MSK Week 6 Flashcards
cardinal symptoms in MSK hx
injury pain stiffness swelling deformity instability weakness altered sensation loss of fx
what types of pain are common in MSK conditions
throbbing and aching -> arthritis
burning & stabbing -> nerve
night pain -> red flag (cancer)
3 commonest patterns of inflammatory arthritis? examples of each?
acute - septic arthritis, gout/pseudogout/reactive arthritis
chronic - inflammatory arthritis (RA, PA), chronic tophaceous gout
spinal - ankylosing spondylitis
what should be done when suspecting septic arthritis?
aspirate joint
features of septic arthritis
fever, raised inflammatory markers, joint tenderness/restriction
cause of gout?
urate crystals in joints
what is tophaceous gout?
whitish appearance on swollen joints due to hard deposits of uric acid
what causes pseudogout?
calcium pyrophosphate crystals
features of rheumatoid arthritis
spontaneous sudden joint pain commonly in hands and feet
joint swelling and warmth
eye dryness
stiffness
ulnar deviation of fingers
how does psoriatic arthritis present?
psorisasis on extensor surfaces (knee, elbow)
toe swelling
can affect nails
signs of ankylosing spondylitis
sacroilitis
stiffness in back
question mark posture
xray features of osteoarthritis joint
joint space loss
osteophytes
subchondral sclerosis
subchondral cysts
how to perform GALS?
ask 3 screening questions - clothes, stairs, pain
stand up patient, inspect spine, inspect illiosacral joint, inspect limbs, inspect spine lordosis/kyphosis
ear to shoulder, jaw side to side
arm movements, hand inspection, grip strength and pinching.
limb inspection, patella tap, feet inspection, movements hip flexion, knee flexion, hip internal/external rotation
stand up patient and look at gait
what is developmental dysplasia of the hip?
asymmetrical femur length
what is perthes disorder
necrosis of femoral epiphysis due to avascularisation.
what is slipped upper femoral epiphysis?
femoral head cartilage has slipped off the bone head
4 features on xray of osteoarthritis
joint space loss
subchondral sclerosis
subchondral cysts
osteophytes
difference between intracapsular and extracapsular fracture of femur?
blood supply to head of femur is disrupted in intracapsular fracture - hemiarthroplasty
extracapsular BS preserved - screws/osteotomy
how to perform hip examination?
look
feel - pain, muscle bulge/wasting
move - flexion/internal/external rotation
tomas test
trendelenburgs test
measurement of leg length
gait
joint history questions
pain swelling redness stiffness early morning stiffness? episodic or constant? weakness instability locking
common age for medial/lateral collateral ligament injury
active age teens - mid age
how to perform knee exam
look
feel - joint line, patella tap
move - extension/flexion, temperature
hyperextension
ACL/PCL/MCL/LCL
gait
what eye condition can RA patients also get
sjogrens disease
what lung condition can some RA patients get
pleural effusion
what posture does someone with ankylosing spondylitis have?
question mark posture - ?
25M presented with painful hip, red and swollen o/e, pyrexic, known drug user.
what is the first ddx?
septic arthritis
risk factor of gout
thiazide diuretics recent heavy alcohol intake high purine diet renal failure dehydration psoriasis chemotherapy
what is the strongest risk factor of psoriatic arthritis?
genes
presentation of gout
acute inflammatory arthritis, most common in MTP joint of big toe, coming on at night over 2-4 hours.
might also present with fatigue and high fever
most common age and gender for acute gout?
middle aged male
differentials for someone presenting with acute inflammatory arthritis?
acute gout
septic arthritis
osteomyelitis
cellulitis
who are more commonly affected with pseudogout
elderly women
what is osteomyelitis?
haematogenous spread of bacteria to the joints causing infection, inflammation
most common causative organism of septic arthritis
staph aureus
RF of septic arthritis
prosthetic joints
pre-existing joint disease
DM
recent intra-articular steroid injection
risk factors for rheumatoid arthritis
female 30-50 YO family history smoking obesity
which hand joints are more commonly affected in RA
MCP and PIP joints
which joints are not involved in rheumatoid arthritis?
thoracic and lumbar spine
where are rheumatoid nodules usually found?
elbow finger joints wrist hip lower back Achilles tendon
signs and symptoms of psoriatic arthritis
RA symptoms nail pitting finger swelling scaly skin lesions fatigue lower back pain
what is the question mark posture?
loss of lumbar lordosis and hyper-kyphosis of thorax
most common type of patients to get osteoarthritis
elderly patients over 60
more common in females
risk factors of OA
obesity occupation female injuries genetic
pathogenesis of osteoarthritis
breakdown of articular cartilage, causing subchondral bone sclerosis and osteophyte formation
clinical features of osteoarthritis
joint pain increasing during the day bony enlargement of joint stiffness muscle wasting crepitus
characteristic of joint pains in osteoarthritis
worst on movement, relieved by rest, worse throughout the day
what are Heberden’s and bouchards nodes
bony swelling in osteoarthritis: of PIP = bouchards, DIP = heberden’s
common joints affected in osteoarthritis
vetebrae, hips, knees.
DIPs
difference between OA and RA
pattern of joint involvement
RA has early morning stiffness
OA has no systemic features
what causes of back pain are more common in age 15-30?
mechanical
prolapse intervertebral disc
ank spon
spondylolisthesis
what is spondylolithesis?
slipping of one vertebral disc on top of another
what is cauda equina syndrome
compression of cauda equina (below L1)
bowel and bladder dysfunction bilateral leg pain saddle anaesthesia absent achilles reflex gait disturbance weakness of lower limb muscles
what can cause cauda equina syndrome?
trauma tumor spinal stenosis epidural abscess/haematoma disc herniation
risk factors of osteoporosis
female early menopause alcohol smoking low BMI vitamin D deficiency
where do osteoporotic fractures characteristically occur?
thoracic and lumbar vertebrae
proximal femur
distal radius (colles fracture)
how to investigate osteoporosis>
DEXA scan
serum biochemistry
where does prostate cancer often metastasise to?
bone
what can a pathological fracture indicate?
bone metastasis
what other symptoms of bone mets are there
severe pain spinal cord compression pathological fracture hypercalcaemia anaemia spinal instablity
what is polymyalgia rheumatica
systemic inflammatory disease causing pain and other symptoms
symptoms of polymyalgia rheumatica
morning pain and stiffness in joints fatigue anorexia anaemia malaise low-grade pyrexia
how to perform thomas’ test?
lie patient flat, one hand under back to feel for flattening.
ask patient to bend one knee and bring as close to chest as possible, look at contralateral knee to check for flexion -> indicative of fixed flexion of the hips
how to perform trendelenburg’s test?
stand on my foot and look at other hip to check for dipping.
if dipping positive that means foot that patient is standing on has hip abduction dysfunction
which side will a patient with a trendelenburg gait lean to?
towards injured side
what are 3 common causes of haemiarthrosis in the knee
ACL rupture
peripheral meniscal tear
osteochondral fracture
causes of knee locking
meniscal tear acl rupture loose body arthritis pain inhibition (pseudolocking)
which collateral ligament is more likely to be injured?
medial
symptoms of collateral ligament injury
pain on injured side and effusion
instability
how to perform knee exam?
look
feel - patella tap, joint lines, bony landmarks, temperature
move - active and passive(hyperextension)
special tests - ACL/PCL/MCL/LCL tests.
what is trigger finger?
Stenosing tenosynovitis
swelling of tendon to form a nodule, obstructing extension of tendon due to tendon sheath.
risk factors of trigger finger
female>men
middle age
diabetes
gout/RA
functions in the hand of the median nerve
sensory to radial 3 fingers on palmar side
motor to thenar, lumbricals, flexion of index, middle and wrist.
symptoms of carpal tunnel syndrome
numbless, tingling and pain in radial 3 fingers.
which nerve is usually spared in carpal tunnel syndrome?
palmar cutaneous brunch
how to investigate suspected carpal tunnel syndrome?
Tinel’s sign
phalens test
how to do phalen’s test?
hold wrist flexion for 60s and ask about numbness/tingling
what is dupuytren’s disease
benign proliferative disease of palmar fascia causing permanent flexion of fingers.
symptoms of dupuytren’s disease
starts with slight flexion with one finger getting progressively worse to become curled and permanent.
thickening of palmar fascia
cords
why does basal thumb arthritis happen?
cos force at base of thumb is a lot higher than anywhere else when pinching
what is cubital tunnel syndrome?
ulnar nerve compression at elbow causing sensory and motor deficits of ulnar nerve function
sensory supply of ulnar nerve
ulnar side 2 fingers
motor function of ulnar nerve
flexion of fingers, hypothenar and intrinsic hand muscles
symptoms of cubital tunnel syndrome
numbness and tingling on little and ring finger. hand weakness. worse on flexion of elbow
how to conduct hand examination?
hand on pillow
Look
Feel - joints, muscle, temperature, sensation, squeeze mcp, elbow
Move - wrist flexion/extension active and passive, finger extension, thumb adduction, finger abduction, make fist and squeeze.
function - pincer pinch test
phalens test
4 rotator cuff muscles
supraspinatous
infraspinatous
subscapularis
teres minor
presentation of shoulder arthritis
pain, restricted movements
what conditions can cause painful arc syndrome
subacromial impingement
how to elicit rotator cuff tear injury
test power of shoulder flexion and abduction
what is frozen shoulder?
inflammation and thickening of shoulder joint capsule causing restricted movement and pain, often triggered by injury
which direction of shoulder dislocation is most common?
anterior
what nerve is commonly injured in an anterior shoulder dislocation?
axillary
what else should u consider in someone with acute lower back pain
AAA
red flags of back pain
extremes of ages thoracic pain night pain fever, sweats, weight loss hx of Ca immunosuppresion neurological deficit
yellow flags of back pain
emotional problems
work related/compensation issues
what is radical back pain
when pain follows nerve root distribution down the legs
what scan is best for back
MRI
what is the imaging mark of disc degeneration
narrowed disc space leads to lucency in between vertebrae due to air
what does a T2 MRI show?
water
how to conduct spin exam
Look - muscle, asymm, scoliosis, spinal curvature
feel - vertebrae and muscle for pain
move - lumbar flx/ext, thoracic rotation, cervical flx/ext/lateral flex/rotation
on bed - leg raise + foot dorsiflex to elicit pain, reflex test, dorsiflexion big toe (L5), peripheral pulses, neuro exam if need
what does dorsiflexion of the big toe in a spinal exam test?
L5
how to conduct shoulder exam?
Look
Feel - start at clavicle, any pain, muscle wasting
Move - active & passive, hand behind head, hand behind back. abd/flx/ext, internal/ext rotation
special tests - painful arc, impingement
what is reactive arthritis?
acute polyarticular autoimmune inflammatory arthritis
associated with STI or GI infection
classical triad of reactive arthritis
can’t pee - urethritis
can’t see - conjunctivities
can’t bend the knee - acute arthritis
which joints typically affected in reactive arthritis?
knee and ankle
how to investigate suspected reactive arthritis (e.g high risk of STI)
joint aspirate -> aseptic raised ESR and CRP STI testing stool culture (GI infection)
common features of reactive arthritis
urethritis conjunctivitis diarrhea acute assymetrical polyarthritis brown plaques on sole
what is found in a gout joint aspirate
negatively birefringent needle crystals
polymorphonuclear cells
no bacteria culture
which genetic HLA types are associated with severe RA?
HLA DR4 and DR1
systemic features of rheumatoid arthritis?
fatigue feeling unwell (flu-like sx) fever sweats weight loss
describe swan neck and boutonniere deformity
swan neck involves hyperextension of the PIP and fixed flexion of the DIP
boutonniere involves fixed flexion of the PIP and hyperextension of the DIP
what is palindromic rheumatoid arthritis?
acute onset monoarticular joint pain and systemic illness
who is more susceptible to palindromic RA?
men
eye complications of RA?
sjogren’s, scleritis, episcleritis
where can you find rheumatoid nodules?
elbow, wrists, eyes, lung, heart
pulmonary complications of rheumatoid arthritis?
pulmonary fibrosis, obliterative bronchiolitis, caplan’s syndrome
what is caplan’s syndrome
rheumatoid arthritis associated with pneumoconiosis. patients present with cough, shortness of breath, crackles on asucultation and pulmonary nodules on CXR
what are common liver complication of RA?
mild hepatomegaly
abnormal transaminase
diagnostic test for RA?
anti-CCP
first line investigation for someone suspected of having RA? with clinical signs of synovitis
rheumatoid factor
what is the monitoring score method for someone with RA?
DAS28
what do DAS28 scores mean?
≥ 5.1 implies active disease,
<3.2 well-controlled disease,
< 2.6 remission
carpal tunnel syndrome is a complication of RA - T or F
T
