MSK Flashcards
What are the 4 key features of deep gluteal syndrome?
Buttock pain;
Aggravation of pain on prolonged sitting;
Tenderness on deep palpation of the buttock; and,
Passive stretching or resisted contraction tests cause pain.
(Previously called piriformis syndrome)
What are the DMARDS of choice in RA? (2)
Methotrexate and sulfasalazine are the DMARDs of choice due to their more favourable efficacy and toxicity profiles.
Spondyloarthritis are most commonly associated with what other MSK presentation?
Enthesitis (inflammation of tendonous or ligamentous insertions onto bone)
Achillies, plantar and patellar most common
SUFE - What age, gender and other patient features are most common?
SUFE
> 10 yrs
More common in boys
SUFE:
1) Investigation
2) Mangement
1) AP and frog lateral radiographs showing medial displacement of the femoral epiphysis
2) Same day surgical referral
How do you distinguish between Perthe’s and SUFE based on patient age?
Perthes’ - 4-10yrs
SUFE: > 10yrs
A patient is taking alendronic acid for osteoporosis following several fractures. They are experiencing GI side effects. What’s the next option?
Swap alendronic acid to risedronate
GI symptoms are common adverse effect of bisphosphonates, this is due to a local irritant and erosive effect and not an acid effect.
- Therefore PPI and/or ranitidine would make no difference
What are the 5 Ottwa criteria for knee x-ray?
- Age 55 years or older
- Isolated tenderness of the patella (no bone tenderness of the knee other than the patella)
- Tenderness of the head of the fibula
- Inability to flex the knee to 90°
- Inability to weight bear both immediately and during the consultation for four steps (inability to transfer weight twice onto each lower limb regardless of limping)
Name 3 conditions more common in patients with rheumatoid arthritis?
Hypertension
Ischaemic heart disease
Osteoporosis
Depression
What is sudek’s atrophy?
Alternative name for complex regional pain syndrome
Presents with any of oedema, changes in skin blood flow, abnormal motor activity, allodynia, hyperalgesia or hyperaesthesia - usually lasting 6 months or more, generally changes distal to injury
What features characterise an ACL injury? (3)
Non-contact, twisting injuries characterised by an audible pop or crack and a large immediate swelling
What is the most common mechanism of PCL injuries?
Posterior cruciate ligament injuries are less common and rarely occur in isolation, they usually occur from direct impact to the flexed knee
What nerve is affected in Saturday night palsy - what symptoms may it present with?
Radial nerve
Sensory - Snuffbox, dorsum of proximal thumb, index and middle finger
Motor- finger and wrist drop
Lateral epicondylitis - name 3 presenting features other than lateral epicondyl tenderness?
- What is the name of the two tests which can be done for lateral epicondylitis?
1) Weak hand grip
2) Pain on resisted middle finger extension (Maudsley’s test)
3) Pain on lateral side of the elbow produced by flexing and pronating the wrist with the elbow extended and stabilized (Mill’s test)
A patients with PAD should be taking what medication?
Clopidogrel + statin
FRAX score can be used between which ages?
FRAX may be used for patients aged 40-90 years
You suspect a patient may have rheumatoid arthritis - how urgently do you refer to rheum?
Refer urgently if small joint involvement, persistent symptoms for 3 months before medical opinion sought, or more than 1 joint affected.
A 12yr old patient presents with persistent L knee pain, you are querying osteosarcoma in your head. What’s the next step?
Consider a very urgent direct access X ray (within 48 hours) to assess for bone sarcoma in children and young people with unexplained bone swelling or pain.
Consider a very urgent referral (within 48 hours) for specialist assessment for children and young people if an X ray suggests the possibility of bone sarcoma.
A ‘painful arc’ between 60 and 120 degrees is a sign of what?
Shoulder impingement
(Most commonly due to supraspinatus tendinitis)
What is the management of achillies tendonitis?
- At what point do you refer for physio?
Rest, NSAIDS
Referral to physio only if going on past 7 days
How do you distinguish between gastric and duodenal ulcers in the history?
Gastric - worse by eating
Duodenal - relieved by eating
1st and 2nd line medications for low back pain, no red flags?
1) NSAIDS
2) Codeine +/- paracetamol
NO role for paracetamol alone
What are the three diagnostic criteria for fibromyalgia?
Widespread pain index (WPI) ≥ 7 and symptom severity (SS) scale score ≥ 5, or WPI 3–6 and SS scale score ≥ 9
Symptoms have been present at a similar level for at least three months
The patient does not have a disorder that would otherwise explain the pain
According to the WHO which t-score is diagnostic of osteoporosis?
-2.5 or less
When should patients with OA be referred for surgery?
Joint symptoms (pain, stiffness and reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment.
Refer before there is prolonged and established functional limitation and severe pain.
What vaccination should be offered prior to starting DMARD therapy?
Pneumococcal
(Should also then also have annual flu’s)
When do NICE recommended DEXA scans if underweight?
After 1 year of being underweight if child or 2 years of being underweight if adult
Sooner if bone pain or recurrent fractures
What is the normal range for BMI?
18.5-24.9
What is Sever’s disease?
Calcaneal apophysitis at the point of insertion of the achilles tendon
Presents as heal pain in young/ adolescent atheletes, normal examination other than tenderness to palpation of heel
What criteria should be met to be able to make a clinical diagnosis of OA?
Age 45 or over
Activity related joint pain
Morning stiffness lasting less than 30 mins (or no stiffness)
What are the three criteria of the ottowa ankle rules?
Point tenderness at posterior edge (of distal 6 cm) or tip lateral malleolus
Point tenderness at posterior edge (of distal 6 cm) or tip medial malleolus
Inability to weight bear (four steps) immediately after the injury and in emergency department
What are the characteristics of a testicular hydrocele?
Not seperate from testicle
Soft mass
Transilluminates
Dermatomyositis is most common in what age group, what is it commonly associated with?
50-70’s
Associated with internal malignancy
PMR is commonly associated with an ESR result over…?
Over 40
(Although can be much higher)
CK usually normal
What is QFRacture, how does it differ to FRAX?
Alternative to FRAX
- Includes ethnicitiy (recommended by SIGN in preference to FRAX)
What is the recommended daily calcium intake?
700–1200 mg daily
If at osteopenia/ porosis risk then needs vitamin D also (400-800IU)
What is the recommended daily vitamin D supplimentation for most people?
400-800IU
What is a DAS28 used for and what does it consist of?
Assessing severity in RA
Assessment of 28 joints, swelling and pain
CRP and ESR
Patients global assessment of their health
What is used for diagnosis of osteoporosis, t or z score?
T score < -2.5
Z score matches to age and is not used in osteoporosis diagnosis
A patient with osteoporosis is intolerant of alendronate and risindronate. How should you manage?
Refer to secondary care
They may use:
zoledronic acid, raloxifene, denosumab and teriparatide
Reactive arthritis:
1) Two types
2) Associated with what blood marker?
1) Sexual or enteric (GI) most common triggers
2) 60–90% of the genital and enteric forms of the disease are associated with HLA B27.
A 14-year-old patient consults with a rapidly growing 10 cm soft tissue swelling on the right upper arm. On examination, the swelling is tender, fixed and feels deep to the fascia.
What is the SINGLE MOST appropriate management option?
Refer for urgent USS within 2 days
Adults with suspected sarcoma should have urgent USS within 2 weeks
Children with suspected sarcoma should have urgent USS within 2 days
A 58-year-old woman with mild sero-negative arthritis has been taking naproxen for three months, which controls her symptoms. She develops urticaria which resolves when she stops the naproxen. However, her pain is no longer controlled and paracetamol is ineffective.
Which is the most appropriate alternative medication to prescribe?
Codeine
If intollerant to one NSAID, likely will be to all. Step up the pain ladder to weak opioids
What test is used to diagnose De Quevain’s tenosynovitis?
Finkelstein’s test
Finkelstein’s test is performed how?
Positive if pain on moving a patient’s wrist in an ulnar direction with fingers flexed over their thumb
SIGN guidance suggests DEXA should be performed at what FRAX risk cut off?
Over 10%
How does trigger finger usually present?
Patients with trigger finger initially report an atraumatic catching and locking of the affected digit on flexion and painless snapping. This can progress with inability to actively extend the affected digit
How does morton’s neuroma typically present?
Pain in the third inter-metatarsophalangeal space
Sharp pain while walking, and patients may describe the sensation of having a pebble under the toe
- Loss sensation under the toe is strong indicator
Classically women in 40’s, high heeled shoes
How does Chondromalacia patellae typically present?
Chondromalacia patellae is softening of the articular cartilage of the patella. It is a significant cause of anterior knee pain in teenage girls.
How does Osgood–Schlatter syndrome present?
Osgood–Schlatter syndrome is an example of an overuse syndrome associated with physical exertion before skeletal maturity. Patients, usually boys, complain of pain, tenderness and a lump over the tibial tubercle. Pain follows activity and may be bilateral.
Which NSAIDS have the most favourable thrombotic profiles?
Ibuprofen + naproxen lowest risk
Which is the SINGLE MOST appropriate ESTIMATE of the percentage of patients with knee pain that can accurately localise the site of their pain?
70%
How is risk of osteoporotic fracture assessed in patients with major risk factors under the age of 40?
DEXA
(FRAX only for 40 or above)
What is the difference between t and z scores?
- Which is used to diagnose osteoporosis?
T- SD’s from young adult mean
Z- SD’s from age matches controls
T only for osteoporosis
Exercise is advised for chronic pain. Name 4 strategies that can improve adherance:
- Supervised exercise sessions
- Individualised exercises in group settings
- Additional supplementary material
- Combined group and home exercise programme
What scale is used to diagnose joint hypermobility?
Nine-point Beighton scale
(i.e. Placing hands flat on the floor without bending the knees)
Your patient on methotrexate for RA has a flare. They have a history of gastric ulcer. What management options do you have?
Likely avoid NSAID
1) Intraarticular steroid (if localised)
2) Intramuscular steroid (if generalised)
- Oral steroid if (2) is not practical (Course reducing over 2-4 weeks until see’s specialist)
How do you manage RA flares in GP?
NSAID, lowest effective dose for shortest possible time
Refer urgently to rheum:
Intra-articular/ intramuscular steroids. oral steroids
Tenderness over the calcaneal tubercle and pain is reproduced on dorsiflexion of the toes would suggest what diagnosis?
Plantar fascitis
Plantar fascitis is associated with what other conditions?
Name two other risk factors?
Plantar fasciitis is typically associated with the HLA B27 spondyloarthropathies which includes ankylosing spondylitis, psoriatic arthritis, reactive arthritis and Reiter’s syndrome
Also overweight/ highly active
How does erythema nodosum usually present?
Typically, erythematous, warm nodules and plaques 1–5 cm in diameter develop over the lower legs.
Painful, develops over weeks then fades
May often follow strep infection
(Self limiting over weeks to months)
What is the minimum amount of time you should wait to check urate levels following a gout attack?
2-4 weeks
What are the bnf’s renal recommendations for allopurinol?
Max dose in renal impairement 100mg
If severe renal impairement reduce below 100mg
What is Polyarteritis nodosa?
How may it present?
Polyarteritis nodosa is a vasculitis of medium sized arteries.
Polyarthralgia is present in 60% of cases and myalgia in 30–80%.
- May have weight loss, fever, hypertension and other vague vasculitis signs
Which are the SINGLE MOST appropriate threshold ages at which to consider assessment of fragility fracture risk in patients with no specific risk factors? (M+F)?
Fracture risk assessment should be targeted. In patients with no other risk factors, fracture risk assessment should be considered from age 65 years in women and age 75 years in men.
When are MRI’s indicated in knee pain?
MRI scans are advised in patients aged younger than 60 years with:
- Suspected meniscal tear, ligament injury, suspicious lump or recurrent anterior knee pain.
