MSK Flashcards
Tennis elbow aka…
Lateral epicondylitis
Features of lateral epicondylitis
- Pain and tenderness localised to lateral epicondyle
- Pain on resisted wrist extension
Golfer’s elbow aka…
Medial epicondylitis
Features of medial epicondylitis
- Pain and tenderness localised to medial epicondyle
- Pain aggravated by wrist flexion and pronation
- Symptoms may be accompanied by numbness/tingling in 4th and 5th finger due to ulnar nerve involvement
Features of radial tunnel syndrome
- Pain 4-5cm distal to lateral epicondyle
- Symptoms worsening by extending elbow and pronating forearm
Features of cubital tunnel syndrome
- Initially intermittent tingling in 4th and 5th finger
- May be worse when elbow resting on firm surface of flexed for extended periods
- Later numbness in 4th and 5th fingers with associated weakness
Features of olecranon bursitis
- Swelling over posterior aspect of elbow
- Associated pain, warmth, and erythema
- Typically middle aged patients
Where is intracapsular hip fracture
From edge of femoral head to insertion of capsule of hip joint
Where is extracapsular hip fracture
Trochanteric or subtrochanteric
Treatment of intracapsular hip fracture - undisplaced
Internal fixation, hemiarthroplasty if unfit
Treatment of intracapsular hip fracture - displaced
Replacement arhtroplasty (total or hemi)
Criteria for total hip replacement in displaced intracapsular fracture
- Able to walk independently outdoors with no more than use of stick
- Not cognitively impairment
- Medically fit for anaesthetic and procedureT
Treatment of extracapsular hip fractures
If stable intertrochanetric, dynamic hip screw
If reverse oblique, transverse, or subtrochanetric - intramedullary device
Features of osteoarthritis of knee
- Typically >50, often overweight
- May be severe pain
- Intermittent swelling
- Crepitus
- Limitation of movement
Clergymans knee aka…
Infrapatellar bursitis
Housemaids knee aka…
Prepatellar bursitis
ACL injury features
- May be caused by twisting of knee, popping noise may be noted
- Rapid onset of knee effusion
- Positive draw test
PCL injury features
May be caused by anterior force applied to proximal tibia, e.g. knee hitting dashboard during car accident
Collateral ligament injury features
- Tenderness over affected ligament
- Knee effusion may be seen
Meniscal lesion features
- May be caused by twisting of knee
- Locking and giving way common feature
- Tender joint line
L3 nerve root compression
- Sensory loss over anterior thigh
- Weak hip flexion, knee extension, and hip adduction
- Reduced knee reflex
- Positive femoral stretch test
L4 nerve root compression
- Sensory loss anterior aspect of knee and medial malleolus
- Weak knee extension and hip adduction
- Reduced knee reflex
- Positive femoral stretch test
L5 nerve root compression
- Sensory loss dorsum of foot
- Weakness in foot and big toe dorsiflexion
- Reflexes in tact
- Positive sciatic nerve stretch test
S1 nerve root compression
- Sensory loss posterolateral aspect leg and lateral aspect of foot
- Weakness in plantarflexion of foot
- Reduced ankle reflex
- Positive sciatic nerve stretch test
Roots of musculocutaneous nerve
C5-7
Motor function of musculocutaneous nerve
Elbow flexion (biceps brachii) and supination
Sensory function of musculocutaneous nerve
Lateral part of forearm
Mechanism of injury musculocutaneous nerve
Isolated injury rare, usually injured as part of brachial plexus injury
Roots of axillary nerve
C5-6
Motor function of axillary nerve
Shoulder abduction (deltoid muscle)
Sensory function of axillary nerve
Inferior region of deltoid muscle
Mechanism of injury of axillary nerve
Humeral neck fracture/dislocation
Clinical presentation of injury to axillary nerve
Flattened deltoid
Roots of radial nerve
C5-8
Motor function of radial nerve
Extension of forearm, wrist, fingers, and thumb
Sensory function of radial nerve
Small area between dorsal aspect of 1st and 2nd metacarpals
Mechanism of injury of radial nerve
Humeral midshaft fracture
Clinical presentation of injury to radial nerve
Wrist drop
Roots of median nerve
C6, C8, T1
Motor function of median nerve
LOAF muscles
Lateral two lumbricals
Opponens pollis
Abductor pollis brevis
Flexor pollis brevis
Clinical features of median nerve lesion at wrist
Paralysis of thenar muscles, oppenens pollicis (carpal tunnel syndrome)
Clinical features of median nerve lesion at elbow
Loss of pronation of forearm and weak wrist flexionS
Sensory function of median nerve
Palmar aspect of lateral 3 1/2 fingers
Roots of ulnar nerve
C8, T1
Motor function of ulnar nerve
Intrinsic hand muscle except LOAF
Wrist flexion
Sensory function of ulnar nerve
Medial 1 1/2 fingers
Mechanism of injury of ulnar nerve
Medial epicondyle fracture
Clinical presentation of ulnar nerve lesion
Claw hand
Roots of long thoracic nerve
C5-7
Motor function of long thoracic nerve
Serratus anterior
Mechanism of injury of long serratus nerve
Often during sport, e.g. following blow to ribs
Complication of mastectomy
Clinical presentation of damage to long thoracic nerve
Winged scapula
Roots injured in Erb-Duchenne palsy
Damage to upper trunk of brachial plexus - C5-6
Cause of Erb-Duchenne palsy
Shoulder dystocia
Presentation of Erb-Duchenne palsy
Arm hands by side, internally rotation, elbow extended
Roots injured in Klumpke palsy
Lower trunk of brachial plexus C8, T1
Cause of Klumpke palsy
- Shoulder dystocia
- Sudden upward jerk of hand
X ray changes in osteoarthritis
- Loss of joint space
- Osteophytes forming at joint margins
- Subchondral sclerosis
- Subchondral cysts
Ankle reflex nerve roots
S1-2
Knee reflex nerve roots
L3-4
Biceps reflex nerve roots
C5-6
Triceps reflex nerve roots
C7-8T
Tinels sign
Tapping cause paraesthesia
Phalens sign
Flexion of wrist causes symptoms
Ottawa rules
Ankle x-ray only required if pain in malleolar zone and any of following:
- Bony tenderness at lateral or medial malleolar zone
- Inability to walk 4 weight-bearing steps immediately after the injury and in the emergency department
Risk factors Achilles tendon disorders
Quinolone use, e.g. ciprofloxacin
Hypercholesterolaemia (tendon xanthomata)
Features of achilles tendinopathy
Gradal onset posterior heel pain, worse following activity
Morning pain and stiffness
Features achilles tendon rupture
- Audible pop in ankle
- Sudden onset significant pain in calf or ankle
- Inability to walk/continue sport
Examination features of achilles tendon rupture
- Greater dorsiflexion of injured foot compared to uninjured limb when patient lies prone with feet over edge of bed
- Gap in Achilles tendon
- When calf muscle squeezed, injured foot stays in neutral position
Imaging modality suspected Achilles tendon rupture
Ultrasound
Features adhesive capsulitis
External rotation affected more than internal rotation or abduction
Both active and passive movement affected
What is Boxer fracture
Minimally displaced fracture of 5th metacarpal
What is Buckle fracture
Incomplete fractures of the shaft of the long bone, characterised by bulging of the cortex
Symptoms carpal tunnel syndrome
Pain/pins and needles in thumb, index, and middle finger
Shaking hand obtains relief, classically at night
Examination findings carpal tunnel syndrome
Weakness of thumb abduction
Wasting of thenar eminence (NOT hypothenar)
Tinels sign - tapping causing paresthesia
Phalens sign - flexion of wrist causes symptoms
Treatment carpal tunnel syndrome
6 week trial of conservative treatment if symptoms are mild-moderate:
- Corticosteroid injection
- Wrist splints at night
If severe or persistent symptoms, surgical decompression (flexor retinaculum division)
What is De Quervain’s tenosynovitis
Condition where sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed
Features De Quervain’s tenosynovitis
- Pain on radial side of wrist
- Tenderness over radial styloid process
- Abduction of the thumb against resistance is painful
- Positive Finkelstein’s test
What is Finkelstein’s test
Examiner pulls thumb of the patient in ulnar deviation and longitudinal traction - if positive, this causes pain over radial styloid process and along the length of extensor pollicis brevis and abductor pollicis longus
Most common bacterial cause discitis
Staphylococcus aureus
Investigations discitis
- MRI
- CT guided biopsy for antimicrobial treatment
- Echo to r/o endocarditis (discitis usually due to haematogenous seeding)
Features of posterior hip dislocation
Affected leg shortened, adducted, and internally rotated
Features of anterior hip dislocation
Affected leg abducted and externally rotated, no leg shortening
Who is iliotibial band syndrome common in
Runners (1 in 10 people who run regularly)
Features of iliotibial band syndrome
Tenderness 2-3cm above the lateral joint line of knee
Mechanism of injury ruptured ACL
Sport injury - high twisting force applied to bent knee
Presentation ruptured ACL
- Loud crack
- Pain
- Rapid joint swelling (haemarthrosis)
Management ruptured ACL
Intense physiotherapy or surgery
Mechanism of injury ruptured PCL
Hyperextension injuries
Mechanism of injury ruptured MCL
Leg forced into valgus via force outside the leg
Examination findings ruptured MCL
Knee unstable when put into valgus position
Mechanism of injury menisceal tear
Rotational sporting injuries
Features menisceal tear
Delayed knee swelling
Joint locking
Recurrent episodes of pain and effusion following minor trauma
Demographic chondromalacia patellae
Teenage girls
Features chondromalacia patallae
Pain going downstairs or at rest
Quadriceps wasting
Mechanism of injury patella dislocation
Direct trauma or severe contraction of quadriceps with knee stretched in valgus and external rotation
Types of patella fracture
Direct blow to patella causing undisplaced fragments
Avulsion fracture
Features lumbar spinal stenosis
- Back pain
- Neuropathic pain
Lumbar spinal stenosis vs claudication
In lumbar spinal stenosis, sitting is better than standing, and easier walking uphill than downhill
What is meralgia paraesthetica
Syndrome of paraesthesia and anaesthesia in distribution of lateral femoral cutaneous nerve
Risk factors meralgia paraesthetica
Obesity
Pregnancy
Tense ascites
Trauma
Iatrogenic
Sports
Idiopathic
Iatrogenic causes of meralgia paraesthetica
- Pelvic osteotomy
- Spinal surgeries
- Laparoscopic hernia repair
- Bariatric surgery
- Abduction splints used in management of Perthes disease
Symptoms meralgia paraesthetica
Symptoms in upper lateral aspect of thigh:
- Burning, tingling, coldness, shooting pain
- Numbness
- Deep muscle ache
Aggravated by standing, relieved by sitting
Signs meralgia paraesthetica
- Symptoms may be reproduced by deep palpation just below ASIS and extension of hip
- Altered sensation over the upper lateral aspect of thigh
- Motor weakness
Investigations meralgia paraesthetica
Pelvic compression test highly sensitive - diagnosed based on this alone
Injection of nerve with local anaesthetic abolish pain
Advice to minimise risk of dislocation after hip replacement
- Avoid flexing hip >90 degrees
- Avoid low chairs
- Do not cross legs
- Sleep on back for first 6 weeks
Types of osteomyelitis
Haematogenous - from bacteraemia
Non-haematogenous.- from contiguous spread of infection from adjacent soft tissues to bone, or direct injury/trauma to bone
Most common site of haematogenous osteomyelitis in adults
Vertebral
Risk factors haematogenous osteomyelitis
Sickle cell anaemia
IV drug user
Immunosuppression
Infective endocarditis
Most common form in children
Risk factors non-haematogenous osteomyelitis
Diabetic foot ulcers/pressure sores
Diabetes mellitus
Peripheral arterial disease
Most common organism osteomyelitis
Staph aureus
Most common organism osteomyelitis in sickle cell
Salmonella
Treatment osteomyelitis
Fluclox 6 weeks
Clindamycin if pen allergic
When should DEXA scan be offered without risk score
> 50 with history of fragility fracture
<40 with major risk factors
Interpretation of QFracture score
If 10 year fracture risk ≥10%, arrange DEXA scan
Interpretation of FRAX score
Colour risk given
Patients in orange zone should have DEXA scan to further refine 10 year risk
Patients in red zone should have DEXA scan to act as baseline and guide drug treatment
Features rotator cuff injury
Shoulder pain worse on abduction
Painful arc of abduction
Tenderness over anterior acromion
Subacromial impingement painful arc degrees
60-120
Rotator cuff tears painful arc degrees
First 60
Blood supply scaphoid
Dorsal carpal branch (branch of radial artery) in retrograde manner
Associations with talipes
Most commonly idiopathic
Spina bifida
Cerebral palsy
Edward’s syndrome
Oligohydraminos
Arthrogryposis
Features trigger finger
More common thumb, middle, or ring finger
Initially stiffness and snapping when extending a flexed digit
Nodule may be felt at base of affected finger
Treatment trigger finger
Steroid injection successful in majority of patients, finger splint may be applied afterwards
Surgery for patients non responsive to steroids
Mechanism of injury Colles fracture
FOSH
Features of Colles fractures
- Transverse fracture of radius
- 1 inch proximal to radio-carpal joint
- Dorsal displacement and angulation
Mechanism of injury Smith’s fracture
Falling backwards onto palm of outstretched hand, or falling with wrists flexed
Features Smith’s fracture
Volar angulation of distal radius fragment
Mechanism of injury Bennett’s fracture
Impact on flexed metacarpal, e.g. fist fight
Features Bennett’s fracture
Intra-articular fracture at base of thumb metacarpal
X-ray Bennett’s fracture
Triangular fragment at base of metacarpal
Mechanism of injury Monteggia’s fracture
FOSH with forced pronation
Features Monteggia’s fracture
Dislocation of proximal radioulnar joint in association with ulna fracture
Features Barton’s fracture
Distal radius fracture with associated radiocarpal dislocation
Mechanism of injury Barton’s fracture
Fall onto extended and pronated wrist
Mechanism of injury radial head fracture
FOSH
Clinical features radial head fracture
- Marked local tenderness over head of radius
- Impaired movements at elbow
- Sharp pain on lateral side of elbow at extremes of rotation (pronation and supination)
