Musculoskeletal Flashcards
Long thoracic nerve innervates which muscle? Clinical sign (1)
serratus anterior
winging of scapula
Name the fracture:
- 1 inch proximal to the radio-carpal joint
- Transverse fracture of the radius
- Dorsal angulation and impaction
Fall onto outstretched hands
Colle’s fracture
Name the fracture:
Dinner fork type deformity, AKA
Garden spade type deformity, AKA
Colle’s
Smith’s (reverse Colle’s)
Name the fracture:
Volar angulation of distal radius fragment
Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed
Smith’s fracture
Bennett’s fracture
Name an xray finding (1)
X-ray: triangular fragment at the base of metacarpal
Name the fracture:
Intra-articular fracture at the base of the thumb metacarpal
Common in fist fights
Bennet’s fracture
- Dislocation of the proximal radioulnar joint (aka radial head) in association with an ulna fracture
- Fall on outstretched hand with forced pronation
Monteggia’s fracture
Name the fracture:
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Occur after a fall on the hand with a rotational force superimposed on it.
X Rays reveal the displaced fracture of the radius and a prominent ulnar head due to dislocation of the inferior radio-ulnar joint.
Galeazzi’s fracture
RA
Name two antibodies associated with RA
- RhF
2. Anti-CCP (anti-cyclic citrullinated peptide antibody)
Behcet’s syndrome
Triad of symptoms
Genetic predisposition
Ix
- oral ulcers
- genital ulcers
- anterior uveitis
Genetics
1. HLA B51
Ix
1. Positive pathergy test - skin prick leads to ulcer/ pustule formation
Sjorgren’s syndrome
What is it?
Name two antibodies
Mx (2)
Autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces
- RhF
- Anti-RoLa
Mx
- artificial saliva and tears
- pilocarpine may stimulate saliva production
OA Xray findings (4)
- Loss of joint space
- Subchondral cysts
- Subchondral sclerosis
- Osteophytes
RA Xray findings (4)
- Loss of joint space
- Juxta-articular osteoporosis
- Periarticular erosions
- Subluxation
Bloods for bone disorders: Ca, PO4, ALP, PTH Osteoporosis Osteomalacia Primary hyperparathyroidism Secondary hyperparathyroidism (CKD) Paget's disease Osteopetrosis
Normal, normal, normal, normal Low, low, high, high High, low, high, high Low, high, high, high Normal, normal, high, normal Normal, normal, normal, normal
Ca, PO4, ALP, PTH
High, low, high, high
Options Osteoporosis Osteomalacia Primary hyperparathyroidism Secondary hyperparathyroidism (CKD) Paget's disease Osteopetrosis
Primary hyperparathyroidism
Ca, PO4, ALP, PTH
Low, high, high, high
Options Osteoporosis Osteomalacia Primary hyperparathyroidism Secondary hyperparathyroidism (CKD) Paget's disease Osteopetrosis
Secondary hyperparathyroidism (CKD)
Ca, PO4, ALP, PTH
Normal, normal, normal, normal
Options Osteoporosis Osteomalacia Primary hyperparathyroidism Secondary hyperparathyroidism (CKD) Paget's disease Osteopetrosis
Osteoporosis
Osteopetrosis
Ca, PO4, ALP, PTH
Normal, normal, high, normal
Options Osteoporosis Osteomalacia Primary hyperparathyroidism Secondary hyperparathyroidism (CKD) Paget's disease Osteopetrosis
Paget’s
Ca, PO4, ALP, PTH
Low, low, high, high
Options Osteoporosis Osteomalacia Primary hyperparathyroidism Secondary hyperparathyroidism (CKD) Paget's disease Osteopetrosis
Osteomalacia
SLE
Antibodies (1)
Race
Features: (4)
- ANA
- Afro- Caribbean
Features
- Malar rash
- Discoid rash - erythematous, well demarcated rash in sun-exposed areas. Can become hyperpigmented and hyperkeratotic
- Livedo reticularis
- Non scarring alopecia
Reactive arthritis
Features Triad
Usually 4 weeks post STI
- Urethritis
- Uveitis (conjunctivitis or ant uveitis)
- Arthritis
What is dactylitis?
Swollen fat fingers/ sausage like fingers
Severe inflammation of the finger and toe joints
What is keratoderma blenorrhagica?
waxy yellow/brown papules on palms and soles
What is circinate balanitis?
Associated with which condition?
Painless vesicles on penis associated with reactive arthritis
What does the femoral nerve innervate?
S
M
Common injury
Sensory
Anterior and medial aspect of the thigh and lower leg
Motor
Knee extension, thigh flexion
Hip and pelvic fractures
Stab/gunshot wounds
What does the obturator nerve innervate?
S
M
Common injury
Sensory
Medial thigh
Motor
Thigh adduction
Anterior hip dislocation
What does the lateral cutaneous nerve of the thigh innervate?
S
M
Common injury
Sensory
Lateral and posterior surfaces of the thigh
Motor
None
Compression of the nerve near the ASIS → meralgia paraesthetica, a condition characterised by pain, tingling and numbness in the distribution of the lateral cutaneous nerve
What does the tibial nerve innervate?
S
M
Common injury
Sensory
Sole of foot
Motor
Foot plantarflexion and inversion
Not commonly injured
Popliteal lacerations, posterior knee dislocation
What does the common peroneal nerve innervate?
S
M
Common injury
Sensory
Dorsum of the foot and the lower lateral part of the leg
Motor
Foot dorsiflexion and eversion
Extensor hallucis longus
Injury causes foot drop
What does the superior gluteal nerve innervate?
S
M
Common injury
Sensory
None
Motor
Hip abduction
Injury results in a positive Trendelenburg sign
What does the inferior gluteal nerve innervate?
S
M
Common injury
Sensory
None
Motor
Hip extension and lateral rotation
Injury results in difficulty rising from seated position. Can’t jump, can’t climb stairs
Pseudogout
Name x5 RFs
- Low phosphate, low magnesium
- Acromegaly
- Wilson’s disease
- Haemochromatosis
- Hyperparathyrodism
Pseudogout
What do you seen on joint aspiration?
What do you see on xray?
Which joints are usually affected?
- Weakly-positively birefringent rhomboid-shaped crystals
- Chondrocalcinosis
- Knee, wrist, shoulder
Ottowa rules
When to get an xray
Pain in the malleolar zone AND
1. An inability to weight bear immediately AND in the ED for four steps
OR
2. Bone tenderness at the posterior edge of lateral OR medial malleolus
Pain in the midfoot zone AND
1. An inability to weight bear immediately AND in the ED for four steps
OR
2. Bone tenderness at the navicular
OR
3. Tenderness at base of the fifth metatarsal
Systemic sclerosis types (3)
- Limited
- Diffuse
- Scleroderma
Systemic sclerosis - Limited Antibodies (2) Associated with which condition? First symptom Where does scleroderma typically affect?
ANA anti-centromere Associated with CREST syndrome Raynauds first symptom Scleroderma affects face and distal limbs
Systemic sclerosis DiffuSe Antibodies (2) Where does scleroderma typically affect Systemic features (4)
ANA
anti-scl-70
Scleroderma affects trunk and proximal limbs mainly
Other effects:
- ILD - interstitial lung disease
- PAH - pulmonary arterial hypertension
- Renal disease
- HTN
Systemic sclerosis
Scleroderma - what is it?
Antibodies (1)
ANA
tightening and fibrosis of skin, can manifest as plaques
What is CREST syndrome
What disease and subtype is it associated with?
CREST syndrome: Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
Associated with limited systemic sclerosis
Hypersensitivities
Type I
Name two
Anaphylaxis
Atopy
Hypersensitivities
Type II
Name four
Autoimmune haemolytic anaemia
ITP
Goodpastures
Pernicious anaemia (B12)
Hypersensitivities
Type III
Name two
SLE
post Strep GN
Hypersensitivities
Type IV
Name five
TB GVHS Allergic contact dermatitis Scabies Guillian Barre
What is this type of sensitivity?
SLE
post Strep GN
III
Immune complex
What is this type of sensitivity? TB GVHS Allergic contact dermatitis Scabies Guillian Barre
IV
delayed hypersensitivity
T cell mediated
What is this type of sensitivity?
Anaphylaxis
Atopy
I
Anaphylactic
IgE binds with mast cells
What is this type of sensitivity? Goodpastures Pernicious anaemia (B12)
II
IgG or IgM binds to antigen on cell surface
Cell bound
Marfan’s syndrome
What is it?
AD/AR
- defect in the FBN1 gene on chromosome 15 that codes for the protein fibrillin-1
- AD
Marfan’s syndrome
Features (5)
- Tall
- Pectus excavatum
- Aortic (or mitral) valve issues e.g regurg/ prolapse/ dissection
- Pneumothorax
- High-arched palate
Wegener's/ granulomatosis polyangitis Features (5) p/c-ANCA Small/medium/large vessel vasculitis? Rx
- Saddle shape nose
- Epistaxis
- Haemoptysis
- Dyspnoea
- Chronic sinusitis
c-ANCA
Small
Rx immunosuppressive therapy
Churg Strauss Features p/c-ANCA Small/medium/large vessel vasculitis? Rx
- Sinusitis
- Asthma
- Mononeuritis multiplex
- Eosinophilia
p-ANCA
Small
Rx immunosuppressive therapy
Microscopic polyangiitis
Small/medium/large vessel vasculitis?
Features (4)
Small 1. raised creatinine, haematuria, proteinuria 2. palpable purpura 3. cough, dyspnoea, haemoptysis 4. fever p-ANCA
Ankylosing spondylitis
HLA?
What is Schober’s test?
Examination findings (3)
HLA B27 Reduced forward flexion (should be >5cm) 1. Reduced forward flexion 2. Reduced lateral flexion 3. Reduced chest expansion
AV node block Apical fibrosis Aortic regurgitation Anterior uveitis Achilles tendonitis Amyloidosis cAuda equina peripheral Arthritis
Associated with which condition?
Ankylosing spondylitis
Features (not the ones you will remember i.e stiff in the morning, better over the day, lower back pain)
Ankylosing spondylitis
Most useful Ix of choice (1)
Findings on Ix (4)
What might you find on CXR?
2nd line investigation
Xray sacroiliac joints 1. sacroiliitis: subchondral erosions, sclerosis 2. squaring of vertebrae 3. bamboo spine 4. syndesmophytes CXR 1. Apical fibrosis
MRI
Ankylosing spondylitis
Mx (4)
- Exercise
- NSAIDs
- Physiotherapy
- anti-TNF (DMARDs)
Antiphospholipid syndrome
What is it?
Features (5)
Autoimmune condition which predisposes patients to thrombosis Features 1. Venous/ arterial thrombosis 2. Recurrent miscarriages 3. livedo reticularis 4. thrombocytopenia 5. prolonged APTT
Antiphospholipid syndrome
Mx (2)
Associated with which other disease?
Antibody
- Low dose aspirin
- Lifelong warfarin
SLE
Anti-cardiolipin
Polyarteritis nodosa
Small/ medium/ large?
What is it?
Features (4)
Medium vessel vasculitis? Systemic necrotising medium vessel vasculitis 1. Assoc Hep B 2. Mononeuritis multiplex 3. Renal infarcts - HTN 4. Livedo reticularis
Fever, myalgia, weight loss, rash
Dermatomyositis
What is it?
What three cancers are associated with it?
an inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions
- Breast
- Lung
- Ovarian
Dermatomyositis
What is it?
What three cancers are associated with it?
an inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions
- Breast
- Lung
- Ovarian
Dermatomyositis
Features
Antibody
- Gottron’s papules
- Helitrope rash
- Weakness of proximal muscles
- Shawl rash (photosensitivity)
ANA
Drug induced lupus
Antibodies (2)
ANA and anti-histone
Drug induced lupus
Caused commonly by which two drugs
procainamide
hydralazine
Gout drugs causes:
- Diuretics
- Ciclosporin
- Alcohol
- Pyrazinamide
- Aspirin
DCAPA
Punched out erosions on xray =
gout
Gout Mx
Acute
Prophylaxis
- NSAIDs or colchicine
If CI or not tolerated - Pred
- Allopurinol
- Febuxostat
Aim uric acid <300
Tennis elbow AKA
What is it
lateral epicondylitis
pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended
Myopathies
Features (3)
- Proximal muscle weakness
- Bilateral
- Difficulty in getting up from sitting
Myopathies Causes Inflammatory (1) Inherited (2) Endo (2) Other (1)
Inflammtory
Polymyositis
Inherited
Duchenne muscular dystrophy
Becker
Endo
Cushings
Thyrotoxicosis
Other
ETOH
How to diagnose OA (3)
- > 45yo
- Exercise related pain
- Nil morning stiffness, or morning stiffness lasts >30mins
Osteogenesis imperfecta
Abnormality in _______
AD/AR
abnormality in type 1 collagen
AD
Which patient’s should be started on bisphosphonate without a DEXA
If has had fragility fracture AND aged >=75yo (65yo according to RCP, 75yo according to NICE)
What DXA scan score should you get to be started on bisphosphonates?
-2.5
List 6 medications that worsen osteoporosis
- PPIs
- Steroids
- SSRIs
- Antiepileptics
- Glitazones
- Heparin
- Aromatose inhibitors
PASHGAS or
GASHPAS
RF for osetoporosis
- Low BMI
- Steroid use
- RA
- FH of fracture
- Smoking
- ETOH
SSRELF
Name four groups of people who should take vit D
- If you are not exposed to the sun very often (e.g house bound)
- Age 3 months - 5yo (unless formula fed)
- All pregnant and breastfeeding women
- > 65yo
Predisposing RF for Paget’s disease (4)
Age
Gender
Geogrpahic
- increasing age
- male
- FH
- northern latitude
Isolated raised ALP =
Pagets
Rx for Paget’s (1)
Bisphosphonates
Paget’s complications (5)
- Deafness (cranial nerve entrapment)
- Sarcoma bone
- Fractures
- Skull thickening
- High output cardiac failure
Arthritis mutilans/ telescoping fingers =
Psoriatic arthropathy
Diseases associated with Raynauds (3)
Rx
- SLE
- Reactive arthritis
- Scleroderma (most common)
Rx CCB (nifedipine)
RA Mx (
- DMARD monotherapy +/- prednisolone
Name three TNF inhibitors
- Infliximab
- Etanercept
- Adalimumab
What scoring system can be used to assess management of RA?
DAS28
Name 7 factors that if +ve suggest a poor prognosis of RA
- RhF +ve
- Anti-CCP +ve
- X-ray: early erosions within 2 years
Name 7 factors that if +ve suggest a poor prognosis of RA
- RhF +ve
- Anti-CCP +ve
- X-ray: early erosions within 2 years
- Poor functional status at presentation
- Extra-articular features such as nodules
- HLA-DR4
- Insidious onset
RA: Name five (three early, two late) findings on xray
Early x-ray findings
- loss of joint space
- juxta-articular osteoporosis
- soft-tissue swelling
Late x-ray findings
- periarticular erosions
- subluxation
Rotator cuff muscles SITS
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Supraspinatus
Abducts arm (with deltoid)
Infraspinatus
External rotation
Teres minor
Adducts
External rotation
Subscapularis
Adducts
Internal rotation
Most common bacteria causing septic arthritis
Staph Aureus
Most common bacteria in young adults who are sexually active causing septic arthritis
N. gonorrhea
Mx septic arthritis
Fluclox or clinda in pen allergic for 6-12 weeks
Sjogren’s syndrome rx
- Artificial saliva and tears
2. Pilocarpine
- keratoderma blenorrhagica
- circinate balanitis
- dactylitis
Associated with which condition?
Reactive arthritis
Features 1. Sensory polyneuropathy 2. Raynaud's 3. Parotitis Associated with which condition?
Sjogrens
- blue sclera
- deafness secondary to otosclerosis
- dental imperfections are common
Associated with which condition?
Osteogenesis imperfecta
Most common shoulder dislocation?
Commonly caused by which direction of force?
How does the patient hold their arm?
Anterior
Posterior direction
Externally rotated, adducted/ side of body
Reduced range of movement
Weakness/ crepitus and tenderness over cuff insertions and subacromial region =
Xray can show?
Rotator cuff injury
Bony avulsion
