Musculoskeletal Flashcards
1
Q
What blood test must be carried out before starting azathioprine?
A
check thiopurine methyltransferase deficiency (TPMT)
2
Q
What is ankylosing spondylitis and list sx?
A
a HLAB27 associated spondylarthropathy
sx- Morning pain and stiffness of back and hip that improves with activity
3
Q
List 3 examination fidings of ank spon?
A
Reduced chest expansion
Reduced forward flexion
Reduced lateral flexion
4
Q
What are sx and mx of achilles tendonitis?
A
sx- Gradual onset of posterior heel pain (worse after activity), morning pain and stiffness is common
mx- simple analgisia, physio
5
Q
What is the ix of choice in achilles tendon rupture?
A
USS
6
Q
List 3 indications for methotrexate?
A
Inflammatory Arthritis
Psoriasis
Chemo–>ALL
7
Q
List the cautions of methotrexate use in preganancy?
A
Women should stop 6 months prior to pregnancy
Men should use effective contraception for 6 months after tx
8
Q
What other medication must be co-prescribed with methotrexate?
A
Folic acid (should be taken 24 hours apart)- reduces the risk of myelosuppression
9
Q
What abx should be avoided when using methotrexate and why?
A
Trimethoprim, and co-trimoxazole- increases risk of marrow aplasia
10
Q
What is the tx for methotrexate toxicity?
A
Folinic Acid
11
Q
What is osteomalacia?
A
Softeneing of bones secondary to vit D deficiency.
12
Q
List sx of OM?
A
Bone pain
Bone/muscle tenderness
Fracture (*NOF)
Proximal myopathy- ‘waddling gait’
13
Q
List the bone profile in a patient with OM?
A
Low Vit D, Calcium, Phosphate
High ALP
High PTH
14
Q
What is systemic sclerosis?
A
Condition of unknown aetiology characterised by hardened sclerotic skin and CT
15
Q
What is limited cutatenous systemic sclerosis and list its features?
A
a subtype of systemic sclerosis which predominantly affects face and distal limbs.
16
Q
What is often the first sign of limited cutaneous systemic sclerosis?
A
Raynauds Phenomenon
17
Q
What is the antibody associated with Limited cutaneous systemic sclerosis?
A
Anti centromere antibodies
17
Q
What antibody is associated with diffuse cutaneous sclerosis?
A
anti SCL-70
18
Q
What is diffuse cutaneous sclerosis and list its features?
A
A subtype of systemic sclerosis which predominantly affects the trunk and proximal limbs. Carries a worse prognosis
19
Q
What is CREST syndrome?
A
a subtype of limited cutaneous sclerosis.
Calcinosis
Raynauds
oEsophageal dysmotility
Sclerodactyly
Telangiecstasia
20
Q
What is dermatomyositis?
A
an inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions
*polymyositis is a variant of the disease where skin manifestations are not prominent
21
Q
List the features of dermatomyosistis?
A
Skin manifestations
Photosensitive malar rash
macular rash over back and shoulders
Heliotrope rash in periorbital region
Grottons papules- roughened red papules over extensor surfaces of fingers
other features:
Proxiaml muscle weakness
Raynauds
Resp muscle weakness
ILD
Dysphagia
22
Q
What antibodies are present in dermatomyositis?
A
anti-Mi-2 antibodies
anti jo-1 antibodies
antibodies to signal recognition particle (SRP)
23
Q
What are the features of antiphospholipid syndrome?
A
Venous/arterial thrombosis
Recurrent miscarriages
Livedo reticularis
Pre-eclamsia, Pulmonary HTN
24
What is the results of a joint aspiration in pseudogout?
Positively birefringent rhomboid-shaped crystals
25
What antibodies are highly specific for SLE?
anti-dsDNA
anti smith
26
how can pseudogout and gout be distinguished on x-ray?
chondrocalcinosis, the finding of calcification of the articular cartilage. Although not specific, this is suggestive of pseudogout.
27
What is Marfan's syndrome?
an autosomal dominant connective tissue disorder. It is caused by a defect in the FBN1 gene on chromosome 15 that codes for the protein fibrillin-1.
28
State 5 features of Marfan's?
Pectus excavatum
Tall stature
High arched palate
Pes planus
Scoliosis
heart (aortic regurg, aortic dissection, dialtion of aortic sinuses, mitral valve prolapse)
repeated pneumothoraces
eyes (blue sclera, upwards lens dislocation, myopia)
29
Where is the most common site where osteomyelitis occurs in children?
long bone is the metaphysis
30
what is the investigation of choice in osteomyelitis?
MRI
31
What is the most common reason for a THR revsion?
Aseptic loosening
32
What antibodies are present in anti-phospholipid syndrome?
anticardiolipin antibodies
anti-beta2 glycoprotein I (anti-beta2GPI) antibodies
lupus anticoagulant
33
What is de-quervin's tenosynovitis?
A common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed.
34
List the 4 common features/sx of de-quervain's tenosynovitis?
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
pain over radial styloid process when thumb in ulnar deviation
35
What is the mx of de-quervain's tenosynovitis?
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required
36
What are the x-ray findings of ank-spon?
Subchondral erosions
Subchondral sclerosis
Squaring of lumbar vertebrae (bamboo spine)
37
What are the x-ray findings of OA?
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
38
What are the x-ray findings of RA?
Loss of joint space
Periarticular erosisons
Soft tissue swelling
Subluxation
39
What are the x-ray findings of gout?
Soft tissue swelling
Punched out bone lesions
Overhanging scelrotic margins
40
What are the common joints in the hands are affecetd by OA?
Carpometacarpal Joints
DIPJ>PIPJ
Squaring of thumb
41
In cauda equina what late sign would indicate irreversible damage?
Urinary incontinence
42
What T score indictaes osteoporosis?
T-score of < -2.5 confirms a diagnosis of osteoporosis.
43
What is the most common cause of discitis?
Staph aureus
44
What is discitis?
an infection in the intervertebral disc space.
45
List the priamary cause and 3 secondary causes of iliopsoas abscesses?
1- Staph aureus- hetrogenous spread
2- crohns, IVDU, Diverticulitis, endocarditis, Vertebral osteomyelitis
46
what are the sx of an iliopsoas abscess?
Fever
Back/flank pain
Limp
WL
47
What is the ix of choice and subsequent mx of a ilopsoas abscess?
CT Abdomen
Abx
Percutaneous drainage
Sx- if PD fails or other intra-abdominal pathology shown
48
What 2 muscles comprise the iliopsosa compartment?
Illiacus
Iliopsoas
49
What medication is indicated in patients with renal complications with a background of systemic sclerosis?
ACEI
50
What clinical features are present if the femoral nerve is damaged?
Weakness in knee extension,
loss of the patella reflex,
numbness of the thigh
51
What clinical features are present if the obturator nerve is damaged?
Weakness in hip adduction,
numbness over the medial thigh
52
What clinical features are present if the Sciatic nerve is damaged?
Weakness in knee flexion and foot movements,
pain and numbness from gluteal region to ankle
53
What nerve is most at risk and thus a complication of posterior hip dislocation?
Sciatic nerve
54
What is the management of plantar fascitis?
Initially with rest, stretching and weight loss if overweight
55
What are the causes of compartment syndrome?
Following fractures
Ischaemia repurfusion injury
56
What are the common types of fractures that result in compartment syndrome?
Supracondylar fractures
Tibial shaft fractures
57
List the sx of compartment syndrome?
Pain (esp on movement, not controllled by analgesia/opiates)
Parasthesia
Pulseless/pulse
paralysis of muscle group
pallor
58
How is compartment syndrome diagnosed
Needle manometry- measure intracompartmental pressure
>20mmHg- Abnormal
>40mmHg- Diagnostic
59
What is the mx of compartment syndrome?
Escalating to the orthopaedic registrar or consultant
Removing any external dressings or bandages
Elevating the leg to heart level
Emergency Fasciotomy +/- derbridement
60
what sx are present in an L3 nerve root compression?
sensory loss over anterior thigh
weak hip flexion, knee extension and hip adduction
reduced knee reflex
+ve femoral stretch test
61
what sx are present in an L4 nerve root compression?
Sensory loss over anterior aspect of knee and medial malleolus
weak knee and hip extension
reduced knee reflex
62
what sx are present in an L5 nerve root compression?
Sensory loss dorsum of foot
weakness in foot and big toe dorsiflexion
Knee reflex intact
63
what sx are present in an S1 nerve root compression?
Sensory loss over posterolateral aspect of leg
weakness of plantar flexion
64
What are the Ottawa Ankle rules that minimise the use of xrays in ankle injuries?
If pain in malleolar zone AND
1. Inability to weight bear for 4 steps
2. Tenderness over distal tibia
3. Bone tenderness over distal fibula
65
What is a toddler's fracture?
Oblique tibial fracture
66
What is a greenstick injury?
unilaterla cortical breach in bone
67
What other conditions are linked with pseudogout?
Haemochromotosis
Hyperparathyroidism
Low magnesium and phosphate
Acromegaly
Wilson's disease
68
What are the features of Behcet's diseases?
Oral ulcers
Genital ulcers
Anterior uveitis
69
What are the expected bone chemistry results (PTH, Ca, PO4, and ALP) in osteogenesis imperfecta?
All values are normal
70
What is osteogenesis imperfecta?
An autosomal dominant group of conditions that affect collagen metabolism thus leading to bone fragility thus more to prone to fractures
70
List 4 features of Osteogenesis Imperfecta?
Present in childhoos
Blue sclera
Fractures following minor trauma
deafness 2ndry to osteosclerosis
Dental imperfections
71
List the triad of sx in reactive arthritis?
1. Urethritis
2. Conjuntivitis
3. Arthritis
72
What investigation is key to perform in SLE?
ANA antibody screen- good to rule out
73
What investigations are done to diagnose SLE?
ANA antibody= +ve
ESR= Increased
Low complement levels (suggest active disease)
anti dsDNA
anti Smith
74
How would a posterior hip dislocation present as?
affected leg:
- shortened
- Internally rotated
- Adducted
75
How would a anterior hip dislocation present as?
Externally rotated + Abducted
76
List 3 complications of hip disclocations?
Sciatic or femoral nerve injury
Osteoarthritis
Recuurennt hip dislocations
Avascular necrosis
77
Which bones are affected in osteosarcoma?
Metaphysis region of long bones (femur, tibia, humerus)
78
What Xray changes are seen in osteosarcomas?
- Codmans triangle- periosteal elevation
- Sunburst appearance
79
What genetic associations are there with osteosarcomas?
Retinoblastoma
80
What is the most common malignant bone tumour?
Osteosarcoma
81
Which bones are affected in Ewings sarcoma?
Pelvis and Long bones
82
List 3 benign bone tumours?
1. Osteoma- linked with gardeners syndrome
2. Osteochonroma- most common BBT
3. Giant cell tumour- xray- double bubble, soap sign
83
What are the features of osteochondritis dissecans?
- Knee pain and swelling
- Knee catching and locking
- Painful clunk when extending and flexing knee
84
What xray changes would be present in osteochondritis dissecans?
Sunchondral crescent sign
Loose bodies
85
What would a RA joint aspirate show in synovial fluid analysis?
Yellow , cloudy fluid
Increased WBC count- predominantly polymorphular neutrophils
Absence of crystals
86
What are the triad of symptoms in Felty's syndrome?
RA
Splenomegaly
Low WCC
87
What is the highest risk complication in individuals with marfan's syndrome?
Repeated pneumothoraces
88
What are the following test results in polymyalgia rheumatic (ESR, CRP, CK, EMG) ?
ESR, CRP- Elevated
Normal EMG and CK
89
What is the mx of RA flares?
Oral or IM corticosteroids
90
List 4 causes for AVN of the hip?
Long term stroid usage
Alcohol excess
Chemotherapy
Trauma
91
What is the Ix of choice for AVN of hip?
MRI
92
What are the sx of tennis elbow?
Pain and tenderness at elbow joint
Pain worse on wrist extension against resistance w/ elbo extended
Painful supination of elbow
93
What is Ehlers danlos syndrome?
Autosomal dominant connective tissue disorder, most likely affecting type 3 collagen
94
What type of collagen is affected in ehlers danlos?
Type 3
95
What score is used to assess hypermobility?
Beighton score
>5/9 in adults and >6/9 in children
96
What is Sjogren syndrome?
Autoimmune disorder affecting the exocrine glands, thus resulting in dry mucosal surfaces
97
List 5 sx of Sjogren's syndrome?
Dry eyes- Keratoconjunctivitis Sicca
Dry mouth
Vaginal dryness
Arthralgia
Raynauds
98
List the antibodies specific to Sjogren?
Anti RO and Anti La
99
What abx should never be co-prescribed with methotrexate?
Trimethoprim or Co-trimoxazole
100
What monitoring is required with methotrexate use?
FBC, U&Es, and LFTs every 3 months
101
What is the mx of sjogren's?
Artificial tears and saliva
102
What antibody/ies are present in dermatomyositis?
Anti Jo-1
Anti Mi-2 (more specific)
103
What antibody/ies are present in polymyositis?
Anti Jo-1
104
What antibody/ies are present in drug-induced lupus?
Anti-histone
105
What is the mx of anti-phospholipid syndrome (secondary thromboprophylaxis) ?
Long term coagulation with Warfarin (target INR 2.0-3.0)
106
How does the mx of anti-phospholipid syndrome differ in pregnancy?
During pregnancy, women with APS are typically managed with low molecular weight heparin (LMWH) and low-dose aspirin to reduce the risk of miscarriage and other complications such as pre-eclampsia.
Warfarin must be avoided due to teratogenicity.
107
What nerve roots form the sciatic nerve?
L4-S1
108
List the clinical features of sciatica?
Lower back pain
Unilateral leg pain
Paraesthesia
Weakness
Diminished reflexes
109
What IX can be performed in clinic to diagnose sciatica?
Straight leg raise (SLR) - radiating pain is felt when the hip is flexed to between 30 and 60 degrees.
110
What is the mx of sciatica?
1st line- NSAIDs
alt if NSAIDs contrindicated- Codeine +/- Paracetamol
111
What are the deficits in a C6 nerve root compression? (Motor, refelx, sensory)
Motor- Weakness in elbow flexion and wrist extension
Reflexes- Biceps ans supinator affected
Sensory- Along lateral forearm, thumb and first finger
112
What are the deficits in a C7 nerve root compression? (Motor, refelx, sensory)
Motor- Weakness in elbow extension and wrist flexion and finger extension
Reflexes- Triceps reflex
Sensory- Middle finger
113
List the clinical features of spinal stenosis?
Bilateral back, buttock/thigh/leg pain, with associated numbness, tingling, weakness
Symptoms are exacerbated when walking/ exertion, or prolonged standing - claudication.
Symptoms are exacerbated by back extension, and relieved by flexion which increases the canal space - trolley cart sign.
Symptoms are relieved by rest, or sitting down/leaning forwards
114
What is the 1st line Ix in suspected spinal stenosis
MRI Spine
115
What is the cauda equina?
The collection of peripheral nerves (L1-S5) in the lumbar canal
116
List the clinical features of cauda equina syndrome?
Back pain
Scaitica (UL/BL)
Lower limb weakenss
Bladder dysfunction
Saddle anaesthesia
Bowel dysfunction
ED
117
List 3 red flags for back pain?
Age > 50 years
Gradual, insidious onset of symptoms which have not improved with 4-6 weeks
Severe back pain, often worse at night disrupting sleep
Back pain exacerbated by increased by valsalva (e.g. sneezing, defaecation)
Localised pain on palpation
Systemic features - weight loss
History of malignancy
118
What is the mx of olecranon bursitis?
Non-infective - RICE, analgesia, consider symptomatic aspiration or steroid injection
Infective
-Aspirate bursal fluid and send for MCS
-Antibiotics (flucloxacillin 1st line) whilst a/w MCS
119
What is the mx of suspected cauda equina syndrome?
1st line: MRI - ideally obtained within 1-2 hours of presentation
emergency surgical decompression within 24-48 hours
120
List 3 causes of compartment syndrome?
Commonly due to trauma, including fractures, crush injuries, or muscle overuse.
Ischaemia-reperfusion injury
Burns
Vascular injuries
Bleeding disorders
Prolonged limb compression
Tight bandages
121
What are the clinical features of compartment syndrome?
Commonly in lower limb
Classically severe pain disproportionate to injury
Tightness
Paraesthesia
122
What examination findings may be present in compartment sysndorme?
Decreased sensation- particularly first web space of foot
Diminished pulses, and pallor or cyanosis.
Pain with passive stretch of affected muscles
Severe cases:
Paralysis
Absent pulses.
123
What Ix may aid diagnosis of compartment syndrome?
Compartment pressure measurement with manometry can aid diagnosis (>40mmHg diagnostic)
124
What is the definitive mx of compartment syndrome?
Immediate decompression via open fasciotomy
125
List 2 complications of compartment syndrome?
Myoglobinuria
Nerve damage
Renal damage
Limb loss
126
What is the pathophysiology behind compartment syndrome?
Increased pressure within a muscle compartment leads to compromised tissue perfusion and nerve function
127
What is dermatomyositis?
an inflammatory condition resulting in symmetrical proximal muscle weakness and skin lesions.L
128
List the clinical features of dermatomyositis?
Heliotrope periorbital rash
Red macular rash affecting back and shoulders
Gottron’s red papules on extensor surfaces
Symmetrical, proximal weakness +/- tenderness
Fatigue
Weight loss
Night sweats
129
List the causes of dermatomyositis?
most cases- idiopathic
may indicate an underlying malignancy in as many as 25% of patients - ovarian, breast, lung
130
What is the mx of dermatomyositis?
Steroids - Prednisolone
Patients should be screened for malignancy
131
What is the most common causative organism in discitis?
Staphylococcus aureus
132
What is the GS ix for discitis?
MRI - the most sensitive and specific diagnostic test
133
What is the 1st line mx for discitis?
IV ABx - with cover for staph aureus - flucloxacillin, clindamycin
Surgical debridement may be required
134
What is the 1st lien mx for tennis elbow?
Analgesia - 1st line: paracetamol or topical NSAID.
2nd line: PO NSAID
135
What are the clinical features of carpal tunnel syndrome?
Intermittent paraesthesia, sensory changes, or neuropathic pain in the distribution of the median nerve
Reduced grip strength or loss of dexterity
Symptoms are often worse during the night, often disturbing sleep
Patients may shake their hands to relieve the pain
136
What Ix is conducted in carpal tunnel syndrome?
CTS is a clinical diagnosis, but nerve conduction studies can be performed for confirmation.
137
What is the mx of CTS?
Mild-moderate symptoms - try the following:
Wrist splint
Corticosteroid injection into the carpal tunnel
if sx persistent- Carpal tunnel decompression surgery
138
List the RF for fibromyalgia?
Depression/anxiety
Dissatisfaction with family/work
Associated with chronic fatigue syndrome, IBD, chronic headache syndromes
139
What clinical features will be present in fibromyalgia?
Chronic widespread pain (Affects both sides of body + above and below waist + persists >3months)
Associated fatigue
Joints feel swollen
Low mood
Symptoms may worsen with physical or emotional stress
140
What is required to make a diagnosis of fibromyalgia?
Based on clinical assessment
Presence of at least 11/18 tender points on palpation
141
What is the mx of fibromyalgia?
Aim to improve symptoms and quality of life
Patient education
Graded exercise
Refer for cognitive-behavioural therapy (CBT)
Pharmacotherapy for symptom management (e.g., analgesics, antidepressants)
Neuropathic medications can help pain and sleep (amitriptyline/pregabalin/gabapentin/duloxetine)
142
What is the plantar fascia?
a fibrous band of connective tissue, extending from the calcaneus bone to the tendons of the forefoot and proximal phalanges, which supports the arch of the foot
143
List RF of plantar fasciitis?
Age 40-60, obesity, high arched feet, flat feet, excess use (walking, standing, running)
144
What examination may be done to diagnose plantar fasciitis?
Pain on palpation of the heel
Positive Windlass test - extension of the 1st MTP reproduces the pain
145
What is morton's neuroma?
A benign, thickening of the common digital plantar nerve due to persistent irritation from compression (usually within the third intermetatarsal space).
146
Where do ganglion cysts arise from?
originate from the synovial lining of joints and tendons.
147
How can a ganglion be differentiated from other types of lumps?
They transilluminate, reflecting their fluid contents, which helps differentiate them from other types of lump.
148
What is the mx of ganglion cysts?
They often resolve without intervention.
Treatment is generally only recommended by if the cyst is causing significant pain or affecting the range of movement of a joint.
- Aspiration-high recurrence rates
- Surgery
149
What causes gout?
Deposition of monosodium urate monohydrate within the synovium (as a result of hyperuricaemia)
150
What are the RF of Gout?
Factors which increase urate synthesis ( high cell turnover), or impair urate excretion.
Drugs: Aspirin, thiazides, furosemide, cytotoxics, ciclosporin
Comorbidities: CKD, psoriasis
151
What sit he 1st lien Ix of Gout?
Measure the serum urate level - if 360 or more, this confirms the diagnosis
152
What Ix is indicated if the 1st line ix for gout remains uncertain?
Joint aspiartion
153
What are the results of joint aspiration show in gout?
polarised light microscopy - Needle shaped, negatively birefringent crystals
154
What is the 1st line mx for the acute mx of gout?
NSAID (naproxen) OR colchicine OR Short course of oral prednisolone ( this is off label)
155
What is the main SE of colchicine?
Diarrhoea
156
What is the 1st line chronic mx of gout?
Allopurinol OR Febuxostat
+ Colchine
157
Whe should urate lowering theraphy be initiated?
Urate lowering therapy (ULT) should be considered after the first attack of (2-4 weeks after acute attack).
158
What is the MOA of Allopurinol?
xanthine oxidase inhibitor
159
What is the MOA of Febuxostat?
xanthine oxidase inhibitor
160
What should be done prior to starting Fexubostat?
Ensure LFTs are checked before commencing treatment
161
What is the mx of pseudogout?
Manage with NSAIDs or steroids (PO/IA/IM)
162
What is pseudogout?
microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals
163
List the clinical features of Greater trochanteric pain syndrome?
Chronic pain felt in around the greater trochanter and around the buttock, thigh or lateral hip.
Pain may come and go or be persistent and is exacerbated by activity or external pressure - e.g. exercise, or lying in bed on the affected side
Symptoms are usually of gradual onset and progressive
On examination - tenderness on palpation of the GT, antalgic gait, trendelenburg may be positive
164
List the differential of hip pain i children?
DDH
SUFE
Transient synovitis
Perthes
Septic arthritis
165
What are the examination findings in DDH?
Leg length discrepancy
Reduced hip abduction due to hip contractures
Barlow’s sign positive (Adduction- subluxation/dislocation)
Ortolani's sign positive- (clunk when femoral head relocated into acetabulum?
166
What is the Ix of choice to diagnose DDH?
Ultrasound if age < 6 months
AP pelvic XR if > 6 months
167
What is the mx of DDH?
Age < 6 months - Pavlik harness
Age 6-18 months - closed reduction with spica casting
Age > 18 months or failed treatment - open reduction and hip reconstrucion
168
What are the clincial features of perthes?
Several weeks of limping
Hip pain (but may be painless)
Progressive hip stiffness
O/E: Antalgic gait, restricted ROM esp. abduction and internal rotation
169
What are the clinical features of SUFE?
Pain in the hip or knee
Restricted ROM
Loss of Internal rotation and flexion
170
What is JIA?
Joint swelling for more than 6 weeks in <16 years old with no defined cause
171
What re the different types of JIA?
Periarticular (<4 joints affected)
RhF negative
RhF positive
Stills Disease (Systematic sx and ANA +ve)
Psoriatic
Enthetitis related
Undifferentiated
172
What is the 1st line mx for peri articular JIA?
NSAIDs
173
What is the 1st line mx for polyarthritis?
DMARDs (Methotrexate)
174
List 2 complications of JIA?
Uveitis (ANA positive patients)
Joint contracture
Growth disturbances
Osteoporosis
Amyloidosis
Anaemia
Psychosocial impact
175
What is the role of ACL?
Responsible for restraint vs anterior/forward movement of the tibia
176
What is the mechanism of injury for an ACL injury?
A sudden deceleration or change in direction on a fixed foot - for example, netball
177
What are the clinical features for an ACL injury?
Sudden painful Pop
Rapid swelling
Positive Lachman test
Anterior draw may be positive
Lateral knee tenderness
178
What is the Ix of choice for an ACL injury?
MRI
179
What is the role of the PCL?
Responsible for restraint vs backwards/posterior movement of the tibia
180
What is the mechanism of injury of a ruptured PCL?
A high energy, direct blow to the proximal tibia, whilst the knee is inflexion (e.g. RTC or contact sport injury)
181
What are the clinical features of a PCL injury?
Pain in the back of the knee
Positive posterior draw test
Posterior sag test may be positive
Mild knee effusion/swelling can be present
182
What are the clinical features of a meniscal injury?
Knee pain - localised over the anteromedial or anterolateral joint line
Locking or clicking
Effusion, tenderness as above
McMurray test may be positive
183
What is the Mechanism of injury of a MCL injury?
A direct blow to the LATERAL aspect of the knee - for example during contact sport
184
What is the Mechanism of injury of a LCL injury?
A direct blow to the MEDIAL aspect of the knee - for example during contact sport
185
What are the clinical features of a Quadriceps tendon rupture / Patellar tendon rupture?
Unable to perform straight leg raise
Unable to extend knee
Patella migration - away from the rupture
186
What is OA?
Degeneration of the articular cartilage, and remodelling of bone
187
Which joints in the hands are most affected by OA?
The Carpometacarpal Joints and DIPJs>PIPJs
188
List the clinical features of OA?
Pain worse at the end of the day
Bony deformities (Hebden, Bouchard)
Sqauring of CMC
Wasting of thenar eminence
Joint tenderness and swelling
crepitus
189
What are the xray findings in OA?
LOSS
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
190
What is the 1st line of mx in OA?
Paracetamol + Topical NSAIDs
191
What is Osteomalacia?
'Softening' of bones due to inadequate mineralisation
(Rickets in children)
192
What is the most common cause of osteomalacia?
Vitamin D deficiency
193
List the clinical features of osteomalacia?
Bone pain (esp, back, legs, pelvis)
Weakness
Fragility fractures
194
What sx may be seen in Rickets?
Bone pain
Skeletal deformities in Rickets - knock knee, bow legs, scoliosis, thickening of ankles/wrists
Short height
Waddling gait
195
What would be the results of a bone profile in osteomalacia?
LOW: calcium, phosphate
HIGH: PTH (compensatory), ALP
Low Vitamin D/ chronic kidney disease
196
What is the mx of osteomalacia?
Treat underlying cause - most commonly replacement of vitamin d
197
What is the mode of infection and spread in acute osteomyelitis in adults?
Usually contiguous spread
198
What is the mode of infection and spread in acute osteomyelitis in children?
Typically haematogenous spread
199
What the most common causative organism in acute osteomyelitis?
Staphylococcus aureus
200
What the most common causative organism of acute osteomyelitis in sickle cell patients?
salmonella
201
What is the 1st line ix for osteomyelitis?
Typically, X-ray- soft tissue swelling, periosteal reaction and cortical destruction
202
What is the GS Ix for osteomyelitis?
MRI
203
What is the mx of osteomyelitis?
Abx- Flucloxacillin, usually for a minimum of 6 weeks
204
What is OA?
Complex skeletal disease characterised by low bone density and micro-architectural defects in bone tissue, resulting in increased bone fragility and susceptibility to fracture
205
What bones do fragility fractures most affect?
Wrist
Spine
Hip
206
What is a fragility fracture?
fractures occurring spontaneously (vertebral), following a fall from standing height or less or during a routine activity.
207
List 5 RF for osteoporosisi?
hx fragility fracture,
falls,
hypogonadism,
premature menopause,
endocrine disorders,
malabsorptive disorders,
rheumatoid, myeloma, COPD/CLD/CKD.
Smoker,
alcohol > 14 units/wk,
low BMI
208
Which hormones/electrolytes manage bone remodelling?
PTH, Calcitonin, vitamin D
209
Where is calcitonin produced?
C cells of thyroid gland
210
What score is indicative of osteopenia?
T Score - 1.0 - -2.5 = osteopenia
211
What score is indicative of osteoporosis?
T score < -2.5 = osteoporosis
212
What is the 1st line mx of osteoporosis?
oral bisphosphonates e.g. alendronate or risedronate
213
List alternative tx of osteoporosis if 1st lien mx is not tolerated?
zoledronic acid, strontium ranelate, raloxifene,
denosumab, and teriparatide.
214
What is the MOA of bisphosphonates?
Pyrophosphate analogues - inhibit osteoclastic bone resorption
215
List the adverse effects of bisphosphonates?
gastritis/oesophagitis,
osteonecrosis of jaw,
atypical fractures
216
What is the MOA of Desonumab?
monoclonal antibody which inhibits RANK-ligand - inhibits osteoclast development
217
List the SE for desonumab?
Dyspnoea, Diarrhoea
218
What is ontogenesis imperfecta?
An autosomal dominant disease characterised by low levels of type 1 collagen - ‘brittle bone disease’
219
What are the nerve roots for the Musculocutaneous nerve and its sensation?
C5-C7
Lateral forearm
220
What is the motor innervation of the Musculocutaneous nerve?
Biceps and brachialis- flexion and supination of elbow
221
What would the clinical features be if there was a Musculocutaneous nerve radiculopathy?
Loss of elbow flexion, loss of biceps reflex
222
What are the nerve roots for the axillary nerve and its sensation?
Nerve roots - C5/C6
Sensation - Regimental badge - lower deltoid
223
What is the motor innervation of the axillary nerve?
Deltoid and teres minor - abduction, flexion and ER of the shoulder
224
What can cause an axillary nerve palsy?
Anterior shoulder dislocation
Fracture of the neck of the humerus
225
What are the features of an axillary nerve palsy?
Loss of shoulder abduction, regimental badge numbness
Radial nerve
226
What are the nerve roots for the radial nerve and its sensation?
Nerve roots - C5-T1
Sensation - Posterior arm and forearm, lateral 2/3rd of dorsal hand and fingers
227
What is the motor innervation of the radial nerve?
Triceps - elbow extension
228
What can cause a radial nerve palsy?
Fracture of proximal humerus
Fracture of radius
Saturday night palsy - falling asleep with arm over back of chair
229
What are the clinical features of a radial nerve palsy?
Loss of elbow extension, wrist extension, absent triceps reflex, loss of sensation over posterior forearm/arm
Wrist drop - cannot extend wrist/fingers → unopposed flexion
230
What are the nerve roots for the median nerve and its sensation?
Nerve roots - C5-T1
Sensation - Hand - thenar eminence, lateral 2/3 palm and lateral 3.5 fingers
231
What is the motor innervation of the median nerve?
anterior compartment of forearm - wrist flexion and abduction, pronation of forearm,
LLOAF muscles of hand
232
What can cause a median nerve palsy?
Carpal tunnel syndrome
Supracondylar humeral fractures
233
What are the clinical features of a median nerve palsy?
Hand of benediction, loss of sensation/motor as above
234
What are the clinical features of an ulnar nerve palsy?
Numbness over the medial 1/3rd hand, fingers and hypothenar eminence.
Weakness in flexion and aDduction of wrist
Claw hand.
235
What are the causes of ulnar nerve palsy?
Fractures of the medial epicondyle
Supracondylar humeral fractures
Cubital tunnel syndrome
236
What is the motor function of the femoral nerve?
Muscles in the anterior thigh - knee extension and thigh flexion
237
What is the sensory function of femoral nerve?
Anterior + medial thigh, medial leg and foot
238
What is the motor function of obturator nerve?
Thigh aDduction
239
What is the sensory function of the obturator nerve?
Medial thigh
240
What is the most likely nerve to be affected in a hip fracture?
Femoral nerve
241
What is the most likely nerve to be affected in an anterior hip dislocation?
Obturator nerve
242
what is the motor function of the sciatic nerve?
Posterior compartment of thigh - knee flexion + all muscles of leg and foot
243
what is the sensory function of the sciatic nerve?
Posterior thigh, lateral side of leg and sole and dorsum of foot
244
What is the motor function of the superior gluteal nerve?
Gluteus medius and minimus - hip aBduction
245
What is the sign present in a superior nerve palsy?
Positive trendelenburg sign - when standing on the affected leg/during walking the pelvis drops on the contralateral/swing side
246
What nerve innervates the gluteus maximus?
Inferior gluteal nerve
247
What is the motor function of the gluteus maximus?
hip extension/lateral rotation
248
What is the 1st line mx of Raynauds?
calcium channel blockers (nifedipine)
249
What is the 2nd line mx of raynauds?
IV Prostacyclin (epoprostenol infusions)
250
What genetic allele is most associated with RA?
Associated with HLA-DR4
251
Which joints are spared in RA?
Spares the DIP joints
252
What is the mx of RA flares?
Short-term treatment with steroids
253
What is the 1st lien mx of RA?
Commence DMARD monotherapy
254
What are the adverse effects for methotrexate?
Myelosuppression - monitor FBC
Liver cirrhosis - monitor LFTs
Methotrexate pneumonitis, pulmonary fibrosis
255
What are the adverse associated with sulfasalazine?
**Oligospermia**, interstitial lung disease, heinz body anaemia
256
What are the adverse associated with Leflunomide?
**Hypertension**, liver impairment, interstitial lung disease
257
What are the adverse associated with Hydroxychloroquine?
**Ophthalmic disease**- retinopathy, corneal deposits
258
What is the mx of RA in pregnancy?
Safe DMARDs during pregnancy: Sulfasalazine, Hydroxychloroquine (SHafe in pregnancy)
AVOID Methotrexate & leflunomide
259
What is palindromic rheumatism?
Relapsing/remitting monoarthritis of large joint
260
What is the mx of palindromic rheumatism?
Management: DMARDs as above - hydroxychloroquine
261
What markers may be raised in bloodworks of a patient with sarcoidosis?
Hypercalcaemia (overproduction of 1,25-(OH)2D3 by macrophages)
Raised ACE
Raised ESR
262
What spirometry pattern is consistent with sarcoidosis?
Restrictive pattern - low FVC, high Fev1%
263
List the muscles and their respective function of the rotator cuff?
Supraspinatus - 1st 15 degrees of shoulder ABduction
Infraspinatus - lateral rotation
Teres minor - ADduction and lateral rotation
Subscapularis - ADduction and medial rotation
264
What is the mx of spinal mets?
Analgesia as per WHO 3-step ladder
Bisphosphonates
---For all patients with vertebral involvement from myeloma or breast cancer
---Consider in prostate cancer if other analgesia fails
Radiotherapy or surgery
265
What are the clinical features and mechanism of injuryW of a mallet finger?
Extensor tendon avulsed from distal phalanx
Mechanism: ball striking tip of finger causing hyperextension
266
What is the Ix and Mx of a mallet finger?
Investigation
XR to ensure no avulsion fracture
Management
Splint for 6 weeks
267
What are the clinical features of flexor tenosynovitis?
**Kanavel signs:**
Uniform swelling
Pain palpation tendon
Pain passive flexion
Finger held in flexion
268
What is the mx of flexor tenosynovitis?
If any Kanavel signs ------- > Urgent surgery to release pus
Antibiotics
269
what is the mx of paronychia?
Warm compress
Topical (fusidic) systemic (flucloxacillin) antibiotics
If severe i.e. fluctuant pus or abscess- incision and drainage
270
What are the complications associated with a scaphoid fracture?
Higher risk in proximal or displaced fractures
Non-union
Avascular necrosis
--Impairment of vascular supply to involved bone fragment
--Stiff and painful wrist
--Later on: loss of strength, reduced ROM wrist and osteoarthritis
271
What is a colles fracture?
Distal radial fracture
Results in dorsal displacement of distal fragment
‘Dinner-fork’ deformity
272
What is the mx of a colles fracture?
Immobilise in dorsal backslab cast and elevate with sling
Manipulation under anaesthetic (MUA) if above does not results in satisfactory position
If complex (comminuted, intra-articular, re-displaced) or above fails- surgical fixation
273
What are the features of frozen shoulder?
External rotation is affected
both active and passive
274
How is an undisplaced intracapsular/subcapital hip fracture managed?
THR or Hemiarthroplasty
275
What is the management of an undisplaced intracapsular fracture?
Internal fixation or hemiarthroplasty if unfit
276
What is the mx of stable intertrochanteric fracture?
DHS
277
What is the mx of subtrochanteric fracture?
Intermedulalry nail
278
What is the most appropriate imaging modality for a meniscal tear?
MRI
279
What is the name of the fracture that is most common with fist fights?
Bennett's fracture- Intrarticular fracture of base of thumb
280
What is monteggia's fracture?
Dislocation of the proximal radioulnar joint in association with an ulna fracture (FOOSH with forced pronation)
281
what is galeazzi fracture?
Radial shaft fracture with associated dislocation of the distal radioulnar joint
282
What is Potts fracture?
Bimalleolar ankle fracture
283
what is the feature of medial epicondylitis?
pain and tenderness localised to the medial epicondyle
pain is aggravated by wrist flexion and pronation
284
what are the features of lateral epicondylitis?
Worsening symptoms with the wrist extended and supinate
285
What are the features of a subacromial impingement?
Pain on overhead activities and demonstrate a painful arc of abduction on examination - worse between 90 and 120 degrees. There may also be popping, snapping or grinding.
286
What is the neurovascular structure is most likely to compromised in scaphoid fracture?
Dorsal carpal arch of the radial artery
287
What nerve is most likely affected in meralgia paraesthetica?
lateral cutaneous nerve of thigh
288
What is the mx of primary thromboprophylaxis in antiphospholipid syndrome?
low-dose aspirin
289
What is the initial mx of choice for discoid lupus erythematous?
Initial mx- Topical steroids
290
What is the 2nd line mx of choice for discoid lupus erythematous?
hydroxychloroquine
291
Is hydroxychloroquine safe in pregnancy?
Yes- cna be continued
292
What are the most common causes of drug induced lupus?
Most common causes
procainamide
hydralazine
Less common causes
isoniazid
minocycline
phenytoin
293
What is the name of the rash associated with antiphospholipid syndrome?
Livedo reticularis
294
List the cardiac complications involved in Ehlers Danlos?
Aortic regurgitation
Mitral valve prolapse
Aortic dissection
295
What Ix must be conducted in a patient taking alendronate for 5 years?
Assess 10 year fracture risk
