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MSK problems Flashcards

1
Q

Possible causes of acute lower back pain?

A 
Acute lower back pain 
• Mechanical, simple back pain
• Nerve root pain
• Possible serious spinal pathology
• Suspected cord compression
• Sciatica - lumbar disc prolapse
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2
Q

Pathophysiology of cauda equina?

What are the red flags for cauda equina syndrome?

A 
CAUDA EQUINA (spinal cord ends at L1)f
-Compression of nerves at bottom of spinal cord leads to damage

Symptoms

  • Back pain
  • Leg weakness
  • Altered peri-anal or perineal sensation = saddle anaesthesia
  • Loss of bladder/bowel control
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3
Q

What are the red flags for metastatic spinal cord compression?

A

Red flags of MSCC
• Back pain worse on coughing and lying flat
• Leg weakness
• Bowel/bladder dysfunction
•Reflexes - increased below compression, absent at level of compression, normal above level

(Cauda equina will normally have reduced reflexes)

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4
Q

What are the red flags for ruptured AAA?

A

Red flags for ruptured AAA
• Central umbilical pain radiating to the back
• Expansile and pulsatile central abdominal mass
• Hypotensive/collapse/shock
• Bruising
• Acute unwell

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5
Q

What must you include in your examination of someone presenting with acute back pain?

A

Acute back pain

  • Gait assessment
  • Spine examination
  • Peripheral nerve examination
  • Peripheral vascular examination
  • Abdominal examination
  • Rectal examination
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6
Q

How can you examine for nerve root pain?

A

Femoral stretch test for femoral nerve irritation (L2-L4)

Straight leg test for sciatica (L4 to S3)

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7
Q

What is the main cause of sciatica?

A

Lumbar disc prolapse

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8
Q

When is an X-Ray indicated for back pain?

A 
Over 55
Systemically unwell
History of trauma 
History of malignancy
Infection
HIV suspected
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9
Q

What is the management for suspected cord compression?

A

16mg dexamethasone + PPI
Urgent MRI
Urgent neuro/oncology referral

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10
Q

What are the most common distal radial fractures? What most commonly causes them?

A

Colles’ - falling on outstretched/extended hand (FOOSH)
Smiths’ - falling on flexed wrist

** check for ulnar styloid fracture in both

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11
Q

What is smiths fracture?

A

Radia fracture

-DISTAL part moves VOLAR (palmer)

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12
Q

How will Colles fracture present?

A
  • Pain
  • Dinner fork abnormality
  • Tender and swollen (check pulses)
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13
Q

Investigations of Colles fracture and what is seen?

A

Wrist X-Ray

-EXTRA ARTICULAR fracture with DORSAL DISPLACEMENT (of the DISTAL radius- making dinner fork shape)

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14
Q

Acute managment of Colles fracture?

Longer term managment of Colles fracture?

A

Colles fracture

  1. Analgesia (heamatoma block +gasonair)
  2. Closed reduction (pull on it)
  3. Immobalise with Below elbow backslab or POP
  4. Elevate (sling)
  5. X ray to check position and check for ulnar styloid fracture

Longer term

  • change to cast (6-8 weeks) once swelling reduces
  • *Arrange fracture clinic follow up
    • Advice patient to keep moving their thumb, elbow and shoulder
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15
Q

Complications of colles fracture?

A

Complications of colles fracture

  • Median nerve injury (can abduct thumb)
  • Carpal tunnel syndrome
  • Osteoarthritis
  • Reflex sympathetic dystrophy (Sudek’s atrophy) – refer to physio (long lasting pain disorder)
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16
Q

When is MUA urgent in a distal radius fracture?

A

Compound fracture

Nerve compression

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17
Q

On a lateral hip X-ray, what indicates a fractured neck of femur?

A

Interrupted Shenton’s line shows fractured NOF (imaginary curved line drawn along inferior border of superior pubic ramus to inferomedial border of neck of femur)

18
Q

What is the most common type of shoulder dislocation?

What mechanism of injury causes this?

A
  • Anterior dislocation is most common (95%)
  • Blow to an abducted, externally rotated and extended extremity
  • Can also be caused by force/trauma to posterior arm or FOOSH
19
Q

Who does anterior dislocation most commonly affect?

What are complications of anterior dislocation in older patients (40 years)

A

Young males playing contact sports
Elderly patients falling on outstretched hand

Avulsion injruies/rotator cuff injuries common in older patients (MRI or USS)

20
Q

What causes a posterior shoulder dislocation?

A

Posterior shoulder dislocation

  • Trauma to anterior shoulder
  • Fall onto stretched out internally rotated arm
21
Q

What mechanism of injury is associated with posterior shoulder dislocation?
What does it look like on Xray?

A

Posterior shoulder dislocation

  • Epileptic seizures
  • Electrical shocks
  • Direct blow during trauma

Light bulb sign on X ray

22
Q

What is found on examination of anterior shoulder dislocation?

A
  1. Loss of shoulder contour - flattening of deltoid
  2. Anterior bulge from head of humerus- visable/palpable
  3. Step-off deformity at acromion with palpable gap below acromion
  • their arm will probs be slightly abducted
  • may also show damage to axillary nerve (sensation badge area and abduction arm)
23
Q

How can you test for injury to the axillary nerve?

A
  • Loss of sensation over lateral shoulder (badge area)

- Lack of contraction of deltoid during attempted abduction

24
Q

How can you assess the radial nerve?

A
  • Weakness of wrist extension
  • Reduced sensation on dorsum of hand
  • Abnormal triceps and brachioradialis reflexes
25
Q

What might occur at the same time as an anterior shoulder dislocation?

A

Fracture of the humeral head, neck or greater tuberosity

26
Q

What changes are seen on an X-Ray in anterior shoulder dislocation?

A
  • Humeral head lies inferior to coracoid process on AP view

- Head of humerus anterior to glenoid on axillary view

27
Q

What is the most common method to manipulate an anterior shoulder dislocation?

A

External rotation method
• Patient SUPINE on bed
• Affected arm is ADDUCTED and flexed to 90 degrees at the elbow
• Arm is slowly EXTERNALLY ROTATED
The shoulder should be reduced before reaching the coronal plane

28
Q

What is the managment of anterior shoulder dislocation?

A

Anterior shoulder dislocation

  • MUA to muscle relax (midazolam +/- propofol)
  • Re Xray
  • Physio
  • Immoblisation (broad arm sling)
29
Q

What are the two joints in the ankle and what movements do they facilitate?

A

True ankle joint

  • Tibia, fibula, talus
  • Facilitates dorsi/plantarflexion

Subtalar joint

  • Calcaneus + talus
  • Facilitates eversion/inversion
30
Q

What is an ankle sprain?
What mechanism of injury usually occurs?
What ligament usually affected?

A
  • Injury of ligaments
  • Inversion injury (85%)
  • most common injury site: lateral malleolus (Lateral joint capsule + anterior talofibular ligament)
31
Q

How does an ankle sprain present?

If the patient had numbness/tingling after a sprain what would you think?

A

Ankle sprain

  • tenderness and swelling
  • bruising
  • functional loss e.g. pain on weight bearing
  • mechanical instability if SEVERE

*extensive bruising/swelling suggests ligament tear or fracture

Peroneal nerve injury (common) → ↓sensation over dorsum and lateral leg and ankle → ↓ proprioception at ankle joint

32
Q

Investigations for ankle sprain?

A
  1. Bedside-examination – examine from knee down for tenderness over proximal fibula, lateral + medial malleolus and ligaments, Navicular, calcaneus, Achilles tendon, 5th metatarsal base
  2. Do Ottowa ankle rules to determine if X-ray is required
33
Q

How can you manage a simple ankle sprain?

Managment if unable to weight bare?

A 
POLICE 
-Protect from further injury
-Optimal loading(gentle movements and weight bare when symptoms allow) 
-Iceand analgesia 
-Compression
-Elevationabove hip level 

**Full recovery can take a month and advise to come back if not weight bearing after 4 days*

If unable to weight bare

  • Crutches
  • Below knee cast – 10 days for immobilisation
  • OPD follow up
34
Q

What are the 1st, 2nd, 3rd degree ankle sprains

A

Classified by severity of damage to ligaments
1st deg = damage to a few ligament fibres
2nd deg = significant damage to lig, but still intact
3rd deg = rupture of lig

35
Q

Complications of ankle sprains?

A

Complications of ankle sprains
-Weakness and instability – related to↓ankle proprioception due prolonged immobilisation → recurrent sprains

Peroneal tendon subluxation – reflects torn peroneal retinaculum → perineal tendon to slip anteriorly

  • Clicking or Slipping sensation
  • Movement of ankle → subluxation
  • Refer to orthopoedics
36
Q

Differentials for ankle sprain

A

Ankle fracture or dislocation

37
Q

What are the Ottawa ankle rules?

What do they indicate?

A

Ottawa ankle rules are used to determine if x-ray is required to exclude fracture:

ANKLE X-RAY indicated if any of the following
• Tenderness over posterior edge of lateral or medial malleolus
• Unable to weight bearimmediately after AND now

FOOT X-ray indicated if any of the following
• Tenderness in base of 5th metatarsal
• Tenderness at navicular bone
• Unable to weight bearimmediately after AND now

38
Q

Initial managment of NOFF?

A

Managment of NOFF

ABCD(hypothermia) E assessment

IV access

  • Bloods - FBC, U+Es (AKI), CK (could be lying for ages), glucose, crossmatch to prepare for surgery
  • IV fluids if hypotension/dehydrated
  • IV morphine (titrate up) + antiemetic
  • ECG (look for arrhythmias/MI, may explain fall)

Additional

  • Femoral nerve block (women in AndE)
  • Lateral hip X-ray (repeats/MRI may be needed if cant see)
  • Refer to orthopaedic surgery
  • May need to realign or apply splint in the mean time
39
Q

What is the surgical treatment for patients with OA and severe refractory pain?

A

Surgical (if significant impact on QofL and refractory to non surgical treatment)

Knee – Arthroscopic knee lavage ± debridement
Hip – total hip replacement (end stage OA). This can be cemented/non cemented/hybrid

40
Q

What are the long term complications of this hip replacement?

A

Long term

  • Aseptic loosening
  • degeneration artificial socket
  • hip dislocation
  • revision (1 in 8 require revision in 10 years
41
Q

Who are distal radial fractures most common in ?

A

Osteoporotic post-menopausal women get distal radial fractures

ACC (23 decks)

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