Musculoskeletal Flashcards
What is the diaphysis, metaphysis and epiphysis of a long bone?
Diaphysis is central tubular shaft of bone that contains the yellow bone marrow containing medullary cavity. The epiphysis is at the proximal and distal ends of the bone and the metaphysis separates the diaphysis from the epiphysis. In children, the growth plate is between the epiphysis and the metaphysis. The epiphysis and metaphysis are mainly spongy/cancellous bone.
What are the 2 types of bone marrow and where are they stored?
Red marrow = contains haematopoietic material - it contains stem cells that can become RCC, WCC and plts.
It is found mainly in the cancellous bone and in flat bones (sternum, scapula).
Yellow marrow = mainly fat and stem cells to make bone and cartilage. Predominantly in the medullary canal of the diaphysis of long bones.
For which category of patients is it appropriate to commence PO alendronate in without waiting for a DEXA scan?
If >75 and fragility fracture (eg NOF)
What lifestyle triggers should you advise gout patients avoid?
Avoid purine rich foods (liver,kidneys, game, oily fish, seafood, high fructose-content (especially sugary drinks) and yeast products
Stop smoking
Aim for gentle weightloss if overweight
Avoid heavy or binge drinking of alcohol
Regular exercise but not intensive
Consider vitamin C supplement
Which joint is most commonly affected in gout?
The big toe (the first metatarsophalangeal joint) is the joint that upto 75% of people with gout first present with.
Lower limbs joints affected > upper limb.
What is the typical presentation / onset of pain in gout?
Typically monoarticular, relatively rapid onset of pain + swelling with maximal pain, redness and swelling within 24 hrs of onset. +/- tophi (visible growths of uric acid crystals that appear like swollen nodules under the skin - usually takes 10+ yrs after the 1st attach to develop but can be present at the first presentation, especially in post-menopausal women who may present with several small joint tophi)
If <30 years then consider renal or enzymatic disorder.
What is the recommended investigation for somebody presenting with suspected gout?
If there is a strong suspicion of gout and no concerns re septic arthritis etc then NO immediate diagnostic investigations are needed and can treat based on clinical diagnosis.
Arrange to measure serum uric acid 4-6 weeks after the acute attack to assess for hyperuricaemia (>380 micromol/L). Not definitive as can have gout without high urate and vice versa but supports the diagnosis.
Consider joint XR. In gout can see non-specific soft tissue swelling and subcortical cysts +/- bone erosion in advanced gout.
Why is serum uric acid measured 4-6 weeks after an acute gout attack and not during?
During an acute attack, serum uric acid can be normal as it goes into the joint.
What is the optimal management of an acute gout attack?
R.I.C.E
Advice re lifestyle triggers to avoid
NSAID or colchicine (colchicine has a slower onset of action, main side effect is diarrhoea)
DO NOT STOP ALLOPURINOL / FEBUXOSTAT IF PATIENT ALREADY ESTABLISHED ON URATE-LOWERING THERAPY
Can consider adding in paracetamol or combining NSAID + colchicine if inadequate analgesic affect although need to be cautious as typically elderly people
Can consider intra-articular steroid injection if diagnosis is certain and suitably qualified clinician
Short course oral steroids an alternative if intra-articular contraindicated / polyarticular
What are the key contraindications for colchicine?
Pregnancy (teratogenic)
eGFR <10
Severe hepatic impairment
Bleeding disorders
What is the optimal long-term management of gout?
Check serum uric acid 4-6 wks after acute attack - consider raised if >380 micromol/l.
Consider joint XR.
Assess for risk factors - bloods to check lipid profile, HbA1C, renal function. Blood pressure monitoring.
Advise on avoiding lifestyle triggers
Advise future attacks should be treated as soon as possible for maximal effect - consider Rx colchicine / NSAID ready for use.
Discuss urate-lowering therapy @ the first presentation. Especially consider in those with:
1) 2 or more attacks per 12 months
2) Tophi
3) Evidence of joint damage on XR
4) eGFR <60
5) A Hx of renal stones
6) Diuretic use
7) Young age at the onset of gout
First line urate-lowering agent = allopurinol. Start @ 100mg/day and then repeat serum uric acid every 4 wks, titrating up the dose until SUA <300 micromol/L.
Second line ULT = Febuxostat (eg if renal impairment prevents adequate titrating up of allopurinol dose). Check LFTs prior to starting.
Consider co-prescribing colchicine/NSAID for the first 6 months of starting urate-lowering therapy as commencing ULT can precipitate an acute attack.
ULT is normally life-long but can consider stopping if normalised SUA levels, risk factors have been addressed and no more acute attacks.
What is the typical presentation of club foot / talipes equinovarus and how should it be managed.
Club foot / talipes equinovarus presents with inverted + plantar-flexed feet.
Bilateral in 50% of cases.
Most are idiopathic (unknown cause) but some association with Edward’s syndrome, spina bifida and cerebral palsy.
Most are picked up @ 6 week noenatal check -> unable to passively correct the inversion and plantarflexion.
Mx = Ponseti Method = manipulation and progressive casting + achilles tenotomy in majority + nighttime brace until ~ 4 yrs.
What is the classical presentation of degenerative cervical myelopathy.
Classically in the >50s. Progressive neurological symptoms including pain/stiffness in the neck/upper or lower limbs, UMN signs in U or L limbs including hyperreflexia/babinski sign/ clonus/spasticity, sensory loss in U/L limbs, falls/gait disturbance, autonomic dysfunction (urinary/faecal incontinence, impotence). Suspect in those presenting with symtpoms suggestive of bilateral carpal tunnel syndrome as they are often misdiagnosed as CTS.
What is the gold standard 1st line investigation if degenerative cervical myelopathy is suspected?
MRI spine - urgent if progressive disease / impacting QOL, non-urgent is symptoms not progressive.
Urgent referral to neurosurgical / orthopaedic spinal team.
What are the presenting signs/symptoms of achilles tendon rupture?
Symptoms - audible pop, sudden onset significant pain in calf +/- ankle, inability to walk afterwards
Signs - examine for Simmond’s triad -> have patient lying prone with their feet over the edge of the bed -> 1) greater dorsiflexion of the injured foot compared to the uninjured 2) feel for a gap in the tendon 3) when you gentle squeeze the calf muscle the foot will stay in the same position.
What is the 1st line investigation of choice if you suspect achilles tendon rupture based on clinical findings?
USS
What are risk factors for achilles tendon rupture?
Quinolone antibiotics (eg ciprofloxacin) Hypercholesterolaemia (predisposes to tendon xanthomata = ^ chance of rupture)
What are the presenting signs/symptoms of lateral epicondylitis / tennis elbow?
Pain over lateral epicondyle / lateral aspect of elbow
Pain on RESISTED WRIST EXTENSION or RESISTED FOREARM SUPINATION when the elbow is extended
Acute pain typically lasts for 6-12 wks
What are the presenting signs/symptoms of medial epicondylitis / golfer’s elbow?
Pain over medial epicondyle
Pain on RESISTED WRIST FLEXION OR PRONATION
May have tingling / numbness in 4th + 5th digit due to ulnar nerve involvement
What are the presenting signs / symptoms of radial tunnel syndrome?
Compression of the posterior interosseous branch of the radial nerve due to overuse = presents similarly to lateral epicondylitis but the pain is more distal to the lateral epicondyle
What are the presenting signs / symptoms of cubital tunnel syndrome?
Compression of the ulnar nerve.
Presents w/ INTERMITTENT TINGLING IN THE 4TH AND 5TH DIGITS + later progresses to numbness and weakness + pain in elbow when flexed for a prolonged time / resting on a firm surface.
What are the presenting signs / symptoms of olecranon bursitis?
SWELLING OVER POSTERIOR ASPECT OF ELBOW + PAIN + HEAT + REDNESS. Typically affects middle aged males
What are risk factors for Dupytren’s contracture?
Manual labour, Phenytoin treatment, alcoholic liver diease, Diabetes, previous trauma to the hand, older age, male gender, strong association with family history
explain the straight leg raise test?
SLR -> if pain on the right lower back on elevating the right leg 30 - 80 degrees = suggestive of ipsilateral sciatica
(<30 = need to seek alternative Dx, pain after 80/90 degrees = normal)
If pain on the OPPOSITE side when raising the leg = suggestive of severe root irritation suggestive of CENTRAL DISC prolapse = @ risk of cauda equina
What are the Ottawa rules for who should get an XR after an ankle injury?
Pain in the malleolar region AND
* pain at the posterior aspect of the lateral OR medial malleolus
OR
* unable to WB both at the time of the injury and at the time of assessment
What is the main side effect of hydroxychloroquine (an antimalarial often used as an adjunct in rheumatoid arthritis)
IRREVERSIBLE RETINOPATHY
-> need baseline and then annual eye examinations
Which drug sometimes used for rheumatoid arthritis can cause increased blood pressure?
Leflunomide
Which drugs for rhematoid arthritis can reduce sperm count / quality?
Sulfasalzine (used for IBD, RA and psoriasis) -> reduces sperm count and quality reversibly while using
What is the triad of. Felty’s syndrome?
Rheumatoid arthritis + neutropenia (recurrent infections) + splenomegaly
What is the typical presentation of reaction arthritis?
Pain in the knees / ankles a few weeks after an initial systemic infection (normally STI - chlamydia - or GI - salmonella) Rash on palms of hands / soles of feet Red sore eyes (uveitis) Urethritis in men / cervicitis in women = Reiter's syndrome
What is the usual inheritance of ehlers danloss?
autosomal DOMINANT
What antibodies are associated with sjogren’s syndrome?
Anti-Ro Anti-La
What antibodies are associated with antiphospholipid syndrome?
anti-cardiolipin
lupus anticoagulant
anti B2 glycoprotein
what antibody is associated with limited systemic sclerosis / CREST syndrome?
Anti centromere
What antibody is associated with diffuse systemic sclerosis?
AntiScl-70 / anti-RNA-polymerase
Diagnostic criteria for ankylosing spondylitis?
New York Criteria
DEFINITE diagnosis = radiological (XR or MRI) features of sacroillitis PLUS at least 1x clinical criteria (lower back pain for >3 months not relieved by rest, limited sagittal and frontal ROM, reduced chest expansion)
PROBABLE diagnosis = either radiological features without any clinical or all 3x clinical without any radiological
What is the typical presentation of Paget’s disease?
High bone turnover with new, deformed bone formed.
Presents w/ bone pain, deformity, normal calcium and phosphate, very high ALP, may develop heart failure due to the increased outload demand to supply the new bone vessels
SLE management?
1st line = low dose steroids or NSAIDs
If not controlled -> hydroxychloroquine
Initial dose of steroids for suspected temporal arteritis?
If acute or intermittent visual loss associated with GCA - then IV hydrocortisone before high dose oral steroids
If not then PO 60-100mg prednisolone (high dose!)
Typical presentation of anterior cruciate ligament injury in the knee?
initial ‘popping’ sound and immediate swelling
positive LACHMANS test = when you pull the tiba forward when knee midly flexed + get excessive anterior give (>2mm) .
Tests to test for injuries in the knee?
Anterior drawer test / Lachmann’s test -> tests for ACL tear
Posterior drawer test -> tests for a PCL tear
Valgus stress test -> for a medial collateral ligament tear
Varus stress test -> for a lateral collateral ligament tear (doesn’t have an L in! the opposite of what you would think!)
Mcmurray’s test = for a meniscal tear
What is Felty’s syndrome?
1) Rheumatoid arthritis
2) Neutropenia
3) Splenomegaly
What is Caplan’s syndrome?
Pulmonary fibrosis after silica or asbestos exposure
Similar appearance to TB on XR with well-defined nodules that can cavitate
Clinical tests for DDH?
Barlow’s = attempting to dislocate the hip
Ortolani’s = attempting to relocate the hip
Galeazi sign = for older children (~6 months) -> knees at different heights when you bend them into the chest due to different limb lengths
Clinical findings in RA v OA?
RA - z-deformity of the thumb, swan-neck deformity, ulnar deviation of the fingers,
OA - Bouchard’s nodes (at the PIP joint) and Heberden’s nodes (at the DIP joints)
What is the most common type of primary bone tumour?
Osteosarcoma
Osteoclastoma is rare and Ewing’s sarcoma presents in children
X-ray findings in pseudogout?
chondrocalcinosis
x-ray findings in rheumatoid arthritis?
1) Joint space narrowing
2) Juxta-articular osteoporosis
3) marginal erosions
x-ray findings in OA?
1) Joint space narrowing
2) Subchondral cysts
3) Osteophytes
3) Subchondral sclerosis
if yuo suspect compartment syndrome you should loosen the cast - true or false?
FALSE
You need to completely remove any potentially constricting casts
Different types of wrist fracture?
South Africans Can’t Play rugby
Smiths fracture = distal radius fracture with Anterior tilting of the distal radius fragment Colles fracture (most common wrist fracture) = distal radius fracture with Posterior tilting of the distal radius fragment
Galleazi fracture = fracture of the radial shaft + dislocation of the inferior radio-ulnar joint
Monteggia fracture = fracture of the ulnar + dislocation of the radial head
Typical presentation of Pott’s disease?
= TB of the spine
-> leads to kyphosis
typical presentation of adhesive capsulitis / frozen shoulder?
should is TENDER to examine
GLOBAL reduction in movement especially for PASSIVE EXTERNAL ROTATION
association with thyroid disease and diabetes
initial Mx of sciatica?
Rest + analgesia
Refer for physio if still ongoing pain after 6 wks
typical presentation of fat embolisation syndrome?
24 - 72 hours AFTER an injury (normally pelvic or long bone of the leg fracture)
Respiratory distress + petechial rash
which is more common - anterior or posterior dislocation of the shoulder?
anterior dislocation is most common!
typical presentation of subacromial bursitis?
In patients with EXCESSIVE OVERHEAD ABDUCTION eg swimmers -> presents similarly to impingement syndrome
typical presentation of impingement syndrome?
= rotator cuff tendonitis (SUPRASPINATUS IS THE MOST COMMONLY AFFECTED = SUPRASPINATUS TENDONITIS)
= painful arc = pain on abduction between 60 -120 degrees
Typical presentation of reflex sympathetic dystrophy after a cast is removed?
A very tender, pink, sweaty hand after removal of a cast
-> mx = physio + NSAIDS
