MSK pathology (LL)

Question 1

What is greater trochanter pain syndrome (trochanteric bursitis)?

Answer 1

common condition that complicates many total hip replacements
inflammation of the bursa between the greater trochanter and fascia late caused by acute or repetitive trauma
more common in women, active patients and bilateral in 50%

Question 2

What are the symptoms of trochanteric bursitis?

Answer 2

hip pain that may radiate down the lateral aspect of the thigh to the knee
pain worse on movement and at night, especially when they lie on affected side

Question 3

How is trochanteric bursisitis confirmed on examination?

Answer 3

point tenderness when palpating the greater trochanter
further confirmation can be achieved by active adduction of slightly flexed hip past the midline (with knee slightly flexed) and this will exacerbate the pain as it tightens the fascia late over the bursa

Question 4

How is trochanteric bursisitis managed?

Answer 4

corticosteroid injections are helpful
physiotherapy (to stretch basic data and relieve pressure on bursa)
surgical management (fascia late release and excision of bursa) is rare

Question 5

What is Osgood Schlatter’s disease?

Answer 5

Common in adolescents, a traction injury of the patellar ligament leading to prominent and tender tibial tuberosity

Question 6

How is Osgood Schlatter’s disease managed?

Answer 6

Spontaneous recovery takes time and restricting sporting activity is wise

Question 7

What are the causes of a meniscal tear?

Answer 7

classically occurs when there is twisting strain on a flexed, weight bearing knee
little force is required in older adults and degenerative tears are seen in knee OA

Question 8

Where are medial meniscal tears most common?

Answer 8

medial meniscus is most commonly affected as it is less mobile and they are associated with ACL tears
meniscus is mainly avascular so will not repair spontaneously after a tear or heal after surgery

Question 9

How do meniscal tears present?

Answer 9

symptoms are initial pain which can be intermittent and swelling hours later

Question 10

What are the mechanical symptoms of a meniscal tear?

Answer 10

locking of the knee (blocked extension giving fixed flexion)
spontaneous ‘giving way’ of the knee

Question 11

What is seen on examination in a meniscal tear?

Answer 11

effusion and fixed flexion deformity with medial joint line tenderness

Question 12

What investigations are used in medial meniscal tears?

Answer 12

X-ray will be normal but important to exclude fractures/OA

MRI - mainstay of imagiing

Question 13

How are meniscal tears managed?

Answer 13

arthroscopic repair is indicated in many patients, especially young and active
tears in the vascular zone are more amenable to repair
degenerative tears secondary to OA should be treated conservatively until joint replacement is needed anyway

Question 14

How are meniscal tears managed when they are in the avascular zone?

Answer 14

partial meniscectomy is the treatment of choice, to prevent ongoing mechanical symptoms
total meniscectomy is avoided due to a high risk of secondary OA

Question 15

What causes ligament injuries?

Answer 15

occur when force greater than tensile strength of the ligament occurs in sporting injuries or trauma

Question 16

What is the most common ligament tear?

Answer 16

ACL tear
MCL second most common
multiple ligaments may be involved and collateral ligament damage is more common when the knee is in extension

Question 17

What are the important questions to ask in a ligament tear history?

Answer 17

full mechanism of injury
swelling in first hour - indicated complete rupture
patients describe ‘pop’ at time of injury
patients cannot weight bear and knee feels unstable

Question 18

What would be seen on examination in a ligament tear?

Answer 18

There will be a firm end point when testing the ligament
partial tears do not give increased mobility but pain when testing
Lachman’s test is more sensitive than anterior draw test for ACL pathology

Question 19

What are the investigations required for a ligament tear?

Answer 19

x-ray (excludes OA and fractures)
MRI
Diagnostic arthroscopy if clinical signs but MRI shows intact ligaments

Question 20

How are ligament tears managed conservatively?

Answer 20

sprains/partial tears will spontaneously heal with physiotherapy as the intact fibres splint the torn ones
adhesions complicate the process so active movement with a brace is encouraged
physiotherapy and patient education about activity limitations should be used

Question 21

How are ligament tears managed surgically?

Answer 21

ACL - tendon graft repair
PCL - bony avulsion
Collateral ligaments - surgical repair should be performed within 2 weeks

Question 22

What causes pre-patellar bursitis?

housemaids knee

Answer 22

unaccustomed kneeling

presents with anterior knee pain and fluctuant swelling

Question 23

What causes infra-patellar bursitis?

Answer 23

unaccompanied kneeling

presents with anterior knee pain and fluctuant swelling

Question 24

How is pre/infra patellar bursitis managed?

Answer 24

avoidance of kneeling

corticosteroid injection for troublesome symptoms

Question 25

What is anserine bursitis?

Answer 25

pain in upper medial tibia

tenderness (+/- warmth, swelling) over the upper medial tibia

Question 26

What is a popliteal cyst?

bakers cyst

Answer 26

pain in the popliteal fossa

tender swelling of the popliteal fossa, usually reducible by massage with the knee in mid-flexion

Question 27

How is a popliteal cyst managed?

Answer 27

most often caused by RA or OA, can rupture into muscle planes and cause calf swelling
treatment of non-ruptured cyst is aspiration and hydrocortisone infection