MSK

Question 1

Please present your examination (normal knee)

Answer 1

I performed a knee examination on this gentleman. On general inspection, the patient appeared comfortable and there was no equipment around the bed.
Assessment of the lower limbs revealed a normal gait and normal knee joint appearance. The range of movement in both knee joints was normal. There were no abnormalities on assessment of the cruciate and collateral ligaments of either knee. I would ideally perform McMurray’s test for meniscal injury.
In summary, these findings are consistent with a normal knee examination.
For completeness, I would examine the ankle and hip joints, assess neurovascular status of the lower limbs, and look at any previous imaging.

Question 2

Please present your examination (normal hip)

Answer 2

I performed a hip examination on this gentleman. On general inspection, the patient appeared comfortable and there was no equipment around the bed.
Assessment of the lower limbs revealed a normal gait and normal hip joint appearance, and negative Trendelenburg test. The range of movement in both hip joints was normal and Thomas’ test was negative.
In summary, these findings are consistent with a normal hip examination.
For completeness, I would examine the knees and the spine, assess neurovascular status of the lower limbs, and look at any previous imaging.

Question 3

Please present your examination (normal hands)

Answer 3

I performed a hand examination on this gentleman. On general inspection, the patient appeared comfortable and there was no equipment around the bed. On examination of the hands and elbows, there was no tenderness, swelling or deformity.
There was a full range of movement in the hand and wrist joints. The motor function of the hands was intact and there were no gross neurological abnormalities. Phalen’s, Tinel’s and Finkelstein’s tests were negative.
In summary, these findings are consistent with a normal hand examination.
For completeness, I would examine the elbows, fully assess neurovascular status of the upper limbs, and look at any previous imaging.

Question 4

Please look at this image and discuss your findings

Rheumatoid hands

Answer 4

There is widespread swelling of the MCP and PIP joints.

There is evidence of ulnar deviation of the fingers at the MCP joints and hyperextension/ hyperflexion of the MCP and PIP joints.
There is a classic swan neck/Boutonniere/Z-thumb deformity present.

There are no apparent skin or nail changes on this image.

This findings are suggestive of a symmetrical deforming polyarthritis, such as rheumatoid arthritis. I would also consider osteoarthritis in this case and would carry out some investigations to distinguish these.

Question 5

Please look at this image and discuss your findings (Osteoarthritic hands)

Answer 5

There is widespread swelling of the PIP and DIP joints, with a nodular appearance, suggestive of Bouchard’s and Heberden’s nodes.

There are no apparent skin or nail changes on this image.

This findings are suggestive of a polyarthritis such as osteoarthritis. I would also consider rheumatoid arthritis in this case and would carry out some investigations to distinguish these.

Question 6

How would you investigate this patient? (polyarthritis presentation)

Answer 6

After taking a full history, I would investigate with beside tests, blood tests and imaging.
I would examine for any extra-articular features, such as eye disease, cardiorespiratory disease and skin changes. I would take a full set of baseline bloods - FBC, U&E, ESR, LFTs as well as an autoimmune screen including RF, anti-CCP.
In the first instance I would request radiographs of the hand and wrist. I would consult with my senior regarding the need for 2nd line imaging such as USS or MRI.

Question 7

How do you manage hip/knee osteoarthritis?

Answer 7

I would consider conservative, medical and surgical approaches to manage this patient alongside the MDT.
Conservative includes OT input to modify ADLs and physiotherapy. Medical includes analgesia according to the WHO ladder and steroid injections. The next step would be referral to orthopedics for consideration for surgery such as an arthroplasty.

Question 8

How do you manage rheumatoid arthritis?

Answer 8

I would consider conservative, medical and surgical approaches to manage this patient alongside the rheumatology team. A disease activity score such as DAS28 would be useful monitor the treatment.
Conservative includes OT input to modify ADLs and physiotherapy. Medical includes analgesia according to the WHO ladder, steroids for acute flares, and long-term DMARDs such as methotrexate. Biologics such as TNFalpha inhib Infliximab may be indicated for refractory disease.

Question 9

Please comment on this radiograph (osteoarthritis)

Answer 9

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

Question 10

Please comment on this radiograph (rheumatoid arthritis)

Answer 10

Reduced joint space
Erosions
Soft tissue swelling
Periarticular osteopenia

Question 11

What are the indications for a knee replacement?

Answer 11

Osteoarthritis, inflammatory arthritis, trauma
They consist of a tibial, femoral and patellar component
Potential complications include infection, loosening, wear, periprosthetic fracture, dislocation

Question 12

How would you distinguish a osteoarthritis from an inflammatory arthritis?

Answer 12

Based on
hx (morning stiffness? worse at end of day? large vs smol joints)
bloods (ESR? anti-CCP?)
imaging (LOSS/ RESP)

Question 13

What’s your approach to crystal arthropathy?

Answer 13

Asym oligoarthritis of small joints in hands or feet *typically monoarthropathy i.e. 1st MCP = dec ROM and dec function

~ urate crystal deposition in joints, ppt by trauma, surgery, infection, dehydration

Long term = gouty tophi on joints, ears, tendons, renal stones, inc CV risk

RFs: diet, drinking etoh, cell death, drugs, dec excretion (CKD)

Synovial fluid =
Needle-shaped monosodium urate crystals with Negative birefringence

X-ray = punched out PA erosions, normal joint space, soft tissue swelling

Rx: rest and elevate,
high dose NSAID or colchicine +/- steroids.
prevention - address CV risk factors, lose weight, dec ETOH, avoid purine rich foods. medical - start allopurinol 3 wks after attack

VS CPPD - usually monoarthropathy of larger joints in elderly
~ inflam like RA

Synovial fluids = Rhomboid-shaped calcium pyrophosphate dihydrate crystals with Positive birefringence

Rx: cool pack, rest, elevate. +/- intra-articular steroids, NSAIDs / colchicine

Question 14

What’s your approach to septic arthritis?

Answer 14

If suspecting septic arthritis i.e. acutely inflamed/tender/swollen joint w/dec ROM and pt unwell - important to act as joint destruction can occur quickly

<30 yrs - gonorrhoea
>30 yrs - s aureus

~ age
~ joint damage - prosthesis, gout, RA
~ infection risk - immunosuppression

Ix: source of infection?
joint aspiration - inc WCC/PNM
bloods - inc WCC, CRP/ESR, BCs
X-ray

Rx: systemically unwell - sepsis 6 protocol
empirical Abx, refer to surgeons for joint aspiration +/- debridement (do not aspirate if prosthetic)
analgesia

Question 15

What are your differentials for arthritis?

Answer 15

Monoarthritis - septic, crystal, osteo, trauma (haemarthrosis)

Oligo - crystal, psoriatic, reactive, ank spond, osteo

Poly - (sym) rheumatoid, osteo, systemic i.e. CTD, IE
(asym) reactive, psoriatic

Question 16

How would you manage this fracture?

Answer 16

I would first resus the patient according to ATLS principles, along with a primary and secondary survey. At this point I would ensure the patient had adequate analgesia. I would assess NV status and see whether the fracture is open or closed. (Open - follow BOAST guidelines including swabs, IV Abx, photographing the wound, covering with saline soaked gauze, applying an occlusive film and referring the patient for debridement). X-ray in at least 2 views or CT in polytrauma.
I would then reduce the fracture if displaced, either closed or open. Closed with traction, or manipulation under anaesthetic. Open reduction is needed for intra-articular fractures or where there is neurovascular damage.
To hold the fracture, non-operative options include slings, backslab, cast. Operative would be external fixation particularly if soft tissue damage, or ORIF for comminuted fractures.
The patient will then undergo rehabilitation under the MDT team including physio and OT support. They may need VTE prophylaxis. The patient would be brought back to fracture clinic for re-xray and assessment of NV status.

Question 17

What are the complications of fractures?

Answer 17

There are general complications associated with surgery and immobility and specific. Specific complications can be immediate, early or late. Immediate includes damage to NV or adjacent soft tissue, bleeding and pain. Early includes compartment syndrome, VTE/PE, infection.
Late includes malunion or non-union, AVN, joint disease and neuropathic pain.
General - surgery = ABD, BPI, immobility = 5Ws

Question 18

How do you describe fractures

Answer 18

“This is a plain radiograph of the upper/lower of x patient. Ideally, I’d have a second view and some previous imaging to compare to”

PADS
Pattern- “There is a complete/incomplete, transverse/olique/spiral’ fracture”
Anatomy- “of the distal/mid/proximal 1/3rd of the left/right x bone”
Deformity- “with anterior/posterior/medial/lateral/dorsal/volar” translation or angulation
Soft tissues, joint involvement, ?impaction

“I’d ideally assess for soft tissue injury, if the fracture is open/closed and the neurovascular status of the limb”