MSK clinical 1 Flashcards
why is the humeral head retroverted
increases the range of movement at the glenohumeral joint (30degrees on average)
what condition commonly affects the trapezium
osteoarthritis - the commonest site in the hand
what type of accident is associated with trauma to he midcarpal joint
dislocation due to high energy injury
- (peri) lunate dislocation with or without fracture
what type of joint is the 1st carpometacarpal joint
saddle
what disease commonly occurs at the first carpometacarpal joint
osteoarthritis
what is the position of safe splinting
collateral ligaments of MCPs are at full stretch when fingers 90 degrees flexed
collateral ligements of the IPJs are at full stretch when fully extended
what condition commonly affects the metacarpophalangeal joints
swelling due to rheumatoid arthritis
what clinical sign is seen at the metacarpophalyngeal joints in rheumatoid arthritis
ulnar drift
what type of joints are the interpharyngeal joinrs
hinge
where would you find heberden’s nodes
the distal interphalangeal joints
where would you find bouchards nodes
at the proximal interphalangeal joints
Flexor muscles of the thumb
flexor pollicis longus and brevis
extensor muscles of the thumb
extensor pollicis longus and brevis
abduction muscles of the thumb
adductor pollicis longus and brevis
adduction muscles of the thumb
adductor pollicis
what is the muscle of the thumb responsible for opposition
opponens pollicis
nerve supply to the muscles of the thumb in the thenar eminence
flexor pollicis brevis, abductor pollicis brevis and opponens pollicis
– median nerve
nerve supply to the muscle of the thumb in the palm of the hand
opponens pollicis
– ulnar
Allens test
how to test for patency of the radial and ulnar nerves
- hand is ellevated and patient is asked to make a fist for about 30 seconds
pressure is applied over the ulnar and radial nerves as to occlude them both
still elevated the hand is then opened and it should appear blanched (pallor at the finger nails)
ulnar pressure is released and the colour should return in 7 seconds
what is the palmar aponeurosis
fibrous sheet of fascia which blends with palmaris longus
what condition can occur in the palmar aponeurosis
dupuytren’s contracture
what is a dermatome
sensory area of skin supplied by a single spinal nerve
what is a myotome
group of muscles supplied by one segment of the spinal cord
where on its course is the axillary nerve at risk
surgical neck of the humerus
what injuries can affect the axillary nerve
- fracture of humeral neck (surgical neck particularly)
- shoulder dislocation
- pressure on posterior cord of the brachial plexus
what is the motor deficit in an axillary nerve lesion
loss of shoulder abduction (deltoid)
sensory deficit in an axillary nerve lesion
badge area
during its course where is the radial nerve most at risk
spiral neck of the humerus - humeral shaft/radial groove
sensory deficit in a radial nerve palsy
1st web space dorsally (thumb and index)
nerve roots of the sciatic nerve
L4-S3
when is the sciatic nerve at risk
posterior dislocation of the hip
IM injections
what are the criteria for rheumatoid arthritis
morning stiffness
arthritis in 3 or more joint areas
arthritis of hand joints
symmetric arthritis
rheumatoid nodules (subcut over bony prominences, extensor surfaces and juxta-articular regions
serum rheumatoid factor
radiographic chanfes (erosions or definite bone decalcification
what is pannus
abnormal layer of fibrovascular tissue or granulation tissue
symptoms of arthritis
pain stiffness swelling functional impairment systemic symptoms
what are the signs of arthritis
tenderness swelling restriction of movement (heat) (redness) systemic features
systemic features of rheumatoid arthritis (non-specific)
fatigue
weight loss
anaemia
specific systemic features of rheumatoid arthritis
eyes lungs nerves skin kidneys
investigations for rheumatoid arthritis
immunology - rheumatoid factor - IgG, IgM
anti cyclic citrullinated antibodies (antiCCP, ACPA) - very specific
Xray
USS to show inflammation
how is rheymatoid arthritis assessed
using the disease activity score
how is the disease activity score for rheumatoid arthritis calculated
number of swollen joints/28
number of tender joints/28
ESR
CRP
what does a DAS28 score of 2.4 represent
clinical remission
what does a DAS28 score of >5.1 indicate
eligibility for biologic therapy
Aetiology of hallux valgus
Genetic Foot wear (particularly female)
Symptoms of hallux valgus
Pressure symptoms from show wear
Pain - particularly in ball of foot and over bunion and when crossing toes
Metatarsalalgia = pain in ball of foot
Management of hallux valgus
Change shoes! Give insoles Activity modification Analgesia Operative - release soft tissuers, osteotomy of 1st metatarsal (+/- proximal phalynx)
Hallux rigidus - what is it and what is the cause
Stiff big toe - osteoarthritis of the 1st metatarsophalangeal joint
Unknown aetiology potentially genetics or microtrauma
Symptoms of halux rigidus
Many assymptomatic
Pain at extreme of dorsiflexion
Limited range of movement
Treatment for a ganglion
Arise from joint or tendon sheath
- hit with a bible!
- aspiration
What are the risks for developmental dysplasia of the hip ?
Being the first born Oligohydramnios (underlying kidney and bladder problems) Breach presentation Family history Being more than 10lbs at birth
Clinical features of congenital dysplasia of the hip
Orltolani’s sign
…
Screening for developmental dysplasia of the hip
Selective ultrasound screening
- for breech presentations, family history, >10lbs and thought to have abnormal hip
Presentation of perthes disease
Usually male (10:1) Primary school age Short stature Limp KNEE PAIN ON EXERCISE Stiff hip joint Systemically well
Aetiology of developmental dysplasia of the hip
Idiopathic
Avascular necrosis of the hip
Possible relationship to minor trauma or coagulation tendency
Treatment of developmental hip dysplasia
Maintain hip motion and analgesia
Restrict painful activity; “supervised neglect”
Consider osteotomy in selected groups of older children
Presentation of slipped upper femoral epiphyses
- teenage boys> girls
- mainly overweight
- pain in hip or knee
- externally rotated posture and gait
- reduced internal rotation, especially in flexion
Mimics of multisystem connective tissue disease
Drugs - cocaine, PTU
Infection - HIV, endocarditis, hepatitis,TB
Malignancy - lymphoma
Cardiac myxoma
Cholesterol emboli
Scurvy
Does SLE affect men or women more?
Women 9:1
Age of presentation of SLE
15-50
Criteria for SLE
S= serositis (pleurisy, pericarditis) O= oral ulcers A= arthritis (2+ joints) P= photosensitivity
B= blood (haemolytic anaemia, leukopenia, thrombocytopenia R= renal (high blood and protein) A= ANA positive I = immunologic (anti-Sm, anti-dsDNA N= neuropsych (unexplained seizures and psychosis)
M= malar rash = butterfly N = discoid rash (-->alopecia)
Complications of scleroderma
Pulmonary hypertension
Pulmonary fibrosis
Renal crisis
Small bowel bacterial overgrowth
Investigations if suspect SLE
Urine dipstick - haematuria and proteinuria
Blood - anaemia, thrombocytopenia, raised CRP and ESR
ANA testing - positive for 90%
Antibodies to double stranded DNA - highly specific for SLE
Complications of SLE
Increased incidence of atherosclerosis
Increased thrombosis risk
Increased infection risk due to immunosuppressive treatment
Presentation of scleroderma
C - calcinosis of subcut tissues R - raynaud's E - oesophageal and gut dysmotility S - sclerodactyly (swollen tight digits) T - telangiectasia
Features of sjorgren’s syndrome
Dry eyes and mouth
Parotid gland enlargement
1/3 have systemic upset
- fever, fatigue, myalgia, arthalgia
Giant cell arteritis classification criteria
Age at onset 50+ years old New headache Temporal artery tenderness ESR 50+ Abnormal temporal biopsy
Treatment for mild multisystem autoimmune diseases
Hydroxychloroquine
Treamtent for moderate multi-system autoimmune diseases
Azathioprine
Methotrexate
Mycophenolate
Treatment for severe multi-system autoimmune disease
Cyclophosphamide
Rituximab
Causes of raised plasma urate
Malignancy (Leukaemia), inborn errors of metabolism, cytotoxuc drugs –> overproduction
Under-excretion
- renal impairment
- hypothyroid
- exercise, starvation, dehydration
- drugs - ALCOHOL, ASPIRIN, DIURETICS (thiazide commonly)
Presentation of gout
Severe monoarthropathy with joint inflammation
- commonly MTP joint of big toe
Treatment of acute gout episode
- NSAIDS
- colchicine
- steroids
- Ice and elevation
Long term management of gout
LIFESTYLE - less purine rich meat and alcohol; lose weight and avoud prolonged starvation
Allopurinol - prevents urate acid synthesis by blocking xanthine oxidase
feboxiostat if allopurinol not tolerated
Uricosuric agents to increase secretion - sulphinpryazone
Basis of psuedogout
Pyrophospate dehydrate crystals –> monoarthritis of the elderly
Management of pseudogout
Intra-articular steroid injections
NSAIDs not as effective
Presentation of polymyalgia rheumatica
Sudden onset of shoulder +/- pelvic girdle stiffness
Systemic - anaemia, malaise, weight loss, fever, depression
Who is commonly affected by polymyalgia rheumatica
Elderly females
(>50 but more commonly 70)
Females (2:1Males)
Common if have giant cell arteritis
ESR levels of someone with polymylagia rheumatica
> 40
Treatment of polymyalgia rheumatica
18-24 month course of prednisolone
- will need bone prophylaxis
Drugs which can cause gout
Cytotoxic drugs (used in chemo) Ethanol Aspirin Diuretics Cyclosporin antibiotics
Which condition commonly has high levels of antinuclear antibodies (ANA)
Systemic lupus erythematosis
Drug induced LE
Reumatoid arthritis
Sjorgen’s
Scleroderma
Old age
Chronic inflammation
How accurate is antinuclear antibody levels for SLE
High sensitivity for SLE
Low specificity for SLE
IF ANA TEST IS NEGATIVE SLE IS EXTREMELY UNLIKELY
ANCA stands for
Antinuclear cytoplasmic antibodies
risen levels of ANCA may indicate
Infection Inflammation Drugs Connective tissue disorders Inflammatory bowel disease
Secondary anti-phospholipid syndrome
Connective tissue disorders - SLE, RA, systemic sclerosis, sjorgen’s
Chronic infection - HIV, hep C, malaria
Drugs - phenytoin, phenothiazines, anti-hypertensives
Lymphoproliferative disease
Features of anti-phospholipid syndrome
- vascular thrombosis
- recurrent fetal loss
- livedo reticularis
- thrombocytopenia
Functions of complement
Phagocyte chemotaxis
Opsonisation
Lysis of micro-organisms
Maintaining solubility of immune complexes
Name for a malignant tumour arising from connective tissue
Sarcoma
How do sarcomas spread
Along fascial planes
Haematogenous spread to lungs
Are malignant tumours of the skeleton common or rare
RARE
Osteosarcoma
Malignant bone-forming tumour
Osteoid osteoma
Benign bone-forming tumour
Can be excruciatingly painful but are sensitive to aspirin
Endochondroma
Benign cartilage forming tumours
Chondrosarcoma
Malignant cartilage forming tumour
- tend to be very aggressive
Fibroma
Benign fibrous tissue tumours
Malignant fibrous tissue tumours
Fibrosarcoma
Haemangioma
Vascular tissue tumour
Malignant vascular tissue tumours
Angiosarcoma
Benign tissue tumours
Lipoma (fatty lumps)
Malignant adipose tissue tumour
Liposarcoma
Marrow tissue tumours
Malignant: ewing’s sarcoma, lymphoma, myeloma
Tumour like lesions
Benign - simple bone cysts and fibrous cortical defect
Commonest primary malignant bone tumour in younger patient
Osteosarcoma (still very rare)
Commonest primary malignant bone tumour in older patient
Myeloma
Still very rare
Presentation of bone tumours
PAIN - activity related if large enough to weaken bone, unexplained, progressive pain at rest and night
Mass
Abnormal x-rays - incidental
First line investigation for suspected bone tumour
XRAY
Red flags regarding pain that may suggest bone tumour
Worsening, activity related pain, unexplained pain at rest and at night
Xray findings for an inactive bone lesion
Clear margins
Surrouding rim of reactive bone
Cortical expansion can occur with aggressive benign lesions
Xray findings for aggressive bone lesion
Less well defined zone of transition between lesion and normal bone
Cortical destruction = malignancy
Periosteal reactive new bone occurs when lesion destroys the cortex
Codman’s triangle, onion skinning (layering of new bone) or sunburst patterns
Best investigation for bone and soft tissue tumours
MRI
- accurate for limits of disease both within and outside bone
Investigations for bone or soft tissue tumour suspect
Xray CT (sarcoma spread to lungs/haematogenous spread) Bloods MRI of lesion Bone scan CT, chest, abdo and pelvis
BIOPSY (needle core or open)
Cardinal features of malignant primary bone tumour
Increasing pain Unexplained pain Deep-seated boring nature Night pain Difficulty weight bearing Deep swelling
Clinical features of bone tumour
Pain - increasing, analgesics (eventually ineffective), not related to exercise, deep boring ache, worse at night
Loss of function - limp, reduced movement, stiff back
Swelling - diggise in malignancy, near end of long bone, warm over swelling and venous congestion, pressure effects
Pathological fracture - more commonly caused by osteoporosis
Joint effusion
Deformity
Neurovascular effects
Systemic effects of neoplasia
Treatment of bone tumours
Chemo
Surgery - limb salvage usually possible
Radio
Soft tissue tumour features of malignancy
Painless Deep tumours of any size Subcutaneous tumours >5cm Fixed, hard or indurated mass Rapid growth, hard, craggy, non-tender
Most common cancers to cause bone metastasis
LUNG BREAST!! PROSTATE KIDNEY THYROID GI TRACT MELANOMA --> vertebrae > proximal femur > pelvis > ribs >sternum > skull
Imaging of choice for soft tissue tumour
MRI
Peak age incidence of osteosarcoma
10-25 years
Peak age incidence for ewing’s sarcoma
E10-18
Peak incidence for chondrosarcoma
45-60 years
Treatment of hallux rigidus
Activity modification
Shoewear with rigid sole
Analgesia
Surgery - chielectomy to remove dorsal impingement
Joint affected by
Claw toe
Hammer toe
Mallet toe
Claw - extended MTP, flexed PIP and DIP
Hammer - extended MTP flexed PIP and extended DIP
Mallet - flexed DIP rest neutral
Aetiology of lesser toe deformities
Imbalance between flexors/extensors
Shoewear
Neurological
Rheumatoid arthritis
Symptoms of lesser toe deformities
Deformity
Pain from dorsum or plantar side
Most common site for morton’s neuroma
Middle metatarsophalyngeal joint
Where does a dorsal foot ganglia arise from
Tendon or joint sheath
Symptoms of dorsal foot ganglia
Pain from pressure from shoe wear
Pain from underlying problem (arthritis or tendon pathology)
Rate of return for dorsal foot ganglia
50%
Presentation of plantar fasciitis
Pain on weight bearing after rest - early morning
Common condition that takes 2 years to resolve
Common in theatre nurses and the overweight
Treatment for plantar fasciitis
Rest, cross training
Stretching - achilles tendon
Ice
NSAIDs
Orthoses
Weight loss
Corticosteroid
Night splinting
If someone presents with ankle arthritis under 50 with no known trauma what should you investigate for
Haemochromatosis
Presentation of posterior tibial tendon dysfunction
Acquired adult flat foot
Stages:
- Medial pain, no deformity
- Flat foot, flexible deformity
- Flat foot, fixed deformity
- Flat foot, fixed deformity and ankle involvement
Diabetic feet commonly have what feet deformities
Ulceration
Charcot foot
Aetiology of diabetic foot ulcer
Diabetic neuropathy - patient unaware of trauma
Diabetic autonomic neuropathy - lack of swearing/normal sebum production so skin is dry and cracked and more sensitive to minor trauma
Poor vascular supply
Lack of patient education
Treatment of diabetic foot ulcer
Prevention! Modify detriments to healing - diabetic control - smoking - vascular supply - external pressure - internal pressure (deformity) - infection - nutrition
Cause of charcot arthropathy
Any cause of neuropathy of which diabetes is most common cause
Historically common with syphilis
? Neurotrauma - lack of proprioception and protective pain sensation
? Neurovascular - abnormal autonomic nervous system results in increased vascular supply and bone resorption
Charcot arthropathy is characterised by…
Rapid bone destruction
- fragmentation
- coalescence
- remodelling
Complications of charcot’s foot
Deformity leads to ulceration leads to infection leads to amputation
Foot manifestations of rheumatoid arthritis
Swollen and painful joints due to synovitis and erosions
Tendon or ligament ruptures
Stress fractures
Avascular necrosis of bones
May involve hallux and lesser toes
Tarsal tunnel syndrome
Pressure on tibial nerve in tarsal tunnel
–> vague symptoms of pain (neuralgic) and altered sensation
Treatment of tarsal tunnel syndrome
Decompression
Effects of peroneal tendon disorders
Subluxation or dislocation
Injury or degeneration
Most common direction of hip dislocation
Posterior
Typical position of the leg in a posterior dislocation
Holds leg in a flexed, adducted, internally rotated position with some shortening of the leg
Most common associated injuries in a posterior hip dislocation due to a head on collision
Fractures of patella or femur
Posterior force on the tibia may result in rupture of the posterior cruciate ligament
Posterior wall acetabelar fractures and fractures of the femoral head
Sciatic nerve injury (suspect if patient has weakness of plantarflexion and dorsiflexion with sensory disturbance below the knee
Potential problems associated with fracture of a growth plate
Premature growth arrest resulting in an angular deformity
Limb length discrepancy may also result
Presentation of a hip fracture on examination
Leg shortened and externally rotated on examination
Complications associated with a hip fracture
Non union
Failure of fixation
Avascular necrosis
What is the blood supply to the hip
Majority is derived from capsular vessels which are formed from the anastomoses of the medial and lateral femoral circumflex vessels - these vessels are branches of the profunda femoris
What are the ALTS steps
Primary survey - airway, breathing circulation to detect and rectify immediately life-threatening injury (airway obstruction, major thoracic trauma causing serious respiratory compromise and hypovolaemic shock); this will include airway management and fluid resuscitation
Secondary survey - head to toe examination to detect any important but not life-threatening injury
A limited history is obtained from the patient, relatives or paramedical staff
Lateral cervical spine, chest and pelvic radiographs are obtained in all patients
Which injuries are associated with haemarthrosis of the knee
Tear of the anterior cruciate ligament
Fractures of the tibial plateau or osteochondral fractures of the femoral condyle
Dislocation of the patella
Meniscal tears if there is a peripheral detachment
Rupture of patellar of quadriceps tendon causes a lot of bleeding but there is no contained haemarthrosis because the capsule is disrupted
Investigation of choice in a suspected ruptures anterior cruciate ligament
MRI
Management of ligament injury - ACL
Non-operative in the acute setting
ACL tears or ACL and MCL tears often associated with marked swelling and stiffness of the knee in the weeks after injury
Physiotherapy is the initial management to allow time for swelling and stiffness to resolve
Surgical reconstruction once the swelling has resolved
Presentation of a posterior shoulder dislocation
Shoulder fixed in internal rotation
If the elbow is flexed to 90 it will be apparent that the shoulder is internally rotated and no external rotation is possible
What can cause an achilles tendon rupture
Dorsiflexing force applied suddenly to the forefoot that is resisted by powerful plantarflexion of the gastrocnemius and soleus muscles
What is genu recurvatum
When both knees are extended at rest –> hypermobility
Empiric antibiotic treatment in a septic arthritis
Suspect staph aureus or strep pyogenes so give IV flucloxacillin and benzylpenicillin or amoxicillin for 2 weeks
Then oral antibiotics for 4 weeks
What must you consider before starting someone on biologic therapy such as anti-TNF
Careful history to rule out current infection; check past history for infection with tuberculosis (do chest Xray at baseline)
Patients should not have a malignancy or have had a malignancy in the previous 10 yrs
Those with MS and heart failure are excluded
Antibodies to screen for coeliac disease
Anti-endomysial antibodies
If suspecting gout what investigation would you do
Polarised light microscopy of joint contents - will show negatively birefringent crystals
Antibody findings that are suggestive of SLE
Anti-nuclear antibodies and antibodies to double stranded DNA
Which blood products are associated with increased risk of thrombotic complications
Anti-phospholipid antibody and lupus anticoagulant
Management of anti-phospholipid syndrome
Lifelong anticoagulation - aspirin and heparin should be given throughout all future pregnancies and thereafter given warfarin
What is the difference between subluxation and dislocation
Subluxation is partial dislocation of the bone from its normal position so that some of the articular surfaces are still in contact
Dislocation is complete dislocation of the bone from its normal position so that the articular surfaces are no longer in contact
Which lobe of the lungs is most commonly affected by aspiration pneumonia
Right lower lobe
Are calf DVTs more or less likely to thrombose to the lungs
Less
What is the cause of webbing of fingers and toes
Failure of programmed cell death
What do you call webbing of the fingers
Syndactylyl
What do you call too many fingers
Polydactylyl
Which embryonic component is responsible for muscle development
Myotome
When does the pubic symphysis become mobile
Childbirth
Which fracture can lead to carpal tunnel syndrome
Colles fracture
Where is hip pain commonly referred to
Groin and knee
Sometimes thigh laterally
Main nerve supply to the hip joint
Obturator
Damage to the sciatic nerve would cause
Drop foot
Nerve supply to sartorius
Femoral
What is a locked knee
A knee that cannot be fully extended - can flex fully
Most common associated problem with juvenille idiopathic arthritis
Uveitis
What is a bursa
Sac lined with synovial membrane, filled with a small amount of synovial fluid that provides cushioning to allow muscles to move over each other
Medical term for knock knees; bow legs
Genu valgrum
Genu varum
Neuropraxia
Transient damage to a nerve such as compression, stretching
- have good prognosis
Neurotmesis
Partial or complete severance of a nerve, with disruption of the axon and its myelin sheath and the connective tissue elements
