MSK Flashcards
why is the time course important in joint pain?
acute=infection or trauma, onset of chronic problem
chronic=chronic infection (TB), RA, spondyloarthroathies, connective tissue disease
gout=acute but recurs
give the differnetial diagnoses for monoarthropathies and polyarthropathies.
acute monoarthritis=trauma, septic arthrits, goit, pseudogout
chronic monoarthritis=infection, spondyloarthropathies
acute polyarthritis=SLE
chronic polyarthritis=RA, spondyloarhtropathies, osteoarthritis, chronic gout, connective tissue disease
give some typical causes of symmetrical and asymmetrical joint involvement.
RA
spondytloarthropathies
what is morning stiffness typical of?
RA, inflammatory causes
what may shoulder and pelvic girdle pain and morning stiffness be?
polymyalgia rheumatica
what MSK conditions are associated with skin and nail changes?
psortiatic arthritis, reactive arthritis, SLE
give some symptoms that can be asscoiated with MSK conditions.
ibd=enteropathic arthritis
anterior uveitis->eye pain and blurred vision=spondyloarthropathies
scleritis=severe RA
chlamydia trachomatis->urethritis, conjucntivitis, arthritis (reiters triad)=reactive arthritis
why is the site of the back pain important/
sacroiliac joints and buttocks=ankylosing spondylitis
1 level=osteoporotic crush fracture
where can back pain radiate to?
ribs and abdomen=osteoporotic crush fracture
buttock and bilateral leg pain=spinal or root canal stenosis
why is numbess important in the history of back pain?
lumbar disk prolapse=paraesthesia and numbness, usually unilateral
spinal or root canal stenosis=bilateral paraesthesia and numbness
spinal cord compression=numbness and paralysis below site of pain
what medical conditions may be associated with back pain?
carcinoma, leukaemia, myeloma
tuberculous arthritis
RA
osteoporosis
what is the normal carrying angle of the elbow and what causes it to increase?
5-10 degrees
turners syndrome
what changes in the hands suggest MSK conditions?
swelling around joints=synoviits
deformity=damage to joint or soft tissue, tendon rupture
ulnar deviation, swan neck deformity, Z thumb=RA
Heberdens at DIP and bouchards at PIP=osteoarthritis
dactylitis=psoriatic arthritis, reiters disease
contraction deformities=scleroderma
give some features of the hands seen in MSK conditions
psoriasis: pitting, onycholysis, hyoerkeratosis, ridging, nail discolouration
splinter haemorrhages: RA, SLE
what nerves are tested in finger and wrist movement and sensation?
radial=wrist flexion, base of thumb
median=abduct thumb, lateralborder index finger
ulnar=abduct fingers, medial border of hand
what is tinnels sign?
positive if tapping flexor retinaculum leads to parasthesia in distribution of median nerve
what may cause the leg to be shortened and externally rotated?
fractured neck of femur
what causes discrepancies in leg length?
true=hip disease on shorter size
apparant=true shortening or tilting of pelvis
what does Thomas’ test find?
fixed flexion deformity of hip
what are the degrees of hip movement?
45 degrees external rotation, 35 internal rotation, 40 abduction, 20 adduction, 10 extension
what will cause a positive Trendeleburgs test?
muscle weakness e.g. l5 root lesion, proximal myopathy, hip joint disease
how will osteoarthritis of the knee present/
bony swelling and quadriceps wasting
what do you need to look for when inspecting a patient with back pain?
increased thoracic kyphosis: smooth due to multilevel disease, sharply angulated due to local vertebral obstruction
prolapsed lumbar disk=standing with knees slightly flexed
what does issues with toe walking or heel walking suggest?
S1 lesion
l4/5 lesion
compression of which nerves causes loss of knee jerk and ankle jerk reflex?
l4
s1
what is the revised jones criteria for rheumatic fever?
major: joints, new cardiac murmur, nodules, erythema, sydenhams chorea
minor: long PR, increased ESR, athralgias, increased CRP, increased temp
need 2 major, or 1 major and 2 minor, plus evidence recent GAS infection
give some SE of steroids.
buffalo hump, easy brusing, cataracts, larger appetite, obesity, moonface, euphoria, thin arms and legs, hypertension, hyperglycemia, avascular necrosis of femoral head, skin thinning, osteoporosis, negative nitrogen balance, emotional liability
what is important in the hx (socrates)/
Site What is the pattern of joint involvement? i.e. Which joints are
affected? Small or large joints? One or more than one joint?
What was the speed of onset like? Is the condition bilateral?
If so, is it symmetrical or asymmetrical?
Onset When did it start?
What was the onset like? (Acute e.g. gout; Subacute e.g.
septic arthritis, rheumatoid arthritis (RA); Chronic e.g.
osteoarthritis (OA))
Has it been constant since the onset?
If episodic, what are the frequency, regularity and duration of
the episodes?
Character e.g. ache, sharp pain, throbbing
Radiation e.g. neck pain to upper limb; lower back pain (LBP) to
buttocks/ lower limb; hip pain to knee
Associated symptoms Stiffness and/or swelling, crepitus (grating of surfaces against
each other)
Erythema, increased local temperature
Fatigue, malaise, depression
Systemic temperature (e.g. gout, sepsis)
Rashes/skin conditions (e.g. psoriasis, erythema nodosum)
Nodules (e.g. rheumatoid nodules, gouty tophi)
Fever, abdominal pain, weight loss (e.g. systemic symptoms
of vasculitis/connective tissue disease or symptoms
suggestive of associated inflammatory bowel disease)
Dry mouth and gritty eyes
Timing Is there a relationship with the time of day? Ask: ‘What do your
joints feel like on rising; How do you feel at the end of the day?
How do you sleep?’
e.g. RA – significant early morning stiffness (>60 mins usually)
& joints stiffen up again after period of rest/ in evening
OA – minimal to moderate early morning stiffness (<30 mins
usually) & joints made worse by activity. Also stiffen up in
evening.
Exacerbating factors Exercise in mechanical/ degenerative conditions; Rest in
inflammatory conditions.
Alleviating Factors NSAIDs.
Exercise / Rest as above.
Severity Very severe – acute gout +/- sepsis
Slightly less severe – RA/ OA (usually)
Any movements that are particularly painful? Is function
limited by pain?
what is important in the social hx?
Occupation. Does the problem affect their employment?
• Sports and hobbies
• Home circumstances (type of dwelling e.g. house, bungalow; dependents, carers,
social support)
• Ability to carry out activities of daily living – a detailed history is likely to be needed
here. For example, a patient with osteoarthritis of the hip may have difficulty getting in
and out of a car or bath, picking up objects from the floor, putting on their shoes and
socks, cutting their toenails etc.
• Smoking
• Alcohol consumption
what is important in the family hx?
Is there a family history of RA, OA, psoriasis, gout, Ulcerative Colitis, Crohn’s disease,
connective tissue disease or any other autoimmune disease?
what are the GALS screening qs?
Do you have any pain or stiffness in your muscles, joints or back?
• Are you able to completely dress and undress yourself without any difficulty?
• Are you able to climb up and down stairs without any difficulty?
what is the posterior sag test>
Position the patient with the knee flexed to 90° and the foot flat on
the bed. Inspect from the side. A posterior sag of the upper tibia, with a ‘step’ visible
below the patellar, is suggestive of posterior cruciate ligament (PCL) damage.
what is the anterior draw test?
Position the patient with the knee flexed to 90° and the foot flat on
the bed. Stabilise the leg using your own forearm – for infection control reasons you
should not sit on the patient’s bed. With the fingers of both hands behind the knee and
the patients hamstrings relaxed, place your thumbs over the tibial tuberosity and apply
a forward pull. Significant movement indicates a positive draw test and suggests
anterior cruciate ligament (ACL) damage.
what is the lateral collateral ligament test?
Flex the knee to 20°. Grasp the patient’s heel with
one hand while exerting pressure against the inside of the knee with the other hand.
The varus stress applied will cause lateral gaping in the laterally unstable knee. A small
amount of lateral joint gaping is physiological and is the asymmetry of the gaping that
constitutes the abnormal finding.
what is the medial collateral ligament test
As above but apply a valgus stress against the lateral
aspect of the knee and assess for medial gaping.
what is the lachmans test?
This test has higher sensitivity and specificity than the anterior draw
test for detecting ACL laxity. However, the REMS national curriculum specifies that the
anterior draw should be taught to medical students (1). Many orthopaedic surgeons
will ask you to perform the Lachman’s test instead and in the OSCE, you may perform
either test, depending on your personal preference.
Flex the knee to 20°. Place one hand behind the tibia with your thumb on the tibial
tuberosity. Grasp the patient’s thigh with your other hand and pull anteriorly on the
tibia. You should feel a firm end-point as the anterior cruciate ligament (ACL) prevents
forward translocation of the tibia on the femur. A soft end-point suggests ACL damage.
If the patient’s thigh is too large, or your hand is too small, to stabilise the limb
adequately, you may perform Lachman’s test with the patient’s thigh supported by the
edge of the examination couch.
what is mcmurrays tets?
. The test is designed to trap or catch a torn meniscus between the
femoral condyle and the tibial plateau and should only be performed if the patient’s
history is suggestive of a torn meniscus (In the OSCE, if you need to perform this test,
you will be instructed to do so).
Flex the patient’s hip to 90° and maximally flex the knee. Externally rotate the knee
and, maintaining this rotation, move the knee gradually from the fully flexed position to
the fully extended position. The test is repeated using internal rotation. A palpable,
audible, or painful click over the medial or lateral joint line indicates a meniscal tear.
The test is useful when positive but is unreliable when negative. It is difficult to perform
on an acutely painful knee.
what is schobers test?
quantitative evaluation of
flexion of the lumbar spine. Mark a 15cm length of the lumbar spine with the patient
in the erect position), measuring 10cm above and 5cm below the posterior superior
iliac spines (Dimples of Venus). Instruct the patient to flex his or her spine
maximally. Re-measure the distance between the marks. Normal flexion increases
the distance by at least 5 cm.
what is a straight leg raise test/
Ask the patient to lie flat on the couch. Passively flex their thigh with
their leg extended. If the patient complains of back or leg pain the test is positive
(hamstring tightness is not relevant). Paraesthesiae or pain in a nerve root distribution
[64]
indicates nerve root irritation. Back pain suggests, but is not indicative of, a central disc
prolapse, and leg pain suggests a lateral protrusion.
Lower the leg gradually until the pain disappears then dorsiflex the foot. This increases
tension on the nerve roots, aggravating any pain or paraesthesiae (Lasegue’s sign)
what is the bowstring test?
. Perform a straight leg raise. If the patient experiences pain, flex the knee
slightly then apply firm pressure with the thumb in the popliteal fossa to stretch the tibial
nerve. Radiating pain and paraesthesiae suggest nerve root irritation.
what is the femoral stretch test?
With the patient prone and the anterior thigh fixed to the couch,
flex each knee in turn. This causes pain in the skin overlying the anterior compartment of
the thigh by stretching the femoral nerve roots in L2-L4. The pain produced is normally
aggravated by extension of the hip.
how is the rotator cuff tested?
Resisted active abduction (supraspinatus) initiates abduction - first 15
degrees, deltoid abducts up to 90 degrees; trapezius and serratus anterior
cause scapular rotation for abduction beyond 90 degrees).
o Resisted active external rotation (infraspinatus, teres minor)
o Resisted active internal rotation – “lift off” test (subscapularis). Ask the
patient to place their hand behind their back with the dorsum of their hand
resting over their mid-lumbar spine. The dorsum of the hand is then raised off
the back by maintaining or increasing internal rotation of the humerus and
extension at the shoulder. To perform this test the patient must have full passive
internal rotation so that it is physically possible to place the arm in the desired
position and pain cannot be a limiting factor during the manoeuvre. The ability
to actively lift the dorsum of the hand off the back constitutes a normal lift-off
test. Inability to move the dorsum off the back constitutes an abnormal lift-off
test and indicates subscapularis rupture or dysfunction
how is the acromioclaviculart joint tested?
Place the arm into forced adduction across the body at 90° of flexion at the
shoulder = “scarf test”. Note any pain or tenderness over the ACJ
how is medial epicondylitis (golfers elbow) tested?
In the supinated position, ask the
patient to make a fist and flex their wrist against resistance. Pain will be felt at the
medial epicondyle.
how is lateral epicondylitis (tennis elbow) tested?
In the pronated position, ask the patient
to extend their wrist against resistance. This will re-produce pain at the origin of the
extensor muscles (lateral epicondyle).
what are bouchard and heberdens nodes
Bouchard’s nodes at PIPJs in osteoarthritis (OA)
• Heberden’s nodes at DIPJs in O
what deformities are seen in RA?
Swan neck and Boutonniere deformities of IPJs in rheumatoid (RA Windswept deformity (ulnar deviation at MCPJ in RA)
how is carpal tunnel syndrome tested?
Sensory - Test light touch in the median nerve distribution.
o Motor - Test palmar abduction against resistance (with the patient’s palm
supinated and held out flat, ask them to point their thumb vertically up to the
ceiling. Apply resistance by pushing the thumb back towards the palm with your
own thumb).
o Provocation –
• Tinel’s test - tap strongly over the median nerve as it goes through the
carpal tunnel. Reproduction of pain, numbness or tingling in the
cutaneous distribution of the median nerve is a positive test.
• Phalen’s test – ask the patient to hold both wrists in palmar flexion for
one minute. Reproduction of pain, numbness or tingling in the
cutaneous distribution of the median nerve is a positive test.
• Compression test – di
how is the ulnar nerve tested?
Sensory - Test sensation in the ulnar nerve distribution
o Motor –
• Ask the patient to cross their index and middle fingers
• to grip a piece of paper between their thumb and index finger without
flexing their thumb IP joint (Froment’s sign). You will need to
demonstrate to the patient what you are asking them to do.
• To abduct their fingers against resistance
how is the radial nerve tested?
o Sensory - Test sensation in the anatomical snuffbox
o Motor - Test wrist and finger dorsiflexion against resistance.
