MSK Flashcards
XR findings of osteoarthritis
Loss of joint space
Osteophytes
Subcondral sclerosis
Subcondral cysts
XR findings of rheumatoid arthritis
Loss of joint space
Juxta-articular osteoporosis
Soft-tissue swelling
Peri-articular erosions
Subluxation
Compartments of the knee
Medial
Lateral
Patellofemoral
Investigations of osteoarthritis
Clinical
Bedside: obs (systemically well)
Bloods: infection, inflammation, bone profile
Imaging: x-ray
Management of osteoarthritis of hip or knee
MDT approach
Conservative: risk factor modification such as weight loss and exercise, physio to strengthen muscles and modifications of ADLS under supervision of OT
Medical includes analgesia according to Who pain ladder and sometimes IA steroids but this only short term relief
Ultimately surgery may be required, decision made by orthopod after weighing up pros and cons
Why would a patient have arthroscopy?
Anterior cruciate ligament tear
Meniscus tear (trim or repair torn meniscus)
Synovitis (remove inflamed tissue)
Osteoarthritis sometimes to clean debris
What is a patellofemoral joint replacement and when would it be done?
Partial knee replacement (unicompartmental)
Replacing the back of the patella and front of the femur, replacement sits between
Due to isolated patellofemoral arthritis, preserves more natural anatomy in knee for younger, active patients
Complications of knee replacement
Infection
Pain
Bleeding
Stiffness
Ankylosing spondylitis presentation
Reduced lateral flexion
Reduced forward flexion
Reduced chest expansion
Investigations and management for ankylosing spondylitis
Bedside: spirometry (restrictive)
Bloods: ESR, CRP
Imaging: XR of sacroiliac joints (sacroiliitis: subcondral erosions, sclerosis), CXR, if negative do MRI
Conservative: exercise, physio
Medical: NSAIDs, consider DMARDs, consider anti-TNF
Acute back pain in a&e management
Neuro exam (including DRE for sensation and tone)
Urgent MRI
Surgical decompression
(may also see bilateral sciatica and urinary dysfunction in cauda equina)
Presenting difference between spinal stenosis and prolapsed disc
Spinal stenosis
- better when sitting
- better when leaning forward
- back pain and claudication pain
(laminectomy)
Prolapsed disc
- worse when sitting
- leg pain worse than back
- LMN and sensory signs
(conservative management for 4 weeks, then MRI)
Differentials for leg length discrepancy
Developmental dysplasia
Fractured femur
Hip osteoarthritis
Pelvic tilt (true leg length the same)
What is Shenton’s line and why is it significant?
Curved line along inferior border of superior pubic ramus and inferiomedial border of neck of femur
Suspect hip fracture or dislocation if line disrupted
What are the types of gait?
Antalgic - stance phase reduced on affected leg
Hemiplegic - circumduct leg due to weakness and spasticity
Diplegic - bilateral hemiplegic
Parkinsonian
Ataxic (like drunk)
Neuropathic - foot drop, dragging toes, high stepping
Myopathic - weakness of hip abductors, waddling
Indications for differnet types of hip replacement
Intracapsular, undisplaced - internal fixation (cannulated screws)
Intracapsular, displaced - THR or hip hemiarthroplasy
Extracapsular (intertrochanteric), undisplaced - dynamic hip screw
Extracapsular, displaced - intramedullary device
Angles of ROM in a hip exam
Flexion - 120
Extension 180
Internal rotation - 40
External rotation - 45
Abduction - 45
Adduction - 40
What does Trendelenberg’s test check?
Identify weakness of hip abductors
Stand on one foot, drop to opposite side of weak hip
Septic arthritis cause
Staphylococcus aureus
Neisseria gonorrhoeae in sexually active young adults
Which tests would you omit in a knee exam if you saw a replacement scar?
Patellar effusion
Ligament/menisci tests
Rheumatoid arthritis investigations and management
Bedside: obs
Bloods: infection, inflammation, rheumatoid factor, anti-cyclic citrullinated peptide antibody
Imaging: x-ray of hands and feet
Short-course briding prednisolone + DMARD e.g. methotrexate
TNF-inhibitors if no response to 2 DMARds including methotrexate
Epicondylitis investigations and management
Consider x-ray or USS
Physio
Analgesia
Steroid injection
Episodes 6 months - 2 years (acute pain usually a couple of months)
Gout investigations and management
Bedside: obs
Bloods: urate after acute attack
Imaging: synovial fluid analysis, erosions on radiograph (chondrocalcinosis in pseudogout)
Acute: NSAIDs, steroids, colchicine
Long-term: allopurinol, febuxostat
Osteoarthritis hand features
Bouchard’s nodes (PIP)
Heberden’s nodes (DIP)
Squaring of thumbs
Rheumatoid arthritis hand features
Swan neck deformity (late)
Boutonniere deformity (late)
Ulnar deviation
Carpel tunnel investigations and management
Clinical
Nerve conduction studies
Electromyography
USS
Wrist splint
Steroid injection
Surgery to relieve pressure
Osteoarthritis of hand management
Conservative
1. Paracetamol and topical NSAIDs
2. Oral NSAIDs
Rotator cuff muscles
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Painful arc affected muscles
First 60 degrees: rotator cuff tear
60-120 degrees: supraspinatus impingement
Shoulder movements and relevant muscles
Empty can test - supraspinatus
Painful arc - rotator cuff and supraspinatus
External rotation against resistance - infraspinatus and teres minor
Internal rotation against resistance - subscapularis
Scarf test - acromioclavicular joint pathology
Erb’s vs Klumpke’s
Erb - C5, C6 - waiter’s tip
Klumpke - T1 - claw hand
ACL tear management
Conservative: rest, elevation, ice, physio, bracing
NSAIDs
Surgical reconstruction - patellar tendon autograft or hamstring tendon graft (back of knee)
Which knee replacement is preferred in older patients?
Total knee replacement - usually more severe knee damage, and also provides better pain relief and improved function (despite more risk of complications and longer hospital stays)
Is hemiarthroplasty or total hip replacement preferred in older patients?
Hemiarthroplasty
Investigations and management for mechanical back pain
MRI only if malignancy, fracture, cauda equina suspected
Stay active
NSAIDs (+ PPI >45yrs)
