MSK Swellings

Question 1

what is important to ask in a history of trauma

Answer 1

onset, trauma, painful, size changes, systemic symptoms, other swellings, functional problems

Question 2

what must you include in an exam of a swelling

Answer 2

site, size, shape 
generalised or discreet 
consistency- is it fluctuant 
surface texture 
mobile/ fixed
temperature 
transluminable
skin changes 
local lymphadenopathy

Question 3

what are the history and exam features of a infection swelling

Answer 3

systemic upset
pyrexia
trauma (break in skin)
association with medical co morbities

calor, dolor, rubor, tumor

Question 4

what is cellulitis

Answer 4

inflammation and infection of the soft tissues

Question 5

describe the presentation of cellulitis

Answer 5

pain, generalised swelling, erythema, spectrum from minor infection to sepsis

Question 6

what organisms commonly cause cellulitis

Answer 6

bet- haemolytic streps, staphylcocci

Question 7

what is the management for cellulitis

Answer 7

rest, elevation, analgesia, splint, antibiotics (oral/ IV depending on severity)

NOT SURGERY

Question 8

what is an abscess

Answer 8

discrete collection of pus

Question 9

how do abscesses present

Answer 9

defined and fluctuant swelling, erythema, pain, history of trauma (bite, PWIDs)
spectrum from minor to septic

Question 10

how do you manage abscesses

Answer 10

surgical incision and drainage

rest elevation, analgesia, splint, antibiotics

Question 11

how can you get an infected joint (septic arthritis)

Answer 11

traumatic (joint penetration)

haematoginous spread

Question 12

why is septic arthritis an orthopaedic emergency

Answer 12

as causes irreversible damage to hyaline articular cartilage

Question 13

how does septic arthritis present

Answer 13

acute monoarthropathy
decreased ROM +/- swelling
systemic upset
raised WCC and inflammatory markers

Question 14

how do you manage septic arthritis

Answer 14

urgent orthopaedic review, aspiration (M, C and S), urgent open/ arthoscopic washout + debridement

Question 15

name 4 swelling specifically relating to joints

Answer 15

ganglia (bakers cyst), bursitis, gout, rheumatoid nodules

Question 16

what are ganglia

Answer 16

outpouchings of the synovium lining of joints which are filled with synovial fluid

Question 17

what do ganglia look like

Answer 17

discreet, round swellings, non tender, vary in size (mm to cms), skin mobile, fixed to underlying structure
often on wrists, feet and knees

Question 18

what is the management for ganglia

Answer 18

based on symptoms/ function impairment

• nothing
• NOT ASPIRATION
• percutaneous rupture
• surgical excision

Question 19

what is a bakers cyst

Answer 19

cyst/ ganglion of the popliteal fossa

Question 20

what is the presentation of a bakers cyst

Answer 20

can appear as general fullness of the popliteal fossa
soft and non tender
associated with OA
painful rupture- swelling and bruising down calf

Question 21

what is the management for a bakers cyst

Answer 21

non operative

Question 22

what is bursitis

Answer 22

inflammation of the synovium lined sacs that protect bony prominences and joints

Question 23

what is a possible complication of bursitis

Answer 23

can become secondarily infected and form an abscess

Question 24

what is the management for bursitis

Answer 24

NSAIDs/ analgesia, antibiotics, incision and drainage (secondary infection), V rarely excision (chronic cases)

Question 25

what is gout

Answer 25

an inflammatory arthritis most commonly affecting the great toe but can affect other joints (esp the knee) caused by deposition of uric acid crystal in the joint due to elevated serum urate

Question 26

what is tophi

Answer 26

deposition of urate acid crystals in the joint

Question 27

what cause acute attacks of gout

Answer 27

episodes of inflammation

Question 28

what will chronic gout cause

Answer 28

progressive joint damage

Question 29

what is gout associated with

Answer 29

purine rich food, alcohol, dairy

Question 30

what is podagra

Answer 30

gout in the big toe

Question 31

how does gout present

Answer 31

severe pain, red, hot, swollen joint

Question 32

What shows on an aspiration of gout

Answer 32

negatibely birefringent monosodium urate crystals

Question 33

what is the treatment for gout

Answer 33

NSAIDs, steroids, allopurinol

Question 34

what are rheumatoid nodules

Answer 34

appear around joints in rheumatoid patients, associated with repetitive trauma

Question 35

what is the presentation of rheumatoid nodules

Answer 35

chronic, in more severe RA, rheumatoid factor positive

Question 36

what is seen in histology of rheumatoid nodules

Answer 36

intense inflammatory changes

Question 37

how do you treat rheumatoid nodules

Answer 37

do not respond to DMARDs, excision if problematic, recurrence high

Question 38

what are bouchards and heberdens nodes

Answer 38

bony swellings of the interphalangeal joints in the HAND caused by bony spurs due to chronic trauma

Question 39

what the specific features of bouchards nodes

Answer 39

proximal IPJ, less common, OA or RA

Question 40

what are the specific features of heberdens nodes

Answer 40

distal IPJ (think outer hebrides) , more common, just in OA

Question 41

what is dupuytrens disease

Answer 41

progressive disease resulting in digital flexion contractures (not a disease of flexor tendons)

Question 42

what is the pathology of dupuytrens

Answer 42

excessive myofibroblast proliferation and altered collagen matrix composition (type 3) cause thickened and contracted palmar fascia avascular process involving o2 free radicals

Question 43

what are the three factors thought to interact and cause dupuytrens

Answer 43

``` genetic predisposition (autosomal dominant, common in northern europe men>women), environmental factors (alcohol, diabetes and trauma), local and global protein expression (up and down enzyme regulation) ```

Question 44

what is the management of dupuytrens

Answer 44

dependent on functional impediment needle fasciotomy (cutting fascia to relive pressure), collaginase injection limited fasciectomy dermofasciectomy + graft

Question 45

what are the two types of giant cell tumour of the tendon sheath

Answer 45

localised (common) and diffuse (uncommon associated with PVNS)

Question 46

what is a giant cell tumour of the tendon sheath

Answer 46

regenerative hyperplasia with inflammatory process, benign

Question 47

how do giant cell tumour of the tendon sheath present

Answer 47

slowly enlargingm firm, discrete swelling, volar aspects of digits, can occur in toes, may/ nay not be tender

Question 48

what is the management for giant cell tumour of the tendon sheath

Answer 48

leave alone if no functional issue surgical excision (marginal)

Question 49

what is an osteochondroma

Answer 49

benign tumour- outgrowth of physis commonly occurring near the knee (distal femur/ proximal tibia metaphyseal regions) its growth parallels that of the patient

Question 50

who gets osteochondromas

Answer 50

occurs in adolescence

Question 51

what does an osteochondroma look like pathologically

Answer 51

cartilage capped ossified pedicle

Question 52

is there a risk of malignant change in osteochondroma

Answer 52

yes but low

Question 53

when is there a higher chance of malignancy in osteochondromas

Answer 53

in multiple hereditary exostosis- multiple tumours

Question 54

what is the presentation of an osteochondroma

Answer 54

painless hard lump symptoms with activity- pain from tendons, numbness from nerve compression rarely can be painful due to fracture

Question 55

what is the management for a osteochondroma

Answer 55

close observation | surgical excision

Question 56

what is an ewings sarcoma

Answer 56

malignant primary bone tumour of the endothelial cells in the marrow

Question 57

which bone tumour has the worst prognosis

Answer 57

ewings sarcoma

Question 58

who gets ewings sarcoma

Answer 58

most common age 10-20 years

Question 59

where is the most common place to get ewings sarcoma

Answer 59

diaphysis/ metaphysis of long bones and pelvis

Question 60

what is the presentation of ewings sarcoma

Answer 60

hot, swollen, tender joint or limb with raised inflammatory markers- CAN MIMIC INFECTION BE SPECIFIC- ASK ABOUT NIGHT PAIN AND DURATION OF SYMPTOMS INVESTIGATE EARLY

Question 61

what is the management for ewings sarcoma

Answer 61

prognosis poor surgical excision problematic often radio and chemo sensitive

Question 62

what is a lipoma

Answer 62

benign neoplastic proliferation of fat, often subcutaneous

Question 63

what is the presentation of a lipoma

Answer 63

``` can be discreet or less well defined slow growing and painless/ non-tender can be large (several cms) soft, movable masses no overlying skin changes ```

Question 64

how do you manage lipomas

Answer 64

based on symptoms can be left alone surgical excision (removal vs scarring)

Question 65

what is a sebaceous cyst

Answer 65

(epidermoid/ pilar) | when hair follicles fill with caseous materal (keratin)

Question 66

what is the presentation of a sebaceous cyst

Answer 66

slow growing, painless, mobile discreet swellings can become infected often of face, neck and trunk

Question 67

what is the management for a sebaceous cyst

Answer 67

excision if required

Question 68

what is myositis ossificans

Answer 68

abnormal calcification of a muscle haematoma

Question 69

what is the typical history of myositis ossificans

Answer 69

trauma, initial soft tissue swelling, hardness develops over several weeks

Question 70

how can you image myositis ossificans

Answer 70

XRs and MRI (shows peripheral mineralisation)

Question 71

how do you manage myositis ossificans

Answer 71

observation intervene only if symptoms demand must wait until maturity of ossification- otherwise risk recurrence