Musculoskeletal Flashcards

Question

1. Incomplete spinal cord pathology differentials 2. Cauda equina vs conus medullaris syndrome

Answer 1

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

Answer 2

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 - **3C**s = **C**artilage (McMurray’s), **C**ollaterals, **C**ruciates (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)

Answer 3

**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

Answer 4

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

Answer 5

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

Answer 6

**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

Answer 7

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

Answer 8

1. Breast 2. Prostate 3. 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

Answer 9

* 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

Answer 10

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

Answer 11

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.

Answer 12

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: * **S**upraspinatus: abducts arm before deltoid, most commonly injured * **I**nfraspinatus: rotates arm laterally * **T**eres minor: adducts and rotates laterally * **S**ubscapularis: 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_ * 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) * 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 * 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 * 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

Answer 13

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

Answer 14

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