MSK Flashcards
What are the features of spinal stenosis?
Usually gradual onset
Unilateral or bilateral leg pain with or without back pain, numbness, weakness which is worse on walking, relieves when sitting down, leaning forwards and crouching down
Pain may be described as ‘aching’, ‘crawling’
Clinical exam often normal
MRI to confirm diagnosis
Features of ankylosing spondylitis
Ix and Mx?
Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
the ‘A’s
- apical fibrosis
- anterior uveitis
- aortic regurg
- achilles tendonitis
- AV node block
- amyloidosis
ESR CRP usually raised (though normal doesnt exclude)
HLA-B27 isn’t useful diagnostically, but is positive in 90% of AS patients
Plain Xray of sacroiliac joins is most useful in establishing the diagnosis:
- sacrioliitis: subchondral erosions, sclerosis
- squaring of lumbar vertebrae
- bamboo spine (late and uncommon)
syndesmophytes (due to ossification of outer fibers of annulus fibrosus)
- CXR: apical fibrosis
If xray -ve but clinical suspicion is high - MRI
Mx - encourage regular exercise such as swimming
- NSAIDS are firs tline
- physiotherapy
- DMARDs only useful if peripheral joint involvement
Signs, causes and management of an iliopsoas abscess
Collection of pus in iliopsoas compartment
Primary causes - haematogenous spread of bacteria, commonly S aureus
Secondary - Crohn’s, diverticulitis, colorectal, UTI, GU cancer, verbal osteomyelitis, femoral catheter, lithotripsy, endocarditis, IVDU
Fever, back/flank pain, limp, weight loss
On exam
- patient in supine position with the knee flexed and the hip mildly externally rotated
- place hand proximal to patients ipsilateral knee and ask to lift thigh against your hand –> pain due to contraction of the psoas muscle
- lie patient on normal side and hyperextend affected hip. should elicit pain as psoas muscle is stretched
Ix - CT abdo
Mx - ABX
- percutaneous drainage
- surgery if failure of percutaneous drainage or another intra-abdo pathology that requires surgery
Cauda equina syndrome
Most common cause is central disc prolapse, typically at L4/5 or L5/S1
Other causes - tumours, infection, trauma, haematoma
Lumbosacral nerve roots below the spinal cord are compressed. can present in a variety of ways
- low back pain
- bilateral sciatica in 50% of cases
- reduced sensation/pins and needles in the perianal area
- decreased anal tone
- urinary dysfunction (incontinence is a late sign that may indicate irreversible damage)
Ix - urgent MRI
Mx - surgical decompression
Sites of nerve root compression how they present
L3 - sensory loss over anterior thigh
- weak quads
- reduced knee reflex
- positive femoral stretch test
L4 - sensory loss anterior aspect of knee
- weak quads
- reduced knee reflex
- positive femoral stretch test
L5 - sensory loss dorsum of foot
- weakness in foot and big toe dorsiflexion
- reflexes INTACT
- positive sciatic nerve stretch test
s1 - sensory loss posterolateral aspect of leg and lateral aspect of foot
- weakness in plantar flexion of foot
- reduced ankle reflex
- positive sciatic nerve stretch test
What is polymyositis and how is it investigated?
Inflammatory disorder of typically insidious onset leading to symmetrical, proximal muscle weakness. Blood tests typically reveal a significantly raised CREATINE KINASE. May manifest in the presence of malignancy
Features - proximal muscle weakness +/- tenderness, Raynaud’s, respiratory muscle weakness, interstitial lung disease, dysphagia, dysphonia
Ix - high CK, other muscle enzymes high in 85-95% of pts, EMG, muscle biopsy, may have anti-synthetase abs.
Dermatomyositis is a variant of the disease where skin manifestations are prominent, for example a purple (heliotrope) rash on the cheeks and eyelids
SLE investigations
99% are ANA positive (high sensitivity, low specificity, used as a rule out test)
20% rheumatoid factor positive
anti-dsDNA: highly specific but less sensitive (70%)
anti-Smith: high spec, sensitivity 30%
also: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La)
Monitoring
- inflam markers, usually ESR used.
- during active disease CRP may be normal so a raised CRP may indicate an underlying infection
C3,C4 low during active disease
Colles and Smith’s fractures?
And Barton’s fracture?
Colles
- fall onto extended outstretched hands
- described as a dinner fork type deformity
- classic colles fractures have the following 3 features:
1. transverse fracture of the radius
2. 1 inch proximal to the radio-carpal joint
3. dorsal displacement and angulation
Smiths
- reverse colles fracture
- volar angulation of distal radius fragment (garden spade deformity )
- caused by falling backwards onto the palm of an oustretched hand or falling with wrists flexed
Barton’s
- distal radius fracture like colles/smiths with associated radiocarpal dislocation
- fall onto extended and pronated wrist
Scaphoid fractures?
Most common carpal fractures
Surface of scaphoid is covered by articular cartilage with small area available for blood vessels (fracture risks blood supply)
Forms floor of anatomical snuffbox
FOOSH
Signs -swelling and tenderness in anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb
Ulnar deviation AP needed for visualisation of scaphoid
Radial head fracture?
Galeazzi fracture?
Monteggia’s fracture?
RADIAL HEAD FRACTURE
Common in young adults
usually caused by FOOSH
Marked local tenderness over the head of the radius, impaired movements at the elbow and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination)
GALEAZZI FRACTURE
- radial shaft fracture with associated dislocation of the distal radioulnar joint
- occur after a fall on the hand with a rotational force superimposed on it
- on exam - bruising, swelling and tenderness over the lower end of the forearm
- x ray reveals displaced fracture of radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint
MONTEGGIA’S fracture
- dislocation of the proximal radioulnar join in association with an ulna fracture
- FOOSH with forced pronation
- needs prompt diagnosis to avoid disability
What is osteomyelitis, Ix and Mx
Infection of the bone Haematogenous - most common form in children - results from bacteraemia - RFs: sickle cell anaemia, IVDU, immunosuppression due to either medication or HIV, IE
Non-haematogenous
- most common form adults
often polymicrobial
- RF: diabetic foot, DM, peripheral arterial disease
S.aureus most common except patients with sickle cell - Salmonella
Ix - MRI
Mx - flucloxacillin 6 weeks
- clindamycin if pen allergic
Achilles tendinopathy and achilles tendon rupture
Achilles tendinopathy
- gradual onset of posterior heel pain that is worse following activity
- morning pain and stifness are common
- Mx usually supportive - simple analgesia, reduction in precipitating activities, calf muscle eccentric exercises
Achilles tendon rupture
- ‘pop’ in ankle whlie playing sport or runnin, sudden onset significant pain or inability to walk/continue
- examine - pt lie prone iwth feet over edge of bed. look for abnormal angle of declination, may have greater dorsiflexion of injured foot, feel for gap in tendon and gently squeeze calf muscle (the foot will stay in neutral position)
ULTRASOUND is initial imaging modality of choice
acute referral to orthopaedic specialist following suspected rupture
Factors and Mx of Raynaud’s
Primary (disease) or secondary (phenomenon)
- 2dary causes: connective tissue disorders commonly scleroderma, RA, SLE
Mx
- refer to secondary care
- first line: CCB: nifedipine
- IV prostacyclin (epoprostenol infusions)
DEXA scan interpretation
T score
> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis
Ottowa Rules for ankle fracture?
Pain in the malleolar zone and any one of the following findings:
- bony tenderness at the lateral malleolar zone
- bony tenderness at the medial malleolar zone
- inability to walk four weight bearing steps immediately after the injury and in the emergency department
