MSK Flashcards
Two main types of persistant pain disorders - fibromyalgia and CRPS. Define ACR criteria for FIbromyalgia:
Pain in >=9/18 joint pairs
Chronic pain >3 mo
Phyiscal (3) and mental sx (2) of fibromyalgia
Joint stiffness
Feeling of joint swelling
Fatigue
“fibro fog”
sleep disturbance
Strongest evidence based mx for fibromyalgia
Aerobic exercise
other mx - medical (Duloxetine/Pregabalin), analgesia, acupuncutre, CBT
Complex regional pain syndrome - what does the Budapest criteria involve?
Symptoms (1+) and signs (1+) - vasomotor (e.g. temperature asymmetry), sensory (allodynia/hyperaesthesia), motor (reduced range of motion) and oedema (asymmetry)
CRPS: distinguish type 1 and 2
Type 1 - absence of previous nerve injury
Type 2 - develops in presence of nerve injury, e.g. post #
Aims:
Reduction
Fixation
Reduction - acheive mechanical alignment of joint
Fixation - provide stability
General - 6-9 weeks of joint in fixed position to allow healing
Principles of # mx
* Initial assessment
* Managed in A&E or need admission?
* Mx of long bone # (3)
* General principle overall
Initial:
* Primary survey (A-E) –> Resus –> secondary survey
* Pain management
* XR (/CT)
* Manage in A&E (simple) or admitted (complex) - refer to trauma & ortho
Mx
* Reduction (closed or open) - alignment
* Fixation (conservative or operative) - stability & time for bone healing
* Rehab
Joint immobilisation for 6-weeks
Acute MSK pain mx
Ix - rule out #, dislocation, bleeding, neurovascular compromise (pulses, sensory, motor supply)
Mx - # (splint) , soft tissue (POLICE) + pain mx
Rotator cuff injury - a partial or full tear in one of the 4 muscles of shoulder. List the muscles & their main functions:
- Supraspinatus - abduction
- Subscapular - internal rotation
- Infraspinatus & teres minor - external rotation
but all have multiple functions
“Painful arc syndrome”: where is the pain for
- impingement syndrome (supraspinatus tendonitis)
- Acromio-clavicular joint arthritis
- 60-120, 170-180
Rotator cuff tear
Ex
Ix
Mx
Ex - E.g.
* supraspinatus: empty can test.
* drop arm test positive
* May also have impingement syndrome (painful arc between 60 - 120).
Ix -
* U/S is diagnostic
Mx -
* conservative (rest/adaptation/NSAIDs/physio), surgery (arthroscopic rotator cuff repair)
Shoulder: Capsule pathologies = OA and frozen shoulder.
30% of patients with frozen shoulder have which condition?
What is it also linked to?
F or M affected more?
It affects all active/passive movements but which the most?
DMT1
& metabolic syndrome
F>M, middle/old age
External rotation
Progression of frozen shoulder
- 6 mo per phase
- freezing –> frozen (stiff) –> thawing (reduced pain)
- Can take years to resolve
- May reqs referral for surgery if severe
Shoulder: Capsule pathologies = OA and frozen shoulder.
Joints affected by OA = acromio-clavicular and gleno-humeral.
Describe test for AC joint?
Scarf test
Shoulder dislocation
* Special test for shoulder instability?
* Associated defects (2)?
* Nerve damage causing reduced sensation in the regimental badge area?
- Apprehension test (crank) - supine, arm abduction –> apprehension on external rotation
- Hill Sachs defect (proximal humerus #) and the Bankart lesion - anterior labral tear
- Axillary nerve
Shoulder dislocation - glenohumeral joint
* Special test?
* Associated defects (2)?
* Nerve damage causing reduced sensation in the regimental badge area?
- Apprehension test (crank) - supine, arm abduction –> apprehension on external rotation
- Hill Sachs defect (proximal humerus #) and the Bankart lesion - anterior labral tear
- Axillary nerve
Ix & Mx shoulder dislocation
Lightbulb sign is indicative of?
- XR / MRI for other lesions
- Analgesia (Entonox), Reduction, Immobilisation
- Posterior
Humeral fractures: - neurovascular risks for each
* surgical neck of humerus
* midshaft
* distal humerus (supracondylar) - most common elbow fracture in children
- axillary nerve damage, and AVN if >1cm displaced
- radial nerve damage
- brachial artery injury (absent radial pulse), compartment syndrome (elbow swelling)
Olecranon bursitis = “student’s elbow”: swollen, warm and tender elbow joint.
What would you do if infection suspected?
How could you manage it?
- Aspiration –> MC&S, crystals, gram staining
- Aspirate fluid & abx if infected, or steroid injections, or conservative
Distal radius #s
Need to check if neurovascular compromised (median, ulnar, radial nerve)
distinguish Colle’s, Smith’s and Barton’s
1. Colles = FOOSH; dorsally (posterior) displaced distal radius; dinner fork, extra-articular
2. Smiths= fall backwards; garden spade, extra-articular
3. Barton’s= intra-articular # + disloation of radio-carpal joint
General mx distal radius #:
* Colles’
* Smith’s
* Barton’s / either if unstable:
- Non-surgical; immobilise in case
- Surgery
- Surgery
Scaphoid # is most common wrist fracture, causing swelling & tenderness in anatomical snuff box, pain on movement and thumb telescoping.
Ix - scaphoid series.
If x-ray shows no injury what is the next step and why?
Mx for confirmed scaphoid fractures - if undisplaced or if displaced/affects proximal pole rather than waist ?
- Splint
- Re-xray after 10 days
- risk of AVN due to disrupted radial artery blood flow(evident at later stage)
Mx
- Immobilisation with splint/back-slab and refer to ortho
- Cast 6-8weeks if undisplaced
- surgical fixation if displaced or proximal scaphoid pole
What are
Monteggias
Galaezzi’s
#s
GRUM
Fractures of the foream, with dislocations of the radio-ulnar joint
Galaezzi = distal radial #, FOOSH
Moteggias = proximal ulnar #
Classify #NOF into two categories:
- Intracapsular = subcapital, transcervical, basicervical
- Extracapsular = interotrochanteric, subtrochanteric up to 5cm distal
Presentation and examination findings of #NOF
- Hip pain –> knee, unable to weight bear
- O/E: shortened, externally rotated & abducted leg
What sign can be seen on XR for #NOF (intracpaulsar) & hip dislocation?
Disruption of Shenton’s line
Curved line between medial side neck of femur and inferior side of pubic ramus
Garden Classification for intracapsular #NOF (1-4)
- Undisplaced; partial #
- ”, full
- Displaced, partial
- ”, full
Mx of #NOF varies depending on type of # - what are the general principles?
* Extracapsular (intero and subtrochanteric)
* Undisplaced intracapsular (Garden I-II)
* Displaced intracapsular (Garden III-IV)
- Extracapsular: internal fixation (intero - dynamic hip screw, sub - intramedullary nail)
- Garden I-II: internal fixation
- Garden III-IV: hemiarthroplasty (hip replacement) or total hip replacement
NICE RECOMMEND ARTHROPLASTY FOR ALL PATIENTS WITH DISPLACED INTRACEPSULAR FRACTURES - GARDEN III AND IV
Risk of AVN with intracapsular #s
Distiguish THR from hemiarthroplasty
THR - replacement of femoral head with prosthetic head and acetabulum (ball & socket)
Hemi - just ball
3 complications of #NOF
- Hip dislocation
- Peri-prosthetic #
- Infection
O/E: Hip dislocation
Shortened, internally rotated and flexed leg
Trochanteric bursitits presents with gradual onset lateral hip pain that is worsened by activity. What examination findings would you expect?
- Positive Trendelenberg’ sign (hip dips on unaffected side)
- Pain on resisted movement - abduction and int/ext. rotation
Pelvic #s (pelvic ring/pelvic ramus) have a bimodal presentation - in young with high energy impacts or in elderly with low energy impacts.
What sx must you be aware of, suggestive of an internal # or haematoma?
- Haematuria
- PV bleeding
- Loin eccyhmosis
- Shock - hypovolaemia
List the Ottowa Knee Rules.
For XR
1945 - Knee-ver again!
* Unable to flex knee to 90 degrees
* * Isolated Tenderness of patella or **head of fibula*
* Unable to walk 4 steps immediately after injury or in ED
* >55
List the Ottowa Ankle Rules.
Exclusions include -
For XR
Pain (in malleolar area) + bony tenderness (in medial/lateral mallelous or posterior edge of tibia) or inability to walk 4 steps/WB immediately after/in ED.
Exclusions - >10 days injury, pregnancy, skin injury, <18.
Ottowa rules for Foot X-ray
Same as for ankle x-ray but with different anatomy.
Pain in midfoot area + 1 of
- bony tenderness in navicular bone or 5th metatarsal base
- inability to wlk 4 steps or weight bear immediately/ in ED
Patella #
- 2 types?
- common MOI?
- Mx?
- extra-articular or partial/full articular#
- dashboard injury –> avulsion #
- ORIF
Tibial plateu #
MOI
Schatzer classification (1-6) general
Knee forced into valgus or varum - bone breaks before ligmaent breaks
1-3 generally from low-energy impact
4-6 higher-energy
except for Schatzer 4 = split fracture of medial condyle or osteoporotic fracture
1= #, 2= depressed, 3= both, 4= split, 5= bicondylar, 6 = dislocation
Ankle fracture - Dans Weber Classification - from most stable to least stable (aka requiring ORIF);
* A
* B
* C
Initial mx
Other #s can have conservative mx - cast 4-6wks, serial X-rays and physio
A: below joint, tibiofindibular syndesmosis (TFS) intact
B: at level of joint, TFS partially torn
C: above joint, TFS disrupted
Initial mx: Prompt reduction (reduce pressure on overlying skin + subsequent necrosis) - surgical or conservative mx
Metatarsal stress # - also known as March #
- MOI
- RF
- Px
- Most common metatarsal affected
- Sign on x-ray
- Mx options
- overuse injury & prolonged standing
- female, eg. runners
- dull ache that eases during exercise, but painful at beginning and afterwards (e.g. maintain ability to go on runs despite pain)
- Grey cortex and periosteal erosion
- conservative (avoid aggrevating activity) or cast
- 2nd
Lisfranc joint complex injuries
* Can affect which areas of the foot?
* MOI
* x-ray findings (3)
* Mx options (2)
- Lisfranc ligament, tarsal or metatarsal bones, other ligaments of the midfoot. Fracture or strain/tear.
- Rotation whilst plantarflexed, strapping (think snowboarder/horse-rider in stirrups)
- Widening between 1st and 2nd metatarsal, displacement of 2nd TMT joint, associated #s (Fleck)
- Cast or ORIF
Achilles tendon injuries - distinguish
* Tendinitis
* Tendinosis
* Tendinopathy
- inflammation of the tendon
- microtears
- general damage/swelling/reduced function
Risk factors for Achilles tendon rupture / tendinopathy (4)
Quinolones - Ciprofloxacin, Levofloxacin
Inf. - RA/ank spond
Diabetes
Raised cholesterol
Achilles tendon rupture
* example patient
* triad of clinical findings
* gold standard inv
* mx
- middle aged man unaccostomed to exercise, sprinting, felt as if they were hit on calves + popping sound
- (MR) Simmonds triad - Simmond’s test +ve (x plantarflexion), Rests in dorsiflexion, palpable gap in heel
- U/S
- Cast with alteration from plantar flexion to neutral + rehab (or surgery)
Brachial plexus originates from which nerve roots?
Roots –>
C5-T1
Roots, Trunks, Divisions, Cords, Branches
Mononeuropathies - upper limb
Signs + cause of the following neuropathies:
* Axillary: sensory, motor deficits (2)
Axillary
* Loss of sensation in regimental badge,
* X shoulder adduction
* deltoid wasting
* Shoulder dislocation, surgical neck of humerus #
Median neuropathy
- name of pathology caused by compression to medial nerve
- findings (motor, sensory)
- causes of compression to extensor retinaculum
- Ix (1)
- mx (cons, medical, surgical)
- cause of bilateral CTS
- Carpal Tunnel syndrome
- motor: wasting of thenar eminence, weakness of thumb and 4/5th fingers; specifically 2LOAF (lateral 2 lumbricals, opponens policis brevis, abducens policis, flexor policis)
- sensory - paraesthesia of thenar eminence, palm –> 1/2 of 4th finger, dorsal 2-3rd finger tips
- compression to the extensor retinaculum - oedema, pregnancy, obesity, diabetes. Wrist #.
- Ix - nerve conduction studies
- Mx - conservative (wrist splint, weight loss, physio); medical (CS injections); surgical: flexor retinaculum division
- bilateral = RA
Radial neuropathy
- Findings (sensory, motor)
- Causes
- Dorsal paraesthesia (webbing);
- Wrist drop; weakness in forearm extensors (triceps)
- Midshaft # of humerus, wrist #
Ulnar neuropathy
* Motor, sensory findings
* Froment’s test shows what?
* Ulnar claw =
* Cause
- Motor: Weakness of majority of muscles of the hand (Except 2LOAF) muscles; hypothenar eminence wasting
- Paraesthesia of 1/2 ring finger and 5th and outer dorsum
- Froment’s - compensation for inability to adduct thumb - flexor policis longus causes hyperflexion of the DIP joint - check with removing piece of paper from grip
- Ulnar claw = unable to extend 4/5th fingers
- Cause - Klumpke’s paralysis (C5-T1), wrist #
Musculocutaneous neuropathy (rare)
typical cause
Axilla stabbing
The sciatic nerve branches into:
1. Common peroneal (fibular) nerve (–> superficial/deep branches)
2. Tibial nerve
Common peroneal nerve neuropathy
- supply from which spinal cord levels?
- motor findings (for deep PNN and superficial)
- sensory findings
supplied by L4, L5, S1
Foot drop:
- Deep = x dorsiflex
- Superfical = x eversion
sensory loss over dorsum & lower lateral part of leg
The other branch off the sciatic nerve is the tibial nerve.
Tibial neuropathy
- Supplied by which spinal cord levels?
- Motor findings
- Sensory findings
- Cause
-
- L4, L5, S1, S2, S3
- Cant stand on tiptoes (x plantarflex); pes planus, pronated foot, abnormal gait
- sensory = leg, foot
- Tibial tunnel syndrome - pain of median ankle
**Meralgia paraesthetica **is lateral thigh pain & paraesthesia, caused by compression of which nerve?
* From which nerve roots does it originate?
* Sx can be ellicited on examination by compression of ? and extension of?
* Important negative in MP
* Mx - medical (2)
* surgical (3)
- Lateral Femoral Cutaneous Nerve (LFCN)
- L2, L3
- ASIS compression & Hip extension
- No motor weakness; sensation symptoms only
- Medical = Amitryptiline, CS injections
- Surgical = 1. Decompression
2. Transection
3. Resection
Two types of Brachial Plexus injury
1. Affects superior trunk (C5,C6)
2. Affects inferior trunk (C8, T1)
- Erb’s: causes wrist flexion and elbow pronation. Post shoulder distocia.
- Klumpke’s - causes ulnar claw and Horner’s (if T1 affected). birth injury/difficult delivery.
Risk factors for AVNFH
Findings on xray (3)
Long term steroid use , Alcohol abuse.
Flattening of femoral head & irregular borders, osteopenia (reduced bone density), sclerosis.
Plantar fascitis - most common cause of adult heel pain
Initial mx (3)
And then refer to…
Rest, stretching & weight loss (if overweight)
Orthotics - insoles/heel pads
Back Pain Red Flags
* Cauda Equina
* Spinal mets
* Spinal infection
* Ank spond
- urinary retenion/incontinece, faecal incontience, saddle anaesthesia, reduced anal tone
- weight loss, localised bony tenderness, thoracic back pain
- fever, IVDU
- <40, M, progressive lower back pain, morning stiffness & pain at night
General mx for backpain
Conservative - low/high risk
Medical
What drugs are specifically not recommended by NICE for lower back pain?
- Low severity - self help, exercise, reassurance
- High severity - CBT, group exercise, physio.
- Medical - NSAIDs –> Codeine –> Benzos short couse.
- Not advised: neuropathic agents, opioids, antidepressants
**Sciatica - ** shooting pain down back of the leg
Nerve roots affected?
Causes?
First line mx?
If above fails after 4-6 weeks?
Screen for?
- L3/L4
- disc prolapse, spinal stenosis, spondylosithesis
- NSAID and physio
- Referral - ?neuropathic agents or specialist treatment (e.g. CS/local anaesthetic injections)
- bilateral sciatica - sign of cauda equina
Name of disease & cause
Isolated rise in ALP.
XR = osteoporosis circumstripta (lytic lesions), cotton wool spots, V shaped defects.
Paget’s disease of bone
Excessive bone turnover- but disordered bone modelling (uncoordinated activity of osteoblasts/osteoclasts resulting in patches of lysis and sclerosis)
Which bones does Paget’s particularly affect?
Mx?
- Axial skeleton - head (skull enlargement, hearing loss if bones of skull affected), spine (back pain)
- Bisphosphonates, NSAIDs for pain & monitoring
2 main complications for Pagets
- Osteosarcoma
- Spinal stenosis –> spinal cord compression
Cancers most likely to metastasize to bone (5)
Prostate
Renal
Thryoid
Breast
Lung
PoRTaBLe
Key presenting sx for central spinal stenosis
stenosis = compression of the spinal cord (central), nerve root (lateral) or foramina (of the vertebral foramina)
Intermittent neurogenic claudication (presents like PVD but ABPI normal & pulses present)
Osteomyelitis
* 2 modes of spread
* Ix (2)
* Mx (acute osteo & chronic)
- hematogenous (blood inf) & direct (op/open #)
- XR (subtle changes) –> MRI (dx)
- Acute - surgical debridement & abx (Fluclox +/- Rifampicin 2 week). Chronic - abx 3 mo.
XR changes for osteomyleitis (however may not be obvious for several weeks)
- Periosteal reaction
- Localised osteopenia
- Destruction of bone
Fever & back/flank pain & IVDU
Iliopsoas abscess
Bone tumours
Malignant:
* Osteosarcoma
* Chondrosarcoma
* Ewing’s sarcoma
*Which is the most common primary malignant bone tumour?
*
Benign:
* Osteoma
* Osteochondroma
* Giant cell tumour
Key points/demographics for each:
* Ewing’s - pelvis/long bones, severe pain, onion skin (XR)
* Chondrosarcoma - cartilage, axial skeleton, middle age
* Osteosarcoma - most common, children/teens, long bones prior to epiphyseal closure. Codman triangle & Sunburst (XR). Rb mutation, radioX and Paget’s (RF).
