MSK Flashcards
What is epicondylitis
inflammation at the point where the tendons of the forearm insert into the epicondyles at the elbow
What are the 2 epicondyle and what movement are they responsible for
medial and lateral epicondyle
medial= flex the wrist
Lateral= extend
Why do you get epicondylitis
it is a result of repetitive use and injury to the tendons at the point of insertion
What are the names of the 2 epicondylitis
Medial is known as golfers elbow and lateral is known as tennis elbow
What do patient typically present with in golfers elbow
they report gradual-onset medial elbow pain exacerbated by activity, particularly flexion of the wrist
Treatment for golfers elbow
self-limiting, Rest, physiotherapy, NSAIDS
presentation of tennis elbow
pain in outer elbow , the pain often radiates down to forearms
what tests are done for tennis elbow
Mill’s test and cozens test
Treatment for tennis elbow
self-limiting, Rest, physiotherapy, NSAIDS
What is osgood - schlatter disease
it is caused by the inflammation at the tibial tuberosity where the patella ligament inserts. It is a common cause of anterior knee pain in adolescents
is osgood-schlatter more common unilateral or bilateral
unilateral
What age group and gender is osgood schlatter disease common in
10-15 year olds
male
Pathophysiology of Osgood Schlatter disease
The patella tendon inserts into the tibial tuberosity. In patients with osgood-schlatter disease multiple minor avulsion fractures occur where the patella ligament pulls away tiny pieces of the bone. This leads to growth of the tibial tuberosity, causing a visible lump below the knee. Initially, this lump is tender due to inflammation. As the bone heals and inflammation settles, the lump becomes hard and non-tender.
A hard, non-tender lump is then permanently present at the tibial tuberosity.
Presentation of osgood-schlatter disease(3)
presents with a gradual onset of symptoms :
-Visible or palpable hard and tender lump at the tibial tuberosity
- Pain in the anterior aspect of the knee
- pain exacerbated by physical activity, kneeling and on extension of the knee
Management of osgood-schlatter disease
Initial management focuses on reducing pain and inflammation.
Reduction in physical activity
Ice
NSAIDS (e.g., ibuprofen) for symptomatic relief
Once symptoms settle, stretching and physiotherapy can be used to strengthen the joint and improve function.
What is fibromyalgia
it is a chronic pain syndrome characterised by widespread body pain
presentation of fibromyalgia
Widespread body pain
tiredness
other possible symptoms:
- headaches
-IBS
- Bladder issues
-restless leg syndrome
-depression/anxitey
-cognitive impairment
-sleep disturbances
What are the risk factors fibromyalgia
FHx
Rheumatological conditions
20-60yrs
female
Treatment options for fibromyalgia
- antidepressants , painkiller
CBT, counselling
Lifestyle changes
What is gout
type of crystal arthropathy associated with chronically raised uric acid levels
What happens in gout
urate crystal are deposited in the joint causing it to become hot, swollen and painful
Name 7 risk factors for gout
Male
Obesity
High purine diet (e.g. meat and seafood)
Alcohol
Diuretics
Existing cardiovascular or kidney disease
FHx
Name 3 typical joints where gout occurs
base of big toe( metatarsophalangeal joint)
Wrists
Base of thumb ( carpometacarpal joints)
What emergency condition should you exclude if you suspect gout
septic arthritis
What will an aspiration fluid show in gout
No bacterial growth
needle shaped crystal
Monosodium urate crystals
X-ray finding in gout
lytic lesions
punched out erosions
Acute flare management of gout
NSAIDs
Colchicine
Steroids
Prophylactic management of gout
Allopurinol
Lifestyle changes- losing weight , staying hydrated and minimising alcohol and purine based food
What is polymyalgia rheumatica
chronic inflammatory disease characterised by aching and morning stiffness in the neck, shoulder and pelvic girdle
Name 4 risk factors for polymyalgia rheumatica
age over 50 years
Prior history of giant cell arteritis
Female
Fhx
Clinical features of polymyalgia rheumatica
Pain, stiffness and weakness in the muscles of their neck shoulders , buttocks and hips
symptoms are worse first thing in the morning
What other condition is strongly linked with polymyalgia rheumatica
Giant cell arteritis
Clinical examination features of polymyalgia rheumatica
proximal muscles tender to touch
active and passive range of motion is limited by pain
what are the 2 lab investigations done in polymyalgia rheumatica and what are their typical findings
Full blood count (FBC): normocytic anaemia or thrombocytosis
Inflammatory markers: ESR and CRP are elevated
What are the 3 relevant imaging done in polymyalgia rheumatica
ultrasound
MRI
FDU PET
Medical management for Polymyalgia rheumatica
Glucocorticoids (e.g. prednisolone)
What is osteoarthritis
often described as wear and tear, it is not an inflammatory condition
it is progressive, degenerative joint disorder
name 4 risk factors for osteoarthritis
increasing age
female sex
obesity
Less commonly, articular congenital deformities or trauma to the joint
symptoms of osteoarthritis
Joint pain
stiffness
limitation in day to day activities
3 typical clinical finding for osteoarthritis
Reduced active and passive range of movement
Tenderness over the joint line
Crepitus on movement
Is CRP/ESR normal or abnormal in osteoarthritis
normal
What imaging is used for osteoarthritis and what are the findings
X-ray
Mnemonic = LOSS
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
Diagnostic criteria for osteoarthritis
more than or equal to 45 year old
Has activity-related joint pain
has either no morning joint0related stiffness or morning stiffness that lasts no longer than 30 min
First line Management for osteoarthritis
conservative management
what are the conservative management for osteoarthritis
Education and advice about condition
Exercise
weight loss if obese
Medical management for osteoarthritis
1st line :NSAIDs
2nd line: Paracetamol and topical analgesia
management for acute exacerbation of osteoarthritis
Corticosteroid injections
surgical option for osteoarthritis
Joint replacement or fusion of the joint
What is osteoporosis
a condition where there is a reduction in the density of the bones
Risk factors for osteoporosis
Older age
female
low BMI
Rheumatoid arthritis
Alcohol and smoking
Long term use of corticosteroids
Post-menopausal women
Name of tool used to asses likelihood of a fragility fracture due to osteoprorosis
FRAX tool
diagnostic investigation for osteoporosis
DEXA scan
T score meanings on DEXA scan for osteoporosis
T score = 0, normal bone density. Your bones are as strong as people your sex/age
T score >0, good bone density. Your bones are stronger than people your age/sex
T score between -2.5 and 0, osteopenia
T score <-2.5, osteoporosis
symptoms of osteoporosis
ASYMPTOMATIC UNTIL A FRACTURE APPEARS. Osteoporosis does not cause any
pain! It leads to fractures which can cause pain
Treatment for osteoporosis
Lifestyle changes
Vitamin D and calcium
Bisphosphonate
Most common shoulder dislocation
anterior dislocation
what are posterior dislocations associated with
electric shock and seizures
How do patients with anterior shoulder dislocation often present
The patient with anterior dislocation keeps the arm at the side of body in external
rotation
How do patients with posterior shoulder dislocation often present
Posterior dislocation is diagnosed clinically as the arm is held in medial rotation and is locked in that position
What is adhesive capsulitis
aka frozen shoulder
it is a complication of shoulder injury or surgery
4 risk factors for frozen shoulder
middle age
diabetes
women more than men
thyroid disease
2 classification of frozen shoulder
Adhesive capsulitis can be:
Primary – occurring spontaneously without any trigger
Secondary – occurring in response to trauma, surgery or immobilisation
Signs and symptoms of frozen shoulder
Affect ADLs, severe stiffness shoulder + coracoid pain test
Treatment for frozen shoulder
Physiotherapy and NSAID first line
IA steroid injection
What is colles’ fracture
distal radial fracture with dorsal displacement of the distal fragment
has a dinner fork deformity
Who are at higher risk for colles fracture
elderly and osteoporotic pt
What type of injury is likely to lead to colles fracture
FOOSH
Treatment for colles fracture
Straightening the deformity and immobilisation for six weeks
What is a smiths fracture
aka reverse colles fracture
a fracture of the distal radius caused by falling onto flexed wrist
What age is pulled elbow common
in children under 5 years
How does pulled elbow happen
when swinging children by hands
Signs and symptoms of pulled elbow
not using the arm, elbow in extension, forearm in pronation, no swelling
marked resistance and pain with supination of the forearm
how is a pulled elbow diagnosed
X-ray
Tx for pulled elbow
Reduction and mobilisation
where is the scaphoid bone located
in the anatomical snuffbox
is scaphoid fractures usually diagnosed by X ray or MRI
MRI
It often shows a normal XRAY
Treatment for scaphoid fracture
Immobilise
Common type of injury that cause scaphoid fracture
FOOSH
What is a major risk/complication of a scaphoid fracture
Avascular necrosis
What is carpal tunnel syndrome
caused by compression of the medial nerve as it travels through the carpal tunnel in the wrist
7 risk factors for carpal tunnel syndrome
repetitive strain
obesity
perimenopause
rheumatoid arthritis
Diabetes
Acromegaly
Hypothyroidism
Presentation of carpal tunnel syndrome
gradual onset
intermittent symptoms
worse at night
numbness, pins and needles, burning sensation and pain
name the 2 special test for carpal tunnel syndrome
Phalen’s test
Tinel’s test
which fingers are effected in carpal tunnel syndrome
thumb, index, middle and part of the ring finger
What investigation is used to diagnose carpal tunnel syndrome
nerve conduction studies
Treatment for carpal tunnel syndrome
NSAID
Splints
Steroid injection
Surgical decompression
What is dupuytrens contracture
flexion contracture of the hand , patient often describe finger getting caught on things
What test is used for dupytrens contracture
tabletop test
Risk factors for dupuytrens contracture
Men 40-60
diabetes
Smoking
Management for dupuytrens contracture
Monitor in early cases
Corticosteroid injection
Surgery
What happens in de quervain’s tenosynovitis
the sheath of the tendons on the thumb side of the wrist becomes inflamed or swollen,
restricting the tendons’ movement
what test is used for de quervain
Finklestein
Treatment for de quervain
Analgesia, splint, steroid injection and surgery
What is scoliosis
curvature of the back - left to right
difference between a back strain and sprain
back sprain overstretching or tearing of ligament around the spine
back strain is the overstretching or tearing of muscles or tendons
Recommendation for back sprain/strain
try to keep active as possible
offer NSAID
How does a strain/sprain present
Pain around affected joint, tenderness, swelling, bruising, functional loss
Conservative management for sprains and strains
RICE
Rest
Ice
Compression
Elevation
What is osteomyelitis
an inflammation of the bone as result of an infection
What is the most common causative of osteomyelitis
Staph aureus
Risk factor for osteomyelitis
Penetrating injury
Surgical contamination
IV drug use
Diabetes
Periodontitis
When should a diagnosis of primary or recurring osteomyelitis be considered
If a patient presents with a vague history of non-specific pain and low grade fever of 1-3 months
What is the typical presentation of haematogenous osteomyelitis
malaise , fatigue, local inflammation and a low grade fever
Management for acute osteomyelitis (conservative and medical )
Conservative: affected limb should be immobilised and pain management with analgesia administered.
Medical: high dose empirical antibiotics following local guidelines.
Management for chronic osteomyelitis
Surgical debridement of the affected area and iv antibiotics
What is bursitis
inflammation of the small fluid sacs called bursa which are localised near joints
what are 2 common types of bursitis
clergyman’s (infrapatellar) and housemaid’s (prepatellar) knee.
Risk factors for bursitis
Age
occupation
Rheumatoid arthritis
Gout
Diabetes
Wound/skin tears on the knees
Presentation of bursitis
Swelling and erythema of the knee
Pain and tenderness
Reduced range of movement
Hx may include recent trauma or repetitive knee movement
Conservative management for bursitis
Rest ice and elevation
cushion or padding when kneeling
physiotherapy
Medical/ surgical management in bursitis
ibuprofen with ppi in elderly
incision and drainage
corticosteroid injection
What is chondromalacia
aka runner’s knee. a condition where the cartilage on the under surface of the patella deteriorates and softens
Presentation of chondromalacia
Vague occurring pain that is felt behind the knee Worse after every day activities including:
prolonged sitting
walking up and downstairs
after squatting or kneeling
Worse after repetitive use i.e. physical sport
Conservative management for chondromalacia
Avoid strenuous and overuse of the knee
Physiotherapy
Physio taping
Medical and surgical management for chondromalacia
Paracetamol, ibuprofen, naproxen
arthroscopy
Shaving of cartilage behind patella patellectomy
What will x-rays show in chronic osteomyelitis
intramedullary scalloping , cavities and a ‘fallen leaf’ signs indicating section of endosteal sequestrum fallen into the medullary canal
What is a herniated disk pulposis
occurs when a portion of the nucleus pushes through a crack in the annulus
Presentation of a herniated disc
Pain
Sensation changes
Weakness
Incontinence if severe
Management for herniated disc
Heat and massage, avoid activities that worsen pain
Pain relief
What is meniscal injury
Injury/degenerative changes of the knee joint
Presentation of meniscal injury
Pain- worse on activity
popping and clicking
Unstable knee
Locking of knee
Limited ROM of knee
Slow swelling
Which test is used to determine presence of meniscal tear
McMurrays test
How to know to which menisci is injured
Pain during external rotation = medial meniscus injury
Pain during internal rotation = lateral meniscus injury
Gold standard investigation for meniscal injury
MRI
Management for meniscal injury
Conservative - RICE
Physiotherapy
What is metabolic bone disease
Broad spectrum of disorders affecting the bone
Metabolic bone disorders can be caused by osteoporosis, osteomalacia (due to CKD, Malnutrition, malabsorption) Pagets disease.
The underlying pathogenesis involves bone demineralization due to imbalance between osteoblasts and osteoclasts
Risk factors for metabolic bone disease
Medications e.g steroids
Family history
Endocrine e.g Hypopituitarism
CKD
Diet (vegetarian)
Dark skinned
Presentation of metabolic bone disease
Weakness
Reduced height
Fractures
Gait problems
Reduced ROM
reduced power
pathophys of paget’s disease
Osteoclasts are bone resorbing cells while osteoblasts are bone forming cells.
Pagets disease occurs when there is an increase in bone resorption (osteoclasts), there is a compensatory increase in osteoblasts which results in abnormal bone formation.
Risk factors for pagets disease
Mechanical stress
Enviromental factors
Genetic factors
Infections (paramyxovirus)
presentation of pagets disease
Bone pain
bone deformity
fracture
increased bleeding
weakness
gait abnormality
blood investigations and it’s findings for pagets disease
Alkaline phosphatase -raised
FBC- anemic
calcium/parathyroids hormone
what imaging is done in pagets disease and what is its findings
x-ray- may appear as radiolucent chnages or ;cotton wool’ pattern in the skull
Management of pagets disease
walking stick
analgesia
Bisphosphonates
Pathophysiology of renal bone disease
Parathyroid hormone helps calcium absorption but inhibit phosphate absorption from kidney but helps reabsorption of phosphate from intestine
In renal osteodystrophy, the kidney is unable to produce vit D which results in low levels of calcium in the body and rise in PTH as result of positive feedback mechanism. A rise in PTH causes there is increased absorption of phosphate from kidneys
Risk factors for renal bone disease
Diabetes
autoimmune disease
family history
hypertension
HIV
cancer
Immunosuppression
Presentation of renal bone disease
Limb/abdominal swelling
Tetany,parasthesia
Pruritus
SOB
Investigation and its finding in renal bone disease
Bloods:
FBC (Anaemia)
Phosphate (High] Calcium (Low),Vitamin D (Low)
Alkaline phosphatase (may be high or normal depending on concomitant pathology)
Albumin (Low if nephrotic syndrome)
Creatinine and urea (raised)
X-ray/Imaging:
Parathyroid ultrasound. DEXA scan. Nuclear bone scan
Management for renal bone disease
Bisphosphonate
Manage vit D deficiency
High phosphonate managed by diet or phosphate binders
What is septic arthritis
infection of one or more joints either by direct inoculation or haematogenous spread of infectious organism
2 Most common causative agent for septic arthritis
staphylococcus or streptococcus
Name some risk factors for septic arthritis
RA
OA
Joint prosthesis
IVDU
Diabetes
Cutaneous ulcers
Presentation of septic arthritis
hot swollen and painful joint
less than 2 week hx
fever and other signs of systemic infection
What are the Ix (6)for septic arthritis ad its finding
FBC- raised inflam markers
ESR- elevated
CRP- raised
Blood culture- to check organism
Synovial fluid WBC- >100,000 = sepsis
X-ray and ultrasound
Management for suspected gram positive organism in septic arthritis
Vancomycin
Management for suspected gram negative organism in septic arthritis
ceftriaxone
What is slipped upper femoral epiphysis
most common hip disorder amongst adolescents
its a weakness in the proximal femoral growth plate, which leads to a fracture displacing the metaphysis anteriorly and superiorly
Grading system for a slipped upper femoral epiphysis
grade 1: 0-33% slippage
grade 2: 34-50% slippage
grade 3: >50% slippage
Risk factors for slipped femoral epiphysis
Trauma to hip/femoral area
obesity
Puberty
Growth hormone deficiency
Presentation of slipped upper femoral epiphysis
may have recent trauma
limping
poorly localised pain
antalgic gait and externally rotated hip
maybe be unable to bare weight
Examination finding in slipped upper femoral epiphysis (4)
-Reduced internal rotation of hip
-Problematic leg is shortened and externally rotated
-Trendelenburg’s gait positive
-possible antalgic gait
Ix for slipped upper femoral epiphysis
Bloods to rule out endocrine causes
X-rays- draw klein line - trethowan sign is when the klein line passes above the femoral head confirming a slipped upper femoral epiphysis
2 signs u look out for in slipped upper femoral epiphysis and what are they
trethowan sign- when the klein line passes above the femoral head confirming the diagnosis
Steel sign - crescent shaped line of increased density over the metaphysis
Conservative, medical and surgical management for slipped upper femoral epiphysis
conservative- rest and immobilisation( crutches or wheelchair)
Medical- analgesia
Surgical:
- percutaneous in situ fixation
- open fixation of growth plate using bone graft
what is pseudogout
its a form of arthritis characterised by sudden painful swelling in one or more of your joints
what crystal are deposited in pseudogout
calcium pyrophosphate crystal
Risk factors for pseudogout
Older age
Trauma to joint
Mineral imbalance
Hyperparathyroidism
Acromegaly
Haemochromatosis
Wilsons disease
Presentation of pseudogout
Sudden onset
pain and swelling in the affected joint
lasts for 7-14 days
Ix for pseudogout
to rule out imbalances do tsh, parathyroid test and U+E
Joint X-rays and ultrasound : detect calcification
Joint fluid analysis
Management for pseudogout
rest, ice, elevate
NSAIDs
Colchicine
Prednisolone
Corticosteroid injection
What is Rheumatoid arthritis
a form of inflammatory arthritis
Risk factors for RA
women
Aged 70 and over
Smoking
HLA DR4 and DR1
Winter
Presentation of RA
Gradual onset
Symmetrical symptoms
pain, swelling and stiffness of joints
Early morning stiffness lasting more than 30 min
Examination finding on RA
Join swelling B/L
Pain on palpation
swan neck
Boutonnieres - PIP and DIP hyperextension
Ulnar deviation
RH nodules
Ix for RA
FBC, ESR,CRP,LFT
ANA- positive
anti-ccp antibodies
Rhaeumatoid factor
x-ray
Management for RA
Refer to rheumatologist
give nsaids at low dose
methotrexate
flare up- glucocorticoids
What is ankylosing spondylitis
type of arthritis that mainly affects the back , by causing inflammation in the spine
risk factors for ankylosing spondylitis
HLA B-27 positive
FHx
Presentation of ankylosing spondylitis
Dull ache /pain
SOB if ribs affected
Fever
Weight loss
Paraspinal tenderness
Reduced ROM
Kyphosis
what is spinal stenosis
narrowing of the spinal canal which puts stress on the nerves running through.
more common in the lower back and the neck
presentation and history of spinal stenosis
Pain(relived by leaning forward or lying supine)
weakness/fatigue
Changes in sensation
What is rotator cuff
group of four muscles that are positioned around the shoulder joint
