MSK Flashcards
MSK screening assessment
GALS
- gait
- arms
- legs
- spine
Red flag symptoms for cauda equina
- perianal numbness
- bilateral sciatica
- faecal and urinary incontinence
- painless retention of fluid
- impotence
Red flag symptoms for spinal fracture
Major trauma
Sudden onset central spinal pain, better when lying down
Red flag symptoms for cancer
- 50+ yo
- Severe unremitting pain that remain when the person is supine
- Aching night pain that disturbs sleep
- unexplained weight loss
- PMHx of CA
Red flag symptoms for infection
Fever
Immunocompromised - HIV, Diabetes
TB
When to suspect ankylosing spondylitis
- Pain at night, not relieved when supine
- stiffness in morning, not relieved with movement
- gradual onset of symptoms
- Uveitis
Sciatica
Pain arising from lower back, radiating to BELOW the knee
Management of non- specific lower back pain
Conservative:
- weight loss
- pain relief - NSAID
- physiotherapy
- CBT
Diagnosis of back pain
History
Examination
Neurological examination - loss of sensation, reflexes
Cauda equina management
Surgical decompression within 48 hrs of sphincter symptoms
When to use opiod
If NSAID is contraindicated
Can be used +/- paracetamol
NSAID use
Prescribe weakest dose for the shortest time
Consider PPI adjunct
Take with meals
How to prevent back pain
Good posture Correct manual handling Exercising and stretching regularly Avoid sitting for long periods of time Healthy weight Supportive mattress
Sciatica management
If chronic and nothing else has worked: Epidural injections with local anaesthetics
Spinal decompression
Clinical presentation of osteoarthritis
- initially asymmetrical monoarthritis (can develop into polyarthritis)
- gradual onset
- functional impairment
- pain worse at end of day
Signs of OA
- Bony swellings - Herberdens nodes
- joint deformity
- Joint effusions (knee).
- Joint warmth and/or tenderness (synovitis).
- Muscle wasting and weakness.
- Restricted and painful range of joint movement, crepitus
- joint instability
Which joints does OA normally affect
DIPJ and first CMCJ at base of thumb
OA in hands signs
- Thenar eminence muscle wasting
- The CMC joint may develop a fixed flexion deformity, with hyperextension of the distal joints.
- Advanced disease - ‘squaring’
- ulnar deviation at affected joints.
- Herberden’s nodes
Signs of hip OA
- Pain in the anterior groin on walking or climbing stairs
- Pain which may occur at rest and may disturb sleep.
- Painful restriction of internal rotation with the hip flexed.
- An antalgic gait
- A fixed flexion external rotation deformity, with compensatory increased lumbar lordosis and pelvic tilt.
Signs of Knee OA
- Bilateral and symmetrical, affecting the medial tibiofemoral commonly
- Unilateral osteoarthritis of the knee is usually secondary to predisposing trauma or disease.
- Knee gives way
- Crepitus and tenderness along the joint line or with pressure on the patella.
- Restricted flexion and extension.
- Small-to-moderate effusions.
- Varus deformity
- Antalgic gait
RF for OA
Age Obesity Repetitive movements FHx Hip OA - Female
Signs of OA on Xray
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
Management of OA
Conservative: Weight loss Smoking cessation Muscle strengthening Hot/cold compresses Appropriate footwear
Pharmacological:
Paracetamol
NSAIDs - topical gel
When to refer an OA pt
Occupation therapist - activities of daily living affected
Podiatrist - insoles
Orthopaedic surgeon - not controlled with conservative management and severe pain
Score for OA of hip and knee management
Oxford hip and knee score
RA presentation
- Symmetrical, mainly small joints of hands and feet affected
- can be affected at any age but commonly 40s
- Morning stiffness that persists for more than 1 hour
- Pain worse at rest and better on movement
Signs of RA hand
Rheumatoid nodules Ulnar deviation Herberden's and Bouchard's nodes (commonly PIPs) Z thumb Swan neck deformity
Extra-articular and systemic features of RA
Vasculitis Malaise Fatigue Fever Sweats Weight loss
Investigations of RA
Bloods:
- FBC
- U+Es
- LFTs
- CRP
- RF
Xray (not commonly done) - mainly clinical diagnosis
Management of RA
Refer pt with persistant synovitis with unknown cause to rheumatologist - 3ww
When to urgently refer RA pt
Within 3 working days if:
- polyarticular
- small joints of hand or feet affected
- delay of 3+ months between onset of symptoms and seeing GP
When to suspect flare of RA
Worsening signs or symptoms of: stiffness, pain, joint tenderness, loss of function, snovitis
Increase in CRP
Management of RA flare
Seek specialist advice
Offer short term glucocorticoid injection if localised flare
Bursitis presentation
Swelling on joint Gradual onset - hours to days Painless - can be tender or warm Fluctuant History of trauma or skin abrasion
Features of septic bursitis
Increased tenderness and pain Red, hot, swollen Local cellulitis Fever Immunocompromised
Management of bursitis
Conservative:
- rest, ice, reduced activity
- avoid trauma
- tubigrip
If septic: - aspirate and culture - abx - flucloxacillin (if allergic - clarithromycin) - review after 7 days
Osteoporosis pathophysiology
Low bone mass and structural deterioration of bone tissue
Causes of osteoporosis
Ageing - osteoclast activity has higher activity than osteoblasts
Menopause - lack of oestrogen therefore osteoclast activity not inhibited
Complications of osteoporosis
Hip fractures
Vertebral fractures
Which joints does gout normally affect?
Metatarsophalangeal joint 78%
- midfoot, ankle, knee
- fingers, wrist and elbow joints
Presentation of gout
Severe pain Swelling Redness Warmth Tenderness Tophi
RF for gout
Alcohol intake
Drug use - ACEi, Beta blockers, diuretics
FHx
Investigations for gout
Most of the time not needed - clinical diagnosis
Joint fluid microscopy and culture
Serum uric acid measured 4 - 6 weeks after acute attack to confirm hyperuricaemia
Xray - soft tissue swelling and subcortical cysts
Management of gout
Conservative:
- Rest and elevate the limb
- Keep exposed in cool environment
- ice pack
- Lifestyle advice - reduce alcohol intake, weight loss
Pharmacological:
- NSAIDs (oral colchicine) max dose - continue 1 -2 days after the attack
- co prescribe a PPI
If cannot tolerate NSAIDs in gout
A short course of oral corticosteroids or a single intramuscular corticosteroid injection
- if intra-articular injection is not possible
- in oligo-/polyarticular gout.
Mx if acute monoarticular gout and co-morbidity provided the diagnosis is certain, the person (and joint) are suitable for injecting
Joint aspiration and intra-articular corticosteroids
Allopurinol in gout
Do not stop allopurinol or febuxostat during an acute attack of gout if the person is already established on these drugs
Gout follow up
Check serum uric acid
BP
HbA1c, lipid profile, renal function
Manage underlying conditions e.g. HTN
Prevention of gout
- Urate lowering therapy (ULT) life long
1st line - allopurinol
2nd line - febuxostat - Consider prescribing colchicine when initiating or increasing the dose of a ULT as prophylaxis against acute attacks secondary to ULT, and continue for up to 6 months.
Who should receive urate lowering drugs
Two or more attacks of acute gout in 12 months. Tophi Chronic gout arthritis. Joint damage Renal impairment (eGFR less than 60 ml/min) A history of urinary stones Diuretic use Young age of onset of primary gout.
Septic arthritis presentation
Systemically unwell (with or without a temperature) Acute painful, hot, swollen joint.
Inflammatory arthritis - Seropositive:
- RA
- SLE
- scleroderma
- Vasculitis
- Sjogren’s
Inflammatory arthritis - seronegative
Ankylosing spondylitis Psoriatic arthritis Reactive arthritis Inflammatory bowel disease arthritis Infective arthritis
SLE summary
Pt demographic: women in 40s, Afro- Caribbean
Presentation:
- Remitting and relapsing
- malar rash
- malaise, alopecia, headache
- arthralgia
- secondary fibromyalgia ( pain all over body)
- Raynaud’s
Investigations:
- Bloods - FBC, ESR
- Serology - Anti nuclear factor (ANA), Anti dsDNA, Anti-Ro/La
- Urinalysis - haematuria/ proteinuria
Management: Refer to radiologist
Conservative:
- avoid sun exposure
Pharmacological:
- paracetamol/ NSAIDs
- if not enough - corticosteroids or DMARDs
When is Cyclophosphamide used in SLE
Cyclophosphamide is reserved for treatment of life-threatening disease, particularly lupus nephritis, vasculitis and cerebral disease
Psoriatic arthritis summary
Inflammation, pain and swelling of joints in some people who have psoriasis
Management: refer to a rheumatologist
- NSAIDs
- Intra-articular steroid injection
- DMARDs
- skin ointments
- Steroid creams
- Retinoid tablets - vit A
Reactive arthritis summary
Reactive arthritis commonly affects young adults, most frequently white and carrying the HLA-B27 allele
Causes: C. trachomatis and Chlamydia pneumoniae are the most frequent
Presentation:
- develops 2-4 weeks after a genitourinary or gastrointestinal infection
- acute, with malaise, fatigue, and fever.
- asymmetrical, predominantly lower extremity, oligoarthritis
- Heel pain
- Triad: urethritis, conjunctivitis, and arthritis
Ix: Bloods: FBC, ESR, CRP Serology: HLA B27 Joint aspiration - rule out septic arthritis Stool culture
Mx: Physiotherapy NSAIDs Corticosteroids Abx - treat causative organism
Ankylosing spondylitis
Bone fusion
Signs:
Xray - bamboo spine
