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Medicine Y6 > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

1
Q

Lower Back Pain: red flags

A
  • Signs of malignancy
    • age < 20 years or > 50 years
    • history of previous malignancy
    • night pain
    • systemically unwell e.g. weight loss, fever
  • Signs of cauda equina
    • faecal / urinary incontinence
    • loss of anoperoneal sensation / tone
  • History of trauma

(Dr Joshi)

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2
Q

Ankle Injury: indications for x-ray

A

The Ottawa Rules: An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:

  • bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
  • bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
  • inability to walk four weight bearing steps immediately after the injury and in the emergency department
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3
Q

A pt presents with frontal balding, cataracts, a pacemaker and a slow-releasing handshake. What is the diagnosis?

A

Myotonic dystrophy

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4
Q

What are the clinical features of myotonic dystrophy?

A

Slow-releasing handshake Myopathic facies Cataracts Frontal balding Cardiomyopathies + heart blocks (cause of death) Learning difficulties

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5
Q

After examining hands in RA, what else should you examine / ask about?

A
  • eyes (episcleritis or scleritis in ~5%))
  • voice changes (inflamm at cricoarytenoid joint –> hoarseness)
  • neck pain
  • auscultate chest (pleuritis, pulmonary fibrosis in severe cases)
  • auscultate heart (pericarditis, myocarditis, CAD in severe cases)
  • examine abdo for splenomegaly (Felty’s Syndrome = RA, splenomegaly, low WBC)
  • examine limbs for peripheral neuropathy

(Mirza)

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6
Q

Define rheumatoid arthritis

A

A chronic systemic inflammatory condition causing joint destruction and deformity, primarily affecting the small joints of the hand and feet and progressing proximally.

(UpToDate)

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7
Q

Summarise the epidemiology of rheumatoid arthritis

A

Prevalence: ~1% population

Usually presents in 50s, F:M 2:1 in younger pts

(BMJ)

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8
Q

Explain the aetiology / risk factors of rheumatoid arthritis

A

Unknown aetiology

RFs:

gentic: HLA DR4, PTPN22
smoking: weak
* (BMJ)*

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9
Q

Rheumatoid arthritis: hand signs

A
  • Swan neck deformity (PIP hyperextended, DIP flexed)
  • Boutonniere’s deformity (PIP flexed, DIP hyperextended)
  • Ulnar deviation
  • Z-shaped thumb
  • Rheumatoid nodules (over extensor tendons)
  • Morning stiffness >1h

(BMJ)

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10
Q

Rheumatoid arthritis: diagnostic criteria

A

ACR-EULAR criteria: >6/10 needed

A- Joint Involvement

0: Large Joint
1: 2-10 large joints
2: 1-3 small joints (with or without involvement of large joints)
3: 4-10 small joints (with or without involvement of large joints)
5: >10 joints (atleast 1 small joint)

B- Serology

0: Negative RF and negative ACPA
2: Low-positive RF or low-positive ACPA
3: High-positive RF or high-positive ACPA

C- Acute Phase Reactants

0: Normal CRP and Normal ESR
1: Abnormal CRP and Abnormal ESR

D- Duration of Symptoms

0: <6 weeks
1: >6 weeks
* (Radiopaedia, BMJ)*

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11
Q

Identify appropriate investigations for rheumatoid arthritis

A
  • Bloods:
    • diagnosis: rheumatoid factor, anti-CCP Ab, CRP, ESR
    • DMARD-prep: FBC, HepB/C screen, LFTs
  • Imaging: radiographs

(BMJ)

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12
Q

Outline a management plan for rheumatoid arthritis

A
  • Conservative - pt education
  • Medical
    • 1st line: methotrexate + 1 other DMARD (sulfasalazine, leflunomide, ~hydroxycholorquine))
      • corticosteroid (eg prednisolone PO)
    • +/- NSAID
    • 2nd line: a biological (+ DMARD)
      • Anti-TNF (infliximab, etanercept) or
      • Tocilizumab (anti-B/T cell) or abatacept (anti-T cell)
    • 3rd line: Rituximab (anti-B cell) + DMARD
  • Surgical (eg prosthetic joints)
    • Indicated if tx-refractory +

progressive or risk of tendon rupture / nerve compression / stress fracture.

(BMJ, NICE)

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13
Q

Identify the possible complications of rheumatoid arthritis

A
  • Common
    • Work disability
    • Coronary artery disease
  • Less common
    • Felty Syndrome (RA + splenomegaly + low WCC)
  • Eye (scleritis or episcleritis in 5%)
  • Voice (hoarse)
  • Lung (pleuritis, pulmonary fibrosis)
  • Heart (pericarditis, myocarditis)
  • Peripheral neuropathy

(BMJ)

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14
Q

Describe the following types of fracture

Oblique:

Comminuted:

Transverse:

Spiral:

Segmental:

A

Oblique: fracture lies oblique to the long axis of the bone

Comminuted: >2 fragments

Transverse: fracture lies perpendicular to the long axis of bone

Spiral: fracture lies severely oblique with rotation along the long axis of the bone

Segmental: more than one fracture along a bone

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15
Q

Outline the grading system for open fractures

A

Gustilo and Anderson classification system

Grade: Injury

1: Low energy wound <1cm
2: Greater than 1cm wound with moderate soft tissue damage
3: High energy wound > 1cm with extensive soft tissue damage

3 A: Adequate soft tissue coverage

3 B: Inadequate soft tissue coverage

3 C: Associated arterial injury

(Passmedicine)

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16
Q

Explain the risk factors of osteoarthritis

A

RFs:

mechanical - osteoperosis, trauma, mechanical stress, periarticular muscle weakness, joint abnormality, obesity

hormonal - low oestrogen levels (post-menopausal)

congenital - articular congenital deformities

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17
Q

Generate a management plan for osteoarthritis

A
  • Conservative
    • wt loss, local muscle strengthening, supports, braces
  • Medical
    • 1st line: paracetamol + topical NSAID (if knee / hand)
    • 2nd line: PO NSAID (+PPI) or opiods or intra-articular steroids
  • Surgical
    • Joint replacement

(PassMedicine, NICE)

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18
Q

Identify the possible complications of osteoarthritis

A

Short term: effusion

Long term: Functional decline, spinal stenosis in cervical / lumbar OA

Tx-related: NSAID-related GI bleed or AKI, surgical complications

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19
Q

Generate a management plan for ankylosing spondylitis

A
  • Conservative
    • Regular exercise, physiotherapy
  • Medical
    • 1st line: NSAIDs
    • 2nd line: DMARD (only if peripheral joint invovlement)
    • 3rd line: Anti-TNF (severe refractory disease)
  • Surgical: if thoracic kyphosis

(Passmedicine, BMJ)

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20
Q

Explain the aetiology / risk factors of ankylosing spondylitis

A

HLA B27 (90% ank spond pts have it, 10% total pop)

Male

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21
Q

Summarise the epidemiology of ankylosing spondylitis

A

M:F 10:1

20% present in juveniles

Usually presents 20-30y

(BMJ, Passmedicine)

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22
Q

What are the characteristic signs of ankylosing spondylitis on a plain radiograph?

A

Characteristics of ankylosing spondylitis on plain radiograph:

Sacroilitis: subchondral sclerosis, subchondral erosions

Squaring of lumbar vertebrae

Bamboo spine (late)

Syndesmophytes: ossification of outer fibres of annulus fibrosus

CXR: apical fibrosis

(Passmedicine)

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23
Q

Summarise the prognosis for patients with ankylosing spondylitis

A

Variable progression

  • pts with regular exercise regimes do best.
  • 20% progress to bamboo spine

No increase in mortality

(BMJ)

24
Q

Identify the possible complications of ankylosing spondylitis

A

Long: achilles tendonitis, apical fibrosis, anterior uveitis, arthritis (peripheral) aortic regurgitation, AV node block, amyloidosis, cauda equina syndrome, osteoperosis

(Passmedicine, BMJ)

25
Q

Define fibromyalgia

A

Syndrome of unknown aetiology characterised with widespread pain throughout the body, with tenderness located at specific anatomical sites

(Passmedicine)

26
Q

Summarise the epidemiology of fibromyalgia

A

F:M 10:1

Peak incidence at 30-50

(passmedicine)

27
Q

Generate a management plan for fibromyalgia

A
  • Conservative: education, regular exercise, CBT
  • Medical:
    • Induce remission
      • 1st line: TCA (eg amytryptyline, try for 6w)
      • 2nd line: SNRI (eg duloxetine, 1st line if comorbid depression or fatigue) or pregabalin / gabapetin (if sleep distrubance)
      • 3rd line: TCA +/- SNRI +/- gabapentoid
    • Analgesia: naproxen or tramadol

(BMJ)

28
Q

What are the criteria for normal, osteopenia and osteoperosis on a DEXA scan?

A

Basics

T score: based on bone mass of young reference population

T score of -1.0 means bone mass of one standard deviation below that of young reference population

Z score is adjusted for age, gender and ethnic factors

T score

> -1.0 = normal

-1.0 to -2.5 = osteopaenia

< -2.5 = osteoporosis

(Passmedicine)

29
Q

List signs of a fracture

A

Pain

Unable to wt bare

Skin changes

Deformity

Adjacent structural injury (neurovascular)

Oedema

Crepitus

(lecture)

30
Q

Outline how to describe a fracture from a plain radiograph

A
  1. Describe the film: who, what, when and where
  2. Type of fracture:
  • complete (all the way through bone): transverse, oblique, spiral, comminuted
  • incomplete: bowing, buckle, greenstick
  • Salter-Harris
  1. Location: diaphysis, metaphysis, epiphysis
  2. Displacement: translation, anglulation/rotation
  3. If joint: intra-articular vs extra-articular
    * (lecture, radiopaedia)*
31
Q

What are the features of osteoarthritis on a plane radiograph?

A
  • Loss of joint space
  • Osteophytes
  • Subchondral cysts
  • Subchondral sclerosis
32
Q

What are the special tests of the knee examination?

A

CCC

Collaterals - MCL, LCL

Cruciates - anterior draw and posterior draw test, Lachman’s test

Cartilages - McMurray test (medial: hip flexed, knee 90 degress, externally rotate tibia with valgus pressure at knee, slowy extend leg. +ve sign is pain so just offer)

33
Q

What are the special tests of the hip examination?

A

T T

  • Trendelenberg test (put hands on pts ASISs, get them to lift one leg, if non-weightbearing side droops, there is pathology in hip abductors of other side)
  • Thomas’ test (for fixed flexion deformity: pt supine, flex one hip, +ve if other leg lifts off the bed)
34
Q

What are the special tests of the shoulder examination?

A

I SITS

  • Impingement:
    • Arc: internally rotate, abduct, pain from 60-120 degrees suggests impigment
    • Kennedy-Hawkins test: abduct shoulder 90, elbow 90, internally rotate
  • Supraspinatus: Job’s test (empty beer can: internally rotated, push up)
  • Infraspinatus + Teres Minor: shoulder abducted, elbow 90, push my hands apart
  • Subscapularis: arm behind your back, push against my hand

(lecture)

35
Q

What is the definition of frozen shoulder

A

Pain in all ranges of movement, with a normal shoulder X-ray

36
Q

Generate a management plan for reactive arthritis

A
  • Medical
    • Symptom relief
      • 1st line: NSAIDs
      • 2nd line: steroids
    • If chronic arthritis, consider DMARDs
      • 1st line: sulfasalazine

(BMJ)

37
Q

Summarise the prognosis for patients with reactive arthritis

A

25% have recurrent episodes, 10% have chronic disease

(passmedicine)

38
Q

Identify appropriate investigations for reactive arthritis

A
  • Bloods: CRP, ESP, FBC, RF + ANA (rule out DDx)
  • Cultures: urine, stool, genital
  • Arthrocentesis: synovial fluid -ve for WBCs and crystals

(BMJ)

39
Q

Recognise the presenting symptoms of reactive arthritis

A

Features

  • usually w/i 4w of initial infection - sx generally last ~4-6m
  • asymmetrical oligoarthritis of lower limbs
  • dactylitis
  • symptoms of urethritis
  • eye: conjunctivitis (seen in 50%), anterior uveitis
  • skin: circinate balanitis (painless vesicles on the coronal margin of the prepuce), keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)

(passmedicine)

40
Q

Explain the risk factors of reactive arthritis

A
  • Infection: STI (chlamydia, gonorrhoea), gastroenteritis
  • Genetic: HLA B27

(passmedicine)

41
Q

Define reactive arthritis

A

Reactive arthritis is defined as an arthritis that develops following an infection where the organism cannot be recovered from the joint.

(passmedicine)

42
Q

What is Reiter’s Syndrome?

A

Reiter’s Syndrome = reactive arthritis + urethritis + conjunctivitis

43
Q

Generate a management plan for gout and pseudogout

A
  • Acute
    • Conservative: raise limb, avoid trauma, keep joint cool (ice-pack) but not covered, diet change (reduce red meat/ETOH/fat/sugar, keep hydrated), stop smoking
    • Medical:
      • 1st line: NSAID (indomethacin, to 48h after attack) + PPI
      • 2nd line: colchicine PO (SE: diarrhoea)
      • 3rd line: steroid PO
      • Paracetamol +/- codeine if all above are CI
      • Keep taking allopurinol at same dose, come back in 3d if no improvement
  • Prophylaxis
    • Allopurinol PO (start 2w after attack with NSAID/colchicine cover, titrate dose to serum urate)
    • +/- probenecid (increases urate excretion)
    • R/v serum uric acid, UEs, lipids, glucose at 6w

(Passmedicine, NICE)

44
Q

Define antiphospholipid syndrome

A

Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder or secondary to other conditions, most commonly systemic lupus erythematosus (SLE)

(passmedicine)

45
Q

Generate a management plan for antiphospholipid syndrome

A
  • Conservative:
    • Risk factor modification: manage hyperlipidaemia, HTN, T2DM, obesity. Smoking cessation. Improve mobility.
  • Medical - based on BCSH guidelines
    • Immediate: LMWH or unfractionated heparin
    • Ongoing: Warfarin (target INR and course varies). Start after delivery if pregnant
      • initial venous thromboembolic events: target INR 2-3 for 6 months
      • recurrent venous thromboembolic events: lifelong warfarin, if occurred whilst taking warfarin then increase target INR to 3-4
      • arterial thrombosis: lifelong warfarin with target INR 2-3

(passmedicine, BMJ)

46
Q

Identify appropriate investigations for antiphospholipid syndrome

A

Confirm diagnosis

  • Bloods: lupus anticoagulant, anticardiolipin antibodies, anti-beta2-glycoprotein I antibodies, FBC, UEs

Assess DDx

  • Bloods: ANA, double-stranded DNA, and extractable nuclear antigen antibodies
  • (BMJ)*
47
Q

Identify the possible complications of antiphospholipid syndrome

A

Obstetric: pregnancy loss, pre-eclampsia, IUGR, placental abruption

Thromboembolic: PE, CVA, DVT

(BMJ)

48
Q

What conditions are associated with anti-phospholipid syndrome?

A

Associations:

  • pregnancy
  • SLE (40%) and other autoimmune disorders (RA 6%)
  • lymphoproliferative disorders
  • phenothiazines (rare)

(passmedicine)

49
Q

Summarise the epidemiology of antiphospholipid syndrome

A

F>M, onset in reproductive years

20% of recurrent pregnancy loss

1-5% prevalence in general population

(BMJ)

50
Q

What are the characteristics of rheumatoid arthritis on a plane radiography

A
  • Subluxation
  • Juxta-articular osteoperosis
  • Peri-articular erosions
  • Loss of joint space

(passmedicine)

51
Q

Identify appropriate investigatons in gout / psuedogout

A
  • X-ray joint
  • Aspirate joint + examine under polarised light:
    • needle-shaped negatively birefringent crystals = gout
    • weakly birefringent rhomboid shaped crystals = psuedogout

(Meeran)

52
Q

What are the possible complications of gout?

A
  • Tophus - uric acid crystals in joints/cartilage/bone. Pathognomonic for gout. If untreated can –> severe arthritis.
  • Nephrolithiasis (urate stones)
  • Chronic uric acid nephropathy (–> CKD, usually in combination with RFs eg T2DM, HTN etc)

(UpToDate)

53
Q

Summarise the prognosis for patients with gout

A

Episodes are self-limiting

Recurrence is common

Complications are rare

54
Q

Explain the aetiology / risk factors of gout

A

Hyperuricaemia

Diet (purine-rich): alcohol , red meat, seafood

High cell turnover: malignancy, chemotherapy

RFs: obesity, HTN, T2DM, diuretics

(BMJ)

55
Q

What are seronegative spondyloarthropathies?

A

Inflammatory arthridies affecting the spine and peripheral joints w/o production of rheumatoid factor

  • HLA-B27 associated
  • (AS)*
56
Q

What are the 4 seronegative spondyloarthropathies?

A

PARE

  • Psoriatic arthritis
  • Ankylosing spondylitis
  • Reactive arthritis
  • Enteric arthropathy (associated with IBD, coeliac, Whipple’s disease)

(Adam, OHCM)

Medicine Y6 (14 decks)

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