MSK Flashcards
1
Q
Mx of rheumatoid arthritis?
Flare Mx?
A
- DMARD monotherapy +/- a short-course of bridging prednisolone
- TNF-inhibitor if inadequate response to at least two DMARDs including methotrexate
Flare - steroids PO/IM
2
Q
How to monitor response to Tx in RA? Score?
A
CRP + disease activity
DAS28
3
Q
ESR and CRP in SLE with no flare up?
A
High ESR
Normal CRP
4
Q
Mx of grade I-II Acromioclavicular joint injuries?
A
Conservative with sling + immobilisation
5
Q
Which nerve does a Morton’s neuroma affect and where does it present clinically?
A
intermetatarsal plantar nerve
3rd inter-MTP space
6
Q
2 main fractures which carry risk of compartment syndrome?
A
supracondylar fracture
tibial shaft injury
7
Q
Which joint do Heberden’s nodes affect?
A
DIP
8
Q
Which joint to Bouchard’s nodes affect?
A
PIP
9
Q
What disease are Heberden’s and Bouchard’s nodes commonly seen in?
A
Osteoarthritis
10
Q
What does a positive McMurray’s test suggest?
A
Meniscal tear
11
Q
Allergy to which drugs is a caution for sulfasalazine in RA?
A
Aspirin or sulphonamides
12
Q
When are symptoms in lumbar spinal stenosis usually improved?
A
On sitting vs standing
Walking uphill vs downhill
13
Q
Typical bloods in polymyalgia rheumatica?
A
Raised ESR
Normal CK
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
15
Q
What effect does carpal tunnel syndrome have on sensory and motor axons?
A
action potential prolongation
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
17
Q
Which muscles are involved in shoulder abduction?
A
Supraspinatous - first 15 degrees
Deltoid after that
18
Q
What is the nerve supply of the deltoid?
A
Axillary nerve
19
Q
How should alignment of vertebral bodies be checked?
A
Using 3 longitudinal lines
Anterior, posterior and spinolaminar lines
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)
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
22
Q
Presence of which fat pad is always abnormal?
A
Posterior
Anterior is normal if it lies adjacent to anterior humerus
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
24
Q
Most commonly injured carpal bones?
A
Scaphoid
Then triquetral
25
What is a Colle's fracture?
fracture of the distal radius with dorsal angulation (posterior displacement) of the distal fragment
26
What is a Smith's fracture?
fracture of the distal radius with palmar angulation (anterior displacement) of the distal fragment
27
How do Colle's fractures occur?
Fall onto an outstretched hand
28
Xray changes indicative of infection in hip replacement?
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
29
Which tendons are affected in De Quervain's tenosynovitis?
extensor pollicis brevis and abductor pollicis longus
30
What is Finkelstein's test? What does a positive test suggest?
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
31
Which meds increase risk of marrow aplasia if prescribed alongside methotrexate?
Trimethoprim
| Co-trimoxazole
32
Which drug increases risk of methotrexate toxicity?
high dose aspirin
33
How does psoriatic arthritis affect the hands? What might you see on xray?
Asymmetrical inflammation of DIPs
Plantar spur
Pencil in cup
34
How does RA affect the hands?
Symmetrical inflammation of several small joints (usually MCPs) but sparing DIPs
35
what does morning stiffness indicate?
Few mins = osteoarthritis
| Long time = RA
36
What examination signs suggest a non impacted NOF fracture?
External rotation and leg shortening
| Unable to straight leg rise
37
What classification system is used for NOF fractures?
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.
38
What is the definitive tx for intercapsular NOF fractures?
Total hip replacement
39
3 types of NOF fractures?
subcapital: femoral head/neck junction
transcervical: midportion of femoral neck
basicervical: base of femoral neck
40
How are extracapsular NOF fractures treated?
Dynamic hip screw
41
How are femoral shaft fractures treated?
Operative fixation with an intramedullary nail
42
Initial mx of displaced tibial fracture?
Analgesia and splintage
43
What is Simmond’s test?
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.
44
Tx of an Achilles’ tendon rupture?
Equinus cast
45
What is the anterior draw test for?
Anterior cruciate ligament
46
What is the Lachman test for?
Anterior cruciate ligament
47
What is the primary function of the anterior cruciate ligament?
Preventing anterior translocation of the tibia at the knee
48
What does a periosteal reaction suggest?
A stress fracture
49
Blood supply to femoral head?
Medial and lateral circumflex femoral arteries (from profunda femoris)
Ligamentum teres artery
50
Classical features o/e in osteoarthritis?
Joint crepitus
Abnormal gait
Limited movement
51
What 2 signs might be positive in OA of hip?
Trendelenburg's (due to secondary gluteal weakness)
| Thomas' (fixed flexion deformity)
52
X-ray findings in OA?
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts and chondrocalcinosis
53
RFs for OA?
```
FH
Metabolic:
- Obesity
- Acromegaly
- Alkaptonuria
Bone issues:
- Trauma
- Paget's
Neuropathic joints:
- DM
- syphilis
Inflammation:
- Gout
- RA
- infection
Haematological:
- SCD
- Haemophilia
```
54
Which nerve is affected in carpal tunnel syndrome?
Median nerve
55
What is the motor and sensory innervation of the median nerve?
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.
56
RFs for carpal tunnel syndrome?
```
COCP
Hypothyroidism
RA
Pregnancy
HF
Previous wrist trauma
```
57
Which test and sign are positive in carpal tunnel syndrome?
Tinel's sign
| Phalen's test
58
Tx of carpal tunnel?
rest, splintage, anti-inflammatory medication and steroid injection
surgical release of carpal tunnel (flexor retinaculum)
59
Describe claw hand deformity
extension of the 4th and 5th fingers at the metacarpophalangeal joints and flexion at the interphalangeal joints
60
Damage to which nerve is associated with claw hand deformity? What is the ulnar paradox?
Ulnar
| The ulnar paradox: proximal lesions of the ulnar nerve produce a less prominent deformity than distal lesions
61
What sign is positive in claw hand?
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
62
Injury to which nerve causes wrist drop?
Radial nerve
63
What are the nerve roots for median, ulnar and radial nerves?
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
64
What is the most common cause of wrist drop?
Humeral fracture
65
What is Saturday night palsy?
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
66
How is Thomas' test carried out? What does it rule out?
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
67
Main cause of fixed flexion contracture of the hip?
OA
68
What does Tinel's test involve?
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)
69
Causes of positive Tinel's test?
```
Fluid retention
Previous fracture
Pregnancy
HF
RA
```
70
When is pain worse in carpal tunnel? How can it be alleviated?
At night
| Shaking the wrist
71
Criteria for polymyalgia rheumatics dx?
ESR >40 mm/hr
72
Tx of GCA initially?
IV Methylprednisolone or oral Prednisone 1 mg/kg/d
73
Tx of polymyalgia rheumatica initially and then maintenance?
20mg prednisone po
azathioprine/methotrexate may help lower maintenance dose of steroid
Usually a course of 1-2 years is needed
74
What are Polymyositis and dermatomyositis associated with?
Malignancy
75
What is bamboo spine on xray and what does it suggest?
spinous ligament fusion
| ankylosing spondylitis
76
Tx for sarcoidosis?
prednisolone 40mg od
77
Extra-articular manifestations of RA?
Episcleritis
Splenomegaly
Subcut nodules
Pericarditis
78
What is felty syndrome characterised by?
RA
splenomegaly
neutropenia
79
Characteristic xray findings in RA?
periarticular erosive changes
80
What causes a dinner fork deformity?
Colles fracture
81
What is a boxer's fracture?
Fracture of neck of 5th metacarpal
82
Classical Colles' fractures have which 3 features?
Transverse fracture of the radius
1 inch proximal to the radio-carpal joint
Dorsal displacement and angulation
83
Mx of scaphoid pole fracture?
Surgical fixation due to risk of avascular necrosis
84
Blood supply to scaphoid bone?
Around 80% of the blood supply is derived from the dorsal carpal branch (branch of the radial artery), in a retrograde manner
85
What signs are elicited in scaphoid fractures o/e?
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
Xray views of wrist needed for ?scaphoid fracture?
```
AP
PA
Lateral
Oblique (with wrist pronated at 45º)
Ziter (PA view with the wrist in ulnar deviation and beam angulated at 20º)
```
87
Common cause of bilateral carpal tunnel syndrome?
RA in <50y/o
| Acromegaly in >50y/o
88
What are the Ottawa ankle rules for xray in ?ankle fracture?
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
Weber classification of ankle fracture and tx?
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
What is the medical term for frozen shoulder?
| Who is it commonly found in?
Adhesive capsulitis
| Diabetics
91
Features of adhesive capsulitis in shoulder?
Reduced range of active and passive movement in all directions - loss of external rotation and abduction in about 50% of patients
92
O/E of rotator cuff tear or supraspinatus tendonitis what would you find?
Who are they common in?
```
Limited abduction (painful arc between 60 and 120 degrees) on active movement
Elderly
```
93
O/E of subacromial bursitis what would you find?
Limited abduction but not internal rotation
94
Where does the spinal cord end?
T12-L1
95
Triceps reflex nerve root?
Radial nerve C7
96
What is a Baker's cyst?
distension of the gastrocnemius-semimembranosus bursa
97
Mx for undisplaced fracture of scaphoid waist?
Cast for 6-8 weeks
98
Common cause of acromioclavicular joint injury and what is seen?
Contact sports
| Widening of joint space
99
What is cubital tunnel syndrome and what are the symptoms?
ulnar nerve entrapment at the elbow
| sensory symptoms affecting the 4th and 5th fingers
100
Analgesia for NOF fracture?
iliofascial nerve block
101
Management of intertrochanteric (extracapsular) proximal femoral fracture?
Dynamic hip screw
102
Gustilo and Anderson classification of open fractures?
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
Mx of any open fracture?
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
What is a straight leg rise used to test and when is it positive?
Sciatica
| Pain in distribution of sciatic nerve
105
L3 nerve root compression features?
Sensory loss over anterior thigh
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
106
L4 nerve root compression features?
Sensory loss anterior aspect of knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
107
L5 nerve root compression features?
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
108
S1 nerve root compression features?
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
Tennis elbow affects which tendons?
The common attachment of the extensor muscles of the forearm to the lateral epicondyle of the humerus
110
Tennis elbow findings?
- 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
Key findings in Sub Acromial Impingement syndrome?
```
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
What does knee locked in flexion suggest?
Meniscal injury
113
What does knee giving way suggest?
Ligament damage
114
Ankylosing spondylitis xray findings?
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
What position does the humeral head usually lie in anterior dislocation?
subcoracoid position
116
Poor prognostic features in RA?
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
Which antibodies are associated with drug-induced lupus?
Antihistone antibodies
118
How to differentiate pseudogout from gout?
Chondrocalcinosis
119
What to do in ED for suspected scaphoid fracture?
immobilisation using a Futuro splint or standard below-elbow backslab before specialist review
Xray
120
Criteria for starting anti-TNF alpha inhibitors in axial ankylosing spondylitis? Which drugs are typically used?
failure on 2 different NSAIDS and meets criteria for active disease on 2 occasions 12 weeks apart
infliximab and etanercept
121
Pott's fracture?
Bimalleolar fracture
| Forced foot eversion
122
Bennett's fracture?
| What would you see on xray?
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
Barton's fracture?
Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation
Fall onto extended and pronated wrist
124
Features of femoral nerve damage?
Weakness in knee extension, loss of the patella reflex, numbness of the thigh
125
Features of lumbosacral trunk damage?
Weakness in ankle dorsiflexion, numbness of the calf and foot
126
Features of sciatic nerve palsy?
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
Features of obturator nerve damage?
Weakness in hip adduction, numbness over the medial thigh
128
most common site of metatarsal stress fractures?
2nd metatarsal shaft
129
PRessures in compartment syndrome?
Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic
130
Galeazzi fracture?
dislocation of the distal radioulnar joint with an associated fracture of the radius
131
Monteggia fracture?
fracture of the proximal ulna, with an associated dislocation of the proximal radioulnar joint
132
Mx of reverse oblique, transverse or subtrochanteric NOF fractures?
Intramedullary device
133
Most common causes of drug induced lupus?
procainamide
| hydralazine
134
What is parsonage turner syndrome?
a peripheral neuropathy that may complicate viral illnesses
135
Features of fracture of radial head?
FOOSH
marked local tenderness over the head of the radius
restricted supination and pronation
sharp pain on movement
136
Ix for Achilles tendon rupture?
USS ankle
137
Features of posterior shoulder dislocation? What would you see on xray
Arm is internally rotated and adducted
Resistance to external rotation
Humeral head palpable posteriorly below acromion
X ray: Lightbulb sign
138
Features of anterior shoulder dislocation?
Arm is externally rotated and abducted
Humeral head is felt anteriorly below the clavicle
May be reduced sensation over regimental badge
139
What is Sudek atrophy and what fracture is it common in?
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
Where does the biceps insert and where does typically rupture?
What movement is compromised as a result?
Radial tuberosity
Commonly ruptures proximally (long head)
Elbow flexion
Forearm supination
141
Rheumatoid arthritis joint aspiration findings?
High WBCs - neutrophils
Yellow/cloudy
No crystals
142
Risks of supracondylar fracture?
Radial artery damage - compartment syndrome
Radial nerve damage
+/- median nerve damage
143
Posterior hip dislocation features?
'clunk', leg shortening and internal rotation
144
Features of a fat embolus?
Triad:
Resp: Fever, breathlessness
Neuro: confusion
Petechial rash & retinal haemorrhages
145
management for subluxation of the radial head?
Passive supination of the elbow joint whilst flexed to 90 degrees
146
Features of ruptured pcl?
tibia lies back on the femur
| Mechanism: hyperextension injuries
147
What score can be used to assess hypermobility?
Beighton score
148
Findings O/E of ankylosing spondylitis?
reduced lateral flexion
reduced forward flexion - Schober's test <5cm
reduced chest expansion
149
What is the weight bearing status of patients post hip fracture surgery?
Full weight bearing immediately post-op
150
Where does meralgia paraesthetica affect?
pain in the lateral cutaneous nerve of the thigh distribution
151
In children and adults where is the most common site where osteomyelitis occurs?
```
Children = Minors = Metaphysis
Adults = Elders = Epiphysis
```
152
1st line tx for lower back pain?
NSAIDs
153
Hallmark sign of compartment syndrome?
Pain on passive stretch
154
Osteosarcoma Xray findings?
Metaphysis
Codman's triangle
Sunburst pattern
155
What gene is osteosarcoma associated with?
Retinoblastoma
156
Ewing's tumour Xray findings?
Pelvis and long bones
| Onion skinning
157
What gene is Ewing's tumour associated with?
t(11;22) translocation which results in an EWS-FLI1 gene product
158
Best ix for ankylosing spondylitis?
sacro-ilitis on a pelvic X-ray
159
How do bisphosphonates work and what can they be used to treat?
Inhibit osteoclasts by reducing recruitment and promoting apoptosis
- prevention and treatment of osteoporosis
- hypercalcaemia
- Paget's disease
- pain from bone metatases
160
What needs to be done before starting biologics in RA tx?
CXR - look for TB (can reactivate)
161
What distribution of pathology does a radiculopathy present with?
Dermatomal
162
Biggest risk of posterior hip dislocation?
Sciatic nerve damage
163
What type of ankle sprain is most common and which ligament is affected?
Lateral ligament sprain (inversion) - low ankle sprain
• Anterior talofibular - most important
• Calcaneofibular
• Posterior talofibular
164
Damage to which ligaments contributes to chronic ankle instability?
Syndesmotic sprain (high ankle sprain)
165
When would you MRI an ankle sprain?
If it is still painful after 6-8 weeks
166
Fall onto thumb and pain over base - unable to make pinching movement?
Ulnar collateral ligament injury
167
What type of lesion typically causes a "cotton wool calcification"
Paget's
| Chondrosarcoma
168
Weakness of first 30 degrees of shoulder abduction but no pain?
Suprascapular nerve pathology
169
Mx of undisplaced patella fractures, particularly vertical fractures with an intact extensor mechanism?
Hinged knee brace for 6 weeks and patients allowed to fully weight bear
170
Mx of displaced patella fracture with loss of extensore mechanism?
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
