MSK Flashcards
Swollen knee - aspiration shows weakly positive bifringent crystals. Dx?
P=P! Pseudogout = Positive bifringent crystals, rhomboid shaped
Gout is negative bifringent crystals, and needle shaped
35-55 y/o man, lateral elbow/forearm pain, wrist extension or supination worsens pain, but not flexion or pronation. Point of tenderness distal to lateral epicondyle. Sporting injury Dx?
Tennis elbow
-lateral epicondyle
-wrist extension/supination against resistance provokes symptoms, but not flexion/pronation
Drug tx for Raynaud’s?
CCBs - nifedipine
Colles’ fracture is what?
‘C—>DDD’ - dorsally displaced distal radius fracture
-from fall on an outstretched hand
-common in older postmenopausal women (little old Colleen!)
-‘dinner fork’ deformity
Low vitamin D leads to what condition in:
-adults
-children
Osteomalacia (adults)
Rickets (children)
-inadequate mineralisation of bone cortex
How does polymyalgia rheumatica present and how is it diagnosed? Treatment?
-bilateral pain and morning stiffness of shoulders, neck, pelvic girdle (muscle tenderness rather than joints)
-raised inflammatory markers - ESR
-STEROIDS
What is Osgood-Schlatter disease?
Symptoms?
Treatment?
Small avulsion fractures within the tibial tuberosity occur in growing children
‘Good splatters’ of bone - only small!
Pain and swellings below knee
REST
Treatment for SUFE?
Surgical pinning
Ottowa rules for ankle X-rays?
X-rays only required if bony pain in malleolar zone PLUS:
1) tenderness along distal 6cm posterior edge of tibia/tip of medial or lateral malleolus
2) inability to weight bear immediately and in ED for 4 steps
Ottowa rules for foot xray
Indicated if
-bone tenderness at BASE of 5TH metatarsal
-bone tenderness at navicular bone
-inability to weight bear both immediately and in ED for 4 steps
Barlow’s vs Ortolani’s?
Barlow’s - aDDuct hip whilst applying pressure to knee (posterior force) - palpable subluxation = +ve test
‘Barlow’s = Bad-duct, as dislocates’
Ortolani’s - relocation, with hips and knees flexed, anterior pressure given to greater troxhanters, legs abducted- clunk as relocates =+ve test
‘Ortolani’s = OK again, relocates’
Test to assess ACL injury to knee?
Lachman test
Adult hit by car bumper from side, now has very swollen deformed knee. Likely Dx?
Tibial plateau fracture
-fall from height or struck violently from side ie car bumper
-badly swollen, deformed knee
30 y/o Japanese man with oral & genital ulcers, iritis, and knee/ankle joint pain. Erythema nodosum on shins. Dx?
BEHCET’s disease
-chronic multisystem vasculitis
What may happen if you give allopurinol in acute gout?
Risk of precipitating acute gout!
Should be started after acute attack has resolved
Test for ruptured Achilles tendon?
Simmonds/Thompson test
-patient lies prone
-squeeze calf muscle - should cause plantar flexion. If reduced or absent, it is a positive test
What is a Smith’s fracture?
Volar displacement of distal radius fracture
-fall on to back of hand (‘reverse Colles’ fracture’)
Gamekeeper’s thumb?
Injury to ulnar collateral ligament (UCL) of 1st MCP (thumb.) May see avulsion fracture at ulnar corner at base of PP.
-also called skier’s thumb or UCL tear
Barton’s fracture?
INTRAARTICULAR fractures of distal radius.
-Can be dorsal or volar
-caused by fall on to extended and pronated wrist
-INTRA-ARTICULAR component distinguishes from Smith’s or Colles’
6 y/o, thigh pain and limp, systemically well. Reduced ROM, xray shows patchy avascular necrosis. Dx?
PERTHE’S DISEASE
-idiopathic avascular necrosis of femoral head
-most commonly boys aged 5-12
-atraumatic pain and limp, unusually unilateral
Treatment of Perthe’s?
Non-operative:
Rest
Physio
NSAIDs
Operative
1st line Tx for Rheumatoid arthritis?
METHOTREXATE (DMARD)
Xray changes for rheumatoid arthritis?
-earliest changes: soft tissue swelling, juxta-articular demineralisation
-later: joint-space narrowing, EROSIONS
-eventually: JOINT DEFORMATION
Management for RA?
DMARDs - usually sulfasalazine or methotrexate
Short term - steroids
Monoclonal antibodies ie infliximab for patients who fail to respond to DMARDs
Normal age range for Perthe’s?
4-8 years
What is Perthe’s disease and how does it present?
Avascular necrosis of the femoral head
Atraumatic hip pain/limp
Management for acute gout?
NSAID or oral COLCHICINE
1st and 2nd line for gout prevention
Urate lowering therapy:
1st line - ALLOPURINOL
2nd line - FEBUXOSTAT if allopurinol not tolerated/contraindicated
What lower limb # are patients at risk of with axial loading ie fall from height >6 feet?
Pathognomic bruising for this fracture?
Calcaneal fracture
Bruising on sole of foot = MONDOR sign
Pt kneeling a lot, now has red tender selling superficial to patella. Dx? Tx?
Prepatellar bursitis
(NSAIDs and rest only)
What are the features of CREST syndrome? (limited cutaneous systemic sclerosis)
Calcinosis
Raynaud’s
Esophageal dysmotility
Scerodactyly
Telangectasia
Which 2 antibodies are associated with CREST syndrome?
Anti-nuclear
Anti-centromere
What antibodies are associated with CREST syndrome?
Anti-nuclear
Anti-centromere
Anti Scl-70
What antibodies are associated with Sjögren’s syndrome?
Anti-SSA/Ro
Anti-SSB/La (more specific)
How long do you have to have had back pain for, for it to be considered ‘chronic’?
> 12 weeks
Most common site for bony metastases?
SPINE
How does spinal stenosis present?
Lower back pain, radiating to legs
Associated with walking, RELIEVED BY REST
PAIN DIMINISHES WHEN PT BENDS FORWARD
How do RA and OA differ in the mornings
RA associated with PROLONGED morning stiffness, OA more likely to be for 5 mins, and get worse after use
Xray changes for OA?
Subchondral bone thickening
Bony cysts
Osteophyte formation
Loss/narrowing of joint space
How does ankylosing spondylitis present?
Common in young men 15-25
Back pain - AWAKENS IN EARLY MORNING and IMPROVES WITH EXERCISE
Systemic feature common ie fever, weight loss
Can progress to kyphosis and neck hyperextension (question mark posture)
What antigen is Ankylosing spondylitis associated with?
HLA-B27
Treatment for ankylosing spondylitis?
- EXERCISE
-NSAIDs
-Local steroid injections
-bisphosphonates (reduce # risk)
-TNF alpha-blockers
Most common type of shoulder dislocation?
ANTERIOR - 95% of the time!
Important things to assess in shoulder dislocation for NV intact?
Radial pulse
Sensation in regimental badge area (lateral shoulder) - axillary nerve damage
Most common rotator cuff tear?
Supraspinatus rupture
Test for posterior cruciate ligament injury?
Posterior drawer test
Test for meniscal tears?
McMurray’s test (M for M)
Test for hip abduction?
Trendelenburg test (stand on one leg, look for dropping of buttock on opposite side to weight-bearing hip, if buttock drops then test is positive)
Is warfarin a contraindication for knee joint aspiration?
NO
Characteristic area that Ankylosing spondylitis starts/spreads?
Sacroiliac joints, then progresses proximally to rest of spine
How to clinically look for scaphoid fracture?
Snuff box tenderness
Tenderness over palmar/dorsal aspect of scaphoid
Pain on compressing thumb LONGITUDINALLY
Pain on gentle FLEXION and ULNAR deviation of wrist
If suspected scaphoid fraction but normal xray, how to manage?
Cast for 7-10 days then repeat imaging
(Risk of AVASCULAR NECROSIS!)
How does patella dislocation present?
Who is it most common in?
Knee held in flexion with lateral displacement of patella
Adolescent girls!
40 y/o lady with hx diabetes has unilateral shoulder pain, whole shoulder is tender with limited ROM. Likely Dx?
Adhesive capsulitis / ‘frozen shoulder’
Difference between Barlow and Ortolani?
Barlow = Dislocate by aDDuction
Ortolani = Relocate by aBduction
(B closer to D in alphabet, O closer to R)
When to avoid colchicine?
-blood disorders
-renal impairment
-severe hepatic impairment
-pregnant / breastfeeding
-if taking clarithromycin/erythromycin, verapamil, ketoconazole…
How do supercondylar fractures usually present? What do you need to be careful with?
Children falling on outstretched hand
PAINFUL SWOLLEN ELBOW - hesitant to move
NEUROVASCULAR STATUS ?absent radial and ulnar pulses
Best investigation for DDH (developmental dysplasia of hip) in
-kids <6 months
-kids >6 months
<6 months = ULTRASOUND (due to insufficient ossification of hip)
>6 months = X-rays
Risk factors for DDH?
Female gender
Firstborn baby
Family history
Breech presentation
Oligohydramnios
Spina bifida
Metatarsus adductus (pigeon toe)
Treatment options for DDH in:
<6 months
>1 year
Much older kids?
<6 months - Pavlik harness
>1 year - closed reduction
Older kids: ORIF
Risk factors for Achilles tendon rupture?
-increasing age
-chronic/recurrent tendonitis
-Steroids
-Gout, RA, SLE
-QUINOLONE ABX ie ciprofloxacin!!
How does Achilles tendon rupture present? What test can you do?
-acute sharp pain in the tendon, may hear a ‘snap’, then persistent dull ache
-may be unable to stand on tiptoe
-may be a palpable defect in Achilles tendon (if complete not partial)
Simmonds / Thompson test - patient lies prone, knee passively flexed. Squeeze calf - if absence of normal plantar flexion, this indicates a complete tendon rupture
40 y/o, dribbling football, felt sharp pain in left calf, unable to tiptoe on left foot, but Simmonds test negative. Likely Dx?
Treatment?
GASTROCNEMIUS MUSCLE TEAR
RICE, early weight bearing as tolerated
Risk factors for SUFE (slipped upper femoral epiphysis) ?
-most common in adolescents
-male gender
-African-Caribbean ethnicity
-Obesity
-Family history
-Endocrine disorders ie hypothyroidism
What happens when you flex hip in SUFE?
Obligatory external rotation
Treatment for SUFE?
SURGICAL PINNING
Complications of SUFE?
Osteoarthritis
AVASCULAR NECROSIS of femoral head
Chondrolysis
Deformity/limb length discrepancy
Which is most specific antibody for rheumatoid arthritis?
Anti-CCP antibodies (95-98% specific)
Other is rheumatoid factor, but this is less specific
What are the MRC power grades?
0 - no muscle contraction
1 - flicker of contraction
2 - some active movement
3 - active moment against gravity
4 - active moment against resistance
5 - normal power
Which abx are associated with Achilles tendinopathy and rupture?
Fluoroquinolones ie ciprofloxacin ‘Flox up your tendon!’
What is aplastic anaemia?
Bone marrow failure characterised by peripheral pancytopenia
How to describe Boutonnière deformity?
Fixed flexing deformity at PIP, hyperextension of DIP
Which nerve likely to get damaged with shoulder dislocations?
Axillary nerve
May have numbness over deltoid muscle
