msk Flashcards
What other antibody can be seen if RF is negative (in rheumatoid arthritis)
Anti-CCP (cyclic citrullinated peptide) antibody
What is the diagnostic criteria for RA
DAS 28
Define shoulder dislocation
When the humeral head dislodges from the Glenoid cavity of the scapula
These dislocations are almost always anterior
A 24-year-old man presents to the emergency department after a fall whilst cycling a couple of hours ago. He is grasping his right shoulder and is in obvious pain. The patient does not report any fever or other systemic symptoms and there is no red skin around the joint. An anteroposterior x-ray is ordered which shows that the humeral head is dislodged from the glenoid cavity of the scapula anteriorly.
Given the likely diagnosis, what is the most appropriate initial management?
Kosher technique reduction
The affected arm is bent at the elbow, pressed against the body and rotated outwards until resistance is felt
Then lift the affected arm that is externally rotated in the Sagittal plane as far as possible forwards and finally turn inwards slowly
What is an early radiological finding in RA
Juxta-articular osteoporosis
Soft tissue swelling
What are late radiological findings of RA
Periarticular erosions
Subluxation
Features of psoriatic arthritis
Dactylitis - “sausage fingers”
Asymmetrical poly arthritis
Afebrile
HLA B27
What antibody is anti-phospholipid syndrome
Anti-cardiolipin
Features of anti-phospholipid syndrome
Predisposition to both venous and arterial thromboses
Recurrent foetal loss
Thrombocytopenia
Livedo reticularis
May occur as primary
May be secondary to SLE
Causes a paradoxical rise in APTT
Investigation for anti-phospholipid syndrome
Antibodies - cardiolipin
Thrombocytopenia
Prolonged APTT
Management for anti-phospholipid syndrome
Low dose aspirin
2nd =
Lifelong warfarin with a target INR of 2-3
A patient with sjogrens is more at risk to which type of malignancy
Lymphoma / lymphoid malignancies
Ie weight loss, night sweats, painless swelling
What is sjogrens
An autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces
More common in women
Features:
Dry eyes
Dry mouth
Vaginal dryness
Arthralgia
Raynauds
Sensory polyneuropathy
Parotitis
Renal tubular acidosis
Investigation for sjogrens
RF - positive in most patients
ANA - positive
Anti-Ro /La - positive
Schirmers test - tear formation
Histology - focal lymphocytic infiltration
Management of sjogrens
Artificial tears and saliva
Pilocarpine
What is this ?
Swelling over the posterior aspect of the elbow
May be associated pain, warmth and erythema
Typically affecting middle aged male patients
Olecranon bursitis
Patient experience intermittent tingling in the 4th and 5th finger
May be worse when the elbow is resting on firm surfaces or flexed for extended periods
Later numbness in 4th and 5th finger with associated weakness
Cubital tunnel syndrome
Compression of the posterior interosseus branch of the radial nerve
Thought to be a result of overuse
Symptoms similar to lateral epicondylitis
Can be made worse when elbow is extended and pronating forearm
Pain also tends to be distal to the lateral epicondyl
What disease matches this profile ?
Radial tunnel syndrome
What are features of lateral epicondylitis (tennis elbow)
Pain and tenderness localised to the lateral epicondyl
Pain worse on resisted wrist extension with the elbow extended or supination of the forearm with elbow extended
Episodes last typically between 6 months and 2 years and patients tend to have acute pain for 6-12 weeks
Features of golf elbow (medial epicondylitis)
Pain and tenderness @ medial epicondyl
Pain is aggravated by wrist flexion and pronation
Symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
Antibody for SLE
Anti-dsDNA (specific)
Sensitive - ANA
What is the most common causative organism for discitis
Staph aureus
What is discitis
An infection in the intervertebral disc space > can lead to serious complications such as sepsis or an epidural abscess
Features of discitis
Back pain
Pyrexia
Rigors
Sepsis
Neurological features = lower limb , epidural abscess formation
What are causes of discitis
Bacterial = STAPH AUREUS
Viral
TB
Aseptic
Investigation for discitis
MRI - disc space narrowing will be seen
Treatment for discitis
Standard therapy = 6-8 weeks of IV antibiotic therapy
Patients should be assessed for infective endocarditis via trans thoracic echo (discitis is usually due to haematogenous seeding of the vertebrae implying that the patient has had a bacteria emit adn seeding could have occurred elsewhere
Complications of discitis
Sepsis
Epidural abscess
What is Polymyalgia rheumatica
An inflammatory conditions which result in pain and stiffness and myalgia particularly around the shoulder and pelvic girdle
There is no weakness of the muscles themselves however pain can make movement difficult
Symptoms of Polymyalgia rheumatica
Rapid onset
Aching, morning stiffness in proximal limb muscles
Mild = lethargy, depression, low-grade fever, anorexia and night sweats
What are the tendons involved in De Quervain’s
Extensor pollicis brevis and abductor pollicis longus
What is the test used to confirm De Quervains
Finkelsteins test
How often is methotrexate taken
Weekly
MoA methotrexate
Antimetabolite that inhibits dihydrofolate reductase - an enzyme essenrtal for the synthesis of purines and pyrimidines
Adverse effects of methotrexate
Mucositis
Myelosuppression
Pneumonitis
Pulmonary fibrosis
Liver fibrosis
What else should be given when prescribe methotrexate
Folic acid 5mg
What should not be taken if you are on methotrexate
High dose aspirin
Trimethoprim or co-trimoxazole
Pencil in cup appearance on distal interphalangeal joints
Psoriatic arthropathy
Which is better for a diagnosis of RA : anti - CCP or RF
Anti - CCP it has a higher specificity
Which nerve is commonly injured in a shoulder dislocation - sensation tested in the ‘regimental badge area’
Axillary nerve
Anterior dislocation of shoulder features
Common
Axillary nerve damage
May follow a fall on the arm of shoulder
Always do a radiograph
Tx. = reduction, analgesia, sling
Posterior dislocation of the shoulder
Rare (cause by seizure or electrocution)
‘Lightbulb sign’ on x-ray
Refer to the orthopaedic surgeons
*lightbulb sign on x-ray ?
- = buzzword
Posterior shoulder dislocation
Clinical features of SLE
Rash on cheeks (butterfly rash)
Tired all the time
Tenderness on MCPs and MTPs on hands and feet
Oral ulcers
Drug to help Raynauds
Nifedipine
Positive Anti-Ro / La antibodies show ? *
Sjogrens
A 21-year-old female football player comes to the walk in clinic with severe left knee pain. She states that she has landed awkwardly on her knee during a football game. She heard a ‘snapping sound’ when she injured her knee which was followed by significant swelling around the left knee joint. Physical examination reveals increased laxity on anterior drawer of the left tibia relative to the femur. Which of the following tests would be most appropriate in confirming the diagnosis?
Left knee magnetic resonance imaging (MRI)
Ligamentous injuries of the knee joint are best confirmed though MRI
The footballer is likely to have torn their ACL > patients will complain of a popping sensation followed by a rapid onset of haemarthrosis
*Sudden ‘popping’ sound after suddenly twisting or awkward landing
ACL torn - knee ligament
What are the 2 tests to diagnose ACL tear
Anterior drawer
Lachman’s
A 24-year-old man is brought to the emergency department have suffered a crush injury to his forearm. Assessment demonstrates that the arm is tender, red and swollen. He is experiencing significant pain in the forearm. There is clinical evidence of an ulnar fracture and the patient cannot move their fingers and complains they are numb. Which is the most appropriate course of action?
Fasciotomy
Suspect compartment syndrome for crush injury, limb swelling, inability to move digits
Symptoms of compartment syndrome
Pain - on movement / passive
Excessive use of breakthrough analgesia
Parasthesiae
Arterial pulsation may still be felt
Paralysis of a muscle group
What is the diagnostic measure for compartment syndrome
> 40mmHg = diagnostic
> 20mmHg is abnormal
What drug that manages RA and SLE can cause bull’s eye retinopathy
Hydroxychloroquine
*Bull’s eye retinopathy
Caused by hydroxychloroquine
What does this DEXA scan show ?
Osteopaenia in vertebrae , osteoporosis in femoral neck
(Below 2.5 = osteoporosis, from -1 to -2.5 = osteopaenia, and 0 - -1 = normal)
CREST syndrome / limited cutaneous systemic sclerosis - what is it
Sclerodactyly , Raynauds, Telangiectasis , scleroderma , oesophageal dysmotility , calcinosis , interstitial lung disease
What antibodies are associated with CREST / systemic sclerosis
ANA +
RF +
Anti-scl-70 (diffuse)
Anti-centromere (limited)
What is hemiparesis
Weakness or inability to move one side of the body
What is paraesthesia
Burning or prickling sensation felt in hands/arms/legs/feet
What is aphasia
Difficulty with language or speech
A 32-year-old female intravenous drug user (IVDU) presents to the emergency department demanding analgesia for her back pain. You recognise her as a frequent attender, most recently being treated for a groin abscess.
On examination her heart rate is 124/min, temperature 38.1ºC, respiratory rate is 22/min and she is alert. The patient is lying on her right hand side with her knees slightly flexed and you find tenderness over L3-L4.
What is the likely diagnosis ?
Psoas abscess - characterised by lumbar tenderness (T12 - L5) and her preferring to lie with her knees slightly flexed, IVDU
Common causative organisms = staph and strept.
What is an iliopsoas abscess
Describes a collection of pus in iliopsoas compartment (iliopsoas + iliacus)
Clinical features of psoas abscess
Fever
Back/flank pain
Limp
Wt. loss
Specific test for psoas abscess + investigation
Hyperextension of the affected hip
CT abdo
Management of psoas abscess
Antibiotics
Percutaneous drainage
Surgery only if: 1. Failure of percutaneous drainage 2. Presence of another intra-abdominal pathology
- rising pyrexia in the late afternoon/ evening which is gone by morning , accompanied by worsening joint symptoms and rash
Still’s disease
A 28-year-old man presents to his GP complaining of fever and joint pains that have worsened over the last 3 weeks. The fever occurs each evening and can be as high as 39.5ºC but drops to normal by the morning. He reports pain and swelling in the shoulders, wrists and metacarpophalangeal joints that worsens with the fever. He also says that his girlfriend has noticed a salmon-pink rash on his back however no rash is present on examination. He also complains of a persistent sore throat. He hasn’t noticed any weight loss or night sweats. His past medical history is unremarkable.
What is the most likely explanation for this patient’s symptoms?
Still’s
Mxm = NSAIDs , steroids , biologics or methotrexate
What is important to consider following a FOOSH
Scaphoid fracture do not show up on X-ray
*clicking feeling on internal rotation of knee
= positive Murray’s test
> = meniscal tear
A 17-year-old boy presents to his GP with a 3 month history of lower back pain which is worse in the mornings. A lumbar spine x-ray demonstrates sacroiliitis. No other joints are affected.
What is the most appropriate initial management whilst awaiting a rheumatology referral?
Physiotherapy and NSAIDs
(Exercise regimes and NSAIDs are 1st line for management for ankylosing spondylitis)
What are the early x-ray findings of ankylosing spondylitis
Subchondral erosions
Sclerosis
Squaring of lumbar vertebrae
*burning thigh pain
= meralgia pareaesthetica
*meralgia paraesthetica
= lateral cutaneous nerve of thigh compression
What test is used to diagnose meralgia paraesthetica ?
Pelvic compression test
*shortened leg and externally rotated
Hip fracture
T/F rheumatoid arthritis spares the distal interphalanges
T
The arrows indicate chondrocytes - what is the name given to the space that each of these cells occupies ?
Lacuna - a space within the extracellular matrix
Chondrocytes are ACTIVE cells - they secrete and also maintain the ecm around them
Bone enlargement, thickened cortices, thickened trabecular with mixed areas of lysis and sclerosis are all radiographing findings of what disease
Paget’s disease
What bones does paget’s commonly affect ?
Pelvis
Femur
Skull
Tibia and ear ossicles
What could: serum alkaline phosphatase +++ Ca (normal) Phosphorous (Normal) indicate ?
Paget’s
Treatment of Paget’s
Biphosphonates
Calcitonin
——
Joint replacement may be necessary + pathological fracture need stabilised
Margins of osteons = cement lines
What is A
Haversion Canal
What is osteomalacia
A qualitative defect of bone with abnormal softening of the bone due to deficient mineralisation of osteoid secondary to inadequate amounts of calcium and phosphorus
Rickets is the paediatric version
What bone cell is responsible for ‘drilling’ into the bone to form a new tunnel and are responsible for bone resorption ?
Osteoclasts
What is the function of osteoprogenitor cells ?
They serve as a pool of reserve osteoblasts
What are osteoblasts ?
Bone forming cells found on the surface of developing bone - they have plentiful RER and prominent mitochondria
Osteoblasts line the tunnel and begin laying down new lamellar bone
Where can an osteocyte be found ?
trapped within the bone matrix
What is the basic multicellular unit ?
The collection of osteoclasts and osteoblasts that participate in the process of bone remodelling
What is a ganglion
A cystic swelling which occurs around a synovial joint or tendon sheath - as a result of out-pouching of a weak joint portion of joint capsule or tendon sheath
What is the basic multicellular unit ?
The collection of osteoclasts and osteoblasts that participate in the process of bone remodelling
What anatomical sites are affected by osteochondritis dissecans
This is fragmentation with separation of bone and cartilage within a joint - so only intra-articulatar sites are affected
Ie Talar dome , lateral part of medial femoral condyle in the knee, femoral head, humeral capitellum
what is a giant cell tumour
Often occurring in the knee and distal radius with a ‘soap bubble’ appearance
*soap bubble appearance
Giant cell tumour
*shepherd’s crook deformity
Fiberous displasia
What is a simple bone cyst and why are they clinically relevant
It is a single cavity of benign fluid filled cyst in a bone - most likely from a bone defect from the physis and are therefore metaphysical in long bones
May be asymptomatic - incidental finding on x-ray (usually a child or young adult) however they can cause weakness leading to pathological fracture
What is this : A lucent, multi-loculated cyst found within the medulla of many different bones, often with associated cortical expansion
Aneurysmal bone cyst
What is this : a mostly lucent lesion with a patchy sclerosis found within the metaphysical region of long bones
Echondroma
What is this : a bony spur originating in the metaphysical region of long bones growing away from the epiphysis
Osteochondroma
What is A
Perimysium
What is B
Endomysium
what is Ewing’s sarcoma ?
A malignant tumour of endothelial cells in the marrow - most cases occur between ages 10 and 20
*onion skinning
May be associated with fever, raised inflammatory markers and a warm swelling and may be misdiagnosed as osteomyelitis
T/F do the striations present in skeletal muscles result from the orientation of the myofibrils - which run across the fibre ?
F - they are oriented longitudinally
what is the second most abundant components of cartilage ecm - after water ?
(25%) Organic material - 60% type II collagen and 40% proteoglycan aggregates
Water = 75%
what is the difference between type I collagen and type II collagen
Type II = finer 15-45nm and forms a 3 dimensional meshwork
Type I = 75 nm and form linear bundles
Which primary malignant tumour commonly metastasises to bone
- Breast (most common!)
- Prostrate
- Lung
- Renal
- Thyroid adenocarcinoma
What type of tissue is this
skeletal muscle
What is the most common benign bone tumour
Osteochondroma - however 1% risk of malignant transformation
Pulmonary embolism, pleurisy, MI and pericarditis are complication of what autoimmune disease
SLE
pneumothorax is associated with what autoimmune disease ?
Anti-phospholipid syndrome
What are these features associated with: recurrent pregnancy loss, livedo reticularis, venous thrombosis, and migraine
Anti-phospholipid syndrome
T/F there is an increased incidence of lymphoma in patients with primary Sjogren’s
T
what are all the antibodies that can occur in Sjogrens
Anti-ro
Anti-la
ANA
RF
What is the antibody associated with SLE
Anti-DNA binding molecule
What is the best therapeutic approach to connective tissue diseases ?
Treat symptomatically and monitor closely for major complications
A person with anti-phospholipid syndrome has a PE with no other clinical risk factors - what medication should they be started on
Life long warfarin
Is pulmonary fibrosis seen more in diffuse systemic sclerosis or limited systemic sclerosis
Diffuse = raynauds, dry eyes, facial telangiectasia and puffy hands + pul. Fibrosis
What do low levels of complement proteins mean (in regard to SLE)
That is is active - complement proteins are consumed in response to the formation of immune antigen/antibody complexes
what are the extra-article manifestations common in the spondyloarthritides
Achilles tendinitis
Aortic valve incompetence
Uveitis
Dactylitis
A woman with triple therapy to manage her RA still is struggling with her RA - what management next ?
Anti - TNF therapy
Triple therapy = methotrexate, sulphasalazine, hydroxychloroquine
Allopurinol, feuxostat and colchicine are treatments for what condition ?
Gout
what x-ray finding is indicative for pseudo gout ?
Chondrocalcinosis
*chondrocalcinosis on x-ray ?
Pseudogout
Peri-articular osteopenia and erosion are x-ray findings associated with what disease ?
RA
Which RA treatment is safe to have in pregnancy
Sulphasalazine
What percentage of reactive arthritis cases resolve spontaneously
90%
what are the treatments for reactive arthritis
Intra-articular or orla steroids
DMARDs
What forms Reiter’s disease
Uveitis
Arthritis
Urethritis
MRI early findings for ankylosing spondylitis
Bone marrow oedema
Romanus lesions
Enthesitis
Is crystal arthropathy associated with erosive or hypertrophic joint changes ?
Erosive
Is treatment for Polymyalgia rheumatica likely to continue lifelong ?
No
PMA and GCA persist for around 18 months - 2 years then resolve
What is the immunological test would you require in suspicion of small vessel vasculitis
ANCA
What is the Beighton classification of joint hypermobility
It is a scoring system of 9 point made up of the ability to passively touch the forearm with the thumb with the wrist in flexed position
Passive hyper extension of the fingers or little finger beyond 90 degrees
Hyperextension of the elbows of knees beyond 10 degrees
Ability to touch the floor with both palms with legs straight
> 4 = hypermobility
How does allopurinol reduced urate in gout
Inhibiting xanthine oxidase
Treatment for fibromyalgia
Amitriptyline, gabapentin (analgesics)
Graded exercise and pyschological approaches ie cognitive behavioural therapy
How do you reduce the side effects of steroids
Osteoporosis prophylaxis
Use lowest possible dose for as short a time as possible
Consider steroid sparing agents
Monitor cv risk
*Older man with bone pain and an isolated raised ALP ?
Paget’s
Management is with biphosphonate
what is pagets ?
A disease of increased but uncontrolled bone turnover
Thought to be primarily a disorder of osteoclasts with osteoclastic re-absorption followed by increased osteoblastic activity
The skull, spine and long bones of lower extremities are most commonly affected
Clinical features of Pagets
Older male with bone pain
Isolated raised ALP
Bowing of tibia, bossing of skull
X-ray of pagets - what could be seen ?
Osetolysis in early disease ——> which would become mixed lytic/sclerotic lesions later
Skull x-ray = thickened vault, osteoporosis circumscripta
A 56-year-old woman presents to her GP with three weeks of worsening shortness of breath, fever and dry cough. Four weeks ago she was started on a new medication for an inflammatory arthritis. Auscultation of her chest reveals bibasal fine crackles.
What medication is most likely to have caused this presentation?
Methotrexate = adverse effect is pneumonitis
How long can a woman suffer from chronic fatigue syndrome before a diagnosis can be made
Symptoms have to persist for 3 months to be diagnosed
What classification system is used to classify neck of femur fractures
Garden
When are the Ottawa rules used
To detect possible ankle fracture
What are the garland and salter-Harris classification systems used for ?
Children
Gartland = supracondylar
SalterHarris = growth plate
*dinner fork type deformity
Colles fracture / FOOSH
= distal radius fracture with dorsal displacement of fragments
Early complication of Colles
Median nerve injury
What is lumbar spinal stenosis
A condition in which the central canal is narrowed by tumour or something else
Patients present with a combination of back pain, neuropathic pain and symptoms mimicking claudication
75 year old women presents with horrible pain in her back and legs which has recently got so bad it impairs her walking tolerance : she finds bending over helps, walking up a hill is better than walking down one, and sitting is better than standing.
What is goin awn ….
Lumbar spinal stenosis
Lumbar disc prolapse site - S1
Sensory loss of posterolateral aspect of leg and lateral aspect of foot, weakness in plantar flexion of foot, reduced ankle reflex , positive sciatic nerve stretch test
Lumbar disc prolapse S2 - tests
Can cause weak ankle reflex
Is not positive for sciatic nerve stretch test
Sensory loss on the medial side of the inferior aspect of foot and posterior middle segment
Where are the sciatic nerve roots
L4 L5 S1
Nerve roots and reflexes mnemonic
S1 + S2 i tie my shoe (ankle reflex)
L3 + L4 i kick the door (knee jerk reflex)
C5 + C6 i grab some sticks (biceps reflex)
C7 + C8 i lay them straight (triceps reflex)
What is used to manage an acute flare up of RA
Methylprednisolone IM (intramuscular steroids)
Pain on longitudinal compression of the thumb is a sign for what fracture ?
Scaphoid fracture
What is better for a diagnosis of SLE ? ANA or Anti-dsDNA
ANA is 99% specific
Anti-dsDNA is 60%
What is finkelsteins test
Pain over radial styloid on forced abduction/flexion of the thumb
Used to diagnose De Quervains
What is the definitive management of primary hyperparathyroidism ?
Parathyroidectomy
Sensory loss over dorsum of the foot
L5 nerve root compression
What relieves spinal stenosis
Sitting down
Leaning forward
Walking up a hill»_space; walking down a hill
What are the nerve roots injured in Erb’s palsy
C5 and C6
What is Erb’s palsy
Loss of motor function to deltoid, supraspinatus, infraspinatus, biceps and brachialis
Results in ‘waiter’s tip’ posture
Risk factors for DDH
Family history of DDH
Breech presentation
First born
Down syndrome
Girl
When should babies be speaking a few words
9-12 months
When should a baby have loss of primitive reflexes
1-6 months
When should a baby have head control
2 months
When should a baby be eating with fingers + use a spoon
14 months
When should a baby be able to stack 4 blocks
18 months
When should a baby be able to understand about 200 words, and learns 10 words/day
18 months
When should a baby be potty trained
2-3 years
When should a baby be able to sit alone, and crawl
6-9 months (motor)
When should a baby be able to stand
8-12months (motor)
When should a baby be able to walk ?
14-17 months (motor)
When should a baby be able to jump
24 months
When should a baby be able to manage stairs independently
3 years
Mobile / flexible flat - footedness causes
Ligamentous laxity
Can be familial
This is where the flattened medial arch forms with Dorsiflexion of the great toe
What is the test for flexible/mobile flat footedness
Jack test
Cause of rigid type flat foot
Tarsal coalition
What is Ehlers Danlos
A heterogenous condition featuring abnormal elastin and collagen formation , clinical features include profound joint hypermobility, vascular fragility with ease of bruising joint instability and scoliosis
What is club foot
A congenital deformity affecting boys x2 more than girls
Due to in utero abnormal alignment of joints between the talus, calcaneus and navicular
What is contained in a myelomeningocle
Cerebrospinal fluid, meninges and spinal cord/cauda equine
Pathophysiology of Duchennes
A defect in the dystrophin gene involved in calcium transport results in muscle weakness > progressively gets worse > boys can’t walk by the age of 20 > progressive cardiac and respiratory failure develop
What conditions can atraumatic cervical spine instability occur
Down syndrome
Rheumatoid arthritis
What is the term for acute angular deformity in the spine in Sagittal plane
Gibbus - in an older patient = not a concern
In a young patient = concern
*back pain worse on coughing
Acute disc tear
Management of mechanical back pain
Physiotherapy
Management of chronic osteomyelitis
Antibiotics
Surgery > to gain deep bone tissue cultures + remove sequestrum
Debridement
Bone must also be stabilised (if not already)
Which bone of the Lower limbs takes the longest to heal
Tibia
T/F lower limb fractures heal faster than upper limb fractures
F - upper limb fractures heal faster due to better blood supply
T/F metaphyseal fractures heal faster than cortical fractures
T
What tendon tears require surgery ?
Quadriceps , patelllar (sometimes Achilles)
Otherwise splintage will do
What is a pseudo tumour
An inflammatory granuloma produced in response to metal wear particles in the context of a joint replacement - may be locally invasive but cannot metastasise
Which types of salter-Harris fractures are intra- articular
III and IV
What is an osteotomy
Surgical realignment of a bone which can be used for deformity correction or to redistribute load across an arthritic joint
What Glasgow coma score implies loss of airway control
8
Impaired grip strength may arise if there is malunion of distal radius fracture - is this associated loss extension or flexion ?
Extension
When is surgery indicated in hallux Valgus
Small, non-painful lesion, patient can’t wear shoes anymore = cosmetic surgery is a good reason
Pain and restriction of function = surgery
Not being able to wear high heels = NO
Prophylactic surgery - NO
Management of Achilles tendon it is
Rest
Physiotherapist
Use of heel raise
Splint or boot
NOT A STEROID INJECTION
Test to see if there has been auxiliary nerve damage in an anterior shoulder dislocation
Test for sensation over the lower half of the right deltoid (regimental badge area)
C5-6
How does osteogenesis imperfecta present ?
Blue sclera
Learning difficulties
Hearing loss
Short stature
Childhood fractures
What type of fracture is commonly FOOSH
Scaphoid
What to do if scaphoid fracture is suspected but on x-ray there is no visible fracture ?
What os the next best step in the management ?
Immobilisation of the wrist in a thumb spica cast and arrange a repeat x-ray in 10-14 days
As scaphoid fractures are not always detected by the initial radiographs - especially if I displaced
What is a green stick fracture ?
Occurs in paediatric patients when force is applied to a bone - it bends in such a way that the structural integrity of the cortex surface is overcome
The bending force applied does not break the bone completely
(Kids bones are bendy)
*lower limb weakness, constipation, urinary retention, reduces anal tone and perianal sensation
Cauda equina syndrome
*progressive deformity in 4th and 5th digits of hands, cannot be passively corrected with skin puckering and tethering
Also patient has history of alcohol misuse
Dupuytrens
Nerve damaged in ‘foot drop’
Common peroneal nerve
Muscle affected is tibialis anterior
Investigations to see if antibiotics are working properly
ESR
CRP
Treatment of osteoporosis
Biphosphonates ie alendronate
MoA Biphosphonates
Inhibition of osteoclasts
(Osteoclasts are responsible for Bone resorption which is why they are not useful in osteoporotic patients who already have reduced bone density)
Management of tendinopathies
Conservative - with rest and analgesia (NSAIDs)
What is Baker’s cyst
Extension of the knee synovium that develops between the medial head of gastrocnemius and the semi-membranous muscle
causes of Baker’s cyst
Can be caused by trauma or occur in knees affected by conditions such as rheumatoid , gout, osteoarthritis
1st line for frozen shoulder
Analgesia (NSAIDs) + physiotherapy
2nd line for frozen shoulder
Local intra-articulate steroid injection
Nerve roots of ulnar nerve
C8-T1
Motor = innervates intrinsic muscles of the hand , innervates flexor capris ulnaris adn the medial half of flexor digitorum
Sensory = 4th adn 5th digits adn associated palm area
All the muscles in the hand are innervated by the X nerve apart from the LOAF muscles which are innervated by Y
X = ulnar
Y = median nerve
LOAF = lateral two lumbricals, opponens policis, abductor pollicis brevis , flexor pollicis brevis
Management of cauda equina syndrome
Urgent surgical decompression within 48 hours
This is a medical emergency
Management of osteomyelitis
Empirical antibiotics ie flucloxacillin + fusidic acid
Stop IV and switch to oral abx when the patient is table / 2 weeks post surgery
(Antibiotics for a minimum of 4-6 weeks)
Then surgical debridement = mainstay of treatment for chronic osteomyelitis
Acute infection can be treated with extensive surgical cleaning early on with antibiotics
What type of prothesis is this ?
Dynamic hip screw
What is a common radiogrpahic change seen in osteoarthritis
Loss of joint space / narrowed joint space
Due to loss of articular cartilage
Also : osteophyte formation, subchondral sclerosis, subchondral cysts
Pharmacological management of osteoarthritis
Analgesia - paracetamol, NSAIDs
1st = topical NSAIDs
More severe = intra-articular steroids injections
Surgical management of osteoarthritis
Joint replacement (arthroplasty) in severe cases = good pain reliever but will not improve function
+ Cozens test ?
Lateral epicondylitis aka tennis elbow
The test involves asking the patient to flex their elbow to 90 degrees making a fist and deviating their wrist radially - resistance in this extension positions elicits pain over the lateral epicondyle
Which cancer commonly metastasis to bones and causes sclerotic lesions ?
Prostate cancer
Management of SUFE
Surgery via fixation with a screw
Needs to be promptly - SUFE risk of Avascular necrosis of the femoral head
How is SUFE diagnosed
X-ray = frogs legs
Short displaced epiphysis and widened growth plate
Investigation for cauda equina syndrome
Urgent WHOLE spine MRI Q
Management = aim to decompress within 48 hours
Management of cauda equina syndrome where there is clinical suspicion of malignancy ?
Administration of dexamethasone 16 mg daily in divided doses
Features of a meniscal tear
Does not produce a positive drawer test - unless in combination with ACL tear
Swelling occurs 12-24 hours after injury
*cannot straight leg raise
Quadriceps tendon rupture
+ lachman’s
ACL rupture
What is an osteochondroma
Commonest form of benign bone tumour = which results in bony outgrowth on the external surface with cartilaginous cap
Small chance (1%) that it can become malignant
Can be an autosomal dominant hereditary disorder
FOOSH causes what kinds of fractures
Colles
Smiths
Management of Colles and smiths
- Manipulation under anaesthetic
Then ORIF
Features of Galeazzi fracture
Distal radius fracture 1/3
Distal ulnar joint dislocation
Monteggia fracture features
Proximal ulnar fracture
Proximal radial joint dislocation
Commonest cause of humeral surgical neck fracture
Osteoporosis
Management of humeral surgical neck fracture
Sling
Nerve affected in humeral surgical neck fracture
Axillaru
Commonest cause of humeral mid shaft fracture
Direct trauma
Nerve affected in humeral mid shaft fracture
Radial —> wrist drop
Management of humeral mid shaft fracture
Functional humeral brace
… if there is non-union —> plating and bone graft
Muscles for hip extensions
Gluteus max
Which hand muscles are innervated by median nerve
LOAF
Lumbricals
Opponens pollicis
Abductor pollicis brevis
Flexor pollicis brevis
What are the two muscles involved in De Quervain
Extensor pollicis brevis
Abductor pollicus longus
Structures found in the carpal tunnel
Flexor digitorum profundity
Flexor digitorum superficialis
Flexor pollicis longus
Median nerve
*fractured neck of fibula
Common peroneal nerve damage
*anterior thigh + reduced knee reflex
L3
Bone at base of thumb
Trapezium
Where is the radial artery found
Anatomical snuffbox
*medial aspect heel pain - made worse when walking on toes
Plant fasciitis
How is acute reactive arthritis managed
NSAIDs
Initial imaging modality of choice for Achilles tendon rupture
US
What is the imaging modality of choice for osteomyelitis
MRI
Cardiac complication of Ehlers-Danlos
Aortic regurgitation
SE of bisphosphonates
A wide variety of oesophageal problems
Ie patient must take these at least 30 minutes before breakfast with plenty of water + sit upright for 30 minutes
*McMurray’s - painful click
Meniscal tear
What movement makes lateral epicondylitis worse
Resisted writs extension with the elbow extended
Most common causative organism of osteomyelitis
Staph aureus
Why is Folate co-prescribed with methotrexate
Reduces the risk of myelosuppression
Management of subtrochanteric/extracapsular fracture of femur
IM device
Important side effect of biphosphonate
Heartburn (oesophageal problems)
Useful test to diagnose drug induced lupus
Anti-histone antibodies
Which drugs can cause drug - induced lupus
Isoniazid
Penicillamine
Procainamide
Phenytoin
How can an undisplaced patella fracture with an intact extensor mechanism be managed ?
Conservatively with knee immobilisation
