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MSK Flashcards

1
Q

How do you read an X-ray?

A
  • Basic Information
    • Name / DOB
    • When it was taken/view/body part
      • Remember to always get 2 views
  • Problem
    • Fracture
      • Location
      • Displacement
      • Fracture Pattern
    • Dislocation
      • Direction / Rotation
    • Shadowing
      • Ca / Tumour / Infection / Cyst
    • Osteoarthritis
      • 4 key features
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2
Q

How would you describe the displacement of a fracture

A
  • Angulation (in degrees)
  • Direction
    • Superior / inferior / anterior / posterior / medial / lateral
    • Dorsal / Palmar (Volar) / radial / ulna
  • Translation (as a %)
    • if 100% then off ended
  • Shortening (Compaction)
    • estimate how much shorter in (cm)
  • Rotation
    • Medial / lateral
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3
Q

What are the different types of fracture patterns?

A
  • Transverse
  • Oblique
  • Spiral
  • Comminuted
  • Segmental
  • Impacted
  • Salter-harris (epiphyseal plate fracture)
  • Wedge
  • Greenstick
  • Torus / Buckle
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4
Q

What are the 4 signs of Osteoarthritis (OA) on Xray?

A
  • Loss of joint space
  • Osteophytes
  • Sclerosis
  • Subchondral cysts
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5
Q

What is a greenstick fracture and when does it occur?

A

When only 1 side of the cortex is broken the other is only bent

Occurs in children as their bones are softer and more malleable

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6
Q

What is a Torus / Buckle fracture

A

Axial pressure on a long bone leads to a buckle and a bulge in the cortex at the fracture site

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7
Q

What is a salter harris fracture and how are they classified?

A

Fracture involving the epiphyseal growth plate

5 types depending on location

  1. (S-straight) Transverse through physis
  2. (A-above) Through physis and metaphysis
  3. (L-lower) Through physis and epiphysis
  4. (T-through) Through all 3
  5. (ER-crush) Compression at physis
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8
Q

When are benign and aggresive periosteal reactions seen?

A
  • Benign
    • Callus formation in fractures
    • Slow growing tumours
  • Aggresive
    • Infected bone
    • Eosinophillic granuloma
    • Malignant tumours
    • Osteoid osteoma
    • Bone cysts
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9
Q

What are the types of periosteal rection from least aggresive to most?

A
  • Solid
    • uniformly dense, single thin layer of new bone about 1-2 mm from the cortical surface.
  • Lamellated
    • multiple concentric parallel layers of new bone adjacent to the cortex, reminiscent of the layers on an onion
  • Spiculated
    • represents spicules of new bone forming along vascular channels and the fibrous bands that anchor tendons to bone
  • Codman’s
    • the periosteum does not have time to ossify, so only the edge of the raised periosteum will ossify.
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10
Q

What things must you are generic to any joint examination?

A
  • Look
    • Swelling / brusing / discolouration
    • Scars (ask where they are from)
    • Asymmetry
  • Feel
    • Bony prominences
    • Muscle bulk (for wasting)
    • Tenderness
  • Move
    • Active + Passive movements
    • Resistence against power
  • Joint hypermobility
    • Beighton scoring (4/9 indictates hypermobility)
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11
Q

When observing during a spinal examination what must you look out for?

A
  • Asymmetry
    • Shoulder drop
    • Scapula protrussion
    • Unaligned iliac crests
  • Spine curvature
    • Scoliosis (sideways)
    • Kyphosis (hunchback)
    • Lordosis (big bum)
  • Gait
    • Normal walking
    • Test myotomes by getting patient to walk
      • on their tip toes (S1)
      • on their heels (L5)
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12
Q

What should you feel for during a spinal exam?

A
  • Down the spinous processes
    • feeling for tenderness
  • Paraspinal muscles
  • Scaro iliac joints
  • Verterbral Landmarks
    • Most prominant cervical vertebrate (C7)
    • Iliac crest (L4)
    • Posterior superior iliac spine (S2)
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13
Q

What movements should you do during a spine examination

A
  • Cervical
    • Flexion + Extension (C1) (chin to chest)
    • Rotation (C1/C2) (turn head)
    • Lateral Flexion (C2-7) (ears to shoulder)
  • Thoracic
    • Rotation (Siting and you hold hips straight)
  • Lumbar
    • Flexion + Extension (touch toes / lean back)
    • Later flexion (run arm down same leg)
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14
Q

What special tests are conducted in a spine examination

A
  • Schober’s test
    • Mark skin at sacro iliac join
      • Mark skin 10cm above + 5cm below
      • Patient touch toes
      • 15cm gap should now be >20cm
    • Indicates restriction of lumber spine
      • Ankylosing spondylitis
  • Straight leg raise
    • Raise patient leg while knee is flexed
    • Extend the knee
      • If pain is present down the back of the leg sciatica is likely
      • Pain worsens during dorsiflexion (this is a +ve sciatic stretch test)
    • If pain is in opposite leg it will indicate a disc prolapse
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15
Q

When conducting a periheral neurological exam what are you looking for and feeling for?

A
  • Looking
    • Scarring
    • Loss of muscle mass
    • Fasciculations
    • Gait (lower limb only)
    • Pronator drift (upper limb only)
  • Feeling
    • Muscle mass
    • Isolate movements of each joint and test them
    • Hypertonia (Rigidity)
      • Clasp knife (UMN lesion)
      • Leadpipe / Cogwheel (Parkinson’s)
    • Hypotonia
      • LMN lesion
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16
Q

What do you look for in a patient’s gait?

A
  • Parkinson’s (Festinating) Gait
    • Stooped forward with no arm swing
    • Delayed initiation with festination
    • Pedestal turning
  • Trendelenburg Gait
    • Waddling gait with swinging hips
    • Dennervation to superior gluteal nerve due to damage in L4-S1
  • Stomping / Foot slapping gait
    • Loss of proprioception
    • Do romberg’s test to verify
  • Scissoring gait
    • UMN lesion (cerberal palsy)
  • Cerebellar gait
    • Drunken walk staggering to side of lesion
  • Antalgic gait
    • Patient in pain
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17
Q

What do each of the myotomes in the upper limb do?

A
  • C5 - Elbow flexion
  • C6 - Wrist exension
  • C7 - Elbow extension
  • C8 - Finger flexion
  • T1 - Finger abduction
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18
Q

What do each of the myotomes in the lower limb do?

A
  • L2 - Hip flexion
  • L3 - Knee extension
  • L4 - Dorsiflexion of foot
  • L5 - Dorsiflexion of big toe
  • S1 - Plantarflexion of foot
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19
Q

Describe the MRC power grading

A
  1. No movement
  2. Flicker of contraction
  3. Active movement with no gravity
  4. Active movement against gravity
  5. Active movement against moderate resistance
  6. Normal Movement
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20
Q

What reflexes should you test in both the upper and lower limb

A
  • C5 Biceps brachii
  • C6 Brachioradialis
  • C7 Triceps brachii
  • L3/4 Patella tendon
  • S1/2 Calcaneal tendon
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21
Q

Special tests when examining the neurological function of the upper limb?

A
  • Cerebellar ataxia
    • Finger nose test for past pointing
    • Hand flipping for dysdiadochokinesia
  • UMN lesion
    • Hoffman’s test
      • Hold middle finger at middle phalanx and flick distal phalanx
      • Thumb twitching indicated UMN lesion
    • Pronator drift
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22
Q

Special tests when examining the neurological function of the lower limb?

A
  • Cerebellar Ataxia
    • Heel to shin test
    • Tap feet against examiners hand as for as possible to assess dysdiadochokinesia
  • UMN lesion
    • Babinski’s test
    • Clonus
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23
Q

Signs of an UMN lesion

A
  • Hyperreflexia
  • Hypertonia
  • Weakness
  • Special Tests
    • Babinski’s Sign
    • Hoffman’s Sign
    • Pronator Drift
    • Clonus
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24
Q

Signs of a LMN lesion

A
  • Hypotonia
  • Hyporeflexia / Areflexia
  • Weakness / Wasting
  • Fasciculations
25
Q

Where is each dermatome situated on the upper limb

A

C5 - Regimental Badge Area

C6 - Thumb

C7 - Middle Finger

C8 - Little Finger

T1 - Medial Forearm

T2 - Medial Arm

26
Q

Where is each dermatome situated on the lower limb

A

L1 - Groin

L2 - Anterior Thigh

L3 - Knee

L4 - Medial Malleolus

L5 - Big Toe

S1 - Heel

S2 - Popliteal Fossa

27
Q

What do you use a DRE to asses

A
  • Anal Tone
    • S2,3,4 keeps your shit off the floor
    • Also check voluntary contraction
  • Stool Compaction
  • Perianal Sesation
28
Q

What is spinal stenosis?

What are the complications?

What are the causes?

What are the risk factors?

A
  • Spinal stenosis is the narrowing of the spinal canal causing:
    • Nerve impingement
    • Cauda Equina
    • Neurogenic claudication
  • Caused by
    • Osteophytes
    • Hypertrophy of ligamentum flavum
  • RFs
    • Hyperparathyroidism
    • Paget’s
    • Ankylosing spondylitis
    • Cushing’s
    • Acromegly
29
Q

What is neurogenic intermittent claudication?

What causes it?

How do you differenciated it from vascualar claudication?

A
  • Pain pattern similiar to vascular claudication but caused by nerve impingment
  • Caused by spinal stenosis
  • Differenciate from vascular
    • Proximal pain in thigh rather than calf
    • No pain when cycling as no impingement when in bent position
    • Pain better going up hills as opposed to vascular.
    • Pain worsened by passive leg stretch test
30
Q

How do you investigate neurogenic claudication?

How do you treat neurogenic claudication?

A
  • Investigations
    • X-ray / CT
      • Underlying abnormality such as
        • spina bifida occulta
        • spondylolisthesis
    • MRI
  • Treatment
    • Conservative
      • NSAIDS / Parcetamol
      • Weight Reduction
      • Physio (Forward flexion)
      • Epidural steriod injections
    • Surgical
      • Decompression (Laminectomy)
31
Q

What are the red flag symptoms for back pain? (Mneumonic)

A

A TUNA FISH

  • Age <18 or >55
  • Trauma
  • Unexplained weight loss
  • Neurological symptoms
  • Atypical Pain
    • Thoracic
    • Pain when lying down
    • Non mechanical
  • Fever / Sweats / Rigors
  • Incontinence / Retention (Urinary)
  • Steriods
  • History of Ca.
32
Q

Causes of back pain?

A
  • Trauma
    • Fracture
    • Sprain
  • Rhematoid
    • Ankylosing Spondylitis
    • Rheumatoid Arthritis
    • Polymyagia rheumatica
    • Osteoarthritis spondylosis
    • Septic arthritis
  • Osteomalacia
  • Refered Pain
    • Hip (tumour / athritis / ischeamia)
    • Sciatica
  • Tumour
  • Intervertebral disc
    • Herniated nucleaus pulposus
33
Q

What is cauda equina?

What are the red flag symptoms?

A
  • Medical Emergency involving the impingment of the cauda equina leading to paraplegia and incontinence
  • Red flag symptoms
    • Saddle paraesthesia
    • Faecal incontinence
    • Urinary retention + overflow incontinence
34
Q

What are the causes of Cauda Equina

A
  • Herniation of lumber discs
  • Verterbrae tumours
  • Trauma
  • Infection
  • Congenital stenois (spina bifida)
  • Spondylolysis / Spondylolisthesis
  • Ankylosing spondylitis
35
Q

What are the differential diagnosis for cauda equina

A
  • Conus medullaris syndrome (T12-L2 compression)
  • Mechanical back pain
  • Prolapsed lumber disc
  • Fractured lumber vertebrae
  • Spinal tumour
  • Spinal cord compression
  • peripheral neuropathy
36
Q

What is the options for cauda equina?

A
  • Tumour cause
    • Surgical decompression
    • Radiotherapy
    • Chemotherapy
  • Inflamatory cause
    • NSAIDS
    • Steroid injections
  • Infectious cause
    • Antibiotics
  • General
    • Reduce weight
    • Physiotherapy
37
Q

What is spina bifida?

What causes it?

What are the different types?

A
  • Failure of closure of the posterior neuropore
  • Folic Acid deficiency
  • Spina bifida
    • Occulta
      • Skin intact
      • Vertebral arch defect
    • Cystica (skin not intact)
      • Meningocele, protruding sac made of meninges
      • Myelomeningocele, neural tissue in protruding sac
    • Rachischisis
      • Cleft through the entire spine, leaving the spinal cord exposed
38
Q

What is anencephaly

A
  • Failure of closure of the anterior neuopore
    • Brain does not develop
    • Not compatable with life
39
Q

How can cases of spina bifida occulta be picked up on examination?

A

Spina bifida occulta leaves skin markings over the site of the defect such as increase hair growth, skin tags or discolouration.

40
Q

What are the complications of spina bifida cystica

A
  • Developmental dysplasia of the hip
  • Scoliosis
  • Hyrocehpalus
  • Arnold chiari 2 malformation of the skull
  • Renal Impairment
    • Neurogenic bladding
      • Overflow incontinence
      • Increased risk of UTIs
  • Spinal Cord tethering
  • Meningitis
  • Increased Risk of Latex allergy
41
Q

What are the 2 ascending spinal tracts and what are they responsible for?

A
  • SPinoThalamic
    • Responsible for Pain and Temperature
  • Dorsal Column Medial Leminiscus Pathway
    • Responsible for fine touch, proprioception and vibration
42
Q

What are the 2 descending spinal cord tracts and what are the responsible for?

A
  • Pyramidal Tracts (Corticospinal)
    • Pass through the medullary pyramid and innervate most motor function.
    • Damage leads to UMN lesion signs
      • Spasticity, Clasp Knife Rigidity
      • Hyperreflexia + Hypertonia
      • Muscle Weakness
  • Extrapyramidal Tracts
    • Rubrospinal, Tectospinal, Vestibulospinal, Reticulospinal
    • Damage leads to cerebellar signs (DANISH)
      • Dysdiadochokinesia, Ataxia, Nystagmus, Intention tremor, Slurred speech, Hypotonia
43
Q

What are the symptoms of a central cord injury and what most commonly causes this.

A
  • Causes
    • Hyperextension injury (Whiplash)
    • Spinal cord ischaemia
    • Syringomyelia
      • Chiari malformation increases risk of cyst forming
    • B12 deficiency
    • Cervical Stenosis
  • Symptoms
    • Motor and Sensory defecits, mostly in upper extremities
    • Hands affected with UMN lesion symptoms
    • Burning sensation in hands with cape distribution of sensory loss mostly affecting spinothalamic
44
Q

What is chiari malformation?

A

A Chiari malformation is where the lower part of the brain pushes down into the spinal canal.

45
Q

What are the causes and symptoms of an anterior cord injury?

A
  • Causes
    • Excessive flexion of C-spine causing anterior compression
    • Ischaemic damage due to thrombosis or trauma of the anterior spinal artery
  • Symptoms
    • Motor: Variable paralysis below the affected spinal level
    • Sensory: Only Spinothalamic pathway affected
46
Q

What causes Brown-Sequard Syndrome and what are the symptoms?

A
  • Cause
    • Hemitransection of the cord usually from penetrating trauma
  • Symptoms
    • Ipsilateral loss of motor function
      • Decussates in medulla oblongata
    • psilateral loss of Dorsal column
      • Decussates in medulla oblongata
    • Contralateral loss of Spinothalamic pathway
      • Decussates at exit level
47
Q

What are the causes and symptoms of a posterior spinal cord injury?

A
  • Causes
    • Penetrating injury to back
    • Hyperextension leading to vertebral arch fracture
  • Symtoms
    • Only dorsal column medial lemniscus pathway affected
48
Q

What would be the most likely cause of spinothalamic sensation loss across the thumb and lateral 2.5 fingers?

A

Carpal Tunnel Syndrome

49
Q

What would be the most likely cause of spinothalamic bilateral sensation loss at the level of the umbilicus with accompanying weakness across both lower limbs

A

Complete spinal cord injury

50
Q

What would be the most likely cause of left sided spinothalamic sensation loss at the level of the umbilicus with accompanying weakness the right lower limb

A

Brown Sequard Syndrome

51
Q

What would cause spinothalamic cape sensation loss (across the shoulders and up the neck)

A

Syringomyelia

52
Q

What would right sided spinothalamic sensation loss from the nipple downwards and left sided facial sensation loss

A

Brain stem injury

53
Q

What would cause entire left side spinothalamic sensation loss?

A

Thalamic or cerebral hemisphere injury

54
Q

How do you investigate and manage a spinal cord injury?

A
  • Investigation
    • X-ray/Ct for vertebral fracture
    • MRI for soft tissue injury such as disc herniation or ligamentum damage
      • Could use a CT myelogram for this aswell (spinal cord contrast)
  • Managment
    • Support and maitain stability to prevent further damage
    • Refer to neurosurgeon as emergency spinal decompression maybe needed
55
Q

What are the complications of a spinal cord injury?

A
  • Autonomic dysreflexia
    • Uncontrolled sympathetic stimulation causing
      • uncontrolled hypertension
        • increasing risk of stroke
      • severe headache
      • cold and clammy skin
      • dilated pupils
  • Aspiration
  • Chronic MSK pain
  • Limited regeneration of spinal cord leads to persitence of symptoms following treatment
56
Q

What are you looking for during a hip examination?

A
  • Gait
    • Antalgic (pain)
    • Trendelenburg (superior gluteal nerve injury causing abductor weakness on contralateral side)
    • Parkinsonian (shuffling/festinating)
    • Ataxic (cerebellar)
    • Steppage (foot drop)
    • Stomping (loss of proprioceptive input)
  • Valgus/Varus
  • Muscle wasting
  • Swelling, bruising, discolouration, scarring
  • Leg length
    • Flex knees see if they are the same height
    • Extend legs match medial malleolus
57
Q

What should you feel for during a hip exam?

What special tests can you do?

A
  • Landmarks
    • Great trochanter (trochanteric bursitis)
    • Ischial tuberosity (strained hamstrings)
  • Special test
    • Thomas’ test (dont do in patients with hip replacments as you will dislocated the hip)
      • Place hand under patient’s back and flex leg at hip + knee untill you feel back go down
      • Observe if contralateral leg is also flexed
      • Evidence of a fixed flexion deformity
58
Q

do you like big butts

A

i cannot lie

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