MSK Pathology Flashcards
1
Q
What is cubital tunnel syndrome
A
Compression of the ulnar nerve as it passes around the medial epicondyle
2
Q
What is the 2nd most common nerve entrapment
A
Cubital tunnel
3
Q
Causes of cubital tunnel syndrome
A
Osteoarthritic or rheumatic narrowing of the ulnar groove
Can be without obvious cause
Fractures (injury)
Joint dislocation (injury)
4
Q
Non-operative Rx for cubital tunnel
A
NSAIDs
Bracing/splinting
5
Q
Surgical Rx for cubital tunnel
A
Nerve release
6
Q
Clinical features of cubital tunnel syndrome
A
Hypothenar wasting Clas deformity Numbness Decreased sensation of little ad medial 1/2 of ring finger Tingling in hands and fingers Shooting pain when leaning on the elbow
7
Q
What is a more common name for medial epicondylitis
A
Golfer’s elbow
8
Q
What is more common golfers elbow or tennis
A
Tennis
9
Q
What is the medial epicondyle the common origin for
A
Flexor tendons
10
Q
Pathology of golfers elbow
A
Form repetitive strain injury
Microtears and degeneration in the tendons from overuse
11
Q
Rx for golfers elbow
A
Activity modification
Rest
Physio.
Biological:
Platelet rich plasma injection
12
Q
Which Rx should you never give in golfers elbow?
A
Nerve inject steroids
13
Q
Clinical features of golfers elbow
A
Aching elbow pain (typically over medial elbow)
Worse with activity
Typically affects dominant arm
14
Q
What is a more common name for lateral epicondylitis
A
Tennis Elbow
15
Q
What is the most common elbow overuse injury
A
Tennis elbow
16
Q
In shoulder dislocation what is stability sacrificed for
A
Mobility
17
Q
What type of injury is tennis elbow
A
Repetitive strain injury
18
Q
Ix for tennis elbow
A
Clinical Dx
Mill’s test
Cozen’s test
19
Q
Clinical features of tennis elbow
A
Pain lateral elbow
Worsens with activity
Typically affects dominant arm
Point tenderness over lateral epicondyle
20
Q
Rx for tennis elbow
A
Activity modification
NSAIDS
Physio.
Platelet rich plasma injections
21
Q
What is Adhesive capsulitis also commonly known as
A
Frozen shoulder
22
Q
What are the 3 stages of frozen shoulder
A
- PAIN with freezing (pain and decreased ROM)
- Stiffening or FREEZING(pain slightly resolves but stiffening worsens)
- Resolution/THAWING
23
Q
How long can frozen shoulder take to resolve
A
up to 2yrs
24
Q
Clinical features of frozen shoulder
A
Acute pain on movement and resting
Difficulty sleeping on affected side
Restricted ROM
Pain settles and stiffening begins
Stiffening persists more than the pain
25
Ix for frozen shoulder
Clinical Dx
| Normal on x-ray
26
Rx for early presentation of frozen shoulder
Steroid injection
Physio
Analgesia (NSAIDs)
27
What is a shoulder dislocation
Loss of congruity between the head of the humerus and the glenoid fossa
28
What is the most common direction of dislocation
Anterior
29
What should potentially be considered in a posterior dislocation
Seizures
30
What type of joint is the shoulder joint
Synovial ball and socket
31
Clinical features of should dislocation
Extreme pain
Decreased ROM
Held in ABDUCTED and EXTERNALLY ROTATED position
32
Ix for shoulder dislocation
X-ray
| AP and lateral
33
Rx for shoulder dislocation
Analgesia
Manipulation
Immobilisation
Physio.
34
Complications of shoulder dislocation
Labral tear
Axillary n. or a damage
Damage o brachial plexus
Increased risk of recurrence
35
When should you operate in shoulder dislocations
>2 dislocations
36
How do ACL injuries typically occur
Through sporting
37
Common causes of ACL
```
Twisting injury to the knee with foot fixed to the ground
Landing incorrectly
Stopping sudden
Changing direction suddenly
Collision
```
38
Signs of ACL damage
Unstable knee
Effusion
+ve drawer test
39
Symptoms of ACL damage
Heard a pop
Pain
Quick swelling
Loss of full ROM
40
Ix for ACL damage
Often clinical
| Rarely MRI
41
Rx for ACL injury
Rest
Physio
Swelling reduction
Analgesia
Surgery:
ACL reconstruction
42
Indications for surgical reconstruction in ACL injury
Prevention of further injury
Back to work
Back to sport
Prevention OA
43
Which is stronger the ACL or PCL of the knee
PCL
44
What is a common cause of PCL injury
Car crashes:
| Bent knee hitting the dashboard
45
Signs of PCL injury
Posterior draw test
| Posterior sag
46
Symptoms of PCL injury
Pain
Swelling
Difficult weight bearing
Unstable knee
47
Rx for PCL Injury
Analgesia
Physio.
Immobilisation
Swelling reduction
48
Why is PCL injury treated more conservatively
Surgical reconstruction is more difficult and more difficult to predict compared to ACL reconstruction
49
What is the most commonly fractures carpal bone
Scaphoid
50
What is a common complication of scaphoid fracture
AVN
51
What is AVN
Avascular necrosis
| Death of the bone due to interrupted blood supply
52
Ix for suspected scaphoid fracture
Easily missed on x-ray
| So dedicated scaphoid series
53
Clinical features of scaphoid fracture
```
Tender anatomical snuffbox
Tender over scaphoid tubercle
Pain on axial compression of thumb
Pain on ulnar deviation of pronated wrist
Pain on supination against pronation
```
54
Main cause of scaphoid fracture
Falling
| On outstretched hand
55
Rx for scaphoid fracture
Cast
56
Rx for clinically suspected scaphoid fracture that is not detected x-ray
Cast
| Re-xray in 2 weeks
57
Which of the collateral ligaments is more commonly injury
Medial
58
How is the medial collateral ligament injured
Due to lateral blow to the knee
59
Which ligament does a blow to the lateral knee injure
Medial collateral
60
Which ligament does a blow to the medial knee injure
Lateral collateral ligament
61
Describe injury to the lateral collateral ligament
Less common than medial injury
Tends to be more extensive and involve:
Cruciate
Common perineal nerve
62
Rx for collateral ligament injury
Rest
Firm support
Physio
63
When is surgery indicated for collateral ligament injury
Rarely
| Unless complicated LCL injury
64
Clinical features of collateral ligament injury
```
No or minimal effusion
Swelling
Bruised one side
Lateralised pain
Feel of 'crack' sharp pain
```
65
What is an open fracture
Direct communication between a fracture and the external environment
66
What is the classification system used for open fractures
Gustilo Classification of Open Fractures
67
Complications of open fractures
Infection
Compartment syndrome
Non-union
Neurovascular injury
68
Describe Gustilo Classification System
Classifies open fractures
Based on:
Size of wound
Tissue damage
Classified into:
Stage 1
Stage 2
Stage 3 (3A,B,C)
69
Which open fractures require a vascular surgeon
Stage 3C (involvement of neuromuscular structures)
70
Ix for open fractures
```
Full ALTS assessment
Repeated neurovascular examination
Take photographs with ruler beside it
X-rays
Sometimes CT
```
71
Indications for emergency surgery
Polytraumatised
Gross contamination
Compartment syndrome
Neurovascular compromise
72
What are the BOAST guidelines for dealing with open fractures
```
Analgesia
Take a photograph with a ruler next to it
Splinting
Neurovascular examination of patient
Document it!!
```
73
What is the commonest reason for knee arthroscopy
Meniscal injury
74
What is the function of the menisci
Shock absorbers
75
What are the menisci of the knee
Medial
| Lateral
76
Clinical features of meniscal injury
```
Slow swelling
Painful to weight bear
Sensation of knee giving way
Locked knee (extension limited)
Loss of full ROM
```
77
What does McMurrays test assess for
Knee meniscal injury
78
Surgery options for meniscal injury
Arthroscopy
Meniscal repair
Partial meniscectomy
Meniscal transplantation
79
Conservative Rx for meniscal injury
Physio
Analgesia
Swelling reduction
80
What causes Carpal Tunnel Syndrome
Compression of the median nerve as it passes through the carpal tunnel
81
Is carpal tunnel more common in F or M
F>M
82
Underlying causes of Carpal tunnel
```
Pregnancy
Gout
DM
Idiopathic
Acromegaly
Local tumours
RA
Hypothyroidism
Amyloidosis
Sarcoidosis
```
83
What is the most common neuropathy
Carpal tunnel
84
Symptoms of carpal tunnel
Tingling in median nerve distribution
Numbness in medin nerve distribution
Pain
Can be worse at night
85
What is the median nerve distribution in the and
Lateral 3.5 digits
86
Ix for Carpal Tunnel
Usually clinical Dx (O/E)
Tinel's Test
Phalens Test
Sometimes nerve conduction studies
87
Describe Tinel's test
Tapping over the anterior wrist of the affected
| +ve would elicit symptoms
88
Describe Phalen's Test
Backwards paying
For 60 seconds
+ve if this elicits symptoms
89
Rx for Carpal Tunnel
Splintage
Rest
Weight reduction
Corticosteroid injection
Sometimes surgery if persistent
90
Surgery for carpal tunnel syndrome
Carpal tunnel release
91
Is Trigger finger more common in M or F
F>M
92
Associations with Trigger Finger
DM!
RA
Gout
Thyroid disease
93
Clinical features of trigger finger
Clicking sensation with movement of this digit
Lump in palmar aspect under pulley
May have to use the other hand to unlock the finer
Clicking may progress to locking (in flexed position)
94
Which level of pulley is commonly affected in trigger finger
Level of A1 pulley
95
Ix for trigger finger
Clinical Dx
96
Non-operative Rx trigger finger
Splintage
Rest
Steroid injection
Analgesia
97
Operative Rx trigger finger
Surgery:
Percutaneous release
Open surgery
98
Which finger is the most commonly affected in trigger finger
Ring finger
99
Who does Legg-Calve/Perthes disease affect
Children
100
What causes Legg-Calve
Idiopathic
101
Pathology of Legg-Calve disease
AVN of femoral head occurs
102
What are the phases of Legg-Calve disease
Avascular necrosis at femoral head (due to lack of blood supply)
Fragmentation (revascularisation) - painful phase
Reossification - bone healing
103
Clinical features of Perthes disease
```
Short stature
Limping child
Knee pain (referred from hip)
Groin/hip pain
Stiff hip joint
Limited ROM of hip
```
104
Ix for Perthes/Legg -Calves disease
X-ray
| MRI
105
Outcome of Perthes/Legg-Calves disease
Alot will resolve by itself
106
Is the prognosis better or worse for Perthes disease that occurs <6yrs
Better
| As children bones recover well and model
107
Is the prognosis better or worse for Perthes disease that occurs in Adolescence
Worse
Poorer prognosis
More risk of developing OA
108
Ddx for unilateral Perthes/Legg-Calves disease
Septic hip
JIA
SCFE
109
Rx for Perthes/Legg-Calves
No definitive Rx
Maintain good hip motion.mobility
Analgesia
X-ray surveillance
110
What is the long term prognosis of Perthes/Legg-Calves disease determined by
The risk of developing OA in the deformed hip
111
Who is Legg-Calves/Perthes disease more common in M or F
Males
112
Is majority of Legg-Calves/Perthes disease unilateral or bilateral
Unilateral
| only 15% is unilateral
113
What is the clinical term for irritable hip
Transient synovitis of the hip
114
What is the child cause of hip pain in children
Transient synovitis of the hip (irritable hip)
115
What type of Dx is hip transient synovitis
Dx of exclusion
116
What causes irritable hip
Inflammation of the synovium
117
Clinical features of irritable hip
```
Acute onset
Acute hip pain
Stiffness
Limp
Non-weight bearing
```
118
Ix for irritable hip
Dx of exclusion
Bloods normal
X-ray normal
119
Rx for irritable hip (transient synovitis)
Self limiting
Rest
Analgesia (NSAIDs)
120
What Dx do you need to exclude in order to Dx transient synovitis (irritable hip)
Septi arthritis
Osteomyelitis
Fractures
SUFE
121
What does SCFE stand for
Slipper Capital Femoral Epiphysis
122
What is the cause of SCFE
Unknown
123
Pathology of SCFE
Fracture through the growth plate which results in slippage of the overlying end of the femur
Displacement through the hypertrophic zone
124
What is the difference between stable and unstable SCFE
Stable - can weight bear
| Unstable - cannot weight bear
125
What is a major risk factor for SCFE
obesity
126
What 2 signs can be seen on X-ray in SCFE
Trethowan Sign
| Klein's Line
127
Symptoms of SCFE
Pain in hip or knee
Groin pain
Some unable to weight bear
Limp
128
Signs of SCFE
Externally rotates posture and gait (waddling)
| Reduced internal rotation (esp. in flexion)
129
Difference between chronic and acute SCFE
Chronic is >3 weeks
130
Which view of x-ray will you best see SCFE
Lateral
131
Describe the radiological classification of SCFE
Grade I/mild = <1/3 slippage
Grade II/moderate = 1/3 - 1/2 slippage
Grade III/severe = >1/2 slippage
132
Complications of SCFE
```
AVN (femoral head)
Chorndrylosis
Deformity
Early OA
Stable becoming unstable
```
133
What is a complication of stable SCFE
Stable becoming unstable
134
DD for SCFE
```
Transient synovitis
Infection
Missed DDH
JIA
Perthes
```
135
Operative Rx for SCFE
Pinning
Early internal fixation
Consultation orthopaedic surgeon
136
Where does the metaphysics move in SCFE
Anterior and proximal
137
Does stable or unstable SCFE have a higher risk for AVN
Unstable
138
What is acute osteomyelitis
Acute infection of the bone
139
Who does acute osteomyelitis normally affect
Children
140
What type of organism is the most common for acute osteomyelitis
Bacterial
141
Common Ddx for acute osteomyelitis
Acute septic arthritis
Acute inflammatory arthritis
Trauma (fracture, dislocation)
Transient synovitis
142
Rarer Ddx for acute osteomyelitis
Sickle cell crisis
Gaucher's Disease
Rheumatic fever
Haemophilis
143
Skin Ddx for acute osteomyelitis
Cellulitis
Erisypelas
Necrotising fasciitis
Gas gangrene
144
Potential source of osteomyelitis in infants
Umbilical cord
145
Acute osteomyelitis organisms in infants <1yr
Staph Aureus
Group B strep
E.coli
146
Acute osteomyeltiis organisms in older children
Staph Aureus
Strep Pyogenes
Haemophilus influenza
147
Acute osteomyelitis organisms in adults
Staph Aureus
Coagulative -ve staphylococci
Pseudomonas aeroginosa
148
Acute osteomyelitis organisms in diabetic foot
Mixed infection
| Including anaerobes
149
Acute osteomyelitis organisms in sickle cell disease
Salmonella
150
in which group would candida more commonly cause acute osteomyelitis
HIV/Aids
| Debilitating illnesses
151
Complications of acute osteomyelitis
```
Septicaemia; death
Metastatic infection
Pathological fracture
Chronic osteomyelitis
Septic arthritis
Altered bone growth
```
152
Clinical features acute osteomyelitis in infants
```
May be minimal signs
Or may be very ill
Failture to thrive
Drowsy irritable
Metatphyseal tenderness and swelling
Decreased ROM
Positional change
```
153
Clinical features acute osteomyelitis in children
```
Sever pain
Reluctant to move
Neighbouring joints held flexed
Not weight bearing
Fever
Tachycardia
Malaise (fatigue, nausea, vomiting)
```
154
Clinical features osteomyelitis in Adults
Primarily seen in thoracolumbar spine
Acute backache
Temperature/fever
History UTI, DM or immunocompromised
155
Basic Ix of acute osteomyelitis
```
Hx
Examination
FBC
Diff WCC
ESR
CRP
Blood cultures x3 at peak temperature
U&E's - ill, dehydrated
```
156
Imaging Ix of acute osteomyelitis
```
Xray
USS
Aspiration
Isotope bone scan
Labelled white cell scan
MRI
```
157
Gold standard for making a microbiological Dx in acute osteomyelitis
Bone biopsy and culture (though this is rarely required)
158
Supportive Rx for acute osteomyelitis
Fluids
Analgesia
Rest
Splintage
159
Abx Rx for acute osteomyelitis (including route and for how long)
```
Start on IV then switch to oral
Duration 4-6weeks depending on response
empirical choice (flucloxacillin + benzylpenicillin_
```
160
Indications for surgery in acute osteomyelitis
Aspiration of pus for Dx an culture
Abscess drainage
Debridement of dead/infected/contaminated tissue
161
Common sources of infection for osteomyelitis
Haemotogenous spread
Local spread from contiguous site fo infection - trauma (open fracture), surgery, joint replacement
Secondary to vascular insufficiency
162
Common source of acute osteomyelitis infection for osteomyelitis in adults
UTI
| arterial line
163
Common sources of acute osteomyelitis infection in children
Boils
Tonsilitis
Skin abrasions
164
If there is no resolution of acute osteomyelitis what occurs
Chronic osteomyelitis
165
What is sequestrum
Necrosis of bone
166
What is Involucrum
Formation of new bone
167
Which three common conditions can cause intoeing
Tibial torsion
Metatarsus adducts
Femoral anteversion
168
What is intoeing
When a child walks or runs with their feet turned inwards
169
What is the main Rx for intoeing
In the vast majority it will correct itself
170
Rx for metatarsus adductus
95% will resolve on their own
Stretching/manipulation exercises can help
Some cases:
Casts/special shoes
Surgery
171
What is metatarsus adductus
Common foot deformity noted at birth
| Which causes intoeing
172
when is flexible metatarsus adductus Dx
If the heel and forefoot can be aligned with each other on gentle pressure no forefoot while holding eel steady
173
Ix for metatarsus adductus
Physical examination
| X-ray if non flexible/rigid
174
Signs of Metatarsus adductus
High arch
| Wide separation of big and 2nd toe
175
What causes tibial torsion
Inwards rotation of the tibia
176
Prognosis for tibial torsion
Very good
| Almost always corrects itself as the child grow
177
what common thing does tibial torsion cause
Intoeing
178
What is congenital dysplasia of the hip
Congenital hip dislocation
179
Who is DDH incidence higher in
```
First born
girls>boys
Left>right
Olidohydramnios
Breech position
FH
Other limb deformities
```
180
Which hip is more commonly affected in DDH
Left
181
Ix for DDH
All babies given full hip examination within 72hrs
Early Dx is crucial
Another hip examination at 68 weeks -
182
when is USS recommended for Dx DDH
```
If the hip feels unstable on routine examination
FH of childhood hip problems
Baby was breech
Twins or multiple
premature
```
183
Why are x-rays not used to diagnose DDH
Because most of babies bones are cartilaginous
184
Rx for DDH
Pavlik Harness
185
Describe Pavlik Harness
Where legs are held in flexed abducted position
| Adjusted during growth
186
When is surgery indicated for DDH
If Dx>6 months
Or
Failure of Pavlik Harness
187
Why is the Left hip more affected in DDH
due to the way that babies present down the birth canal
188
What can excessive abduction in Pavlik harness (DDH) lead to
AVN
189
What are 2 clinical signs of DDH
Ortolani's Sign
| Barlows Sign
190
Red flags for Cauda Equine Syndrome
Saddle anaesthesia
Bilateral sciatic
Bowel/urinary dysfunction (incontinence/retention)
191
Rx for Cauda Equina
Urgent decompressive surgery
192
What is sciatica
Pain from lower back down the back of the thighs
193
What is saddle anaesthesia
Loss of sensation of buttocks, perineum ad inner thighs
194
What is caudal equine syndrome
Caused by the compression of the caudal equine (horses tail of the spinal cord)
195
Causes of caudal equine syndrome
```
Central lumbar disc props
Tumours
Trauma
Infection
Iatrogenic (spinal injection/surgery)
```
196
Where is the clavicle most commonly fractures
middle 1/3 (80%)
197
Rx for broke collarbone
Sling
Immobilisation
analgesia
198
Complications of clavicle fracture
Pneumothorax
Blood vessel injury
Nerve injury
199
What is the most common cause of compartment syndrome
Fractures
200
what is the pathology of compartment syndrome
Pressure within muscles build dangerous levels
Occluding vascular supply
Leading to hypoxia and eventually necrosis of the tissue
201
1st line/urgent Ix in compartment syndrome
Measuring intra-compartment pressure
| >30mmHg defined as critical
202
What intra-compartment pressure is considered critical in compartment syndrome
>30mmHg
203
Risk factors for compartment syndrome
Trauma
Bleeding Disorder
thermal injury
Intense muscular activity
204
Rx for compartment syndrome
Surgical review at Dx
Dressing release
Supportive
PROMPT fasciotomy
Worst case scenario:
Amputation
205
Clinical features of compartment syndrome
```
Pain
Muscle tightness
Paralysis
Pallor
Pulselessness
Redness
Oedema
Mottling
Firm wooden feeling on palpation
```
206
Which carpal fracture is easily missed on X-ray
Scaphoid
207
What is a common complication of scaphoid fracture
AVN
208
What is osteoporosis
Metabolic bone disease characterised by low/reduced bone mass and micro architectural deterioration of bone tissue
Fragile bones
209
What is there an increased risk of in osteoporosis
Increased fracture risk
210
Factors that the risk of fracture is related to
```
Increased age
Females following menopause (due to decreased oestrogen)
FH
BMD
Long term steroid use
Smoking
Alcohol
```
211
Endocrine causes of osteoporosis
```
Thyrotoxicosis
hypoparathyroidism
Cushing's
Hyperprolactinaemia
Hypopituitarism
Low sex hormones (hypogonadism)
```
212
Rheumatic causes of osteoporosis
Rheumatoid arthritis
Ankylosing Spondylitis
Polymyalgia Rheumatica
SLE
213
GI causes of osteoporosis
```
IBD (UC or CD)
Malabsorption syndromes (e.g coeliac)
Chronic active hepatitis
Alcoholic cirrhosis
Cystic fibrosis
Chronic pancreatitis
Whipples disease
```
214
Medication Causes of Osteoporosis
```
Steroids!!
PPI
Aromatase inhibitors
Heparin
Warfarin
Enzyme inducting anti epileptic medications
```
215
What is the main clinical relevance of Osteoporosis
Increased risk of fracture
216
Which assessment tool is used to assess the risk of fractures
FRAX assessment tool
217
Clinical features of osteoporosis
No specific symptoms
| but fractures of bones occur n situations which would not normally cause a break in healthy bones
218
Ix for Osteoporosis
FRAX assessment tool (to determine risk of fracture)
X-ray
DEXA scan
Bloods (to rule out underlying causes)
219
Methods of preventing osteoporotic fractures
Minimise risk factors
Ensure good calcium and Vitamin D status
Falls prevention strategies
Medications
220
General Rx for osteoporosis
Quite smoking
Decreased alcohol
Weight bearing exercises
Calcium and Vitamin D rich diet
221
Medication Rx for Osteoporosis
```
Biphosphonates (1st line/main Rx)
Denusomab
Teriparatide (artificial PTH)
Calcium supplements
Vit. D supplements
HRT
```
222
What is Denusomab
Monoclonal Antibody
223
What is the action of Denusomab
Reduces osteoclastic bone resorption
224
What is Teriparatide
Artificial parathyroid hormone
225
Who does HRT help in osteoporosis
Post-menopausal women
226
Side effects of HRT
Increased risk blood clots
| Increased risk breast cancer
227
What is required for the use of bisphosphonates
Adequate renal function
Adequate vitamin D and Calcium required
Good dental health and hygiene also advised
228
Side effects of biphosphonatees
Oesophagitis
Uveitis
Not safe when eGFR<30mls/min
Atypical femoral fracture
229
Side effects of Denosumab
Allergy/rash
| Symptomatic hypocalcaeimia when given to vit D deficient
230
Side effects of Teriparatide
Injection site allergy
Rarely hypercalcaemia
Allergy
231
what is the first line biphosphonate given
Alendronic acid
232
What is Paget's Disease
Localised disease of bone turnover
233
Pathology of Paget's Disease
Increased bone reabsorption followed by increased bone formation
Leads to disorganised/dysregulated bone remodelling
234
Aetiology of Paget's Disease
```
Strong genetic component
Environmental trigger (potentially viral infection?)
```
235
What is the commonest presentation of Paget's Disease
Asymptomatic increase in serum alkaline phosphatase
236
What can develop rarely in Paget's disease
Osteosarcoma
237
Symptoms of Paget's Disease
Majority asymptomatic
```
Bone pain
Bone deformity
Bone fracture
Excessive heat over Paget's bone
Other neurological complications (e.g deafness if occurs at ossicles)
```
238
What complication can arise if Paget's Disease affects the ossicles
Deafness
239
What are the 3 ossicle bones
Malleus
Incus
Stapes
240
Ix for Paget's Disease
Serum Alkaline Phosphate
Xray
Pyridinoline (urine)
Bone scan
241
Should you treat asymptomatic Paget's Disease
No
There is no evidence to treat asymptomatic Paget's disease based on increased alkaline phosphatase alone
Keep an eye on it
242
Supportive Rx for Paget's
NSAIDs
Paracetamol
Physio.
OT
243
Diet Rx for Paget's
Calcium and Vitamin D rich
244
Medication Rx for Paget's
Biphosphonates:
Zoledronic acid (one off injection)
Risedronate
Pamidnate
245
Who is surgery recommended for in Paget's
Fractures
Deformities
Severe OA
246
What is osteogenesis imperfecta
Genetic disorder of connective tissue
247
What is osteogenesis imperfect characterised by
Fragile and fractured bones from mild trauma and even daily acts of life
248
Main clinical feature of osteogenesis imperfecta
Bones that break with little or no force
249
How many different types of osteogenesis imperfect are there?
8
250
Which is the most severe type of osteogenesis imperfecta
Type II
251
What is the cure for osteogenesis imperfecta
No cure
252
Rx for preventing fractures in OI
Prevent fractures:
IV Bisphosphonates
Immobilisation
253
Rx for managing fractures in OI
Rodding
| Surgery
254
Rx for social aspects of OI
Education and social adaptations
| Physio.
255
Rx for genetic aspect of OI
Genetic counselling for parents and next generation
256
Other features of Osteogenesis imperfecta apart from easily fractures bones
Growth deficiency
Defective tooth formation (dentigenesis imperfecta)
Hearing loss
Blue sclera
Scoliosis / Barrel Chest
Ligamentous laxity
Easy bruising
257
Ix for OI
X-ray
DNA collagen testing
Type II often Dx by USS at pregnancy
258
X-ray features of OI
Many fractures!!
Osteoporotic bones with thin cortex
Bowing deformities of long bones
259
What is an important Ddx in OI
Potential child abuse
260
What is Osteomalacia
Metabolic bone disease characterised by incomplete mineralistion of the underlying mature organic bone matrix (osteoid) following growth plate closure in adults
261
Difference between osteomalacia and Rickets
Underlying pathology is the same
Osteomalacia:
Occurs in adults when the epiphyseal plates have closed
Rickets:
Occurs in growing children when the epiphyseal plates are still open
262
Which deficiency causes rickets/osteomalacia
Vitamin D
| Calcium
263
Ix for Osteomalacia
```
Serum calcium level
Serum 25-hydroxyvitamin D levels
Serum phosphate levels
Serum urea and creatinine
Intact PTH
Serum alkaline phosphatase
24 hr urinary calcium
```
264
Ix for Rickets
```
Xray of a long bone
Serum calcium
Serum inorganic phosphorus
Serum parathyroid hormone level
Serum 25-hydroxyvitamin D levels
Alkaline phosphatase and LFTs
Serum createnine and urea
Urinary calcium and phosphorus
```
265
Risk factors for Rickets
```
Age 6-18 month
Inadequate sunlight exposure
Breastfeeding
Calcium defiency
Phosphate deficiency
FH
Malabsorption disease
Asian. African-Carribean
```
266
Risk factors for osteomalacia
Dietary Vitamin D and calcium deficiency
CKD
Limited sunlight exposure
Inherited disorder of Vit D and bone metabolism
FH
267
Clinical features of Rickets
```
Bone pain
Muscle weakness
Stunted growth
Bone deformities: bowed legs
Dental issues
Fracture prone bones
```
268
Clinical features of osteomalacia
```
Vitamin D and Calcium deficient diets
Lack of sunlight exposure
Fractures
Malabsorption syndrome
Diffuse bone pain and tenderness
Proximal muscle weakness
Increased risk of falls
```
269
Rx for osteomalacia
Diet rich in calcium and Vitamin D
Vitamin D and calcium supplements
Vitamin D injection
270
Rx for Rickets
Diet rich in calcium and Vitamin D
Vitamin D and calcium supplements
Vitamin D injection
271
What is Femoral anteversion
When there is excessive femoral torsion and the femur turns inwards
272
What does femoral anteversion cause
Intoeing
273
Ix for femoral anteversion
Hx
| O/E
274
Rx for femoral anteversion
Commonly corrects by itself as child grows
Very rare cases:
Surgery
275
Clinical features of anteversion
Intoeing
| Sitting in W position
276
Is clubfoot a common or rare birth defect?
Common
277
Rx for Clubfoot
Ponseti method
278
Describe ponseti method
Gentle manipulation of the foot
Then putting into a cast
Repeated weekly for 5-8 weeks
279
Clinical appearance of clubfoot
foot turns medially and is inverted
280
Is clubfoot associated with limited space in the womb
Yes
281
Describe a negative trendelenburg test
Normal for pelvis to rise on the side of the lifted leg
282
Describe a positive trendelenburg test
Pelvis falls on the side of the affected leg
283
What is the cause of a positive trendelenburg test
Abductor muscle paralsysis
| Meaning it cannot pull up the pelvis on the affected side
284
How to perform tredenelnburgs test
Place hands on either side of the patients pelvis
Use yourself to support the patient
Ask them to raise one leg
Assess to see if the pelvis dips on the side of the lifted leg
285
What is a chondrosarcoma
malignant tumour of cartilage
286
Symptoms of chondrosarcoma
Pain (particularly at night)
Mass or swelling
If on axial skeleton:
Sciatica
Bladder symptoms
287
Where does a chondrosarcoma typically affect
Most commonly axial skeleton compared to the appendicular skeleton
288
What is the issue with Rx for chondrosarcoma
Relatively insensitive to both chemotherapy and radiotherapy
289
Main Rx for chondrosarcoma
Surgery
290
What is the commonest joint disease in Europe
Knee OA
291
Risk factors for Knee OA
F>M
>55yrs (age)
Trauma to knee
FH
292
Strong associations for knee OA
obesity/increased BMI
Occupation
Age
Genetics
293
Symptoms of knee OA
```
Limited ROM
Crepitus
Joint deformity
Bony overgrowths
Swelling
Pain on initiating movement
Stiffness
Morning stiffness often removes <30 mins
```
294
Rx for knee OA
```
NSAIDs
Capsaicin
Weight loss
Exercise
Local steroid injections
Physio.
```
Surgery: knee replacement
295
Causes of rib fractures
CPR
Direct trauma
Coughing
Metastatic cancer
296
Clinical features of rib fracture
Pain worse on respiration
| Sometime bruising on skin
297
Ix for rib fractures
x-ray
298
Complications of rib fractures
Pneumothorax
| Pneumonia
299
Rx for rib fractures
No specific Rx
Analgesia
Rest
Ice pack
3-8 weeks to heal
300
What can chronic osteomyelitis follow
Acute osteomyelitis
301
Describe de novo chronic osteomyelitis
Never amounts to an acute infection
Moulders unnoticed then presents
Mild bone infection for yrs
Repeated breakdown of healed wounds
302
Pathology of chronic osteomyelitis
Cavities
Dead bone(retained sequestra)
Involucrum
Histological picture of chronic inflammation
303
Ix for chronic osteomyelitis
```
MRI (Dx)
FBC
WBC
ESR
CRP
U&E's
```
```
x-ray
CT
USS
Blood cultures
Aspiration
Isotope bone scan
Labelled white cell scan
Bone biopsy
```
304
De novo causes of chronic osteomyelitis
Following operation
| Following open fractures
305
Organisms for chronic osteomyelitis
Staph. Aureus
E.Coli
Strep. Pyogenes
Proteus
However, commonly more than 1 organism
306
Rx for chronic osteomyelitis
Long term abx.
Surgery (surgical debridement)
Amputation not an unlikely scenario
307
Complications of chronic osteomyelitis
```
Chronically discharging since + flare ups
Ongoing metastatic infection
Pathological fracture
Growth disturbances/deformities
SCC at discharging site
Recurrence
Amputation
```
308
Who is chronic osteomyelitis commonly seen in
Adults
309
Who is acute osteomyelitis commonly seen in
Children
310
What is a rotator cuff tear
Tears in supraspinatus tendon
| Or adjacent sub-scapularis and infraspinatus
311
Which is the most commonly affected muscle in rotator cuff tear
Supraspinatus
312
What are the 2 broad causes of rotator cuff tear
Chronic and cumulative
| Acute tear
313
Describe acute rotator cuff tear
Trauma in younger patient
314
Describe chronic rotator cuff tear
Degeneration condition
Common elderly
Long term overhead activity
315
Which is more common acute or chronic rotator cuff tear
Chronic
316
Clinical features of potato cuff tear
Shoulder weakness
Shoulder pain
Night pain may affect sleep
Lying on affected shoulder
Acute:
Snapping sensation
Immediate arm weakness
Pain same
317
Ix for rotator cuff tear
O/E Clinical
X-ray
USS
MRI but USS is quicker and cheaper
318
non-operative Rx for rotator cuff tear
Analgesia: NSAIDs
Steroid injection
Physio.
319
Operative Rx for rotator cuff tear
Acute, young and active = early surgery
| Chronic = surgery if symptomatic (try non-operative first)
320
What causes painful arc
Impingement syndrome
321
What is impingement syndrome
When the tendon catches under the acromion during abduction
322
When does impingement syndrome cause pain
On shoulder abduction
323
Pathology of impingement syndrome
Caused by a pathology which either:
the volume of the Subacromial space (e.g. OA)
Or
The size of the contents (e.g. Tendinopathy, Bursitis)
324
Clinical features of impingement syndrome
```
Pain
Painful arch
Pain during day to day activities
Weakness
Decreased ROM
Pain at night
Can affect sleep
```
325
Conservative Rx for impingement syndrome
```
Rest
Avoid precipitating activities
Physio.
Analgesia
Ice
Steroid injections
```
326
What types of pathology can cause impingement syndrome
Rotator cuff tendinosis
Subacromial bursitis
Calcific tendinitis
OA shoulder
327
What 2 joints can shoulder osteoarthritis affect
Acromioclavicular
| Glenohumeral
328
Risk factors for shoulder OA
Same as OA
age
Overuse
Shoulder trauma e.g dislocation
329
Clinical features of shoulder OA
```
Pain
Crepitus
Loss or ROM
Morning stiffness <30 mins
Worse with activity
Better with rest
Tenderness
Joint swelling
```
330
Ix for shoulder OA
X-ray
Examination
FBC
331
Rx for shoulder OA
```
NSAIDs
Physio
Analgesia
Heat treatment
Joint replacement/surgery
```
332
Clinical features of olecranon bursitis
Swelling
Redness
Warmth skin
Pain/tenderness
333
What Ix should you carry out if concerned olecranon bursitis is infected
Joint aspirate
| Send for culture an microscopy
334
Complications of olecranon bursitis
Septic bursitis
| Abscess formation
335
Which 2 types of bursitis is it very important to differentiate between
Aseptic
| and Septic
336
Aetiology of olecranon bursitis
Trauma
Infection
Gout
RA
337
Rx for septic bursitis
Urgent drainage
| IV abx
338
Rx for aseptic bursitis
```
Avoid further trauma
Rest
ICE
NSAIDs
Corticosteroid injections
```
339
What is spinal stenosis
Narrowing of spinal canal which results in compression of the spinal cord and spinal nerves
340
What does spinal stenosis commonly result from
Degenerative changes in the lumbar spine
341
Clinical features of spinal stenosis
Unilateral or bilateral leg pain +/- back pain
Sciatica
Relieved by sitting forward
Worse on walking
Claudication type pain
Weakness at and below level affected
Numbness at and below level affected (paraesthesia)
342
Risk factors for spinal stenosis
```
OA/degenerative arthritis
Age
Manual labour
FH
Trauma
Space occupying lesion
Smoking
```
343
Ix for spinal stenosis
X-ray
MRI
Consider:
CT pyelogram
CT spine
EMG walking test
344
What will x-ray show in spinal stenosis
Degenerative changes Overgrowth of the facet joints
Narrowing of the disc spaces
Osteophyte formation.
345
Non-operative management of spinal stenosis
Education
Analgesia
Exercise
Physio.
Nerve root injection
Epidural injection
346
Why does leaning/sitting forwards relieve spinal stenosis
Increased intervertebral space
347
Other Rx for spinal stenosis
Nerve root injection
| Epidural steroid injection
348
Red flags for spinal stenosis
```
Fever
Nocturnal pain
Weight loss
Previous carcinoma
Recent trauma
Neurological deficit
Bilateral sciatica + Saddle Anaesthesia _ urinary/bowel incontinence
```
349
What Rx is required in acute spinal stenosis with acute neurological deficit
Urgent surgical review and decompression
350
What is cervical spondylosis
Specific term for OA of the cervical spine
