MSK Flashcards
Adhesive capsulitis
px & mx
external rotation is affected more than internal rotation or abduction
active and passive movement
painful freezing phase, an adhesive phase and a recovery phase
mx: NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids
Ottawa rule
ankle x-ray is required only if:
pain in malleolar zone
medial or lateral malleolar bony tenderness
inability to walk 4 weight bearing steps immediately after the injury and in the emergency department
Weber classification of fibular fractures
Type A is below the syndesmosis
Type B at level of syndesmosis
Type C is above the syndesmosis which may itself be damaged
Ankle sprain injury mechanism & mx
Low ankle sprains
- inversion injury most common mechanism, anterior talofibular ligament
- Ix: x ray if Ottawa rule & MRI if persistent pain
- Tx: RICE
High ankle sprains
- syndesmosis injury
- external rotation of the foot mechanism
- Ix: x ray- widening of the tibiofibular joint & MRI
Tx- no diastasis then non-weight-bearing orthosis or cast , if diastasis or failed non-operative management then operative fixation
Pagers disease ix & mx
ALP high, other normal
bisphophonates
Types/ eponymous fractures
Bukle/ tores - incomplete fractures of long bone shaft, bulging cortex, children 5-10, conservative mx
Colles- FOOSH, Distal radius fracture with dorsal displacement of fragments, dinner fork type deformity, maybe: median nerve injury,
Smith’s fracture (reverse Colles’ fracture)
Volar angulation of distal radius fragment (Garden spade deformity), backward FOOSH or wrist flexion fall
Bennet - fist fight, first carpo-mcp joint,
Monteggia - proximal radioulnar joint in association with an ulna fracture, FOOsh w forced pronation
Galeazzi fracture - Radial shaft fracture & dislocation of the distal radioulnar joint, Direct blow
Barton
- Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist
Pott’s fracture
Bimalleolar ankle fracture, Forced foot eversion
Elbow pain
feature - medial vs later?
Lateral epicondylitis (tennis elbow) - n worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
Medial epicondylitis (golfer’s elbow)-pain is aggravated by wrist flexion and pronation
Hi dislocation px: anterior v posterior
Posterior - most common, shortened, adduction & internal rotation
Anterior: abducted & external rotation. No shortening
(hip fracture = shorten & external rotation)
Garden classification
hip fracture
1 - stable fracture
2 - complete & displaced
3 - displaced with bony contact
4 - complete bone disruption
Hip fracture mx
Intracapsular (subcaptical )
displaced - total Hip replacement if fit OR hemi arthroplasty if use mobility aid & cognitively impaired & fit for anaesthesia
undisplaced - internal fixation
Extracapsular
- intertrochanteric - dynamic hip screw
- reverse oblique, transverse or subtrochanteric: intramedullary device
Knee unhappy triad
lateral blow causes injury to:
ACL
MCL
Meniscus
Knee injury mechanism causes
ACL & meniscus- twisting
PCL - dashboard
MCL - valgus stress, ski -> abnormal passive abduction
Red flags for lower back pain
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever
Disk prolapse Px depending on nerve root: L3-S1
L3 - sensory loss of anterior thigh, weak hip flexion & adduction, weak knee extension, reduced of knee reflex, +ve fem stretch
L4 - sensory loss of knee & medial malleolus, weak hip adduction, weak knee extension, reduced of knee reflex, +ve fem stretch
L5 - sensory loss big toe, weakness of foot & big toe dorsiflexion, reflexes intact, +ve sciatic nerve stretch
S1 - sensory loss posterlateral leg & foot, weak planterflexion, reduced ankle reflex, +ve sciatic nerve stretch
(mx: as per msk back pain (NSAID & physio) - not neuropathic drugs. If persistant symptoms after 4-6wks -> MRI)
Nerves: motor & sensor function, mechanism of injury
Femoral, obturator, lateral cutaneous nerve, tibial, common peroneal, superior gluteal, inferior gluteal
Femoral nerve
Knee extension, thigh flexion
Anterior and medial aspect of the thigh and lower leg
Hip and pelvic fractures
Stab/gunshot wounds
Obturator nerve
Thigh adduction
Medial thigh
Anterior hip dislocation
Lateral cutaneous nerve of the thigh
No motor
Lateral and posterior surfaces of the thigh
Compression of the nerve near the ASIS → meralgia paraesthetica (pain, tingling and numbness in the distribution of the lateral cutaneous nerve)
Tibial nerve
Foot plantar flexion and inversion
Sole of foot
Not commonly injured as deep and well protected. Popliteal lacerations, posterior knee dislocation
Common peroneal nerve
Foot dorsiflexion and eversion & Extensor hallucis longus
Dorsum of the foot and the lower lateral part of the leg
Injury often occurs at the neck of the fibula
Tightly applied lower limb plaster cast
Injury causes foot drop
Superior gluteal nerve
Hip abduction
No sensory
Misplaced intramuscular injection, Hip surgery, Pelvic fracture, Posterior hip dislocation
Injury results in a positive Trendelenburg sign
Inferior gluteal nerve
Hip extension and lateral rotation
No sensory
Generally injured in association with the sciatic nerve
Injury results in difficulty rising from seated position. Can’t jump, can’t climb stairs
Scaphiod fracture ix, mx, blood suplly
( dorsal carpal branch (branch of the radial artery),)
Ix
- X ray: AP, zeiter-PA in ulnar deviation, & lateral, oblique
- further imaging (MRI) should be arranged for7-10 days later when initial radiographs are inconclusive
Mx
- refer to ortho & immobilisation w Futuro splint or standard below-elbow backslab
- undisplaced: 6-8wk cast
- displaced or proximal: - surgical fixation
shoulder dislocation px & mx
Anterior shoulder dislocation is associated with FOOSH; while posterior shoulder dislocation is more likely associated with seizures and electric shock
internally rotated position= posterior dislocation
. If the dislocation is recent then reduction may be attempted without any analgesia/sedation. However, other patients may require analgesia +/- sedation to ensure the rotator cuff muscles are relaxed.
upper limb myotome
Elbow flexors/Biceps C5
Wrist extensors C6
Elbow extensors/Triceps C7
Long finger flexors C8
Small finger abductors T1
lower limb myotome
Hip flexors (psoas) L1 and L2
Knee extensors (quadriceps) L3
Ankle dorsiflexors (tibialis anterior) L4 and L5
Toe extensors (hallucis longus) L 5
Ankle plantar flexors (gastrocnemius) S1
Nerves: motor & sensor function, mechanism of injury
Musculocutaneous, axillary, radial, median, ulnar, long thoracic
Axillary nerve (C5,C6)
Shoulder abduction (deltoid muscle)
Inferior region of the deltoid muscle
Humeral neck fracture/dislocation
Results in flattened deltoid
Musculocutaneous nerve (C5-C7)
Elbow flexion (supplies biceps brachii) and supination
Lateral part of the forearm
Isolated injury rare - usually injured as part of brachial plexus injury
Radial nerve (C5-C8)
Extension (forearm, wrist, fingers, thumb)
Small area between the dorsal aspect of the 1st and 2nd metacarpals
Humeral midshaft fracture
Palsy results in wrist drop
Median nerve (C6, C8, T1)
LOAF muscles
Features depend on the site of the lesion:
wrist: paralysis of thenar muscles, opponens pollicis
Elbow: loss of pronation of forearm and weak wrist flexion
Palmar aspect of lateral 3½ fingers
Wrist lesion <- carpal tunnel syndrome
Ulnar nerve (C8, T1)
Intrinsic hand muscles except LOAF
Wrist flexion
Medial 1½ fingers
Medial epicondyle fracture
Damage may result in a ‘claw hand’
Long thoracic nerve (C5-C7)
Serratus anterior
No sensory
Often during sport e.g. following a blow to the ribs. Also possible complication of mastectomy
Damage results in a winged scapula
LOAF muscles
Lateral two lumbricals
Opponens pollis
Abductor pollis brevis
Flexor pollis brevis
Erb vs Klumpke
Erb-Duchenne palsy (‘waiter’s tip’)
due to damage of the upper trunk of the brachial plexus (C5,C6)
may be secondary to shoulder dystocia during birth
the arm hangs by the side and is internally rotated, elbow extended
Klumpke injury (claw hand)
due to damage of the lower trunk of the brachial plexus (C8, T1)
as above, may be secondary to shoulder dystocia during birth. Also may be caused by a sudden upward jerk of the hand
associated with Horner’s syndrome
x ray findings of Ank Spond
Sacroillitis
Squaring of lumbar vertebrae
Bamboo spine
Syndesmophytes
chest: Apical fibrosis
Mx of Ankylosing spondylitis
Exercise - swimming
NSAIDs - 1st line
Anti-TNF therapy (etanercept and adalimumab )- failed 2 diff NSAID & meets criteria 2x 12 wks apart
DMARD - only if peripheral joint involvement
Anti
Antiphospholipid syndrome
primary thromboprophylaxis
- low-dose aspirin
In pregnancy: continue aspirin & LMWH once a fetal heart is seen on ultrasound
secondary thromboprophylaxis
- initial venous thromboembolic events: lifelong warfarin with a target INR of 2-3
- recurrent - INR: 3-4
Bone tumour characteristics
benign
-Osteoma - Gardners (FAP), skull
-Osteochondroma (exotosis)- cartilage-capped bony projection on the external surface of a bone, most common
-Giant cell tumour - epiphyses of long bones, tumour of multinucleated giant cells within a fibrous stroma, ‘double bubble’ or ‘soap bubble’
Malignant
- Osteosarcoma - most common, metaphyseal region of long bones prior to epiphyseal closure (young), Codman triangle (from periosteal elevation) and ‘sunburst’ pattern, Rb gene
- Ewing’s sarcoma- young, small round blue cell tumour, pelvis and long bones, ‘onion skin’ appearance
- Chondrosarcoma
- malignant tumour of cartilage
tiredness screening test
FBC, U&E, LFT, glucose, TFT, ESR, CRP, calcium, CK, ferritin, coeliac screening and also urinalysis
Dermatomyositis A bodies?
- antibodies against
- histidine-tRNA ligase (also called Jo-1)
- signal recognition particle (SRP)
- anti-Mi-2 antibodies
Discoid lupus erythematosus mx
topical steroid cream
oral antimalarials may be used second-line e.g. hydroxychloroquine
avoid sun exposure
drug-induced lupus antibodies
ANA positive in 100%, dsDNA negative
anti-histone antibodies are found in 80-90%
anti-Ro, anti-Smith positive in around 5%
drug-induced lupus causes
Most common causes
procainamide
hydralazine
Less common causes
isoniazid
phenytoin
HLA disease
HLA-B27
ankylosing spondylitis
reactive arthritis
acute anterior uveitis
psoriatic arthritis
HLA-DQ2/DQ8
coeliac disease
HLA-DR3
dermatitis herpetiformis
HLA-DR4
type 1 diabetes mellitus*
rheumatoid arthritis
Gell and Coombs classification - hyper sensitivity
Type I - Anaphylactic
Antigen reacts with IgE bound to mast cells
* Anaphylaxis
* Atopy (e.g. asthma, eczema and hayfever)
Type II - Cell bound
IgG or IgM binds to antigen on cell surface
* Autoimmune haemolytic anaemia
* ITP
* Goodpasture’s syndrome
* Pernicious anaemia
* Acute haemolytic transfusion reactions
* Rheumatic fever
* Pemphigus vulgaris / bullous pemphigoid
Type III - Immune complex Free antigen and antibody (IgG, IgA) combine
* Serum sickness
* Systemic lupus erythematosus
* Post-streptococcal glomerulonephritis
* Extrinsic allergic alveolitis (especially acute phase)
Type IV - Delayed hypersensitivity T-cell mediated
* Tuberculosis / tuberculin skin reaction
* Graft versus host disease
* Allergic contact dermatitis
* Scabies
* Extrinsic allergic alveolitis (especially chronic phase)
* Multiple sclerosis
* Guillain-Barre syndrome
New:
Type V
Antibodies that recognise and bind to the cell surface receptors.
This either stimulating them or blocking ligand binding
* Graves’ disease
* Myasthenia gravis
X-ray findings OA vs RA
OA:
Loss of joint space
Osteophytes forming at joint margins
Subchondral sclerosis
Subchondral cysts
RA
Loss of joint space
Periarticular erosions
Subluxation
soft-tissue swelling
Juxta-articular osteoporosis
RA mx
X ray of hands & feet on dx
DMARD monotherapy +/- a short-course of bridging prednisolone.
- a TNF-inhibitor- inadequate response to at least two DMARDs including methotrexate
combination of CRP and disease activity (using a composite score such as DAS28) to assess response to treatment
flares of RA are often managed with corticosteroids - oral or intramuscular
Sjogren’s syndrome ix
rheumatoid factor (RF)
ANA positive
anti-Ro (SSA)
anti-La (SSB)
Schirmer’s test
Systemic lupus erythematosus
px
type 3 hypersensitivity reaction
more common in Afro-Caribbeans and Asian communities
fatigue
fever
mouth ulcers
lymphadenopathy
malar (butterfly) rash: spares nasolabial folds
discoid rash
arthralgia
Raynaud’s phenomenon
livedo reticularis
carditis
pleurisy
glomerulonephritis
anxiety and depression
etc
SLE ix
99% are ANA positive
20% are rheumatoid factor positive
anti-dsDNA: highly specific (> 99%), but less sensitive (70%)
anti-Smith: highly specific (> 99%), sensitivity (30%)
also: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La)
ESR used for monitoring
complement levels (C3, C4) are low during active disease
SLE mx
Basics
NSAIDs
sun-block
Hydroxychloroquine
the treatment of choice for SLE
Limited cutaneous systemic sclerosis px
Raynaud’s may be the first sign
scleroderma affects face and distal limbs
anti-centromere antibodies
CREST syndrome: Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
diffuse = antiscl 70
