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MSK Flashcards

Arms: Nerves Blood vessels Dislocations Hand nerves and tendons

1
Q

Sensations lost in order in nerve compression

A

Light tough, pressure and vibration

Then pain and temperature

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2
Q

Causes of nerve compression in arm - 5 categories

A

Anatomical - fracture deformity, synovial fibrosis
Systemic - alcohol, diabetes, renal failure, Reynaud’s
Inflammatory - RA, infection, tenosynovitis
Mass - haematoma, lipoma
Fluid imbalance - pregnancy, obesity

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3
Q

Pathophysiology of nerve compression

A

Microvascular compression causes intraneural oedema which increases it
Increases pressure and vibratory threshold
Fibrosis, axonal loss, demyelination cause weakness or paralysis of motor nerve

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4
Q

Other signs and tests of nerve compression except motor and sensory - 4

A

2 point discrimation (>6mm = abnormal)
Skin - colour, temperature from SNS dysfunction
Electromyography
Nerve conduction studies

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5
Q

RF for carpal tunnel

A 
MEDIAN TRAP:
Myxoedema
oEdema
Diabetes
Iatrogenic
Acromegaly
Neoplasm
Trauma
RA
Amyloidosis
Pregnancy
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6
Q

What is in carpal tunnel

A

Median nerve
Flexor pollicis longus tendon
4 FDS tendons
4 FDP tendons

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7
Q

Pathogenesis of carpal tunnel syndrome

A

Pressure increases
Epineural blood flow decreases and nerve becomes oedematous
Increasing pressure causes nerve conduction to decrease

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8
Q

Sx of carpal tunnel and tests

A

Paraesthesia and pain often at night on volar aspect of radial 3.5 digits
Tinel and Phalen
Loss of fine motor control and weakness = late
Nerve conduction test and EMG

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9
Q

Differentials for carpal tunnel syndrome

A

Cervical radiculopathy
Thoracic outlet syndrome
Peripheral neuropathies eg diabetess

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10
Q

Treatment of carpal tunnel

A

Activity modification, night splint, NSAIDS
Single corticosteroid injection
Operative release

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11
Q

Complications of surgery for carpal tunnel - 2

A

Ulnar neurovascular structures in Guyon canal can be injured if too ulnar
Damage to recurrent motor branch of median nerve if too radial

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12
Q

Where to find recurrent motor branch of median nerve

A

Kaplan line (from abducted thumb distal surface) and longitudinal line from web spaces of index and middle finger

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13
Q

Differentiate pronator syndrome and CTS

A

Pronator has forearm pain and palmar cutaneous median nerve sensory pain

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14
Q

What is the cubical tunnel

A 
Floor = elbow joint capsule and MCL
Sides = olecrattnon and median epicondylitis
Roof = FCU fascia and fibrous band
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15
Q

Compression of ulnar nerve at medial epicondyle

A

Paralyse FCU, 1/2 FDP, interossei and medial 2 lumbricals
No abduction or adduction
4th and 5th digits reduced movement
1/2 4th and 5th digits no sensation

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16
Q

Compression of ulnar nerve at wrist

A

Paralyse medial 2 lumbricals and interossei
No finger abduction/adduction
Ulnar claw: cannot extend at IPs of 4th and 5th digits (unopposed flexor digitorum), but overextension at MCP (unopposed extensor digitorum)

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17
Q

Test for ulnar nerve

A

Froment’s test - paper between thumb and finger, pulling out causes thumb to flex as flexor pollicis is used to make up for lack of adductor pollicis

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18
Q

Nerve damage in axilla?

A

Radial = paralyse triceps and posterior forearm, so no wrist extension, no cutaneous innervation

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19
Q

Nerve damage in radial groove?

A

Radial nerve - paralyse posterior forearm - wrist drop, no dorsum cutaneous innervation

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20
Q

Posterior forearm paralysis but no wrist drop

A

Deep motor branch of radial nerve injury after elbow, paralysing post forearm except ECRL and supinator

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21
Q

Median nerve damage at elbow

A

Paralyse anterior forearm except FCU and 1/2 FDP
No pronation
Weak flexion
Hand of Benediction when make fist: cannot flex MCP or extend IPs (1-3)
Sensory loss of lateral 1/2 of hand

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22
Q

Median nerve damage at wrist

A

Paralyse thenar muscles and lateral 2 lumbricals

Hand of benediction and sensory loss of lateral 1/2 hand

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23
Q

Nerve damage on shoulder dislocation

A 
Axillary nerve
Paralyse deltoid and teres minor 
No abduction 
Can feel greater tuberosity
Loss of regimental badge sensation
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24
Q

Nerve damage causing weakness of arm movements?

A 
Musculocutaneous at axilla:
- weak shoulder flexion from pec major
- weak elbow flexion from brachioradialis
- weak supination from supinator
Lateral forearm sensory loss
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25
Q

Damage to nerves at birth

A 
C5-6 = Erb’s palsy = dorsum of hand forward, weakened movement to touch shoulder 
T1 = Klumpke = ulnar and medial nerve damage = hand muscles paralysed, to claw with hyperexension at MCPs, median sensory loss on arm
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26
Q

Nerve damage in cervical node biopsy?

A

Axillary - trapezius, partial SCM weakness

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27
Q

Long thoracic nerve damage and how?

A

Serratus anterior = winged scapula, no abduction >90 degrees

Vulnerable as superficial

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28
Q

Cause of no abduction >90 degrees

A

Long thoracic damage = serratus anterior

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29
Q

Surgery to inferior axilla/breast nerve complications

A

Thoracodorsal (C6-8) = cannot raise trunk with arm

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30
Q

Which nerves wraps around humerus?

A

Radial nerve

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31
Q

Which nerve goes behind median epicondyle?

A

Ulnar nerve

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32
Q

3 types of nerve injury

A
  1. Neuropraxia - nerve stretch
  2. Axonotmesis - incomplete nerve injury, Wallerian degeneration
  3. Neurotmesis - complete nerve injury, wallerian degeneration, worst prognosis
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33
Q

4 signs of severe brachial plexus injury

A

Global motor dysfunction
Complete sensory loss
Neuropathic pain
Horner’s syndrome

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34
Q

2 associated problems with brachial plexus injury

A

Paralysed hemidiaphram - insp and exp chest X-ray

Root avulsion could have transverse spinal process fracture

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35
Q

What is cerebral palsy

A

Non progressive CNS injury

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36
Q

MSK upper limb features of cerebral palsy - 6

A 
Thumb in palm
Clenched fist
Wrist flexion 
Forearm pronation 
Elbow flexion 
Shoulder internal rotation
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37
Q

Manage cerebral palsy

A

Physio and nighttime splint
Diazepam, baclofen for antispasticity
Botulinum injection
Surgery

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38
Q

Median nerve anatomy

A

C5-T1, lateral and medial cords of brachial plexus
Medial to brachial artery in antecubital fossa
Anterior interosseus branch (motor to FPL, FDP, index finger and pronator quadratus) distal to elbow
Palmar cutaneous branch proximal to wrist
Recurrent motor branch to thenar muscles at end of carpal tunnel
Motor to pronator teres, palmaris longus, FCR, FDS, LOAF
Sensory to radial 3.5 digits

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39
Q

Nerve injury on lateral knee injury

A

L4-S2 - common peroneal neve/lateral popliteal nerve
Cannot dorsiflex foot and toes
Sensory loss on dorsum of foot

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40
Q

Tibial nerve injury

A

Calcaneovalgus foot
Cannot stand on tiptoe or invert foot
Sensory loss on sole

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41
Q

Nerve injury from proximal fibular fracture

A

Common peroneal nerve compression - cannot dorsiflex foot, lose sensation over dorsum

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42
Q

Where is the brachial plexus?

A

Vertebral column between scalene and anterior muscles
Divisions under clavicle, medial to coracoid process
Follows subclavian then axillary artery

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43
Q

Damage to brachial plexus - 5

A 
Trauma:
Direct - fracture or penetration injury 
Indirect - avulsion/traction, neck stretching at birth
Tumours - pancoast
Radiation
Neuropathy
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44
Q

Nerves and muscles damaged in Erb’s palsy

A

Suprascapular, musculocutaneous, axillary nerves
Supraspinatus and deltoid - abduction
Infraspinatus and teres minor - external rotation
Biceps - supination
Brachialis - elbow flexion

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45
Q

Arterial supply of hand

A

Superficial palmar arch - mainly ulnar

Deep palmar arch - mainly radial, plus princeps pollicis artery to thumb

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46
Q

Most common vessel disease in hands

A

Small vessel occlusive disease in connective tissue disease eg scleroderma, SLE, RA

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47
Q

Difference between Raynaud disease and phenomeon

A

Disease - younger, no underlying disease, no trophic findings (ulcer, ganrene), symmetrical
Phenomenon - identified underlying diseae, rapid progression, older, trophic findings, asymmetrical, abnormal inv

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48
Q

Manage raynaud disease

A

Calcium channel blockers for temporary relief
Quit smoking
Avoid cold

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49
Q

Compartments in forearm

A

Mobile wad - brachioradialis, extensor carpi radialis longus and brevis
Dorsal
Volar

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50
Q

What is Volkmann ischaemic contracture

A

Untreated compartment syndrome - muscle fibrosis and myonecrosis - FDP and FPL

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51
Q

Vessel supply of anterior and posterior arm compartments

A

Anterior - brachial artery

Posterior - brofunda brachii artery

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52
Q

Where do vessels leave the vertebrae

A

Foramen transversum

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53
Q

Joint between vertebrae

A

Zygopophyseal joint

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54
Q

Ligaments in spine - 6

A 
Anterior and posterior longitudinal ligaments
Intertransverse
Interspinous
Supraspinous and nuchal
Ligamentum flavum
55
Q

What makes up intervertebral disc

A

Annulus fibrosis - concentric rings of lamellae of fibrocartilage on epiphyseal rims
Nucleus pulposus in middle - 85% water and proteoglycans
Cartilage plate on top

56
Q

Vessel supply of intervertebral disc

A

Avascular - nourished by diffusion from BV at periphery of annulus and vertebral body

57
Q

Ascending spinal tracts - 6

A

Spinothalamic - ventral and lateral
Spinocerebellar - ventral and dorsal
Fasciculus gracilis and cuneatus

58
Q

Descending spinal tracts - 5

A 
Lateral corticospinal
Ruprospinal
Vestibulospinal
Tectospinal 
Venttral corticospinal
59
Q

2 types of spina bifida

A

Occulta - laminae of L5-S1 don’t develop and fuse properly, concealed by skin and tuft of hair
Cystica - one or more arches fail to develop, causing herniation of meninges (meningocoele) or meninges and cord (meningomyelocoele) - causes limb/bladder/bowel paralysis

60
Q

Vertebrae dislocation?

A

Cervical - large canal, limited cord damage, slips back into place unless ‘facet jumping’ where displaced articular process locks
Thoracic and lumbar have interlocking articular processes so unlikely
Subluxation of lumbar vertebrae = spondylolisthesis in adolescence from abnormal pars interarticularis

61
Q

Complications of whiplash? - 3

A

Tear/stretch anterior ligament
Injure posterior parts eg vertebral arches and processes
Pinch C1 between C2 and occipital bone
Rupture anterior long lig and annulus fibrosis of C2/3 = death

62
Q

Sx of whiplash - 4

A

Occipital headache
Tinnitus
TMJ pain
Migraine sx in eyes

63
Q

Vertebrae most likely to fracture

A

T11 and T12 where transition from inflexible thoracic to mobile lumbar

64
Q

How does a laminectomy work?

A

Excise spinous process and laminae, or pedicles to access canal
Relieve cord or roots from tumour, herniated disc or bony hypertrophy

65
Q

What is lumbar spine stenosis?

A

Narrow vertebral canal compresses nerve root and makes disc herniation more likely
Made worse by arthritic changes and ligamentous degeneration in elderly

66
Q

Sx of lumbar spine stenosis

A

Positional back pain - better leaning forward

Lower limb pain on walking/weight bearing

67
Q

4 age related changes to discs and vertebrae

A

Vertebrae: reduced bone density and strength causing increasingly concave vertebrae
Discs: reduced water, proteoglycans and elastin, with increased collagen
Annulus: lamellae thicken, fissures and cavities
Pressure increases on edge of bodies where discs attach causing osteophytes

68
Q

Herniation of nucleus pulposus - where and sx

A

Posterolateral as no longitudinal ligaments and thinnest. Proximal to spinal nerve roots
Sx - local pain if pressure on ligaments and annulus, and local inflammation from rupture of nucleus
Nerve roots immediately and below are affected

69
Q

Rupture of transverse ligaments of atlas

A

Releases dens, causing atlanto-axial subluxation/incomplete dislocation
Dens drives into medulla of brainstem = death
Or drives into cervical region of cord = quadriplegia

70
Q

Ligament more likely to rupture related to axis/atlas

A

Alar ligaments - thinner than transverse ligament. Attach axis to occiput.
Flex and rotate can cause rupture, allowing increased range of movement

71
Q

Layers gone through for LP

A

Ligamentum flava, dura, arachnoid

Into lumbar cisterna

72
Q

Spinal cord ischaemia - 4 causes

A

From disruption of spinal and medullary arteries in fracture or dislocation
Obstructive artery disease in great anterior segmental medullary artery of adamkiewitz
Aortic clamping in surgery
AAA

73
Q

What is spinal shock?

A

Transient physiological reflexive depression of spinal cord function below level of injury, with sensorimotor loss
Features: hypotension, sweating, bradycardia, hypothermia, flaccid, areflexic, incontinence, priapism, may have perineum spared
Bulbocavernosus reflex returns in 24-48h

74
Q

Bad sign in spinal shock

A

Spasticity developing

75
Q

What is neurogenic shock

A

Acute spinal cord injury with hypotension and bradycardic
Causes circulatory collapse from lack of sympathetic tone causing reduced vascular resistance and pooling of blood in extremities

76
Q

Cord transection at C4-5

A

Quadriplegia

Can breathe

77
Q

Cord transenction at T1-9

A

Paraplegia

Variable trunk function

78
Q

Cord transection at T10-L1

A

Some thigh function

79
Q

Nerves affected in cauda equina syndrome

A

L1-S5
SNS: hypogastric plexus
PSNS: inferior hypogastric plexus and pelvic splanchnic nerve
Pudendal nerve

80
Q

6 causes of cauda equina

A 
Tumour
Disc herniation 
Haematoma
Stenosis
Abscess
Trauma
81
Q

4 sx of cauda equina

A
  1. Lower extremity sensorimotor loss
  2. Neurogenic bladder = overflow incontinence
  3. Bilateral leg pain
  4. Saddle anaesthesia
82
Q

Medical treatment for cauda equina - 2

A

Vasodilator treatment prostaglandins to prevent ischaemia and reduce pain
Antibiotics if infection

83
Q

Immediate cauda equina manageent

A

MRI and CT myelography

Surgical decompression within 48h

84
Q

What is central cord syndrome and what is it caused by

A

Elderly people, extension injury with osteophytes
Selective destruction of lateral corticospinal tract and white matter, causing LMN signs in arms as more central and UMN in lower limbs
Recovers distal - proximal

85
Q

What is anterior cord syndrome

A

Flexion or compression injury
Causes motor and sensory deficit below injury - pain, temperature, motor
Proprioception and vibration preserved

86
Q

What is hemisection of cord?

A

Brown-Sequard syndrome:
Ipsilateral loss of dorsal column and lateral corticospinal
Contralateral loss of lateral spinothalamic at spinal level

87
Q

Where and what is spinal epidural abscess?

A

Pus or inflammatory granulation tissue between dura and adipose

88
Q

RF for spinal epidural abscess - 4

A

Recent spinal procedure
Immunodeficiency
PWID
>60y

89
Q

Cause of spinal epidural abscess

A

Haematogenous or discitis

Staph a, gr neg E. coli, pseudomonas

90
Q

Sx of spinal epidural abscess - 4

A

Systemic sx
Pain
Neuro signs - radiculopathy or myelopathy
Paralysis

91
Q

Management of spinal epidural abscess

A

CT myelogram or MRI
Brace and IV abx
Surgical decompression and stabilisation

92
Q

Neuro sx of TB

A

Abscess, granulation or caseous tissue
Subluxation/dislocation
Ossify ligamentum flavum in kyphosis causes stenosis

93
Q

Destruction that may be seen on CT for spinal TB - 4

A

Fragmentation
Osteolysis
Subperiosteal
Sclerotic

94
Q

MRI for TB?

A 
With gadolinium contrast:
Smooth walled abscess breaching epidural space
End plate disruption
Paravertebral soft issue shadowing
Cord oedema or atrophy
95
Q

Manage spinal TB

A

Drugs
Orthosis
Decompression/stabilisation

96
Q

What is a spinal degeneration condition

A 
Spondylosis
Degeneration of disc and 4 joints including facets 
Causes nerve compression - radiculopathy
Disc herniation
Central stenosis
Myelopathy
97
Q

What is cervical stenosis and 2 causes

A

Congenital or acquired - trauma, degeneration
Absolute = canal diameter <10mm, relative = 10-13mm
Increases risk of radiculopathy or myelopathy from minor trauma

98
Q

Very common condition >50yo with no ankylosis or erosion, and associated condition

A

Diffuse Idiopathic Skeletal Hyperostosis:
Syndesmophytes form in 4+ consecutive levels of ligaments
With enthesopathy of shoulder, elbow, hip, knee, calcaneus

99
Q

Features of DISH - 3 categories

A

Back - lumbar spine stenosis, mild chronic back pain, morning or cold stiffness
Throat - hoarse, stridor, dysphagia, sleep apnoea
Sx - reduced ROM, stenosis/myelopathy sx

100
Q

Manage DISH - 4

A 
NSAIDs
Bisphosphonates
Physio
Cervical traction 
Brace
Decompression and stabilisation
101
Q

Pathophysiology of Ankylosing spondylitis and 3 joints affected

A

Enthesis inflammation causes erosion and soft tissue ossification, and joint ankylosis
Of sacroiliac, spinal apophyseal and pubic symphysis
Annulus inflammation makes bridging syndesmophytes

102
Q

MSK features of Ank spond and 2 tests

A 
Pain and stiffness, sciatica, SOB
Kyphosis
Hip flexion contracture
Faber test - pain on flexion, abduction and external rotation of hip 
Schober test
103
Q

Manage Ank spond

A

NSAIDs, COX2 inhibitor
Physio
TNFa blockers eg infliximab

104
Q

Most common direction of shoulder dislocation

A

Anterior or anteroinferior

105
Q

Sign and image for shoulder dislocation

A

Apprehension sign
Painful and unilateral
Axillary view diagnostic

106
Q

Treat shoulder dislocation

A

Reduction and sling

Then rotator cuff strengthening

107
Q

associated injuries with shoulder dislocation

A

Bankart lesion: anterior tear of glenoid labral (makes recurrence likely)
Hill-Sachs lesion: indentation in humeral head from hitting on labrum

108
Q

Shoulder dislocation posterior - when?

A

Associated with seizures and electrical shock
Seen on axillary view
May have fracture of lesser tuberosity or reverse Hill-Sachs

109
Q

What is Dupuyren’s contracture?

A

Benign fibroproliferative disorder. Nodule in palmar fascia then forms diseased cords and digital flexion contractures

110
Q

5 causes of Dupuytren’s contracture

A 
Alcohol and tobacco 
Diabetes
Epilepsy 
COPD
Familial
111
Q

What is a ganglion on hand and where

A

Normally on dorsum of wrist
Firm and well circumscribed
Joint or tendon sheath fluid

112
Q

Benign bone tumours - 4

A

Chondroma
Osteochondroma
Osteoid osteoma
Fibrous dysplasia of bone

113
Q

What is chrondoma of bone and what is treatment

A

Benign cartilaginous swelling from surface of bone or medulla
Pain and increased fracture risk
Exclude malignancy, rarely need treatmen

114
Q

What is fibrous dysplasia of bone and treatment

A

Developmental abnormality where bone is not properly formed
Pain and increased fracture risk
Treat with surgical stabilisation
Bisphosphonates can ease symptoms

115
Q

What is osteoid osteoma, investigation findings and treatment

A

Benign bone lesion in long bones or spine of males 10-25yo
X-ray = local cortical sclerosis with radiolucent central nidus, which may have central area of calcification
Nidus releases prostaglandins so pain unreleased to activity and relieved by ibuprofen
Manage: CT-guided biopsy and radiofrequency ablation. May be missed on X-ray

116
Q

What is osteochondroma, investigate and management

A

Commonest benign bone tumour
Painful mass in proximal humerus or femur, or around knee as a result of trauma
X-ray = bone spur
Remove if causing symptoms eg pressure on adjacent structures or still growing after skeletal maturity, as can become malignant

117
Q

Bone sarcoma presentation - 4

A

Non-mechanical bone or joint pain
Bone pain at night
Bony swelling
Pathological fractures

118
Q

5 tumours which spread to bone

A 
Prostate
Thyroid
Lung
Kidney 
Breast
119
Q

Where do bone tumours metastasise to

A

Haematogenously to lens or other bones

120
Q

Staging of bone tumours

A

MRI or PET-CT

121
Q

Most common primary malignant bone tumour and sign on imaging

A

Multiple myeloma

Multiple punched out osteolytic lesions

122
Q

Osteosarcoma - where and who

A

10-20yo with peak in growth spurt
In metaphysis of long bones and around knee
Secondary causes = irradiation or Paget’s disease

123
Q

Osteosarcoma on imaging - 2

A

Bony destruction and new formation - sunray spiculation

Periosteum elevation - codman’s triangle

124
Q

Sx of osteosarcoma

A

Pain before mass

125
Q

Inv osteosarcoma spread

A

MRI of area for intramedullary spread

High resolution CT chest for pulmonary mets, especially if raised ALP

126
Q

Manage osteosarcoma

A

Neoadjuvant chemo and amputation

Most will have micrometastatic disease at diagnosis

127
Q

4 radiological features of Ewing’s sarcoma

A

Bone destruction
New bone formation in concentric layers - onion ring sign
Elevated area of periosteum - codman’s triangle
Soft tissue swelling

128
Q

What is Ewing’s sarcoma and management

A

Malignant round cell tumour of long bones (diaphysis) and limb girdle
Adolescents
Often have chromosomal translocation
Treat: chemo, RT, surgery

129
Q

What is bone tumour of middle aged people? Treatment

A

Chondrosarcoma - may be de novo or malignant change from chondroma
On axial skeleton
X-ray shows popcorn calcification
Excise. CRT no effect

130
Q

Sarcoma vs carcinoma?

A 
Sarcoma = malignant neoplasm from mesenchymal cells (connective tissue and non-epithelial tissue):  1. Soft tissues, 2: Primary bone, 3. GI stromal tumour
Carcinoma = from epithelial cells - breast, bowel, lung
131
Q

What are soft tissue sarcomas and different types

A

Any tumour from mesenchyme - fat or muscle etc
Painless enlarging mass
Fibrosarcoma, leiomyosarcoma, liposarcoma, rhabdomyosarcoma (kids)

132
Q

When to suspect soft tissue sarcoma - 4

A

> 5cm
Growing
Deep to deep fascia
Painful

133
Q

Manage soft tissue sarcoma

A

MRI then needle biopsy
Gene expression to improve diagnosis and indicate if chemo will be effective
Excise and radiotherapy

Finals (13 decks)

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