Musc Flashcards
Pes cavus
high arches
Pes planus
flat feet
Popliteal swelling
Baker's cyst popliteal aneurysm (pulsatile - can feel)
Cervical spine movement
lateral flexion - try to touch your ear to each shoulder
flexion - put your chin down onto your chest
extension - put our head back as far as possible
rotation - look over each shoulder
Lumbar spine movement
flexion is all they are really interested in for GALS, can check by putting 2 fingers on adjacent spinous processes = Schober’s test
Can also ask to extend and lateral flexion
NB thoracic spine movement is only rotation and done while they are sitting down
Antalgic gait
a limp - less time spent on painful limb (source can be hip, knee or ankle)
Trendelenburg gait
waddling gait (hips with some sass) from:
hip ABductor weakness
NOF # (would stay external rotated in NOF)
DDH (developmental dysplasia of hip)
SUFE (slipped upper femoral epiphysis)
Sensory ataxic
broad based and looking at feet
Causes:
peripheral neuropathy
dorsal column loss (e.g. MS, tabes dorsalis)
Cerebellar ataxia
broad based, high stepping and looking carefully ahead
Foot drop causes
common peroneal nerve palsy sciatic nerve palsy L4/L5 root lesion MND Peripheral motor neuropathy (alcohol)
GALS screening questions
- Do you have any pain of stiffness in your muscles, joints or back
- Can you dress yourself completely without any difficulty
- Are you able to walk up and down stairs without difficulty
hemiplegic gait
foot plantarflexed and knee extended
leg must be abducted and swung in a lateral arc
Acute monoarthritis
GRASP - Ix
Gout - serum urate
Reactive Arthritis - stool sample and STI swabs
Septic arthritis - clinical and joint aspiration with MC+S (will do anyways for all swollen joints); typically staphlyococcus in adults and gonococcus in young adults
Pseudogout - chondrocalcinosis on XR
Leg length
True = ASIS to medial maleolus Apparent = umbilicus to medial maleolus
Thomas test
place left hand on hollow of spine and passively flex right hip, should feel lordosis flatten and left thigh rise in positive test = fixed flexion deformity
Causes:
OA
other hip pathologies
Blood supply to femoral head
cervical arteries running in joint capsule retinaculum (main supply)
intramedullary vessels in femoral neck
vessels of ligamentum teres (negligible)
Types of NOF
Use the Garden classification for intracapsular:
- displaced intracapsular (high risk of AVN as both cervical arteries and intramedullary disrupted)
- undisplaced intracapsular (moderate risk of AVN as disruption of IM and maybe CA)
- intertrochanteric or subtrochanteric (low risk as vessels typically safe)
Rx for displaced intracapsular
Hip replacement:
hemi-arthroscopy in older pt
total hip replacement in younger as more active post op
Undisplaced intracapsular Rx
Usually pinned in hope that AVN doesn’t develop
Intertrochanteric/subtrochanteric
Dynamic hip screw
Shenton line
medial edge of the femoral neck and the inferior edge of the superior pubic ramus. If contour lost then likely NOF
Garden classification
Intracapsular fracture
I - Incomplete or impacted bone injury with valgus angulation of the distal component
II - Complete (across whole neck) - undisplaced
III - Complete - partially displaced
IV - Complete - totally displaced
Hip flexors
Psoas Iliacus Tensor fasciae latae Sartorius Pectineus ADductor longus ADductor brevis Rectus femoris
Hip extensors
gluteus maximus
hamstrings
hip ABductors
gluteus medius and minimus
Hip ADductors
ADductor magnus, longus and brevis
Hamstrings
Semi-tendinosis
Semi-membranosus
Biceps femoris
Quads
Vastus lateralis
Vastus medialis
Vastus intermedialis
Rectus femoris
Compartments of knee
Medial compartment
Lateral compartment
Patellofemoral compartment
OA can affect all three compartments
Anterior draw
ACL (ANTERIOR cruciate ligament)
Posterior draw
PCL
McMurray’s test
Checks for meniscal tear
Meniscal injuries
young patients common from trauma
older patients common from degenerative tear of lateral meniscus
Ask about locking (as meniscus enters joint space)
Common peroneal nerve (L4-S2)
Superficial branch innervates lateral leg compartment (foot eversion)
Deep branch innervates anterior leg compartment (dorsiflexion)
Sensory supply of lateral leg and dorsum of foot
Injury typically on lateral portion of leg, as when travels out of popliteal fossa moves laterally around fibular neck
Simmond’s test
Achilles tendon rupture if positive
Patient prone with legs hanging, would squeeze calf and plantarflexion should occur
Charcot joint (neuropathic joint)
Most common cause = diabetic foot
Others = tabes dorsalis, cerebral palsy, spinal cord injury
Deformed joint due to repeated trauma as reduced sensation and proprioception; often associated with ulceration and/or infection
Charcot-Marie-Tooth disease
Mixed motor and sensory peripheral neuropathy
Features:
Foot drop
Claw toes
Inverted champagne bottle appearance as muscle wasting in lower leg
Pes cavus
Ankle joints
True ankle joint (dorsiflexion and plantarflexion, articulation of tibia/fibula and talus) Subtalar joint (inversion and eversion, articulation of talus and calcaneus)
Hawkin’s test
Impingement syndrome
Flexed shoulder and elbow both at 90 degrees, internally rotate shoulder and when you do so they have pain
Jobe’s test
Supraspinatus rotator cuff injury
Straight arm ABducted to 90 degrees with thumb pointing to the floor (Gladiator position), and make them resistant you pushing it down
Gerber’s test
Subscapularis rotator cuff injury
Hands on back, dorsum resting on mid back, ask them to take hands off back whilst applying pressure to palms
Resisted external rotation
Teres minor and infraspinatus
Self-explanatory. You resist external rotation
Impingement syndrome
Pain during shoulder ABduction between 60 and 120 degrees
SITS
Supraspinatus (anterior superior) Infraspinatus (posterior) Teres minor (posterior) Subscapularis (anterior inferior) All rest on greater tubercle apart from subscapularis which rests on lesser tubercle
Bankart lesion from anterior dislocation
injury of anterior glenoid labrum
Hill-Sachs lesion from anterior dislocation
depressed posteriolateral head of humerus due to forceful impaction
Frozen shoulder
Adhesive capsulitis of glenohumeral joint. Diabetes and thyroid disease are RF Phases: 1. Freezing (2-9 months) 2. Frozen (4-12 months) 3. Thawing (1-3 years)
Straight leg raise in spine exam
passively raise leg and pain occurs that travels down from back pain to posterior leg = L5/S1 nerve root compression
Schober’s test
Flexion of lumbar spine for ank spond.
At level of dimples of Venus mark as well as 10 cm above and 5 cm below and if measure on full flexion, should increase more than 5 cm (i.e. now 20 cm when was 15 cm)
Femoral stretch test
L4 nerve root compression
Pt lying on front, passively extend hip with leg straight
Neurogenic claudication
Spinal stenosis
Calf/buttock/thigh discomfort whilst walking
Relieved bending forward at waist, which can differentiate from intermittent claudication
Lumbar back pain DDx
Mechanical: muscular, disc prolapse, OA, spinal stenosis
Inflammatory: ank spond
Other serious pathology: infection and cancer. TB, bony mets, myeloma, osteomyelitis
Extra-articular manifestations of RA
Can affect any group
General: malaise, lethargy, low grade fever, WL
CVS: pericarditis/effusion
Resp: pleural effusion, pulmonary fibrosis, Caplan’s syndrome
Renal: renal amyloid
NS: carpal tunnel, polyneuropathy
Eyes: Scleritis, episcleritis, Sjogren’s
Blood: anaemia (any type - macrocytosis can be from folate deficiency withe methotrexate or pernicious anaemia); Felty’s syndrome
Caplan’s syndrome
Rheumatoid pneumoconiosis is a combination of rheumatoid arthritis (RA) and pneumoconiosis that manifests as intrapulmonary nodules, which appear homogenous and well-defined on chest X-ray
Joint characteristics of RA
boutonniere deformity: flexion of proximal interphalangeal joint and extension of distal interphalangeal joint of the hand
Swan neck deformity: hyperextension at proximal interphalangeal joint and flexion at distal interphalangeal joint
Z-thumb: hyperextension of the interphalangeal joint, fixed flexion and subluxation of the metacarpophalangeal joint and gives a “Z” appearance to the thumb
LOSS and LESS
X-ray features of Osteoarthritis (LOSS)
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
Radiological Features of Rheumatoid Arthritis (LESS)
Loss of joint space
Erosions
Soft tissue Swelling
Soft bones (osteopenia which is periauricular)
Psoriatic arthritis
DRAMA: DIP only Rheumatoid like Ank spond like Mutilans Asymmetrical oligoarthropathy Negative correlation of severity
Back Pain Red Flags
Age <20 or >55yrs Neurological disturbance (inc. sciatica) Sphincter disturbance Bilateral or alternating leg pain Current or recent infection Fever, wt. loss, night sweats History of malignancy Thoracic back pain Morning stiffness Acute onset in elderly people Constant or progressive pain Nocturnal pain
Back pain Mx
Neurosurgical referral if neurology
Conservative
Max 2d bed rest
Education: keep active, how to lift / stoop
Physiotherapy
Psychosocial issues re. chronic pain and disability Warmth
Medical
Analgesia: paracetamol ± NSAIDs ± codeine
Muscle relaxant: low-dose diazepam (short-term) Facet joint injections
Surgical
Decompression
Prolapse surgery: e.g. microdiscectomy
Acute cord compression
Bilateral pain: back and radicular
LMN signs at compression level
UMN signs and sensory level below compression
Sphincter disturbance
Acute cauda equina syndrome
Alternating or bilateral radicular pain in the legs
Saddle anaesthesia
Loss of anal tone
Bladder ± bowel incontinence
Osteoarthritis signs
Bouchard’s (proximal)
Heberden’s (distal)
Thumb squaring of carpo-metacarpo joint
Fixed flexion deformity
Osteoarthritis Medical Mx
Analgesia
Paracetamol or NSAIDS like arthrotec (diclofenac + misoprostol)
Joint steroid injections
Osteoarthritis Surgical Mx
Arthroscopic washout (esp knee)
Arthroplasty - replacement
Osteotomy - small area of bone cut out
Arthrodesis - fusion of joint; last resort for pain management
Septic Arthritis Mx
IV Abx - vanc + cefotaxime
Consider washout under GA (esp if prosthetic, must be replaced)
Septic Arthritis Causes
Organisms:
Staph: commonest overall (60%)
Gonococcus: commonest in young sexually active
RF: Joint disease (e.g. RA) CRF Immunosuppression (e.g. DM) Prosthetic joints
RA Hand Symptoms
Symmetrical, polyarthritis of MCPs, PIPs of hands and feet → pain, swelling, deformity
- Swan neck
- Boutonniere
- Z-thumb
- Ulnar deviation of the fingers
- Dorsal subluxation of ulnar styloid
Morning stiffness >1h that improves with exercise
Larger joints may become involved
Rheumatoid nodules
Commonly elbows also fingers, feet, heal
Firm, non-tender, can be mobile or fixed
Can also occur in lungs
Extra-articular symptoms of RA
Cardiac - pericarditis / pericardial effusion
Pulmonary - fibrosis (lower); pleural effusions
Ophthalmic - Epi/scleritis; Sjogren’s
Spenomegaly in 5% (Felty’s in 1%)
So much do full head to toe exam
Felty’s syndrome
RA + splenomegaly + neutropenia
RA Dx:
ACR classification 4/7 of: 1. Morning stiffness >1h (lasting >6wks) 2. Arthritis ≥3 joints 3. Arthritis of hand joints 4. Symmetrical 5. Rheumatoid nodules 6.+ve RF or anti-CCP 7. Radiographic changes
RA medical Mx:
DAS28: Monitor disease activity
DMARDs and biologicals: use early
Steroids: IM, PO or intra-articular for exacerbations (Avoid giving until seen by rheumatologist)
NSAIDs: good for symptom relief
Mx CV risk: RA accelerates atherosclerosis
Prevent osteoporosis and gastric ulcers
RA surgical Mx
Ulna stylectomy
Joint prosthesis
DMARDS SE
Main agents
Methorexate: hepatotoxic, pulmonary fibrosis
Sulfasalazine: hepatotoxic, SJS, ↓ sperm count
Hydroxychloroquine: retinopathy, seizures
Other Agents
Leflunomide: ↑ risk of infection and malignancy
Gold: nephrotic syndrome
Penicillamine: drug-induced lupus, taste change
Boutonierre’s patho
rupture of central slip of extensor
expansion → PIPJ prolapse through “button-hole”
created by the two lateral slips.
Swan-necking patho
rupture of lateral slips → PIPJ hyper-extension
Biologicals
Anti-TNF e.g. infliximab, etanercept, adalimumab
SE = increased infection, AI disease and cancer
Rituximab (anti CD20)
Second line if not responding to anti-TNF
Jaccoud’s arthropathy
Differential of rheumatoid hand caused by SLE or rheumatic fever
Features very similar to rheumatoid hand but is a reversible non-erosive chronic joint disorder occurring after repeated bouts of arthritis
Podagra
Gout on great toe MTP
Tophi
Urate deposits in pinna and tendons
Gout on X-Ray
punched out erosions in juxta-articular bone
reduced joint space
Gout causes
Drugs: diuretics, NSAIDs, cytotoxics, pyrazinamide
↓ excretion: 1O gout, renal impairment
↑ cell turnover: lymphoma, leukaemia, psoriasis,
haemolysis, tumour lysis syndrome
EtOH excess
Purine rich foods: beef, pork, lamb, seafood
Hereditary
Acute Rx of Gout
NSAID: diclofenac or indomethacin
Colchicine when NSAIDs CI: warfarin, PUD, HF, CRF
SE: diarrhoea
In renal impairment: NSAIDs and colchicine are CI → Use steroids
Prevention of gout
Conservative = wt. loss + avoid prolonged fasting and excessive EtOH
Medical
Allopurinol: SE rash, fever, ↓WCC ( with azathioprine). Use febuxostat if SE
Probenecid is also rarely used
Pseudogout RF
↑age OA DM Hypothyroidism Hyperparathyroidism Hereditary haemochromatosis Wilson’s disease
Pseudogout Rx
Analgesia
NSAIDs
May try steroids: PO, IM or intra-articular
Ank Spond presentation
- Gradual onset back pain
- Progressive loss of all spinal movement
- Enthesitis
- Costochondritis
- Question mark posture (thoracic kyphosis + neck hyperextension)
Extra-articular:
- anterior uveitis
- apical fibrosis
- aortic valve imcompetence
Ank spond Mx
Conservative:
Exercise!!
Medical:
NSAIDS - indomethicin
Local steroid injections
Anti-TNF if severe
Surgical:
Hip replacement to increase mobility and reduce pain if necessary
Reactive arthritis causes
Urethritis: chlamydia, ureaplasma
Dysentery: campy, salmonella, shigella, yersinia
Reactive arthritis presentation
- Asymmetrical lower limb oligoarthritis: esp. knee
- Iritis, conjunctivitis
- Keratoderma blenorrhagica: plaques on soles/palms
- Circinate balanitis: painless serpiginous penile ulceration
- Enthesitis
- Mouth ulcers
Reactive arthritis Mx
NSAIDs and local steroids
Psoriatic arthritis features
- DRAMA (joint involvement)
- psoriatic plaques
- nail changes (POSH = pitting, onycholysis, subungal hyperkeratosis)
- enthesitits
- dactylitits
X-ray = pencil-in-cup deformity from punched out erosions
Psoriatic arthritis Rx
NSAIDs
Sulfasalazine/methotrexate/ciclosporin
Anti-TNF
Behcet’s disease presentation
Recurrent oral and genital ulceration
Eyes: ant/post uveitis
Skin lesions: EN
Vasculitis
Behcet’s disease Ix and Rx
Ix: skin pathergy test (needle prick → papule formation)
Rx: immunosuppression
Anti-dsDNA
SLE
Anti-centromere
CREST syndrome
Anti-scl70
diffuse systemic sclerosis
Anti-histone
Drug induced lupus
Causes: procainamide, phenytoin, hydralazine, isoniazid
Anti-Jo1
Polymyositis, Dermatomyositis
Anti-RNP
SLE, MCTD
Anti-Ro / anti-La
SLE, Sjogren’s
Sjogren’s Ix and Rx
Ix
- Schirmer tear test
- Abs: ANA–RoandLa,RF
- Hypergammaglobulinaemia
- Parotid biopsy
Rx
- artificial tears
- saliva replacement solution
- NSAID and hydroxychlorquine for arthralgia
- immunosuppression if severe
Raynaud’s colour change
WBC:
White –> blue –> crimson
Rx - nifedipine
Systemic sclerosis Mx
- Immunosuppression
- Raynaud’s: CCBs, ACEi, IV prostacyclin
- Renal: intensive BP control – ACEi 1st line
- Oesophageal: PPIs, prokinetics (metoclopramide)
- Pulmonary HTN: sildenafil, bosentan
Polymyositis and Dermatomyositis Ix
- Muscle enzymes: ↑CK, ↑AST, ↑ALT, ↑LDH
- Abs: Anti-Jo1 (assoc. with extra-muscular features)
- EMG
- Muscle biopsy
- Screen for malignancy: e.g. Tumour markers, CXR, Mammogram, pelvic/abdo US, CT
Skin changes in dermatomyositis
- Heliotrope rash on eyelids ± oedema
- Macular rash (shawl sign +ve: over back and shoulders)
- Nailfold erythema
- Gottron’s papules: knuckles, elbows, knees
- Mechanics hands: painful, rough skin cracking of finger
tips - Retinopathy: haemorrhages and cotton wool spots
- Subcutaneous calcifications
Antiphospholipid Rx
- low dose aspirin
- warfarin if recurrent thrombosis (INR 3.5)
- IVC filter
SLE features
A RASH POINt MD
- arthritis: jaccoud’s
- renal: proteinuria + HTN
- ANA
- serositis
- haematological: AIHA, reduced WCC and plt
- Photosensitivity
- oral ulcers
- immune phenomenon: anti-dsDNA, Sm + phospholipid
- neuro: psychosis
- malar rash (spares nasolabial folds)
- discoid rash: mainly affects face and chest
Large vessel vasculitis
Giant cell arteritis
Takayasu’s arthritis
Medium vessel vasculitis
Polyarteritis nodosa
Kawasaki disease
Small vessel vasculitis
pANCA
- Churg-Straus
- Microscopic Polyangiitis
cANCA:
- Wegener’s Granulomatosis
ANCA –ve
- Henoch-Schonlein Purpura
- Goodpasture’s Disease
- Cryoglobulinaemia
- Cutaneous Leukocytoclastic Vasculitis
Giant cell arteritis features
- Headache
- Temporal artery and scalp tenderness
- Jaw claudication
- Amaurosis fugax
- Prominent temporal arteries ± pulsation
Giant cell arteritis Ix and Mx
If suspect GCA: Do ESR and start pred 40-60mg/d PO
Temporal artery biopsy within 3 days (skip lesions can occur however)
Kawasaki’s Mx
IVIG + aspirin
Fever >5 days
PAN
Assoc. with Hep B
Features Constitutional symptoms - Rash - Renal → HTN - GIT → melaena and abdo pain
Rx = Pred + cyclophosphamide
Takayasu’s arteritis features
Pulseless disease
- Constitutional symptoms: fever, fatigue, wt. loss
- Weak pulses in upper extremities
- Visual disturbance
- HTN
Churg strauss features
Late-onset asthma
Eosinophilia
Small vessel vasculitis (RPGN and purpura)
Microscopic polyangiitis features
- RPNG
- haemoptysis
- purpura
- not granulomatous
Wegener’s features
URT + LRT + kidneys
URT - chronic sinusitis; epistaxis; saddle-nose deformity
Goodpasture’s Ix and Rx
Ix
Anti-GBM and CXR showing bilateral lower zone infiltration (haemorrhage)
Rx
immunosuppresion + plasmapheresis
Cutaneous Leukocytoclastic Vasculitis
- Palpable purpuric rash ± arthralgia ± GN
Causes
- HCV
- Drugs: sulphonamides, penicillin
Simple Cryoglobulinaemia
Monoclonal IgM linked to myeloma/CLL
leading to hyperviscousity (visual disturbance/thrombosis/headache/seizures)
Mixed cryoglobulinaemia
Polyclonal IgM from SLE, HCV, mycoplasma, Sjogren’s leading to immune complex deposition (GN, purpura, arthralgia, peripheral neuropathy)
Fibromyalgia Features
- Chronic, widespread musculoskeletal pain and tenderness
- Morning stiffness
- Fatigue (on exercise)
- Poor concentration
- Sleep disturbance
- Low mood
Diagnosis of exclusion
Fibromyalgia Mx
- Educate pt.
- CBT
- Graded exercise programs
- Amitriptyline or pregabalin
- Venlafaxine
Bennet’s fracture
Intra-articular fracture of the first carpometacarpal joint (thumb)
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at ulnar base of metacarpal
Monteggia’s fracture
Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disability
Galeazzi fracture
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow
Pott’s fracture
Bimalleolar fracture
Forced foot eversion
Barton’s fracture
Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist
