Musculoskeletal Flashcards
Knee injury DDx
ACL tear
* ACL attaches femur to tibia - restrains anterior tibia movement + tibial rotation/varus/valgus angulation -> if injured anterior translation/rotation
* PC: audible pop, haemarthrosis within hours
* “Terrible Triad”: ACL, MCL & medial meniscus tears - valgus stress from contact injury/high velocity trauma
* Ix: Lachman (or anterior drawer) - supine with knee flexed 30 degrees and externally rotated, one hand behind tibia and one on front of femur -> pull anteriorly on tibia
* Mx: knee MRI -> largely surgical Mx
Patella fracture - direct blow/hyperextenion of knee
* PC: pain, bruise/abrasions to knee, if displaced fracture - defect palpable +/- haemarthrosis
* DIsplaced, transverse fractures prevent straight leg raise (also present in ruptured quads/patella tendon)
* Mx: POP immobilisation/ORIF
Patella dislocation - twisting injury/direct blow with knee in flexion
* Seen in adolescent girls - dislocated laterally +/- osteochondral fracture
* PC: knee in flexion, lateral patella displacement
* May reduce spontaneously
Prepatellar bursitis - friction between skin and patella (if constantly on knees)
* PC: knee pain, redness, swelling, difficulty kneeling/walking
* O/E: tenderness/swelling/warmth/redness superficial to patella
* If systemic Sx ?septic bursitis/septic arthritis
* Mx: rest, ice, NSAIDs +/- aspiration/hydrocortisone inj
Tibial plateau fracture - fracture of tibial condyles
* PC: fall from height/knee hit violently at side “bumper fracture” -> knee varus/valgus -> knee swollen/derformed/bruised - difficult to examine due to pain
* Mx: CT -> complex fractures require early specialist input
Osgood-Schlatter disease - small avulsion fractures within tibial tuberosity from traction of patellar tendon on immature tibial tuberosity during forceful contractions of quads
* Males aged 10-15yrs following sport
* PC: pain/swelling below knee - worse on activity
* Can get enlarged tibial tubercle from healed avulsion fractures
* Mx: rest
Haemarthrosis - bleeding into joint space e.g. haemophilia (can damage articular cartilage if repeat bleeds)
* Mx: administer appropraite factor, removable splint, gentle passive exercise within 48hrs of bleed
Give an overview of hallux valgus
Hallux valgus - most common foot deformity -> big toe (hallux) assumes valgus position
* PC: In either young or elderly, bilateral
* Causes: footwear, familial, joint laxity (Marfan’s/Ehlers-Danlos), weak foot muscles in elderly, rheum disease
* Ix: XR - subluxation/OA 1st metatarsophalangeal joint
* Mx - depends on age, if old conservative otherwise surgical
Compartment syndrome Key Signs & Sx? RFs? Ix? Mx?
Classic = 6Ps: pain, pallor, perishingly cold, pulseless, paraesthesia, paralysis (BUT these tend to be more associated with PVD than compartment syndrome)
Typical presentation: tightness in compartment + acute disproportionate pain (worse on stretching) after trauma:
- Acute is following fracture, soft tissue/reperfusion/thermal injury
- Chronic (pain on exercise) often in long-distance runners
- Other early sign = paraesthesia
- Late signs: pallor, pulseless, paralysis
RFs: Trauma, bleeding disorder (haemophilia), compartment support (tight cast/wrappings), burns, intense muscular activity (long distance runner)
Ix:
- Compartment differential pressure measurement - within 20-30mmHg = fasciotomy needed
- +/- serum CK, urine myoglobin (rhabdomyolysis)
Acute Mx: dressing release + morphine
- 2nd line = complete fasciotomy (open all 4 compartments of lower leg)
- 3rd line = amputation
- If rhabdomyolysis —> hydration +/- Na bicarbonate (urine alkalisation) +/- haemodialysis (metabolic acidosis)
Chronic Mx: limit exercise + NSAIDs
- 2nd line = fasciotomy
RA - Def? Presentation? Ix? Mx?
Def: AI process causing synovial joint inflammation (synovitis) with destruction of peri-articular structures (assoc with HLA DR4/1)
Presentation: joint pain @rest, swelling & stiffness in morning
- Exam:
- Symmetrical swelling w/ DIP sparing
- Muscle wasting, ulnar deviation, volar subluxation @MCPs
- Swan-neck & Boutonnieres’ & Z-thumb deformities
- NOTE: if nail changes/extensor rash = psoriatic arthritis
- Extra-articular manifestations of RA = NO HIVE:
- Nodules - rheumatoid nodules (25%)
- Osteoporosis (worse by steroids & immobilisation)
- Heart & Haem - pericarditis, anaemia, Felty’s syndrome (RA + splenomegaly + neutropenia)
-
Interstitial:
- Pul fibrosis (& pleural effusions, Caplan’s syndrome - nodules from RA + pneumoconiosis)
- Interstitial nephritis (nephrotic syndrome)
-
Vasculitis (high titre RF)
- Peripheral neuropathy presenting as mono-neuritis multiplex
- Other neuro: carpal tunnel, cervical myelopathy
- Splinter haemorrhages, cutaneous ulcers, distal gangrene
- Eye pathologies - secondary sjogren’s syndrome (dry eyes, mouth & cough), episcleritis
Ix: anti-RF/CCP (ANA in 20%), ESR/CRP, FBC (normochromic/cystic anaemia, reactive thrombocytosis) X-rays
Mx:
* 1st - Monotherapy DMARD (methotrexate/sulfasalazine) + bridging pred until Sx resolved
* Target met?
* Yes = keep drug regime + lifestyle changes (stay active, healthy diet, weight loss if appropriate, alcohol/smoking)
* No = titrate cDMARD/trial alternative cDMARD ± dual therapy
* Target met?
* Yes = keep drug regime + lifestyle changes
* No = biological agents if DAS28 score >5.1 (severe burden of disease)
RA Hand X-ray findings?
- Joint erosion
- Periarticular osteopenia
- Ulnar deviation
- Z-thumb
- Swan neck
Extra-articular manifestations of RA –> what would you also examine after hands?
NO HIVE:
- Nodules - rheumatoid nodules (25%)
- Osteoporosis (worse by steroids & immobilisation)
- Heart & haem - pericarditis, anaemia, Felty’s syndrome (RA + splenomegaly + neutropenia)
- Interstitial - pul fibrosis (& pleural effusions, Caplan’s syndrome - nodules from RA + pneumoconiosis), interstitial nephritis (nephrotic syndrome)
-
Vasculitis (high titre RF)
-
Peripheral neuropathy presenting as mono-neuritis multiplex
- Other neuro: carpal tunnel, cervical myelopathy
- Splinter haemorrhages, cutaneous ulcers, distal gangrene
-
Peripheral neuropathy presenting as mono-neuritis multiplex
- Eye pathologies - secondary sjogren’s syndrome (dry eyes, mouth & cough), episcleritis
Finger deformities in RA - flexion & extension?
Swan neck deformity - PIP hyperextension, DIP flexion
Boutonniere’s deformity - PIP flexion, DIP hyperextension
Other signs of RA: Z-thumb, ulnar deviation
Give an overview of:
1. Gout vs Pseudogout
2. Rheumatoid arthritis
3. Infective arthritis
4. Spondyloarthropathies
Gout - purine metabolism disorder -> raised blood uric acid lvl + urate crystals in joints/tissues
* PC: up to 2wks of sudden burning pain/swelling/redness/warmth/stiffness in 1st MTP joint (big toe = 75%)
* Ix: normally clinical Dx
* Definitive (but rarely done) = synovial fluid needle-shaped -ve birefringent crystal
* Bloods - serum uric acid 4-6wks after attack >380mmol/L (often normal lvl during attack)
* Joint X-ray - often normal, non-specific soft tissue swelling/subcortical cysts (bone erosion if advanced)
* Mx:
* Acute: NSAIDs/Colchicine (not in renal/liver impairmen/breast feeding/pregnant/meds e.g. clari, if neither appropriate give oral Pred (5 days)/steroid joint injection)
* Preventative: dietary advice (low purine) + Xanthine oxidase inhibitor e.g. allopurinol (2nd line - febuxostat)
Pseudogout - calcium pyrophosphate deposition
* Acute CPPD crystal arthrtis - same as acute gout attack except knee/upper joints (shoulder/elbow/wrist/pubic symphysis)
* Chronic CPPD crystal inflammatory arthritis - mimics OA/RA with chr intermittent upper/lower limb peripheral joint pain/swelling
* Ix: can be difficult to diagnose with synovial fluid as crystals small/sparse - rhomboid/rod-shaped & weakly +ve birefringent
* Mx: intra-articular corticosteroids
Rheumatoid arthritis - most common inflammatory arthritis (1% population), assoc HLA-DR B1 with environmental trigger
* PC: articular (small joints of hands/feet) & extra-articular
* Dx: RF (non-specific), anti-CCP, ACPA, CRP/ESR raised
* Mx: early/aggressive Tx - DMARDs (methotrexate)
Infective arthritis:
Septic arthritis - destructive arthropathy caused by intra-articular infection (S. aureus)
* PC: Hot swollen joint with reduced RoM (large joint with good blood supply - shoulder/hip/knee)
* Mx: needle aspiration before abx –> fluids for 3Cs & G (cells, culture, crystals, gram stain) –> empirical IV abx (based on aspiration)
* NOTE: if prosthetic joint - biofilm can be created -> more complicated, coag neg staph more common
TB arthritis - tubercular arthropathy never primary always from pul/lymph node TB
* Most common sites - Spine > hip
* Mx: complete course abx
Spondyloarthropathies (reactive arthritis, PA, Ank Spond, enteropathic arthritis): - share assoc with HLA-B27
Reactive arthritis - classical triad of post-inf arthritis (GI/GU), non-gonococcal urethritis, conjunctivitis “can’t see, can’t pee, can’t bend the knee”
* PC: GI/GU inf 3-4wks before onset, asymmetrical oligoarthritis affecting large joints lower limb +/- fever, enthesitis, dactylitis, conjunctivitis/iritis, skin lesions
* Ix: clinical Dx
* Mx: NSAIDs, CSs, DMARDs (40% progress to chronic arthritis)
Ankylosing spondylitis - seronegative axial/sacroiliac spondylitis
* PC: young adults insidious inflammatory back pain (worse in morning, better with use) -> disease progression causes spinal fusion
* Ix: Schober’s test on spinal exam (+ve if <3cm), XR (sacrilitis, sclerosis, erosion, widening joint spaces, fusion), MRI spine/sacroiliac joints (sacriitis, shiny corners = romanus lesions)
* Mx: NSAIDS/physio/steroid inj +/- DMARDs/TNF-alpha/IL-17 blocker
Psoriatic arthritis - chr seronegative inflam arthritis assoc w/ psoriasis
* Derm features psoriasis -> Oligo/monoarticular innitial joint pattern + DIP involvement + dactylitis (entire digit swelling)/sacroilitis
* NOTE: overtime moves to polyarticular joint pattern and erosive arthritis
* Criteria name: CASPAR criteria - established inflame arthritis/enthesitis + ≥3 of options
* Mx:
* NSAIDs for limited disease +/- intrarticular steroids/methotrexate/TNF-alpha inhibitors
* Psoriasis Tx - precipitant avoidance/exercise/physio, topical steroids, calcipotriol, PUVA*
Osteoarthritis - presentation? Ix? Mx?
Pathogenesis - loss of cartilage + bone remodelling –> inflammation & osteophytes
Presentation: pain worse with activity, crepitus + reduced RoM
- Hands - DIP & PIP swelling = Heberden’s (DIP) & Bouchard’s nodules (PIP)
- Common site = base of the thumb (1st carpometacarpal joint)
- Weight-bearing joints affected e.g. knees
- NOTE: midline knee scar = total knee replacement –> fixed flexion deformity post-replacement
Ix: XR (2 views e.g. AP & lateral)
- LOSS: Loss of joint space, Osteophytes, Subchondral sclerosis, Subchondral cysts
Mx:
- Conservative – physio, exercise, weight loss
- Medical:
- Analgesia (paracetamol –> topical NSAID –> oral NSAID/opioid)
- IA CS injection
- Surgical – arthroplasty (e.g. TJR)
OA X-ray changes
Osteoporosis Mx? Using bisphosphonates –> jaw pain & swelling?
0 to -2.5 DEXA:
* Conservative - exercise, reduce alcohol, balanced diet, Tx underlying causes
* Repeat DEXA @2yrs
≤-2.5 DEXA:
* 1st line - Bisphosphonates PO (e.g. alendronic acid) –> if not tolerate can trial Denosumab/Raloxifene/Teriparatide
* Vit D + Ca replacement (if inadequate sunlight/intake exposure)
* Review Tx every 3-5yrs
NOTE:
- If premature menopause –> discuss HRT
- If on high-dose CS (≥7.5mg OD for ≥3 months) –> consider bisphosphonates for bone protection
Osteonecrosis of the jaw
Ankle fracture rules? Classification? Ix? Mx?
Rules = Ottawa rules - for what ankle fractures qualify for an X-ray
- Ankle XR:
- Pain over malleolar zone
- Tenderness along distal 6cm of the posterior edge of tibia/fibula
- Inability to weight bear
- Foot XR:
- Pain over midfoot zone
- Tenderness at base of 5th metatarsal/navicular bone
- Inability to weight bear
Classification = Weber classification - location of the fibula fracture in relation to the Syndesmosis (Distal Tibiofibula Syndesmosis - ligament between tibia & fibula)
- Normal
- A - fracture distal to the syndesmosis
- B - fracture @level of the syndesmosis
- C - Fracture above the syndesmosis
- If also affecting the medial malleolus = bimalleolar fracture
Ix: AP, lateral & oblique ankle X-ray
- CT (distal tibia & hindfoot) - comminuted fracture
- MRI - ankle ligaments & tendons
Mx: depends on Weber classification & level of displacement
- No to all Ottawa rules = conservative Mx: RICE – rest, immobilisation, compression, elevation
- Unimalleolar:
- No evidence of ligamentous injury on X-ray –> discharge w/ cast + fracture clinic follow-up X-rays
- Evidence = UNSTABLE
- Bimalleolar/unstable –> closed reduction (if joint dislocated on X-ray) –> refer for surgical fixation
Ankle fracture X-ray
Systemic sclerosis (scleroderma) - def? Subsets? Presentation? Ix? Raynaud’s Mx?
Def: multisystem disease - inflammation, vascular abn, fibrosis
Subsets:
* Limited cutaneous SS (CREST) - skin changes limited to forearm/calf/distal/peri-oral area
* Diffuse cutaneous SS - more extensive, upper arms, legs, trunk
Presentation:
* Swelling of hands & feet, Reynaud’s phenomenon, skin thickening around hands/mouth
* Heartburn/reflux/dysphagia, bloating
* Arthralgia/myalgia
* Dyspnoea & dry crackles (pul fibrosis, pul HTN)
* Scleroderma renal crisis (renal failure, marked HTN)
Ix:
* Bedside: ECG, urine dip, pulmonary function tests (pul fibrosis)
* Bloods:
* FBC, U&E, LFTs, CRP/ESR,
* Abs: ANA (also in SLE, AI hep), anti-centromere (limited cutaneous), SCL-70 aka topoisomerase (diffuse cutaneous)
* Imaging: CXR, Echo, barium swallow
Mx:
* Specialist MDT
* Conservative: smoking cessation, emollients, avoid cold/gloves (Raynaud’s), physio, OT
* Medical:
* CCB (nifedipine) for Raynaud’s
* Omeprazole, prokinetic (domperidone) for GI Sx
* Analgesia (for joint pain)
* ACEi (for HTN)
* Steroids + IS (methotrexate) –> if diffuse disease/complications (pul fibrosis)
* Scleroderma renal crisis - ACEi + renal dialysis/transplant
GCA - Presentation? Ix? Mx?
GCA is most common primary vasculitis
Presentation: headache, scalp pain/tenderness, aching & stiffness, jaw/limb claudication
- Loss of vision - can have amaurosis fugax, blindness if vision not treated within hrs
- Commonly associated with polymyalgia rheumatica (PMR)
Ix:
- ESR & CRP
- USS temporal artery –> bilateral temporal artery biopsies - up to 2wks after high-dose steroids
Mx: prednisolone, if visual Sx consider IV methylprednisolone
- If persistent active/relapsing - IL-6 receptor blocker (Tocilizumab)
Neck of femur anatomy? Breakdown?
RFs? Presentation? Ix? (incl. fracture type & classification) Mx?
NoF anatomy - blood supply:
- Deep femoral artery (the main branch of the femoral artery) - gives rise to:
- Medial & lateral circumflex femoral arteries - gives rise to:
- Retinacular arteries - progress superiorly up to the head of the femur
- Medial & lateral circumflex femoral arteries - gives rise to:
- Artery of ligamentum teres - only a very small component of perfusion of the head/neck of the femur
- NOTE: retrograde blood supply from distal to proximal
NOF anatomy - joint capsule (ligaments surrounding the head of the femur and acetabulum):
- Intracapsular - fracture within the joint capsule (proximal to the trochanteric line) - high risk of blood supply compromise as retinacular vessels sheared –> Avascular Necrosis (AVN)
- Extracapsular - fracture outside the joint capsule (distal to the trochanteric line) - less risk of blood supply compromise
RFs: elderly, freq falls, osteoporosis, high impact trauma, post-menopausal women
Presentation: externally rotated + shortened leg
- Typically old, frail, osteoporosis/malacia
Ix:
- Examine joints above & below, NV exam of lower limb
- FBC, U&E, LFTs, CRP, G&S (if NoF - need surgery)
- Hip XR –> CT/MRI (if normal X-ray but high suspicion)
- NOTE: NoF fracture Xrays: Shenton line - if not smooth = likely fracture
-
NoF fracture types - based on location:
- Sub-capital (slightly below the head)
- Transcervical
- Basicervical
- Intertrochanteric
- Subtrochanteric
-
Garden classification - level of displacement:
- Stage 1 - incomplete (not all the way through the bone)
- Stage 2 - complete (but fracture components intact)
- Stage 3 - complete with some displacement
- Stage 4 - complete with significant displacement
Mx:
- Conservative - analgesia
- Medical - bisphosphonates (bone protection) + Vit D + DEXA
- Surgical:
- Subtrochanteric - internal fixation = femoral nail
- Intertrochanteric – internal fixation = dynamic hip screw (DHS)
- Intracapsular:
- Undisplaced (Garden I&II) – cannulated hip screw or DHS
- Displaced (Garden III & IV) - higher risk of AVN:
- <55yrs – reduction & fixation w/ screws
- >65yrs – replace:
- Fit = THR (HoF & acetabulum replaced)
- Independent, mobile with ≤1 stick, no cognitive impairment
- Not fit = hemiarthroplasty (just HoF replaced)
- Fit = THR (HoF & acetabulum replaced)
Tenosynovitis of hand & wrist - def? RFs? Presentation of different types? Ix? Mx?
Tenosynovitis def:
- Involves extrinsic tendons of hand & wrist & corresponding retinacular sheath
- Characterised as tendon irritation manifesting as pain –> progress to catching and locking when tendon gliding fails.
RFs: insulin-dep DM, pregnancy/lactation, dom-hand involvement
Presentation: location over retinacular sheat, pain increases with motion,
-
Trigger finger:
- Painful popping on finger flexion/extension (catching of flexor tendon)
- Palpable nodule @level of metacarpal head in palm
-
De Quervain’s disease:
- Pain, tenderness, swelling localised to radial wrist (1-2cm proximal to radial styloid)
- Worse on thumb mov/ulnar deviation
- Finkelstein test (thumb in hand + ulnar deviation –> pain)
-
Intersection syndrome:
- Pain & swelling 4cm proximal to wrist joint ± redness/palpable crepitus
- Much worse on resisted wrist extension
- Extensor pollicis longus:
- Thumb IP mov –> pain @Lister’s tubercle
- Extensor carpi ulnaris:
- Ulnar wrist pain
- Worse with extension/ulnar deviation against resistance
- Flexor carpi radialis:
- Pain @palmar wrist crease over scaphoid tubercle + along tendon ± localised swelling/ganglion cyst
- Worse with resisted wrist flexion, radial deviation
Ix: high-res USS
Mx:
- NSAID ±splinting
- CS injection (sheath/compartment): flexor tendon sheath (trigger finger), 1st dorsal compartment (De Quervain’s disease)
- Surgery (surgical release of compartment)
How do you approach an MSK X-ray?
Describing a fracture on XR approach?
MSK X-RAY APPROACH:
- NOTE: likely knee or hip x-ray in the exam
General:
- Name, DoB ±PC
- XR - date & time, views (AP/lateral), area of body, rotation, penetration (RI_P_E)
- NOTE: always do ≥2 views, compare to previous X-rays, look at imaging for joints above and below
ABCS approach: Alignment & joint space, Bone texture, Cortices, Soft tissues
-
Alignment & joint space:
- Changes suggest –> fracture, subluxation (still touch) or dislocation
- Displacement - describe the position of fragment distal to fracture site described
- Joint space:
- Narrowing due to cartilage loss/calcification (chondrocalcinosis)/new bone (osteophytes)
- Subchondral sclerosis is increased bone density along joint lines (OA)
- Bone texture - altered density (subchondral cyst - increased density, OA)/disruption (blurry - osteomyelitis) in trabeculae (inside of bone)/cortex (outer coating)
-
Cortices - trace around outside of each bone
- Step = possible pathology:
- Fracture
- Bony destruction - inf or tumour (primary/secondary)
- Periosteal reaction (new bone in response to injury/stimuli, appears as pale bone on the outside) - can be only sign of stress/healing fracture, mild osteomyelitis, tumour)
- Step = possible pathology:
- Soft tissues - swelling, foreign bodies (lipohaemarthrosis caused by fracture), effusions
DESCRIBE A FRACTURE:
Where - what bone? location (proximal, middle, distal OR epiphysis, metaphysis, diaphysis)? Does it involve articular surface (intra/extra-articular)?
Types:
1. Simple vs Compound:
- Simple: closed fracture i.e. only bone involved
-
Compound: open fracture i.e. bone exposed to the external environment - (↑risk of infection → ↑fracture non-union) Open fractures are emergencies and require urgent management with:
- IV antibiotics
- Tetanus prophylaxis
- Wound debridement
2. Subtype:
- Complete (all the way through the bone)
- Transverse: perpendicular to long axis of bone
- Oblique: tangential to long axis of bone
- Spiral: oblique and rotating around the shaft
- Comminuted: > 2 fragments –> CT to further assess
- Impacted: broken ends of bone are jammed together by the force of injury, fracture line is indistinct
- Linear: parallel to axis of the bone
- Avulsion: bone attached to tendon/ligament is pulled away from main bone
- Incomplete (not whole cortex, most common in children):
- Greenstick: bone bends and cracks, occurs < 10yrs
- Salter-Harris: growth plate involvement
Displacement - describe the position of distal fragment to body (anterior/posterior)
- Angulation: change in bone axis (varus/valgus, dorsal/palmar, radial/ulna)
- Translation: movement of fractured bones away from each other (% of bone width)
OVERALL: 1) Type (simple/compound > subtype) 2) Relevant region, side and name of bone 3) Displacement (& angulation, translation)
- Example: Simple oblique fracture of the proximal right tibia with posterior displacement
Giving a differential for MSK - structure? Ix? Mx?
DDx: degenerative, infective, inflammatory, traumatic, congenital
Ix: 2 views = AP & lateral views + imaging of joints above and below as well
Mx: conservative, medical, surgical
Dupuytren’s contracture - def? causes? image?
Def: hypertrophy & contracture of palmar aponeurosis (fascia retinaculum)
* RFs: DM, smoking, chronic alcholism, seizures, infections
* PC: palmar nodule and cord adherent to skin, flexion contracture of ulnar fingers (4th/little fingers)
Joints in the hand? Bones in the wrist?
CMCs –> MCPs –> PIPs –> DIPs
Carpal bones: Some Lovers Try Positions That They Can’t Handle
- Base of wrist (radial to ulnar): Scaphoid, Lunate, Triquetrum, Pisiform
- CMCs (radial to ulnar): Trapezium (trapezi”thumb”), Trapezoid, Capitate, Hamate
Landmarks on pelvic XR (hip)? How can I see if hip fracture?
Look at Shenton’s line (inferior pubic rami) = NoF fracture
Fibromyalgia vs Polymyalgia Rheumatica (PMR)
Fibromyalgia - chronic pain syndrome (unknown origin)
* RFs: AI rheum conditions, female
* Clinical Dx - diagnosed by the presence of widespread body pain ≥ 3 months on both sides of body, 11 out of 18 tender areas on digital palpation
* Ix: bloods (exclude other causes) - FBC, TFT, ESR/CRP, vit-D, Ab-testing (RF, anti-CCP, ANA)
* DDx: chronic fatigue, hypothyroid, polymyalgia rheumatica, polymyositis
* Mx: no cure, TCA e.g. amitryptiline, education, exercise, CBT ± referral to psych
Polymyalgia Rheumatica - inflammatory rheum condition
* PC: elderly women with muscle aches and joint stiffness in shoulder/hip (takes 2-3hrs to loosen up in the morning)
* Associated with GCA (15-20% have GCA; 40-60% GCA have PMR)
* GCA = most common primary vasculitis, Ix with bilateral temporal atery biopsies after high dose steroids
* Dx: clinical + ESR, CRP, FBC (to rule out haem disorders)
* Mx: prednisolone + osteoporosis prevention (Ca, Vit D, Bisphosphonates) +/- methotrexate/folic acid
Foot pain differentials
Plantar fasciitis - MOST COMMON cause of pain beneath heel
* Self-lim degen condition from tissue overload/breakdown/incomplete repair
* Assoc w/ age, overweight, sedentary, poor footwear, more likely with flat/pronated foot
* Mx: footwear, preventative, physio, steroid inj
* NOTE: biliateral think psoriatic/reactive arthritis
Morton’s neuroma - irritation interdigital nerve by compression between 3rd-4th metatarsal heads often in tightly fitting shoes +/- inflamed bursa @same site
* O/E: Mulder’s click - squeeze metatarsal heads together -> painful click
* Ix: US scan
Freiberg’s disease - osteochondrosis of toes - articular surfaces 2nd/3rd metatarsal heads collapse
* Commonly girls 12-15yrs
* Pain weight-bearing + restricts activity
* Mx: rest + metatarsal pad +/- surgery
Achilles tendon rupture
* 30-50s recreational athlete - activity with forceful pushoff of foot/fall w/ forced dorsiflexion
* RFs: steroids, gout, RA, SLE, quinolone abx e.g. cipro
* PC: Sharp pain at back of ankle +/- “snap” -> dull ache, unable to stand on tiptoe
* O/E: localised swelling +/- palpable tendon defect, weak plantar flexion
* Simmonds/Thompson test: +ve = absence of plantar flexion on squeezing calf muscle (lying prone/knees passively flexed) -> complete achilles tendon rupture
* Mx: US/MRI (if Dx unclear) -> non-weightbearing + splint/surgical repair
NOTE - DDx for Achilles TR = Medial calf (medial gastrocnemius) tear
* Intermittently active athlete “weekend warrior” - acute forceful pushoff with foot
* PC: “stick struck calf” + “pop” + pain in calf radiating to knee/ankle
* O/E: asymmetrical calf swelling/discolouration spreading to ankle/foot, passive ankle dorsiflexion = pain -> once swelling resolved defect in medial gastrocnemius (note - no defect in achilles tendon, Thompson -ve)
* Mx: RICE + early weightbearing as tolerated
Maisonneuvre fracture - pronation external rotation force -> spiral fracture upper third fibula (assoc w/ tear distal tibiofibular syndesmosis & IO membrane) + medial malleolus fracture (or rupture of deep deltoid ligament)
* NOTE: this injury can be difficult to detect
March fracture - stress fracture of metatarsals - seen in repetitive walking/running (arms/runners)
* Most common site = 2nd MT shaft (others - 3rd MT/navicular)
* PC: tender lump on dorsum of foot - just distal to midshalf of MT bone
* Ix: XR - normal (later = hairline fracture/callus)
* Mx: rest, elevation, analgesia, modified daily acitivity
Calcaneal fractures - young men, axial loading injury (can be B/L)
* Causes: fall from height >6ft, motor vehicle collision, overuse/stress fracture e.g. athlete
* PC: pain, oedema, bruising, heel/plantar arch deformity, can’t weight bear
* O/E: **Mondor sign **- bruising tracking distally to sole of foot (on plantar region)
* Mx: if non-op - cast immobilisation, if op - closed reduction with percutaneuous pinning, ORIF, primary subtalar arthrodesis
- Incomplete spinal cord pathology differentials
- Cauda equina vs conus medullaris syndrome
Incomplete spinal cord lesions:
A. Brown-Sequard syndrome - hemisection of cord normally due to penetrating trauma of cervical/thoracic spine
* Ipsilateral loss of proprioception (dorsal column)/motor (corticospinal) + contralateral pain/temp sensation (spinothalamic)
B. Central cord syndrome - MOST COMMON = damage to central spinal cord (normally due to trauma to cervical cord) - 10% spinal injuries
* Commonly older with cervical spondylosis/OA (or young with substantial trauma to cervical spine e.g. rugby tackle)
* Disproportionate motor impairment in U>L limbs + variable sensory loss below injury + bladder dysfunction/urinary retention
C. Anterior cord syndrome (ventral cord syndrome)
* Affects anterior cord -> motor paralysis & loss of pain, temp & autonomic dysfunction - most commonly due to anterior spinal artery ischaemia
Cauda equina syndrome - NM & urogenital Sx from compression lumbosacral nerve roots (LMN) below conus medullaris (terminal spinal cord @L1)
* Low back pain, sciatica, saddle sensory disturbance, bladder/bowel dysfunction, lower extremity motor/sensory loss
Conus medullaris syndrome - injury/insult to conus medullaris (UMN) and lumbar nerve roots (LMN) - has combo of UMN/LMN presentation but otherwise very simmilar to cauda equina syndrome
Spinal cord transection - spinal cord tear from sign traumatic injury - LMN paralysis at level of injury, UMN (spastic) paralysis below level of injury
* If only partial tear can be some retained sensory-motor function
Special tests during MSK exam for:
* Hand/wrist
* Hip
* Knee
* Spine
Hand/wrist exam:
* Phalen’s test - reverse prayer sign >1 min (pain/paraesthesia = Carpal tunnel syndrome)
* Tinel’s test - median nerve at its course in the wrist - tap (paraesthesia = Carpal tunnel syndrome)
* Finkelstein’s test - hand closed around thumb + ulnar deviation (pain = de Quervain’s tenosynovitis)
Hip exam:
* Trendelenburg’s test - stand on one leg - if hip dips on raised side = muscle weakness on standing leg
* Thomas’s test - lay on back, flex hip on one side with contralateral leg flat - if flat thigh forced up = fixed flexion deformity of this leg
Knee exam - 3Cs = Cartilage (McMurray’s), Collaterals, Cruciates (Lachman’s, A/P-drawer):
* Anterior & posterior drawer - gripping calf -> tug forward (anterior displacement = ACL) / push backwards (posterior = PCL)
* Lachman’s test - flex knee to 30 degrees, right hand pulls towards you holding the tibia, left hand pushes awa holding the femur (anterior displacement = ACL)
* Collateral ligament assessment - varus (LCL) & valgus stress tests (MCL) - knee in varus palpating lateral joint and vice versa
* McMurray’s test (menisci assessment) - passively flex knee, hold the right foot with right hand apply external pressure with the left hand palpating the knee (abducting at the hip) while fixating and external rotating with the right hand, slowly extend at the knee watching for a click/discomfort = medial meniscus tear (opposite for lateral meniscus tear)
Spine exam:
* Schober’s test: - mark midline between dimples of venus & 10cm above - ask to touch toes, measure distance - should increase by 8-10cm (<3cm = ank spond - fusion of sacro-iliac & lower spine)
* Sciatic stretch test - straight leg raise + ankle dorsiflexion (pain in thigh & buttocks = sciatica (L3-S3 nerve root irritation)
* Femoral nerve test - prone + extend hip (pain in thigh & buttocks =L2-4 nerve root irritation)
Give an overview of tennis elbow
**Tennis elbow **(lateral epicondylitis) - wrist extension/supination can cause overuse injury of extensor muscles starting on lateral epicondylar region of distal humerus = tendinosis of origin of extensor carpi radialis brevis (ECRB)
* PC: athelete with lateral elbow/forearm pain exacerbated by use (worst tenderness just distal to lateral epicondyle)
* O/E: wrist extension/supination against resistance with elbow extended exacerbates Sx
* Mx: rest, “tennis elbow strap”, NSAIDs +/- steroid injection
Falling onto wrist differentials?
Distal radius fractures:
* Colles’ fracture - old women with OP fall on an outstretched hand - dorsally displaced distal radius fracture
* Ix: AP/lateral +/- oblique XR
* Mx: if non-displaced - immobilisation, if displaced - closed reduction & immobilisation with plaster splint, surgery if unstable fracture
* Smith’s fracture - fall on flexed wrist, displaced in a palmar direction (palm of the wrist)
* Ix/Mx as above - more likely to need surgery
* Barton’s fracture - intra-articular fracture + dislocation of radiocarpal joint
* Dorsal - like Colles’ but intra-articular
* Volar - like Smith’s but intra-articular
* Mx: normally open reduction & internal fixation
Supracondylar fracture - children falling onto outstretched hand
* PC: painful swollen elbow, reluctant to move +/- elbow angulated/upper limb shortened
* Ix: careful NV status monitoring (close proximity) -> arteriograms (if compromise), AP/lateral XR +/- CT
* Mx: if arterial disruption for vascular surgery consultation + IMMEDIATE open reduction & internal fixation
Scaphoid fracture - most freq fractured carpal bone (70%), fall onto outstretched hand
* PC: snuff bow tenderness
* Not all fractures apparent on X-ray immediately - if tenderness over scaphoid cast 7-10d and re-x-ray - if still no fracture can CT/MRI
* Mx: casting
* Common complication = avascular necrosis
Other hand/wrist fractures:
* Boxer’s fracture - minimally comminuted transverse fractures 5th metacarpal neck = most common metacarpal fracture - from punching solid surface (95% young males) -> Tx w/ closed reduction & splint (K-wire fixation if unstable)
* Bennett’s fracture - intra-articular two-part fracture of the base of the first metacarpal bone (caused by forced abduction) - Tx w/ thumb spica cast if stable non-displaced
* NOTE if three parts (comminuted) = Rolando fracture - normally caused by fistfight = UNSTABLE -> Tx w/ surgical reduction & fixation
* Gamekeeper thumb (chronic) vs skier thumb (acute) - avulsion/rupture ulnar collateral ligament of first metacarpophalangeal joint -> surgery if joint unstable/displaced avulsion fracture/stener lesion
* Mallet finger - injury to extensor mechanism if finger @DIP joint = **most common finger tendon injury in sport **via sudden flexion = unable to extend finger at DIP -> Tx w/ splint to maintain DIP slight hyperextension
Give an overview of sciatica and causes
What is piriformis syndrome?
Sciatica - pain/tingling/numbness +/- weakness from compression of lumbosacral nerve roots
* Distribution - buttocks, hamstrings, outer calf to foot/toes
Causes:
* Herniated intervertebral discs - 90% (L4/5, L5/S1)
* Spondylolisthiasis - prox vertebra moves forward vs distal
* Spinal stenosis - narrowing of spinal canal (from congen stenosis/spondylolisthiasis etc.) - pain resolves from forward flexion vs worse on extension
* Lateral recess/foraminal stenosis -> sciatica
* Central stenosis -> spinal claudication -> bilateral calf pain, paraesthesia, numbness on walking
* Infection - discitis, oesteomyelitis, spinal epidural abscess
* Cancer - mets
Piriformis syndrome - compression of sciatic nerve by piriformis muscle
* Piriformis is small muscle crossing greater sciatic foramen. Sciatic nerve comes out foramen below muscle and can be compressed
* PC: cycling/running -> chr ache, tingling/numbness of buttocks
* Mx: avoid precipitants, CS injections
Adoscent hip problems DDx
SUFE = slipped capital femoral epiphysis (SCFE) - MOST COMMON - fracture through growth plate -> slippage of femur
* 10-15yrs, assoc w/ obesity, endo abn (hypothyroid/hypogonadism)
* PC: gradual onset limp, hip/knee pain, pain on internal rotation/abduction
* Ix: XR - abn klein lines (ant/superior to epiphysis) +/- MRI
* Mx: internal fixation
Perthes disease - AVN femoral head
* 5-10yrs, assoc w/ hyperactivity/short-stature
* PC: same as above
* Ix: XR - sclerosis, cysts, collapse of femoral head
* Mx: analgesia, mobilisation, surgery
Transient synovitis of hip - self-limmiting inflam hip disorder in 5-6yrs secondary to viral URTI/GI illness
* PC: Hip pain improving with time, ambulate with limp, unilateral, rested with abduction/external rotation
* O/E: log-roll = muscle guarding in affected limb
* DDx: if <3yrs suspected septic arthritis, if >9yrs R/O SUFE, ensure not NAI
* Mx: rest + NSAIDs
DDH - spectrum of conditions affecting prox femur/acetabulum (acetabular immaturity, hip subluxation, frank hip dislocation)
* Screen with Barlow & Ortolani manoeuvres up to 3-months + US @6wks (hip XR if >6-months)
* Mx: spontaneous resolution, Pavlik harness +/- surgery
Shoulder injury DDx
Shoulder dislocation - 95% anterior, normally traumatic (combo of abduction/extension/posterior force)
* Pt holds arm at side in external rotation, shoulder loses roundness with anterior bulge
* Ix:
* Assess NV - deltoid patch (axillary nerve damage), radial pulse
* XR - AP (humeral head below coracoid process) + axillary view (humeral head anterior to glenoid)
* Mx: closed reduction, if fracture will require surgery
Rotator cuff tear (supraspinatous rupture = most common)
* PC: following injury e.g. fall with hyperabduction/extension of shoulder -> reduced RoM, weakness, crepitus, tenderness over cuff insertions/subacromial area
* O/E: weakness of abduction
* Mx: analgesia, broad arm sling, physio, surgery if young/severe
Clavicle fracture - violent upward/backward force e.g. landing on hand falling from horse
* Normally fractures from middle to outer 1/3.
* Mx: sling, operative reduction if severely displaced
- Most common tumours to metastasise to the bone?
- Most common site for bony mets?
- Breast
- Prostate
- Lung
Spine is most common site for bony mets
* Complications: cord compression, nerve route compression, leptomeningeal mets
* Lung/breast -> thoracic spine; GI/pelvic -> lumbosacral spine
* PC: lower back pain
Rheumatology key conditions
- SS: CREST (Calcinosis, Raynaud’s, oEsophageal dysmotility, Sclerodactyly, Telangiectasia)
- SLE: SOAP BRAIN MD (serositis, oral ulcers, arthritis ≥2 joints, photosensitivity, blood (pancytopenia), renal involvement, ANA +ve, Immunologic (DS DNA), Neuro Sx (psych, seizures), Malar rash, Discoid rash)
- Sjogren’s: dry eyes, dry mouth, dry cough
Give an overview of SLE
SLE - AI multi-system disease with vasculitis & ANA.
* 15-25yrs Afro-carribean
PC:
* Systemic - fever, malaise, fatigue, weight loss
* Specific - lymphadenopathy & hepatomegaly (50%), myalgia/myositis
* PMHx: spontaneous abortions/thrombosis - antiphospholipid syndrome
ANA, Anti-dsDNA, Anti-Smith
SLE: SOAP BRAIN MD
* Serositis (pleuritis, pericarditis)
* Oral/NP ulcers
* Arthritis ≥2 joints
* Photosensitivity
* Blood (pancytopenia)
* Renal involvement (proteinuria, cellular casts)
* ANA +ve
* Immunologic (dsDNA)
* Neuro Sx (psych, seizures)
* Malar rash
* Discoid rash
Ix:
* Routine bloods - high ESR (normal CRP), mild normochromic/normocytic anaemia
* Compliment C3/4 low
* Auto-ab screen: ANA (95%), dsDNA (lvls reflect disease activity), Sm, SSA (Ro), SSB (La), antiphospholipid (anticardiolipid/lupus anticoag)
Mx:
* Disease monitoring: dsDNA, C3/4 (C3 only low in severe), ESR
* Mild - rest, NSAIDs, remove precipitant (UV, hormones etc)
* Severe (pericarditis/nephritis/AIHA/CNS) - CS (pred) +/- cyclophosphamide (or azathioprine) +/- plasmapheresis
Overview of osteomalacia
Osteomalacia (adult)/RIcket’s (children) - inadequate supply vit D -> inadequate bone mineralisation
* Low vit D -> low Ca/PO4 -> secondary hyperparathyroidism
PC:
* Mild - widespread bone pain (lower back/hips), prox muscle weak/lethargy
* Severe - difficulty walking/waddling gait
* Other: costochondral swelling, spinal curviture, hypocalcaemia signs (tetany, carpopedal spasms), pseudofracture tenderness, multiple fractures (bilateral + symmetrical)
Ix: bloods - mild low Ca/PO4, raised ALP, low vit D (except in Vit D-resistant Ricket’s)
Mx: correct nutritional def (Ca/Vit D/Protein) - 1000mg Ca/800 IU Vit D/1g/kg protein PER DAY
* Can require bisphosphonates, strontium ranelate etc.
Shoulder differential - RFs, Presentation, Ix & Mx?
Key summary:
- Adhesive capsulitis:
- RFs - surgery, immobility, trauma, DM, thyroid disease
- Stiffness & pain, reduced active + passive Mov
- Axillary nerve palsy - after anterior shoulder dislocation (or relocation of dislocation)
- Loss of lateral deltoid sensation, weak abduction & elbow flexion
- Impingement syndrome - inflammation of rotator cuff tendons in subacromial space
- Pain, weakness, reduced active RoM
DETAIL:
Adhesive capsulitis:
- Classification: primary (idiopathic), secondary (after rotator cuff tendinopathy, subacromial impingement, biceps tendinopathy, prev surgery/trauma, joint arthropathy)
- RFs: DM, previous surgery/injury to the shoulder, thyroid disorder, dupuytren’s disease, frozen shoulder in contralateral shoulder
- Presentation:
- Profile: unlikely under <40yrs, middle-aged female
- Dull shoulder pain on flexion, external rotation (> internal rotation)
- Disturbs sleep, stiffness/loss of mobility (passive & active mov)
- Progression: painful –> freezing –> thawing
- Develops over days lasts months-yrs
- Ix: clinical Dx (check HbA1c, BM, XR if atypical features, MRI to rule out subacromial impingement)
- Mx: self-limiting (recovery over months/yrs)
- Education, reassurance, stay active & physio, maintain good posture, simple analgesia
- Meds - IA CS injection
- Surgical - joint manipulation under GA (remove capsular adhesions), surgical release of glenohumeral joint capsule
Rotator cuff syndrome
- Rotator cuff muscles - SITS:
- Supraspinatus: abducts arm before deltoid, most commonly injured
- Infraspinatus: rotates arm laterally
- Teres minor: adducts and rotates laterally
- Subscapularis: adducts and rotates medially
- Spectrum:
- Subacromial impingement (painful arc syndrome) - inflammation of tendons & subacromial bursa from rubbing against the acromion –> pain, weakness, reduced active RoM
- Subacromial bursitis - inflammation of the subacromial bursa –> activity-related pain
- Rotator cuff tendonitis - tendon inflammation from excessive pressure on the acromion/intrinsic tendon pathology –> activity-related pain (normally occupational/athletic)
-
Rotator cuff tear (partial/full thickness):
- Acute most likely supraspinatus tendon, occurs due to falling/lifting heavy
- Chronic - >70yrs, wear & tear
- RFs: >60yrs, Hx repetitive overhead mov, shoulder injury, BMI >25, smoking, DM
- Presentation:
- Shoulder pain esp on abduction ± referred pain to neck
-
Between 60 – 120 degrees: subacromial impingement
- Neer impingement test (one hand on scapula & passive flexion) - pain @60-120
- Hawkin’s impingement test (arm and elbow @90 degrees, arm horizontally across body, passive internal rotation)
-
First 60 degrees: rotator cuff tears (pain on lateral aspect of shoulder, can’t abduct arm >90 degrees)
- Pain on empty-can test = supraspinatus tear/tendonitis
- Pain on external rotation (vs resistance) = infraspinatus tear/tendonitis
- Pain on external rotation in abduction (abduct arm & flex elbow to 90 degrees + passive external rotation) - arm falling back = teres minor/axillary nerve problem
- Pain on liftoff (internal rotation from small of back vs resistance)/belly-press = subscapularis tear/tendonitis
-
Between 60 – 120 degrees: subacromial impingement
- Weakness (more likely in chronic rotator cuff tear > acute)
- Loss of active RoM
- NOTE: if loss of passive & active mov –> adhesive capsulitis (normally just active movement lost in rotator cuff tear)
- Shoulder pain esp on abduction ± referred pain to neck
- Ix:
- Plain XR - need to exclude fracture radiograph urgently needed to exclude fracture
- Usually normal, opacities if calcific tendonitis present
- Large tear - superior migration of humeral head if large tear
- Chronic tear - reduced acromiohumeral distance, sclerosis, cysts
- US: presence of tear seen
- MRI: size, characteristics, location of tear, needed to rule out impingement
- Plain XR - need to exclude fracture radiograph urgently needed to exclude fracture
- Mx:
- Conservative - if minimal pain/LoF/unsuitable for surgery
- Analgesia (NSAIDs), ice, rest (reduced overhead lifting) & physio
- ±Subacromial CS injection
- Acute repairable tear:
- Active & young –> surgery (aerthroscopic/open) + physio
- Sedentary & older –> conservative (2nd - CS inj, 3rd - surgery)
- Acute irreparable tear:
- Weakness & high functional demands –> extensive muscle transfer rehab + physio
- Pain & lower functional demands –> debridement & physio
- Conservative - if minimal pain/LoF/unsuitable for surgery
- Complication: adhesive capsulitis
Glenohumeral OA - more likely >70yrs
- Scarf test - hand on opposite shoulder - pain = acromioclavicular joint pathology eg. OA
Axillary nerve palsy - anterior shoulder dislocation
- Presentation: loss of lateral deltoid sensation, weak abduction & elbow flexion
- Signs:
- Lieutenants badge sign - light touch sensation over lateral deltoid, if parasthesia = axillary nerve injury
- Pain on external rotation in abduction (abduct arm & flex elbow to 90 degrees + passive external rotation) - arm falling back = teres minor/axillary nerve problem
Give an overview of biceps tendon rupture
Biceps tendon rupture
* Biceps brachii - strong forearm supinator & weak elbow flexor
Proximal rupture (PBTR) - most long-head, elderly & more common, assoc w/ rotator cuff disease
* PC: Minimal signs/Sx - pain, bruising proximal arm, if slim “popeye” deformity
* Resolve within 4-wks with no long-term change in forearm/elbow strength
Distal rupture (DBTR) - middle-age men e.g. heavy lifting
* PC: Sudden painful “pop” on heavy lifting, burising/swelling/tenderness in antecubital fossa, “reverse-popeye” deformity
* Pain for wks/months - weakness of elbow flexion/forearm supination
* Tests: Hook test - if intact can hook around tendon edge laterally when acitvely flexing/supinating OR Ruland biceps squeeze test - squeeze bicep (hand resting slightly pronated in lap) -> hand supination if intact
Ix: clinical +/- US/MRI if unclear/partial
Mx: PBTR - conservative, DBTR - timely operative repair
Dermatomyositis overview
DM - idiopathic AU inflam disorder characterised by myopathy with distinctive cutaneous erruption (skin lesions -> muscle involv later)
* PC: heliotrope rash, Gottron’s papules, photosensitivity, nail fold capillary dilatation
* Assoc: ILD, cardiac, oesophageal, dystrophic calcification and underlying malig
* Ix: CK, ANA, MSA/MAAs, EMG, muscle biopsy, skin biopsy
* Mx:
* Muscle - high dose PO steroids +/- immunosupressants/IVIG
* Skin - top antipruritics + top corticosteroids
