MSK Flashcards
1
Q
- On examination, the GP detects lymphadenopathy (enlarged lymph nodes).
- i) The GP examines the patient’s breasts. What else will the GP need to examine? (1 mark)
- ii) Explain your answer to part i) (1 mark)
A
- i) Left Upper Limb or Left posterior trunk
- ii) Axillary lymph nodes receive lymph from the upper limb and posterior trunk so may be sites of metastasic deposits of tumour
2
Q
- On examination of the patient’s left breast, the GP finds a lump that is irregular and fixed to the underlying tissues (i.e. is not mobile).
- What is the significance of this finding?
A
- The lump has invaded local tissue and is likely to be malignant (cancer)
3
Q
- The woman is referred to the breast clinic where she undergoes mammography, biopsy and a CT scan. A carcinoma that has invaded the chest wall posteriorly is diagnosed.
- i) Which muscle will have been invaded first by the cancer? (1 mark)
- ii) State the neural innervation of this muscle. (1 mark)
- iii) Surgical excision of the tumour involves removal of extensive parts of the muscle named in part i). State three movements of the upper limb that will be compromised as a result of this operation. (2 marks)
A
- i) Pectoral major
- ii) medial and lateral pectoral nerves
- iii) Flexion of the shoulder, Adduction of the arm and medial rotation of the humerus
4
Q
- At the same time as her mastectomy, the woman undergoes axillary clearance.
- Apart from fat, what has been cleared from the axilla and why?
A
- Lymph nodes and lymph vessels
- The Lymph nodes contain metastatic deposits from breast cancer, removal of these nodes may stop tumour from spreading to other parts of the body
5
Q
- Explain why the upper limb may become swollen following axillary clearance.
A
- Excision of axillary lymph nodes and lymphatic vessels leads to the interruption of the normal lymphatic drainage of the upper limb
6
Q
- After the axillary clearance operation, the woman has hyperaesthesia (abnormal increased sensitivity to touch) extending from the axilla down the medial side of the arm.
- Even gently stroking the skin is very sore.
- Intra-operative damage to which nerve explains her hypersensitivity?
- What is it’s nerve root?
A
- Intercosto-brachial nerve (T2); lateral cutaneous branch of T2 penetrates the serratus anterior muscle and enters the axilla to supply the skin of the lateral wall of the axilla and the upper medial arm.
7
Q
- When reviewed in the outpatient clinic two weeks post-operatively, the patient also describes weakness of her arm. When asked to push against a wall with her hands, the inferior-medial part of her right scapula is clearly more prominent (“winged scapula”) than the left.
- Which nerve damage and what muscle weakness causes a “winged scapula”?
A
- The long thoracic nerve (nerve to serratus anterior muscle) may have been injured during the operation.
- Serratus anterior muscle holds the scapula against the chest wall and contraction of this muscle moves the scapula around the chest wall i.e. protraction.
- Paralysis of the serratus anterior muscle (due to its nerve injury) causes the medial border of the scapula and its inferior wing to “wing” because of the unopposed action of muscles (e.g. the rhomboids) on the medial border of the scapula.
8
Q
- The patient also has weakness of abduction of the arm beyond about 90 degrees.
- What is the most likely reason for this?
A
- The affected serratus anterior muscle is unable to rotate the scapula laterally (glenoid fossa to face superiorly) to allow complete abduction of the upper limb (i.e. beyond 90).
9
Q
- An 8 year old boy has severe pain in his right arm and an obvious deformity following a fall from a climbing frame.
- His X-ray is below shows a displaced supracondylar fracture of the humerus.
- Which nerve is most at risk of injury?
- (a) Axillary
- (b) Median
- (c) Musculocutaneous
- (d) Radial
- (e) Ulnar C
A
- Median nerve
- Median nerve passes anterior to the distal shaft and metaphysis of the humerus and traverses the cubital fossa together with the brachial artery
- Both structures are at risk in supracondylar fractures of the humerus
10
Q
In supracondylar fractures of the humerus, what nerve and blood vessel is at risk?
A
- Median Nerve
- Brachial artery
11
Q
- A 55 year old woman has had a painful right shoulder for the past two weeks. She says that the pain is particularly bad when she tries to brush her hair or put on her coat. On examination, a painful arc is detected between 60 and 120 degrees of abduction.
- She is diagnosed with inflammation in a tendon that is impinging against the coracoacromial arch of the scapula.
- The tendon of which muscle most likely to be inflamed?
- (a) Deltoid
- (b) Infraspinatus
- (c) Subscapularis
- (d) Supraspinatus
- (e) Teres minor
A
- Supraspinatus tendonitis
- The classical sign is painful arc on resisted abduction between 60 and 120 degrees when the inflamed tendon impinges on the coracoacromial arch
- Outside this range abduction is painless
12
Q
- A 23 year old man fractures his left clavicle playing rugby.
- An X-ray shows that the lateral fragment is displaced inferiorly and medially.
- The action of which muscle is primarily responsible for the medial displacement?
- (a) Pectoralis major
- (b) Pectoralis minor
- (c) Serratus anterior
- (d) Subclavius
- (e) Supraspinatus
A
- Pectoralis major
- The lateral fragment is most likely to be displaced medially due to the action of pectorals major adducting the upper limb and inferiorly due to the weight of the upper limb pulling downwards on the fracture fragment Pectoralis major originates from the anterior border of the medial half of the clavicle and the upper six costal cartilages. It inserts into the lateral lip of the biciptal groove of the humerus. It is a strong muscle and following clavicular fracture, its line of pull acts to adduct the humerus and therefore indirectly adduct the lateral fragment of the clavicle (via the ligaments of the glenohumeral joint and acromioclavicular joint). The medial fragment is likely to be displaced superiorly by the action of sternocleidomastoid, exacerbating the degree of non-alignment of the fracture fragments.
13
Q
- A 23 year old man sustains a right midclavicular fracture in a high speed cycling accident. On examination, his right arm is pale and cold and his radial pulse cannot be palpated. An arterial injury is suspected. Which artery is most likely to have been damaged?
- (a) Axillary
- (b) Brachial
- (c) Common carotid
- (d) Subclavian
- (e) Vertebral
A
- Subclavian
- Subclavian artery has been suddenly occluded preventing adequate perfusion of the upper limb Vascular injuries after a closed clavicular fracture of relatively rare but severe if missed/ Following a mid shaft clavicular fracture the proximal part of the subclavian artery is most commonly affected, where the vertebral and thoracic arteries originate. The subclavian vein can also be inured.
14
Q
- A 50 year old woman develops a melanoma on her left arm. The plastic surgeon palpates her axillary lymph nodes for metastases. An enlarged lymph node can be felt immediately posterior to the anterior axillary fold. Which muscle forms this fold?
- (a) Pectoralis major
- (b) Teres major
- (c) Teres minor
- (d) Latissimus dorsi
- (e) Subscapularis
A
- Pectoralis Major
- Anterior fold is formed by the lateral edge of pectorals major muscle
- The posterior axillary fold is formed by the lateral edges of the latissimus doors and teres major muscle
15
Q
- A 30 year old man falls from his horse and sustains an anterior dislocation of his right shoulder. Closed reduction is performed in the Emergency Department and the patient is discharged. Six weeks later, he presents to his GP complaining of continuing weakness in the shoulder. A small patch of anaesthesia is detected in the upper lateral area of his right arm and on inspection, there is muscle wasting (see image).
- Which nerve has been injured?
- (a) Axillary
- (b) Dorsal scapular
- (c) Lateral pectoral
- (d) Long thoracic
- (e) Upper subscapular
A
Axillary Wasting of the deltoid and slight wasting of teres minor due to an axillary nerve injury Mechanism of injury is traction as the axillary nerve becomes stretched across inferior aspects of the head of the humerus during dislocation Associated small patch of anaesthesia in the regimental badge area in this case Not always present due to overlapping innervation from adjacent peripheral nerves
16
Q
- A 64 year old woman undergoes clearance of her axillary lymph nodes during a mastectomy for breast cancer. In the outpatient clinic six weeks later she describes difficulty raising her arm above her head. When the surgeon asks her to push her outstretched hand against a wall, the appearance below is seen (see image):
- Which nerve has been damaged during the axillary surgery?
- (a) Axillary
- (b) Dorsal scapular
- (c) Long thoracic
- (d) Musculocutaneous
- (e) Thoracodorsal C
A
- Long Thoracic
- Winging scapula due to damage on the Long thoracic nerve susceptible to damage during axillary clearance as it has along superficial course in the external aspect of serrates anterior in the axillary fossa.
- Following long thoracic nerve damage, the serratus anterior is paralysed so is no longer able to pull the scapula forward e.g. when throwing a punch; or to hold the vertebral border against the thoracic cage (in which it acts together with the rhomboids). The inferior fibres of serratus anterior also usually assist trapezius in upward rotation of the scapula, hence the functional deficit described by the patient in this case.
- The winging is often not evident immediately post-operatively but appears several weeks later, once the trapezius muscle fibres have stretched.
17
Q
- An 80 year old woman falls and lands on the lateral aspect of her right flexed elbow.
- She describes complete loss of sensation in her ring and little fingers.
- Her X-ray is shown below.
- Which movement of her right thumb is most likely to be impaired?
- (a) Adduction
- (b) Flexion at the interphalangeal joint
- (c) Opposition
- (d) Palmar abduction
- (e) Radial abduction
A
- Adduction
- Ulnar nerve runs posterior to the medial epicondyle in the cubital fossa.
- Susceptible to damage in medial epicondylar fractures.
- Supplies Adductor pollicis
18
Q
- What is are the muscles of the thumb innervated by?
A
- Ulnar nerve- Adductor pollicis
- Radial nerve- Abductor pollicis longus
- Median nerve- Abductor pollicis brevis, flexor pollicis longus, opponens pollicis
19
Q
- A 70 year old woman falls onto her outstretched left hand. She develops severe pain and deformity of the wrist. An X-ray is shown below (see image). After reduction of the fracture, the pain is improved and she now complains of numbness and tingling in her thumb, index and middle fingers.
- Which of the following movements of her hand is most likely to be impaired?
- (a) Abduction of the fingers
- (b) Adduction of the fingers
- (c) Flexion of the index finger at the distal interphalangeal joint
- (d) Flexion of the index finger at the proximal interphalangeal joint
- (e) Palmar abduction of the thumb
A
- Palmar abduction of the thumb
- Abductor pollicis brevis is supplied by the median nerve in the hand rather than in the proximal forearm so only APB will be affected
20
Q
- A 30 year old man falls onto his outstretched right hand. He complains of pain in his wrist.
- An X-ray is obtained (see below).
- The position of the fracture is indicated with an arrow.
- Which bone has been fractured?
- (a) Hamate
- (b) Lunate
- (c) Pisiform
- (d) Scaphoid
- (e) Trapezium
A
- Scaphoid
- Some Lovers Try Positions That They Cant Handle
- Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Capitate Hamate
21
Q
- A 26 year old man falls from a ladder and lands on his left elbow. His X-ray is shown below.
- Describe the precise anatomical location of the fracture?
A
- Midshaft of the Humerus
28
Q
- A 25 year old man sustains an inversion injury to his left ankle and foot whilst playing football. An oblique X-ray of his left foot is shown below and the position of the fracture is indicated with an arrow. Which bone has been fractured?
- (a) 5th metatarsal
- (b) Cuboid
- (c) Medial cuneiform
- (d) Navicular
- (e) Proximal phalanx of little toe
A
5th metatarsal
29
Q
- A 35 year old man presents to his GP with a two day history of an increasingly painful swelling on the anterior aspect of his right knee. He has spent the last two days tiling his kitchen floor at home. On examination there is a tennis-ball shaped swelling overlying the right knee (see image) which is tender on palpation.
- Palpation of the surrounding tissues is non-tender. Movements of the knee are resisted due to anterior knee pain. What is the most likely diagnosis?
- (a) Infrapatellar bursitis
- (b) Patellar dislocation
- (c) Rheumatoid arthritis
- (d) Septic arthritis
- (e) Suprapatellar bursitis
A
Suprapatellar busitis The patient has suprapatellar bursitis (housemaids knee) due to microtrauma during kneeling and leaning forwards for prolonged periods over the past two days whilst tiling his floor. This has led to acute inflammation in the suprapatellar bursa. In addition to the clues within the history, the location of the swelling on the image is also diagnostic.
30
Q
- A 65 year old man presents to his GP with pain and stiffness of the right knee, increasing over the past 12 months. There is no history of trauma. He is otherwise well. His father had a hip replacement at the age of 68 years and there is no other family history of note. Antero-posterior and lateral X-rays of his knee are shown below.
- What is the most likely diagnosis leading to the patient’s presenting symptoms?
- (a) Gout
- (b) Osteoarthritis
- (c) Osteomalacia
- (d) Osteoporosis
- (e) Rheumatoid arthritis
A
Osteoarthritis The patient’s history (chronic pain and stiffness without systemic symptoms; positive family history) and the X-ray changes are typical of osteoarthritis. The X-ray shows loss of joint space, subchondral sclerosis, and osteophyte formation. Together with subchondral bone cysts (not seen here), these are the cardinal signs of osteoarthritis on an X-ray.
32
Q
- x A 32 year old man sustains direct trauma to the medial aspect of his knee whilst playing football. On arrival in the Emergency Department, there is an obvious deformity of the knee (see image). Dislocation of the patella is diagnosed. Fibres of which muscle typically contract to resist patellar dislocation in this direction? (a) Biceps femoris (b) Rectus femoris (c) Sartorius (d) Vastus lateralis (e) Vastus medialis
A
- Vastus medialis
- Horizontal fibres of vests medals insert into the medial border of the lower patella and contract to resist lateral dislocation
36
Q
- A 70 year old man complains of pain in his foot and leg whilst walking that resolves on rest. He can reliably walk 50 metres on flat ground before the pain starts. The GP examines his leg and is unable to palpate a dorsalis pedis pulse. What is the surface marking for palpation of this pulse?
- (a) Between the tendons of extensor hallucis longus and extensor digitorum longus to the second toe
- (b) Between the tendons of extensor hallucis longus and tibialis anterior
- (c) Immediately anterior to the lateral malleolus
- (d) Immediately posterior to the medial malleolus
- (e) The dorsum of the first web space
A
- Between extensor hallucis longus tendon and extensor digitorum longus to the second toe
38
Q
Circle the appropriate answers to indicate whether the following motor functions will be absent, compromised (reduced power), or present following division of the sciatic nerve.
A
39
Q
- On the diagrams below, accurately shade the area of sensory loss below the knee in this patient. with sciatic nerve dysfunction
A
42
Q
- An X-ray of the patient’s hips and pelvis is shown below. On the image below, precisely indicate the position of the following structures with labelled arrows:
- Right ischial tuberosity (IT)
- Right intertrochanteric line (draw a line to indicate the position then label it) (ITL)
- Right superior pubic ramus (SPR)
- Right acetabulum (A)
A
45
Q
- Once mobile with a walking frame, the patient commences physiotherapy to strengthen the muscles around the hip joint. In the standing position, he is asked to slowly lift the knee of his operated leg until his hip is flexed to 90° (see below). In the table below name two muscles that flex the hip joint and state the peripheral nerve supply of each.
A
48
Q
On the outline of the dorsum of the hand below,, shade the sensory distribution of the radial nerve.
ii)) Mark with an X the most reliable place for testing sensory loss in a radial nerve lesion.
A
49
Q
- The patient undergoes reduction and immobilisation of the fracture.
- Complete the diagram below to show the stages of fracture healing that will take place.
A
50
Q
A
