MSK Flashcards
Which nerve can be damaged in axillary node clearance and what affect may this have?
Long thoracic nerve
Winged scapula
What muscle group is supplied by the musculocutaneous nerve.
All muscles in anterior arm -
Musculocutaneous nerve damage - causes, effects
Rare because deep structure. Stab wound to the axilla.
Weakened flexion of the elbow, loss of sensation on lateral forearm
Radial nerve damage
Causes, results
In the axilla - shoulder dislocation or proximal humeral fracture. Unable to extend forearm, wrist, fingers. Unopposed flexion of wrist causes wrist drop. Sensory loss over the lateral and posterior arm, posterior forearm and dorsal surface of lateral 3.5 fingers.
In the radial groove- humeral shaft fractures. Unable to extend at wrist and hand. Wrist drop. Sensory loss only to dorsal aspect of lateral 3.5 fingers.
Superficial branch damage in forearm - stabbing or laceration of forearm - sensory loss of dorsal aspect of 3.5 lateral fingers
Deep branch in forearm - radial head fracture, posterior radial dislocation. Weakened extension of wrist without wrist drop because carpi radialis longus is unaffected
Surgical neck of humerus fracture - causes and consequences
direct blow to the area or fall on an outstretched hand. Axillary nerve damage, deltoid paralysis therefore unable to abduct the affected limb. sensory impairment to regimental patch. Posterior circumflex artery.
Mid-shaft humeral fracture - causes and consequences
Trauma, radial artery damage.
Distal humeral fractures - causes and consequences.
supraepicondylar - falling on a flexed elbow. Brachial artery damage can result in volkmann’s ischaemic contracture (uncontrolled flexion of the hand). Median, ulnar or radial nerve damage.
Medial epicondyle fractures can damage the ulnar nerve resulting in ulnar claw and loss of sensation over the medial 1.5 fingers
What causes winging of the scapula?
Nerve damage to the long thoracic nerve resulting in serratus anterior paralysis
What muscle is most commonly affected in rotator cuff tendonitis?
supraspinatus
What causes rotator cuff tendonitis?
repetitive use of the shoulder joint above the horizontal e.g. playing racquet sports
Subacromial bursitis
what is it also known as?
What causes it?
How does it present?
Painful arc syndrome
Subscapularis tendon Impingement under the AC joint leading to inflammation
pain during abduction of the arm
Anterior glenohumeral joint dislocation - how?
Joint is weak inferiorly, especially when abducted. When dislocated powerful adductors pull it anteriorly so anterior dislocations are more common.
Posterior glenohumeral joint dislocation
uncommon, usually due to high energy trauma
What is Monteggia’s fracture and how can it occur?
proximal ulna fracture with the head of the radius dislocated at the elbow. force from behind the ulna.
What is Galeazzi’s fracture and how can it occur?
a fracture of the distal radius, with dislocation of the ulna head at the distal radio-ulna joint.
What is Colles’ fracture and how can it occur?
The most common type of radial fracture - typically caused by a fall onto an outstretched hand resulting in distal radial fracture. results in ‘dinner fork’ deformity due to posterior dislocation of the wrist and hand.
What causes fractures of the radial head?
Fall on an outstretched hand. Radial head is forced back into the capitulum of the humerus causing it to fracture
What is Smith’s fracture and how can it occur?
Falling onto the back of the hand. Opposite of a Colles’ fracture, distal radial fragment results in anterior dislocation of the wrist and hand.
What causes scaphoid fractures? Clinical presentation? complication?
Fall on an outstretched hand, most commonly in men aged 20-30 yrs. Requires specific x-ray views to image. Pain in anatomical snuffbox. Requires rapid reduction to prevent avascular necrosis. which may result in later necrosis
What causes lunate fractures? associated injury?
Trauma when there is hyperextension of the wrist. . associated with median nerve damage.
Describe the salter harris classification.
Classification of growth plate fractures.
I - fracture through the physis
II - fracture through the physis and metaphysis
III- fracture through the physis and epiphysis to include the joint.
IV- fracture involving the physis, metaphysis and epiphysis
V- crush injury involving the physis
X-ray often appears normal despite underlying fracture. Injuries of type III, IV and V require surgery.
red flags for back pain x12
1) Thoracic pain
2) Younger than 50 or older than 50
3) non-mechanical pain
4) night pain
5) pain worse when supine
6) neurological signs
7) history of malignancy or HIV
8) immunosuppression or steroid use
9) IVDU
10) Structural deformity
11) history of trauma
12) systemically unwell i.e. fever, weight loss
presentation of facet joint pain
acute or chronic
pain worst in the morning on standing
pain over the facets
pain worse on spinal extension
presentation of spinal stenosis
gradual onset
unilateral or bilateral leg pain, parasthesia, weakness which is worse on walking
relieved by sitting down, leaning forward, crouching
Clinical exam normal, MRI to investigate
presentation of Ankylosing spondylitis
young men
lower back pain and stiffness
worse in morning and improves with activity
presentation of peripheral arterial disease
pain in the buttocks brought on by exercise, relived by rest.reduced peripheral pulses
history of CVS risk factors
AC joint injury
mechanism
management based on grading
FOOSH
I and II - sling and rest
III - debatable
IV, V and VI - require surgery
De Quervain’s tenosynovitis
presentation
test
management
pain on radial side of wrist and radial styloid process.
Finkelstein’s test - flex thumb inside fist then pull hand towards ulnar.
analgesia, splint, steroid injection, surgery.
management of hip factures
intracapsular and displaced- if independently mobile (max aid 1 stick) THR, otherwise hemiarthroplasty
Trochanteric fracture - sliding hip screw
sub trochanteric fracture - intramedullary nail
clinical findings in club foot
inverted, plantar flexed foot which is not passively correctable
management of club foot
ponseti method - manipulation and progressive casting from birth, taking 6-10 weeks. many need Achilles tenotomy in addition.
Night time braces until the child is 4.
surgery rarely required.
Open Fracture Classification
Gustilo and Anderson
1 - low energy <1cm
2 - >1cm wound, moderate soft tissue injury
3 - High energy wound >1 cm with extensive soft tissue damage +all farm yard injuries
3a - adequate soft tissue coverage
3b - inadequate soft tissue coverage
3c - associated arterial injury
management of open fractures
Immobilise the fracture
monitor neurovascular status carefully
tetanus prophylaxia + IV Abx
debride and lavage in 12 hours if high energy, 24 for low energy
delay definitive surgical management until soft tissue coverage (within 72 hours). External fixation may be used in the interim.
What are Osler’s nodes
painful, red, raised lesions found in the hands and feet as a result of deposition of immune complexes
What are bouchard’s nodes?
hard, boney outgrowths from the PIPS. Sign of OA
What are Heberden’s nodes?
permanent bony outgrowth which occur in the DIPs which may deviate distal portion..
What is a ganglion?
Fluid filled swelling associated with a tendon sheath near a joint. Usually asymptomatic.
What imaging for osteomyeltits?
MRI
Posterior hip dislocation - mechanism and presentation
RTA, especially if driver was braking. Shortened and internally rotated leg.
Presentation of anterior hip dislocations
abducted and, externally rotated, palpable bulge, associated with hip prostheses
presentation of femoral shaft fracture
swelling, deformity and shortening of the leg. high impact mechanism.
neck of femur fracture - presentation
low energy, elderly, shortened and externally rotated
radial head subluxation - mechanism and presentation
pulling injuries in young children. reduced ability to supinate or extend the elbow joint.
management of radial head subluxation
Analgesia, reduction by passive supination of the elbow at 90 degrees of flexion
presentation of fat embolism in trauma patients
CVS - early, persistent tachycardia, later tachypnoea, dyspnoea, hypoxia, pyrexia
Derm - 25 - 50% have a non blanching petechial rash
CNS - confusion and agitation, retinal haemorrhages and intra-arterial fat globules on fundoscopy.
Features of Nerve Root compression by level (L3,4,5&S1)
L3 - sensory loss over anterior thigh, weak quadriceps, reduced knee reflex
L4 - sensory loss over anterior knee, weak quadriceps, reduced knee reflex
L5 - sensory loss on dorsum of foot, weakness in foot and big toe dorsiflexion, reflexes normal
S1 - sensory loss on posterolateral leg and lateral foot. Weakness in plantar flexion of foot, reduced ankle reflex.
Management of prolapsed disc
analgesia, physio, exercises. If red flags or persistent symptoms MRI
Motor supply of Ulnar Nerve
medial two lumbricals aDductor pollicis interossei hypothenar muscles: abductor digiti minimi, flexor digiti minimi flexor carpi ulnaris
Sensory supplied by ulnar nerve
medial 1 1/2 fingers (palmar and dorsal aspects)
Trochanteric bursitits- features, most commonly affected group
unilateral lateral hip pain - tender to palpation 50 to 70
women aged
Pathology of and Clinical Presentation of Osteochondritis Dessicans
Subchondral bone damage, which causes swelling and pain in the affected joint, most commonly the knee.
Commonly affects young males with open growth plates.
Presents with pain and swelling after exercise,
painful clunking,
knee catching, locking or giving way
Initial Management of Osteochondritis Dessicans
Low threshold for imaging (radiograph initially) or getting an orthopaedic opinion
Which structure is divided in carpal tunnel release surgery?
flexor retinaculum
Most common site of metatarsal stress fractures?
2nd Metatarsal shaft
First-line management for lower back pain?
NSAIDs
Risk factors for congenital hip dislocation (5)
Female gender Breech presentation Family history Firstborn Oligohydramnios
Presentation of a Meniscal Tear?
Pain worse on straightening the knee
Knee may ‘give way’
Displaced meniscal tears may cause knee locking - patient may have a way to ‘unlock’
Tenderness along the joint line
Special test for meniscal tears?
Thessaly’s test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee
What iliotibial band syndrome?
Who gets it?
Pain on the lateral aspect of the knee, 2-3 cm above the joint line.
Regular runners - common in this group
Management of iliotibial band syndrome
activity modification and iliotibial band stretches
if not helping - physiotherapy referral
Mx of compartment syndrome
- prompt and extensive fasciotomies
- Myoglobinuria may occur so patients require aggressive
IV fluids - frankly necrotic muscle should be debrided and
amputation may have to be considered
burning thigh pain? most likely cause?
meralgia paraesthetica - lateral cutaneous nerve of thigh compression
features of ruptured anterior cruciate ligament and management
Sport injury
high twisting force applied to a bent knee
Loud crack, pain and RAPID joint swelling (haemoarthrosis)
Poor healing
Management: intense physiotherapy or surgery
features of ruptured posterior cruciate ligament and special test
hyperextension of the knee injuries
paradoxical anterior draw test
What is a Hill-Sachs lesion and when does it occur?
Cartilage surface of the humerus is in contact with the rim of the glenoid
anterior dislocation
Occult hip fracture imaging modality
MRI
Presentation of Chondromalacia Palattea
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting
Presentation of dislocation of the patella
Imaging required
Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation
Skyline x-ray views of patella are required, although displaced patella may be clinically obvious
Risk factors for patella dislocation
Genu valgum, tibial torsion and high riding patella
What is Oscood-Schlatter disease? Who gets it? Mx?
inflammation at the tibial tuberosity caused by repeated avulsion of the apophysis into which the patellar tendon is inserted
Athletic teenagers
Management is supportive
Causes of Drupytrens contracture (6)
manual labour phenytoin treatment alcoholic liver disease diabetes mellitus trauma to the hand family Hx
two fractures associated with compartment syndrome
supracondylar and tibial shaft fractures
causative organism of osteomyelitis in sickle cell anaemia
Salmonella
