MSK

Question 1

Osteoporosis: Assessing patients following a fragility fracture

> 75yo vs <75

Answer 1

> 75 started on first-line therapy (an oral bisphosphonate),without the need for a DEXA scan.

<75DEXA scan

Question 2

Signs of carpal tunnel

Answer 2

symptoms of a median nerve palsy in this context can be reproduced by tapping the area of the flexor retinaculum (Tinel’s sign), or by holding the wrist in flexion (Phalen’s sign) or extension (reverse Phalen’s)

Question 3

Meralgia paraesthetica

affects

Answer 3

femoral cutaneous nerve (LFCN)

Question 4

De Quervain’s tenosynovitis

sign

Answer 4

Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus

Question 5

Rheumatoid arthritis: x-ray changes

Answer 5

loss of joint space

juxta-articular osteoporosis

soft-tissue swelling

periarticular erosions

subluxation

Question 6

Heberdens vs bouchards

Answer 6

Heberden’s nodes - swelling of the distal interphalangeal joints.
Bouchard’s nodes - swelling of proximal interphalangeal joints

Question 7

drug induced lupus ab

Answer 7

ANA positive in 100%, dsDNA negative

anti-histone antibodies are found in 80-90%

Question 8

Rheumatoid arthritis management

Answer 8

NICE recommendDMARDmonotherapy+/- a short-course of bridging prednisolone. In the past dual DMARD therapy was advocated as the initial step

choices for initial DMARD monotherapy:

methotrexateis the most widely used DMARD. Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis

sulfasalazine

leflunomide

hydroxychloroquine: should only be considered for initial therapy if mild or p alindromic disease

Question 9

Rheumatoid arthritis management of flares

Answer 9

flares of RA are often managed with corticosteroids - oral or intramuscular

Question 10

Osteomalacia labs

Answer 10

low vitamin D levels
low calcium, phosphate (in around 30%)
raised alkaline phosphatase (in 95-100% of patients)

Question 11

Pagets labs

Answer 11

raised alkaline phosphatase (ALP)
calcium and phosphate are typically normal. Hypercalcaemia may occasionally occur with prolonged immobilisation

Question 12

Methotrexate side effecst

Answer 12

Myelosuppression
Liver cirrhosis
Pneumonitis

Question 13

Sulfasalzine side effects

Answer 13

Sperms low
Rash
Heinze body
Interstitial lung disease

Question 14

Gout acute management

Answer 14

NSAIDS (PPI may be indicated) or colchicine (may be used with caution in renal impairment , side effect is diarrhoea)

Question 15

Indications for urate lowering therapy

Answer 15

urate-lowering therapy to all patients after their first attack of gout
ULT is particularly recommended if:
>= 2 attacks in 12 months
tophi
renal disease
uric acid renal stones
prophylaxis if on cytotoxics or diuretics

Question 16

When can urate lowering therapy be started

Answer 16

Commencement of ULT is best delayed until inflammation has settled as ULT is better discussed when the patient is not in pain

Question 17

Medications of urate lowering therapy

Answer 17

Allopurinol first line - initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 360 µmol/l
Second line febuxostat

Question 18

Which drugs should you consider stopping in gout

Answer 18

Thiazide

Question 19

Chondromalacia patellae.

Answer 19

Runners knee adolescents and young adults
Cartilage under patella inflamed
Worsens with bending knee

Question 20

Osgood schlatter

Answer 20

common cause of knee pain in growing adolescents but typically presents with localized pain and swelling at the tibial tuberosity (the bony prominence just below the kneecap)

Question 21

Osteochondritis dessicans

Answer 21

condition where small fragments of bone and cartilage become detached from their surrounding tissue due to inadequate blood supply. This can cause joint pain and swelling; however, it typically affects children between 10-20 years old who are involved in high-impact sports like football or gymnastics

Question 22

Red flags for back pain

Answer 22

Thoracic pain
Age <20 or >55 years
Non-mechanical pain
Pain worse when supine
Night pain
Weight loss
Pain associated with systemic illness
Presence of neurological signs
Past medical history of cancer or HIV
Immunosuppression or steroid use
IV drug use
Structural deformity

Question 23

De Quervain’s tenosynovitis

Answer 23

sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged 30 - 50 years old.
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus

Question 24

De quervains tenosynovitis mx

Answer 24

analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required

Question 25

Nomenclature extracellular vs intracapsular hip fracture

Answer 25

intracapsular (subcapital): from the edge of the femoral head to the insertion of the capsule of the hip joint
extracapsular: these can either be trochanteric or subtrochanteric (the lesser trochanter is the dividing line), intertrochanteric fracture

Question 26

Pseudogout ix

Answer 26

joint aspiration: weakly-positively birefringent rhomboid-shaped crystals
x-ray: chondrocalcinosis
in the knee this can be seen as linear calcifications of the meniscus and articular cartilage