MSK Flashcards
What is the name of pain, swelling and impaired function of the tendon of the gastrocnemius and soleus muscles?
Achilles tendinopathy
Is mid-portion or insertional Achilles tendinopathy more common?
Mid-portion
Where does mid-portion Achilles tendinopathy affect?
Area of the Achilles tendon roughly 2-6cm above its insertion on the calcaneus
What intrinsic factors can increase risk of Achilles tendinopathy?
Biomechanical abnormalities, diabetes, high cholesterol, hyperuricaemia, and inflammatory disorders
What extrinsic factors increase the risk of Achilles tendinopathy?
Previous injury, footwear, training factors (hard surface, interval training etc), and some drugs
Which drugs increase the risk of tendinopathy?
Corticosteroids
Quinolones
Statins
Aromatase inhibitors
What are the risk factors for Achilles tendon rupture?
-Increasing age
-Tendinopathy
-Poor blood supply
-Some medications
-Some sports or change in exercise regime
-Previous Achilles tendon injury
How long can Achilles tendinopathy take to improve with conservative management?
12 weeks minimum, however can last up to 2 years
What symptoms may a patient report with Achilles tendon rupture?
Sudden onset pain
Audible snap
Difficulty weight-bearing
A patient who runs and has recently started training for a marathon comes in reporting left sided heel pain and stiffness in heel on waking or sitting for a while.
What signs might indicate the likely diagnosis?
Achilles tendinopathy:
-Erythema/oedema/asymmetry
-Tenderness to palpation
-Pain on dorsifelxion
-Poor heel-raise endurance test
A patient who runs and has recently started training for a marathon comes in reporting left sided heel pain and stiffness in heel on waking or sitting for a while.
Is imaging needed to make the diagnosis here?
No - ultrasound or MRI is not routinely needed or recommended in primary care, it is a clinical diagnosis
Is complete Achilles tendon rupture painful?
Not always - roughly 1/3 do not complain of pain
What does Simmonds triad help to exclude?
Achilles tendon rupture
What is Simmonds triad?
Angle of Declination
Palpation
Calf Squeeze test
How is Simmonds triad assessed?
Pt lies prone with feet over edge of couch:
-Angle of declination may be greater (dorsiflexion) in injured limb
-Gap felt in tendon on palpation
-Gentle squeezing of calf will cause foot to remain neutral if acute rupture has occurred
Why can chronic Achilles tendon rupture be difficult to diagnose?
Pain and swelling go down with time, any gap will fill with fibrous tissue, calf may be wasted, and other muscles help with plantar flexion of foot
A patient who runs and has recently started training for a marathon comes in reporting a sudden snap sound while running, left sided heel pain and stiffness in heel on waking or sitting for a while. Simmonds triad is present.
What is the management in this case?
Admission or same-day referral to orthopaedics as per local protocol
A patient who runs and has recently started training for a marathon comes in reporting left sided heel pain and stiffness in heel on waking or sitting for a while. Simmonds triad is not present.
What is the management in this case?
-Manage any underlying conditions
-Ice, rest, simple analgesia
-Weight-bear as tolerated
How long might Achilles tendinopathy take to improve with conservative management?
7-10 days
If Achilles tendinopathy fails to improve after 7-10 days with conservative management, what should be recommended?
Physiotherapy referral
If chronic Achilles tendinopathy fails to improve after conservative management and physiotherapy, what should be recommended?
Referral to sports physician or orthopaedics
What options does secondary care have for managing chronic Achilles tendinopathy?
-Exercise programmes
-Shock-wave therapy
-Surgery
What analgesics are used for mild-to-moderate pain?
-Paracetamol
-NSAIDs e.g. ibuprofen/naproxen
-Aspirin
-Weak opioids
If a child does not respond to both paracetamol and ibuprofen for pain management, what should be done?
Discussion with specialist
Why is it good for combination analgesics to be avoided first-line?
Prescribing single constituent analgesics allows for independent titration of each drug
What are the two types of NSAID?
Non-selective COX-1 and COX-2 inhibitors, and Coxibs (highly selective for COX-2 enzymes)
How do COX enzyme inhibitors work?
Reversibly inhibit cox enzyme thereby inhibiting prostaglandin synthesis, which inhibits vasodilation, inflammation, and platelet aggregation and bronchoconstriction/dilation
Which are the non-selective NSAIDs?
Diclofenac, ibuprofen, indomethacin, naproxen
Which are the coxib NSAIDs?
Celecoxib and etoricoxib
How does aspirin work?
Salicylate NSAID which irreversibly inhibits COX enzymes and blocks thromboxane production.
How does paracetamol work?
Not fully understood but thought to inhibit cox enzymes in CNS
How do weak opioids work?
Binding to opioid receptors in CNS, GI tract and other systems, leading to decreased pain perception.
Why is tramadol different to other weak opioids?
It also directly inhibits noradrenaline and serotonin uptake in CNS to alter how pain is perceived
What are the most common causes of bites?
Dogs, cats, and humans
Where do most human bites occur?
On the hand
What might a deliberate human bite indicate?
Abuse, child abuse, or sexual crime, or expression of frustration in children
Why are abscesses and osteomyelitis more common after cat bites than after dog or human bites?
Fluids can only drain from small skin puncture wounds, so retention of infectious agents etc more common due to cats long but fine sharp teeth
What are the complications of bites?
-Bacterial infection
-Tetanus
-Cat scratch disease
-Viral infections including rabies
-Structural damage
-Psychological effects
What bacteria are common following human bites?
Strep spp
Staph aureus
Haemophilus spp
Anaerobic bacteria
What bacteria are common following animal bites?
Most are polymicrobial
What causes tetanus?
Clostridium tetani which releases tetanus toxin
What are the effects of tetanus toxin?
Generalised rigidity
Muscle spasms
After a bite, what questions should be asked regarding tetanus/BBV risk?
-Tetanus status
-Contaminants and mechanism of bite
-BBV vaccination status
-Biter BBV status if known
Should patients with human bites be offered antibiotics?
Yes IF skin was broken and blood drawn, or skin broken in high risk area or patient at high risk of infection
What prophylactic antibiotics should be offered after a human or animal bite when indicated?
Co-amoxiclav for 3 days
If pen allergic - metro and doxy
What antibiotics should be offered for an infected human or animal bite?
Co-amox for 5 days
Doxycyline and metronidazole for 5 days if pen allergic
How should clinical tetanus be managed?
IV antibiotics and IVIG
Tetanus vaccine after recovery
Supportive care
Who needs antibiotics after a cat/animal bite?
Anyone who’s skin has been broken and bite drawn blood
What can cause a burn?
thermal energy, electrical, chemical, or radiation energy
What can be burnt?
Skin most commonly, but also airways, lungs, muscles, bones, and internal organs
What is a scald?
A burn caused by contact with hot liquid or steam
What is a complex burn?
A burn due to electrical or chemical substance, any thermal burn to critical area (face, extremities, genitalia, perineum), or affecting >15% total surface are of an adult (10% in children)
What is a non-complex burn?
Partial thickness burns up to 15% adult body surface area, up to 10% of child’s surface area, that does not affect a critical area
Deep partial thickness on up to 1% of BSA
Why is the voltage of an electrical burn important to know?
It determines the extent of tissue damage - higher voltage causes more extensive tissue damage
What can some inhalation cause?
respiratory distress via bronchospasm, pulmonary or laryngeal oedema
What are the late complications of burns?
-Wound infection
-AKI (4-14 days post injury)
-Chronic neuropathic pain/itch
-Contractures
-Scarring
-Psychosocial impact
-Sleep disorders
What may cause suspicion of nonaccidental injury?
-Unsuitable explanation for injury
-Injured person is not independently mobile
-Area not easily injured by the self (back/buttocks etc)
-Injury has suspicious shape e.g. cigarette shape
-Injury indicating forced immersion
How should thermal burns be managed initially?
-Stop burning process
-Remove non-adherent clothing/jewellery
-Irrigate with cool/tepid water for 15-30 minutes
-Cover in cling-film
-Elevate
-Analgesia
How should electrical burns be managed initially?
If low voltage and safe to do so:
-Turn off power supply
-A&E admission
How should chemical burns be managed initially?
-Determine the causative chemical
-Remove clothing
-Brush off dry powder chemical, wash away liquid chemical for 1 hour
-Arrange A&E admission
What can cause knee pain?
Loads of things - Local causes (within/around knee), regional causes, or systemic causes
How common is knee pain?
Very - it is second most common MSK complaint after back pain, affecting around 20% of the population
What factors increase risk of developing knee pain?
-Increasing age
-Obesity/overweight
-Previous injury
-Occupational factors
-Sport
-Mental distress/depression
-Social deprivation
A patient presents with acute painful joint swelling. What are the top 3 differentials?
Septic arthritis
Inflammatory arthritis’ such as gout or rheumatoid arthritis
A patient presents with hx of trauma to the knee, and rapid onset of knee swelling over the subsequent couple of hours. What are the differentials?
If large tense effusion present:
-Fracture
-Ligament rupture
-Patellar dislocation
A patient reports stiffness in their knee. What is important to ask about this symptom?
Pattern of stiffness i.e. does it get better or worse with rest and use
What can happen due to a direct blow to anterior knee?
-Patellar fracture
-Cruciate ligament injury if knee flexed/hyperextended
A patient reports knee pain following sudden deceleration and stopping. What might they have injuired?
Anterior cruciate ligament
A patient reports knee pain following direct blow to lateral aspect of knee. What is likely to be injured?
medial collateral ligament or patellar dislocation
A patient reports knee pain following direct blow to medial aspect of knee. What is likely to be injured?
lateral collateral ligament (uncommon) or patellar dislocation
A patient reports knee pain after a sudden twisting motion. What is likely to be injured?
-Menisci
-Anterior cruciate ligament
What are the Ottawa knee rules?
Knee x-ray may be required following injury if any of the following:
- Inability to weight bear immediately after injury and in consultation for more than 4 steps
- Inability to flex knee to 90 degrees
- Tender fibula head
- Isolated patellar tenderness
- Age 55 or older
A teenager presents with knee pain.
It is gradual onset and felt mostly in the front of the knee.
It is worse with sitting for long periods and running.
There are no red flags present in history.
What examinations can be done for the likely cause?
Patellofemoral pain syndrome
Quadriceps contraction test
Patellofemoral glide/tilt/grind test
What is the Patellofemoral glide/tilt/grind test?
Test for Patellofemoral pain syndrome
Moving the patella in all directions to elicit pain
What is the quadriceps contraction test?
Test for Patellofemoral pain syndrome
Apply pressure to patella and contract quadriceps to elicit pain
How is patellofemoral pain syndrome managed?
Adjusting activity, reducing kneeling, not sitting still for too long
Pain treatments if helpful
Physiotherapy
What is Osgood-Schlatter’s disease?
Apophysitis of tibial tuberosity that causes knee pain during adolescence
Is Osgood Schlatter’s usually unilateral or bilateral?
Unilateral in 70-80% of cases
When does Osgood Schlatter’s usually manifest?
During adolescent growth spurt before tibial tuberosity has completed ossification
What is thought to be the mechanism of Osgood Schlatter’s disease?
Small avulsions and inflammation at the apophysis due to traction of patella tendon on tibial tuberosity during forceful contraction of quadriceps muscle
How common is Osgood Schlatter’s disease?
Around 1 in 10 adolescents are affected, 1 in 5 if involved in high impact sports
A 14 year old boy who loves running is brought in with intermittent pain in anterior knee since he started his pubertal growth spurt.
There are no red flags, and pain is localised most to tibial tuberosity.
How long might this condition take to improve?
Osgood Schlatter’s disease
Often settles over weeks to months, but can take until end of growth spurt to completely resolve
Where/how does Osgood Schlatter’s disease usually present?
Unilateral pain localised to tibial tuberosity
Is Osgood Schlatter’s disease usually made better or worse with activity?
Worse
What are the examination findings associated with Osgood Schlatter’s disease?
-Tender over tibial tuberosity +/- swelling
-Pain on resisted knee extension
-Tightness of quads and hamstrings
-Normal passive ROM
-Absence of effusion
A 14 year old boy who loves running is brought in with intermittent pain in anterior knee since he started his pubertal growth spurt.
There are no red flags, and pain is localised most to tibial tuberosity.
How should this condition be managed?
Osgood Schlatter’s disease
-Education
-Analgesia
-Intermittent application of ice packs
-Protective knee pads
-Reduce/stop aggravating sporting activities
-Stretches
Is hypermobility more common in boys or girls?
Girls
A patient with more flexible than usual joints is suffering from joint pain. What is this called?
Joint hypermobility Syndrome
In joint hypermobility syndrome, when do patients feel the worst joint pain/aching?
In the evening after an active day
What developmental sign might have been apparent around age one in a patient with joint hypermobility syndrome?
Late walking with bottom shuffling instead of walking
What might joint hypermobility syndrome be a feature of?
An underlying connective tissue/genetic/skeletal dysplastic disorder
What connective tissue disorders might be underlying in joint hypermobility syndrome?
Marfan syndrome
Ehlers-Danlos syndrome
How can growing pains in children be distinguished from more concerning underlying pathology?
From history, distribution, and entirely normal physical examination
How do most patella dislocations occur?
Twisting or direct blow to knee in slight flexion
In roughly how many people do patella dislocations occur recurrently?
20%
When does patellar instability occur?
When the patella fails to engage securely in the trochlea at the start of flexion
When can surgical management of chronic patellar dislocation take place?
Only after conservative measures have failed and the recurrence has lead to functional impairment
What is the condition called in which a piece of bone or cartilage inside a joint loses blood supply and dies?
Osteochondritis dissecans
In which joint is osteochondritis dissecans most common?
The knee
A sporty 18 year old attends GP surgery with recurrent left knee pain. It is intermittent, vague in location, and the patient reports feeling the joint locking and catching.
What is the likely diagnosis?
Osteochondritis dissecans
A sporty 18 year old attends GP surgery with recurrent left knee pain. It is intermittent, vague in location, and the patient reports feeling the joint locking and catching.
In this case, what investigation would be appropriate?
x-ray of both knees
What is septic arthritis?
Suppurative inflammation within joint space
Who does septic arthritis most commonly affect?
Children
Premature neonates
The elderly
The immune suppressed
What are the most common ways a patient can develop septic arthritis?
-Haematogenous spread
-Direct spread e.g. from penetrating wound or neighbouring infection
An 86 year old is brought in with an acutely swollen right knee which is red and hot, reporting fevers and recent cellulitis around a diabetic foot ulcer.
What is your main concerning differential?
Septic arthritis
An 86 year old is brought in with an acutely swollen right knee which is red and hot, reporting fevers and recent cellulitis around a diabetic foot ulcer.
What other predisposing factors would be concerning here?
-Immune compromise
-Recent joint surgery
-Joint prosthesis
-Penetrating injury
What is the most common causative agent for septic arthritis?
Staphylococcus aureus
What features in a child with a painful joint might indicate septic arthritis?
Refusal to weight-bear
Fever
Systemically unwell
A patient with possible septic arthritis presents to the GP.
What should the management plan be?
Referral to orthopaedics immediately as per local policy
A 75yo diabetic patient presents with an acutely swollen as red left knee. They are apyrexic and feel generally well.
What are the top 2 differentials?
Gout/pseudogout
Septic arthritis
A 67yo with known OA attends the GP surgery with pain in posterior of their right knee with new swelling in the popliteal fossa. This has been ongoing for some weeks and gradually getting worse.
What is the top differential?
Baker’s cyst
How should a potential Baker’s cyst be examined?
Both standing and supine
In what position is Baker’s cyst most visible?
Standing
How does a Baker’s cyst feel to palpation?
Round, smooth, and fluctuant
Tense in full extension then softer/disappear in flexion
What can a ruptured bakers cyst mimic?
DVT - if a Baker’s cyst pops it can cause calf tenderness and swelling of sudden onset
What underlying pathology can cause a Baker’s cyst?
-Arthritis
-Joint instability
-Ligament/meniscal damage
What is the role of imaging in a diagnosis of Baker’s cyst in a child?
Any child with ?Baker’s cyst should have USS to rule out other serious conditions
What is the role of imaging in a diagnosis of Baker’s cyst in an adult?
Clinical assessment is usually enough
USS/MRI can be used to rule out other significant pathology or underlying cause
A 67yo with known OA attends the GP surgery with pain in posterior of their right knee with new swelling in the popliteal fossa. This has been ongoing for some weeks and gradually getting worse.
In the absence of any red flags or serious underlying pathology, how should this condition be managed?
Baker’s cyst
-Optimise any underlying pathology (OA in this case)
-Simple analgesia if painful
-Referral if the cyst is very large or troublesome
What is the common name for lateral epicondylitis?
Tennis elbow
Which tendons are affecting in tennis elbow?
Extensor tendons of forearm
In tennis elbow, where do the affected tendons attach proximally?
Lateral epicondyle of the humerus
Which side do most people get tennis elbow in?
Their dominant side arm
A patient who rows competitively presents to their GP with left sided lateral pain around elbow, especially when extending the wrist.
What is the likely diagnosis?
Tennis elbow i.e. lateral epicondylitis
A patient who rows competitively presents to their GP with left sided lateral pain around elbow, especially when extending the wrist.
Why does this pathology occur?
Tennis elbow
Repetitive overuse causes micro-tears in extensor tendon near their origin
How common is it for racquet sports to cause tennis elbow?
Causes less than 10% of cases of tennis elbow
What proportion of elbow pain presenting to GP is caused by tennis elbow?
two-thirds
A patient who rows competitively presents to their GP with left sided lateral pain around elbow, especially when extending the wrist.
Given the likely diagnosis, how long might this take to get better?
Tennis elbow
80-90% get better within 1-2 years
For tennis elbow, is it better or worse if it affects your non-dominant arm?
Better - more likely to have better pain outcomes at 1 year
A patient who rows competitively presents to their GP with left sided lateral pain around elbow, especially when extending the wrist.
What is the onset of the most likely pathology?
Tennis elbow
Insidious onset without any clear precipitating event
A patient who rows competitively presents to their GP with left sided lateral pain around elbow, especially when extending the wrist.
Given the likely diagnosis, how would you expect the patient’s grip to be?
Tennis elbow
Weakened
A patient who rows competitively presents to their GP with left sided lateral pain around elbow, especially when extending the wrist.
Given the likely diagnosis, what would you expect to find on examination?
Tennis elbow
-Weak grip
-Localised tenderness around lateral epicondyle of humerus
-Pain to resisted middle finger extension
-Pain to wrist dorsiflexion with elbow at 90 degrees
A patient who rows competitively presents to their GP with left sided lateral pain around elbow, especially when extending the wrist.
Given the likely diagnosis, what investigations are warranted in primary care?
Tennis elbow
None are usually needed unless another diagnosis is suspected
What simple management advice can be given for tennis elbow?
-Apply ice/heat
-Rest and avoid aggravating activities for 6 weeks
-Orthosis for support
-Analgesia
A patient who was diagnosed with tennis elbow 3 months ago comes back with persisting symptoms despite following all the advice given originally.
What are the next steps?
-Reassess - is this definitely tennis elbow
-Referral to physiotherapy
When should a patient with tennis elbow be referred to secondary care?
-Refractory pain or severely impaired function
-Persistent symptoms for 6-12 months despite optimal management in primary care
-Uncertain diagnosis
