrome in lower leg
Superficial fibula nerve is affected - loss of sensation to lateral lower leg + dorsum of the foot
First webspace sensation is intact
Deep Posterior Compartment syndrome
Tibial nerve - Reduced plantar flexion, foot inversion
Posterior Tibial artery - reduced pulse detected
Superficial Posterior compartment syndrome
Least likely to be affected as no artery
Name the 4 compartment in the lower leg
Anterior
Lateral
Superficial Posterior
Deep Posterior
What is the commonest ankle sprain?
Lateral ankle - anterior talofibular ligament
What force is associated with an anterior talofibular ligament tear?
Extreme inversion and plantar flexion
What should be looked for in an anterior talofibular ligament injury?
Lateral Malleolus fracture
Why are medial ankles sprains less common?
As the deltoid ligaments are the strongest in the ankle.
In a medial ankle sprain what should be looked for if the deltoid ligaments have been torn?
Medial Malleolus avulsion
What is the energy applied in a medial ankle sprain?
Eversion
What is affected in a high ankle sprain. Syndesmotic Sprain.
Anterior Posterior and transverse tibiofibular ligament
Interossues membrane
Common MOA for clavicle fracture.
FOOSH
Direct fall onto the shoulder
What test is used to detect for acromioclavicular joint issues?
Scarf test
What test is used to detect for a rotator cuff tear or AC impingement?
Empty can test
The upper brachial plexus is made up of what nerve roots?
C5/6
Damage to the upper brachial plexus results in what injury and how might this occur?
Erbs palsy -
Generally by increasing the angle between the shoulder and neck i.e pulling on babies head during delivery
What nerves are affected in an Erbs palsy?
Auxiliary
Musculucutaneous
Suprascapular nerves
Erbs palsy
Waiters tip
Arm adducted and internally rotated
Wrist flexed
+/- HORNERS SYNDROME
What makes up the lower brachial plexus?
C8/T1
A lower brachial plexus injury will present with?
Klumpkes palsy - increased angle between trunk and shoulder
Medial and Ulnar nerve palsy
A klumpkes palsy will present with?
Clawed hand
Medial sensory distribution loss
How does thoracic outlet syndrome present?
Upper extremity swelling
Exertional arm pain
Surgical neck of the humerus fracture - nerve and artery affected
Axillary nerve - badge patch sensation lost
Anterior and posterior circumflex arteries
Humeral shaft fracture - nerve and artery affected
Radial - wrist drop, loss of sensation to dorsum of the hand and forearm
Deep brachial artery
Supracondylar fracture - nerves
Median - medially displaced
Radial - laterally displaced
What is the commonest cause of damage to the ulnar nerve at the level of guyons canal?
Hook of hamate fracture
Compression i.e riding a bike
A boxers fracture is usually due to?
5th metacarpal fracture
Ape Hand
Recurrent medial nerve
Recurrent medial nerve
Innervates thenar muscles
Thumb flexion and opposition
‘inability to button up a shirt’
What do lumbricals do?
Flex MCP
Extend DIP and PIP
Median nerve damage at the level of the wrist.
At rest the index and middle finger are flexed
Medial Claw
Why does a medial claw occur in a distal median nerve injury?
Because the median nerve innervates the lumbricals of the 1st and 2nd digits
As a result at rest there is MCP flexsion and DIP /PIP extension of those digits
What occurs in medial nerve damage at the level of the elbow?
Sign of benediction
When making a fist only the 4th and 5th finger can flex
Why does proximal median nerve injury result in the sign of benediction?
Distal presentation +
Finger flexors - FDP laterally and all FDP are affected.
A distal ulnar nerve injury will present with
Ulnar claw
At rest, as 4/5th digits lumbricals are paralysed - MCP extended DIP/PIP flexed
What does the ulnar nerve damage affect in the hand?
Abductors and Adductors of digits 2-5 Adduction of the thumb Weak 4/5 flexion Hypothenar atrophy Froments test - thumb will bend when pinching paper
Proximal ulnar nerve damage is likely due to?
Medial epicondyle fracture
Leaning or sleeping on the elbow
How will a proximal ulnar nerve injury present?
Okay sign
On making a fist there is the inability to flex 4/5th digits
Why does a proximal ulnar nerve injury result in a Okay sign?
Same as distal lesion +
Flexor digitorum profundus is lost to the 4/5th digits
Finger drop is due to?
Excessive pronation or supination
Radial nerve
What nerve is affected to cause finger drop?
Deep radial nerve - supplies extensor indices
Passes through supinator muscles - compressed during supination
A mid humeral shaft fracture will present with
Reduced supination and extension of the wrist
If someone presents with elbow and wrist reduced flexion where has the injury occurred?
Above the level of the triceps usually at brachial plexus
A patient presents with dizziness and vertigo.
They also complain of arm pain.
Both the pain and the dizziness is made worse when they use the arm.
Subclavian steal syndrome
A stenosis in the subclavian artery means blood flow is stolen an reversed from the vertebral arteries- producing the posterior cerebral symptoms and the claudication like pain in the arm.
What test will illicit pain in an iliopsoas abscess?
Lay patient on unaffected side. Hyperextend their hips. This will stretch their Iliopsoas muscle causing pain.
Causes of Iliopsoas abscess
Primary - Haematogenous spread of bacteria - S.Aureus
Secondary - Crohns #, Diverticular disease, UTI, Cancer, PWID
Male under 25 Metaphysic of long bones - around knee Exostoses with a cartilaginous cap on X-Ray Rare risk of malignant potential Formed or growth plate tissue
Osteochondroma
Can become chondrocarcinoma
20-40 year sold
Previous bone trauma or radiation
Epiphysis of long bones
Soap Bubbles on x -ray and local invasion
Giant Cell
Male
No response to NSAID for pain
X ray shows >2cm nidus a disorganise amass of blood vessels and trabecular tissue
Affects vertebrae
Osteoblastoma
Male under 25
Severe pain particularly at night
NSAIDs are very effective
X ray shows <2cm nidus with a sclerotic halo
Osteoid Osteoma
Middle aged
Surface of the facial bones
No malignant transformation
Link to gardeners syndrome - colonic polyps
Osteomas
Arising from chondocytes
Affects small bones of hand and feet
Chondroma
Male under 20
Arising from osteoblasts
Metaphysis of long bones very aggressive
X ray shows - Lytic sunburst lesion
osteosarcoma
What two conditions are linked with osteosarcoma
Li Fraumeni syndrome
Familial Retinoblatoma
Male causasian under 15 Diaphysis of long bones or pelvis Pain and systemically unwell Locally aggressive Onion skin on xray Responds to chemotherapy
Ewings sarcoma
What bone tumour is commonest in the elderly?
Chondrosarcoma
When do you assess for osteoporosis and how?
FRAX score
Women >65
Male >75
Younger if risk factors like smoking FH falls
Commonest bone tumour in 40-50 years Hypercalcaemia Renal disease Anaemia Bone pain
Multiple Myeloma
Osteomyelitis from haematogenous spread where is it likely to occur?
Metaphysis - young
Epiphysis - old
Describe Salter Harris fractures
Type 1 - Straight across the physis
Type 2 - Passes through physis and into the metaphysis
Type 3 - Passes through physis and into epiphysis
Type 4 - Vertical fracture through metaphysis epiphysis and physis
Type 5 - Crush injury across physis
Lericke syndrome
Claudication of buttocks and legs
Impotence
Absent femoral pulses
+/- leg muscle atrophy
Due to severe atherosclerosis of distal aorta iliac of femoral arteries
Marfans
Autosomal dominant defect in fibrillin 1 gene Upward lense dislocation Pneumothhorax Aortic issues Mitral valve prolapse Dural ectasia
Painful on external rotation with both passive and active movement.
Pain present in internal and abduction but not as severe.
Middle aged female
Adhesive capsulitis
Painful phase -> frozen -> normal
What is the first line investigation into a query osteoporotic vertebral fracture?
X ray spine
What muscles of the hand does the median nerve supply?
Lumbricals 2 and 3rd = Flexors or MCP
Opponens Pollicis = Brings thumb across hand
Abductor Pollicis = Abducts thumb
Flexor Pollicis Brevis = flexes thumb
What does the guideline now say about starting allopurinol for gout prophylaxis?
Start when all signs of inflammation and pain have stopped.
Carpal Tunnel
6 week conservative - wrist splints + steroid injections
Severe or failure of conservative measures = Flexor Retinacular Division
Carpal Tunnel that is resistant to treatment Lower limb stiffness and weakness Autonomic dysfunction Paraesthesia \+ve Hoffmans
Degenerative Cervical Myelopathy
Commonest Metatarsal Stress Fracture
2nd
Management of sciatica
4-6 weeks conservative - gabapentin + physiotherapy
No results - referral to neurosurgery
Leg shortened and internal rotated
Posterior Hip dislocation
Ulnar nerve supplies in the hand
Medial Lumbricals Abductor Digiti minimi Flexor digiti minimi Adductor Pollicis Interossei Flexor Carpi Ulnaris
What scoring system is used to diagnose Ehlers-Danlos?
Beighton Score
>6/9 in children is diagnostic
>5/9 in adults is diagnostic
Perthes Disease - management
<6 years = Observe
>6 years = surgical management
Female 4:1 Forefoot pain - burning or shooting Loss of sensation distally in foot Mulders click # 3rd inter tarsal space
Mortons neuroma - clinical diagnosis -> USS can be helpful
Mortons Neuroma - Management
Avoid high heals
Metatarsal pads
Refer if three months no improvement
- Steroid injection or surgery
Septic arthritis management
Aspirate for culture ASAP - before abx
IV antibiotic - Flucloxacillin for two weeks - 2 weeks oral. Vancomycin if pen allergic
Surgical washout
Management of Osteochondritis Dissecans
Early orthopaedic involvement is key
X-Ray and MRI
What imagining is used in osteomyelitis?
MRI
A positive femoral stretch test in the context of hip pain could indicate what?
Lumbar spine source of the pain
Musculocutaneous
C5-C7
Elbow flexion and supination
Sensory to lateral forearm
Brachial plexus injury
Axillary
C5 C6
Shoulder abduction
Badge patch
Humeral neck fracture
Radial
C5/C8
Extension of forearm wrist fingers and thumb
Humeral mid shaft fracture
Median
C6 C8 T1
LOAF
Wrist - thenar muscles and opponens pollis
Elbow - reduced pronation and wrist flexion
Ulnar
C8 T1
Intrinsic hand muscles - LOAF
Wrist flexion
Medial epicondyle fracture
LOAF
Lumbricals - lateral
Opponens pollis
Abductor pollis brevis
Flexor pollis brevis
Management of frozen shoulder syndrome
Only physio is deemed to be effective
Acromioclavicular injury grade I or II - management
Sling and analgesia
Acromioclavicular injury grade IV V VI - management
Surgery
Three key points in achilles rupture
Calf squeeze - doesn’t illicit plantar flexion
Observe angle of declination
Palpation of tendon
When is scaphoid imaging repeated?
7-10 days later if not initially visualised
L3 - motor and sensory
Motor - weak quadriceps and knee reflex
Sensory - Anterolateral thigh
L4 - motor and sensory
Motor - weak quadriceps and knee reflex
Sensory - Anterior knee
L5 - motor and sensory function
Motor - Ankle and big toe dorsiflexion. Ankle reflex intact
Sensory - Dorsum of the foot
S1 - Motor and sensory function
Motor - Plantar flexion and inversion
Sensory - posteriolateral leg and lateral foot.
Gold standard investiation in degenerative cervical myelopathy.
MRI c-spine
Commonest Metatarsal fracture and the common cause
5th metatarsal
Inversion of foot
What test can differentiate short femur from a short tibia?
Galleazi test
Femur Fracture Garden Classification
- Undisplaced Incomplete
- Undisplaced complete
- Partial displacement
- Fully displaced
A patient with a good premorbid function presents with an undisplaced NOF #. What is the management.
Internal fixation with a cannulated screw.
THR - displaced fracture
Hemiarthroplasty - poor premorbid function
What is the imagining of choice in avascular necrosis of the femoral head
MRI as X ray may not show any signs
Nerve block commonly used in a neck of femur fracture.
Iliofascial nerve block
Lateral Epicondylitis
Tennis elbow
Extended and supinated + resisted extension
Medial Epicondylitis
Golfers elbow
