Musculoskeletal_Medicine Flashcards
Hand & wrist examination? DDx structure? Ix? Common hand pathology? Hand muscles anatomy?
Intro - WIPE (wash, intro, pain & position, explain)
Look
- General - RASS (Redness, Asymmetry, Swelling, Scars)
- Tops:
- Bones:
- OA - Heberden’s nodes (DIP), Bouchard’s nodes (PIP)
- RA - swan neck deformity, boutonniere’s deformity, Z-shaped thumb, ulnar deviation, MCP palmar subluxation
- Skin - scars, thinning, rashes, bruising (steroids)
- Muscle - wasting
- Nails - psoriatic changes (pitting, onycholysis), clubbing, nailfold vasculitis
- Bones:
- Palms - thenar (thumb-side), hypothenar muscle wasting, palmar erythema (RA), carpal tunnel release scar, swellings (e.g. ganglions)
- Extensor surfaces - psoriasis, rheumatoid nodules, gouty tophi (white uric acid crystals under the skin - fingers/elbows)
Feel
- TST (Temperature, Swelling, Tenderness)
- Palms:
- Bulk of thenar/hypothenar prominences
- Tendon thickening - flexor tendon sheaths (hypertrophy/contraction –> Dupytren’s)
- Flex each finger individually and then feel the tendon base as extend (trigger digit)
- Tops:
- Temp - forearm, wrist, MCP
-
Squeeze joints & feel for bony swelling, effusion, synovitis, deformity
- Distal radio-ulnar joint + radial & ulnar styloid
- Anatomical snuffbox (tender = scaphoid fracture)
- Carpals (bimanual palpation)
- MCP (squeeze along row then bimanual palpation if pain elicited)
- Base of thumb (squaring = OA)
- IP joints (bimanual palpation of each - nodes = OA)
-
Tendon tenderness
- Around radial styloid (1st extensor compartment) = de Quervain’s tenosynovitis
- Around ulnar styloid = extensor carpi ulnaris tendinitis
Move (active > passive - feel for crepitus, get a few more degrees)
- Wrist movements - active (prayer sign & reverse prayer sign) & passive (feel for crepitus)
- Finger movements - make fist (tendon, small joint involvement), straighten fully (against gravity - joint disease, extensor tendon rupture, neuro damage)
- Thumb movements - abduction (away from hand upward), adduction (thumb to palm), flexion (thumb to little finger) extension (lateral away from hand), opposition (thumb and little finger)
Functional:
- Power grip = Grip fingers
- Pincer grip on finger
- Ask about writing with pen, button-up shirt
Brief neuro hand exam:
- Motor (against resistance):
- Radial (extensor forearm) - wrist extension
- Ulnar (some of flexor forearm + hand) - finger abduction
- Median (flexor forearm + thumb) - thumb abduction
- Sensory:
- Ulnar (up to halfway through ring finger dorsum/palm) - hypothenar eminence
- Median (rest of the palm + fingertip to PIP dorsal index, middle and half of the ring finger) - thenar eminence
- Radial (dorsum of hand excluding above) - dorsal base of the thumb
Special tests
- 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)
To complete exam
- Examine the elbow, full neurovascular exam
DDx: degenerative, infective, inflammatory, traumatic, congenital
Ix: AP & lateral views (2 views) + imaging of joints above and below as well
Hand/wrist pathology:
- RA - chr AI disorder –> symmetrical deforming polyarthropathy
- Synovitis, bony deformities, palmar erythema, small muscle wasting, reduced RoM, tendon rupture/subluxation
- DIP joints sparred
- Mx: NSAIDs, steroids, DMARDs (methotrexate), surgery
- OA - mechanical joint degradation w/ degen of articular cartilage, periarticular bone remodelling & inflammation
- Signs: joint crepitus, limited RoM, bony deformities
- Mx: analgesia, CS injection, physio/splints, surgery
- Carpal tunnel syndrome - median nerve entrapment neuropathy from compression of the median nerve in carpal tunnel
- Intermittent paraesthesia, pain/burning & numb thumb, first, middle fingers and radial half of ring finger
- Worse @night
- Signs: loss of power + wasting of thenar eminence, sensory loss in median nerve distribution
- Mx: splints, CS inj, carpal tunnel decompression
- Trigger finger - thickening of flexor tendon sheath causing entrapment at A1 pulley
- Discomfort/bump at base of digit and catching/clicking during extension
- Mx: splints, NSAIDs, CS inj, surgical release
Hand muscles anatomy:
-
Median nerve - LOAF (all thumb muscles except adductor pollicis)
- Lateral 2 lumbricals
- Opponens pollicis
- Abductor pollicis brevis
- Flexor pollicis brevis
-
Ulnar nerve (extrinsic hand muscles except most of thumb)
- Adductor pollicis
- Lumbricals (flex MCP, extend IP)
- Palmar interossei (ADduct fingers) = PAD
- Dorsal interossei (ABduct fingers) = DAB
- Radial nerve = extensors
Hip examination? Presentation? DDx structure? Ix? Mx (for OA)? Common pathology?
Intro - WIPE (wash, intro, pain & position, explain)
Function - Gait (Antalgic, Trendelenburg - waddling = abductor dysfunction)
Look
- General - RASS (Redness, Asymmetry, Swelling, Scars)
- Standing inspection:
- Front (pelvic tilt, quads wasting), side (lumbar lordosis, knee flexion, foot arches), behind (scoliosis, gluteal atrophy, iliac crest alignment)
-
Trendelenburg’s test:
- Place hand resting lightly above both hips
- Bend one knee - if the hip dips on the bent side = contralateral abductor muscle weakness
- Lying inspection: compare symmetry & rotation (shortened & externally rotated = fractured NoF), hip scars, dressings, skin changes
Feel - check for pain, start on the normal side
- TST (Temperature, Swelling, Tenderness)
- Bony landmark tenderness:
- Feel around hip joint (tenderness, warmth, effusion)
- Feel along greater trochanter (lateral edge of thigh - trochanteric bursitis) run a hand up to greater trochanter (trochanteric bursitis)
- Feel ASIS –> pubic rami
- Measure true/apparent leg lengths:
- Apparent = umbilicus to medial malleolus (unequal = spinal/pelvic deformity e.g. scoliosis)
- True = ASIS to ipsilateral medial malleolus (unequal = true limb shortening e.g. fracture)
Move (active > passive - feel for crepitus, get a few more degrees)
- Roll side to side
- Flexion:
- Active (as far as can) then passive feeling for crepitus
- Passive internal & external rotation (while knee is bent to 90 degrees, lose IR early in OA)
- Passive abduction & adduction - place a hand on the contralateral pelvic crest to detect mov (crossing over leg for adduction)
- Passive extension - lie face down, scars/muscle wasting? place hand on pelvis/lumbar spine to detect mov
Special tests
-
Thomas’s test (not if hip replacement –> dislocation):
- Place a hand under the lumbar spine (check no lumbar lordosis)
- Flex hip on one side (knee bent)
- If contralateral thigh forced off the ground = fixed flexion deformity (of the side forced off the ground)
- NOTE: need to flex hip on the opposite side to that examining
To complete exam - examine shoulder and knee, full neurovascular exam distal to joint
Presentation:
- Normal gait, no obvious deformities on inspection
- On palpation, there was no pain with a full range of passive and active movement and no fixed flexion deformity and no abductor muscle weakness
DDx: degenerative, infective, inflammatory, traumatic, congenital
Ix: AP & lateral views (2 views) + imaging of joints above and below as well
Mx (for OA):
- Conservative – physio, exercise, weight loss
- Medical – analgesia, IA CS injection
- Surgical – arthroplasty
Common pathology:
- Hip OA - pain, crepitus, reduced ROM (internal rotation lost first)
- Hip fracture - shortened and externally rotated limb
- Hip dislocation - shortened and internally rotated limb
- Abductor muscle weakness - Trendelenburg’s positive
- Trochanteric bursitis - pain over the greater trochanter
- Childhood - dislocation, Perthes, SUFE
Knee examination? Presentation? Ddx structure? Ix? Common pathologies?
Intro - WIPE (wash, intro, pain & position, explain)
Function - Gait (Antalgic, waddling = abductor dysfunction)
Look:
- General - RASS (Redness, Asymmetry, Swelling, Scars)
- Standing up - front (quads wasting, knee swelling), side (fixed flexion deformity, foot arches), back (varus/valgus deformity, baker’s cyst)
- Lying on bed - scars (TKR, arthroscopic ports on either side), wasting, deformity
Feel:
- TST (Temperature, Swelling, Tenderness)
- Effusion:
- Patellar tap (push down thigh & hold, press down on patella with middle finger)
- Sweep test (push down thigh, back of hand sweeps up medial x3, other back of hand sweeps down lateral, +ve is swelling on the medial side)
- Palpation:
- Leg straight - quadriceps tendon, medial & lateral borders of patella, patella tendon
- Knee @90 degrees:
- Patella tendon, tibial tuberosity (down from tendon), medial joint margin
- Lateral joint margin, head of the fibula (slightly lateral and distal to knee), collateral ligaments (hands around upper calf)
Move (active > passive - feel for crepitus, get a few more degrees)
- Knee extension:
- Active = push knee down into bed
- Passive = lift entire leg up @ ankle (hyperextension >10 degrees)
- Knee flexion:
- Active = bring heel towards bum (posterior sag?) then straighten
- Passive = same mov, leave knee flexed (for next part)
Special tests = 3Cs of knees – Cartilage (McMurray’s), Collaterals, Cruciates – Lachman’s, A/P-drawer)
- Anterior & posterior drawer (ant- bring towards = ACL; post - push away = PCL)
- Lachman’s test (flex knee to 30 degrees, right hand pulls, left hand stabilises the femur, checks ACL)
- Collateral ligament assessment:
- Varus stress test (LCL) - put the knee in varus positon while palpating the lateral knee joint line
- Valgus stress test (MCL) - put the knee in valgus position while palpating the medial knee joint line
- Menisci assessment - McMurray’s test - say “would consider doing but may be too painful for the patient”
- Passively flex the 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 movements to test for lateral meniscus tear
To complete exam:
- Assess NV status
- Examine joints below and above (hip and ankle)
- Further imaging if indicated (X-ray)
Presentation:
- Normal gait, no obvious deformities of either knee, on palpation there was no pain and there was a full range of active and passive movement
- There was no evidence of laxity in the knee ligaments bilaterally
DDx: degenerative, infective, inflammatory, traumatic, congenital
Ix: AP & lateral views (2 views) + imaging of joints above and below as well
Common pathologies:
- ACL tear - twisting injury, ‘pop’ swelling within 1 hour, very painful for 2wks
- Increased laxity on anterior drawer test/Lachman’s test
- Mx: physio/surgical reconstruction (if ongoing instability)
- PCL tear - high energy trauma (multi-ligament knee injury/hip dislocation/fracture)
- Increased laxity on posterior drawer test
- Mx: physio/surgical reconstruction
- Meniscal tear - twisting injury, swelling after a few hrs, sharp localised medial/lateral pain worse on hyperflexion/twisting, knee may lock/give way
- Tender over medial/lateral joint line, good RoM unless knee locked, +ve McMurray’s
- Mx: MRI/arthroscopy to confirm, tear usually excised arthroscopically
- Collateral ligament tear
- Varus/valgus laxity, effusion, tenderness over affected ligaments
- Mx: rest, physio, hinged brace
- OA - pain & stiffness, reduced RoM, crepitus
- Prepatellar bursitis - localised swelling over patella, precipitated by period of kneeling
- Signs: tender over patella, normal RoM
- Mx: rest, NSAIDs, aspiration/CS inj
Gait abnormality relevant to MSK vs normal
Antalgic gait - limping due to pain e.g. osteoarthritis, inflammatory joint disease, LL fracture, sciatica
Normal gait cycle: 1) heel strike 2) foot flat 3) mid stance 4) heel off 5) toe off
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
Spot Dx based on observation - rheum & skin
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
RA - Def? Presentation? Ix? Mx?
Def: AI process causing synovial joint inflammation (synovitis) with destruction of peri-articular structures
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, ESR/CRP, X-rays
Mx:
- Create an end target e.g., remission
- 1st - Monotherapy with conventional 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)
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)
Psoriatic arthritis - Signs? Types? Criteria name? Mx?
Signs:
- Extensor plaques with scales (scalp + behind ears)
- Nails - pitting, hyperkeratosis, onycholysis
- Other forms: guttate (drop-like), Koebner phenomenon
Types:
- Mono/oligoarthritis
- Spondylitis (back)
- Asymmetrical polyarthritis (incl DIP-specific)
- Arthritis mutilans
- Rheumatoid-like
Criteria name: CASPAR criteria - established inflame arthritis/enthesitis + ≥3 of options
Mx:
- Conservative:
- Psoriasis - precipitant avoidance (alcohol, smoking, stress, B-blockers)
- Exercise & physio for arthritis
- Medical:
- Psoriasis:
- Topical Tx:
- Topical steroids (hydrocortisone 2.5%/betamethasone 0.05%)
- Calcipotriol
- PUVA = Psoralen + UVA phototherapy
- Topical Tx:
- Psoriasis:
- Arthritis = Methotrexate, anti-TNFs
During rheumatology assessment what do you need to say at the end?
Say you will examine neurovascular status of limb
Rheum examination - observations & assoc Dx
Ankle swelling, erythema, loss of foot sensation + T2DM - Dx?
Charcot arthropathy (a complication of peripheral neuropathy)
Assessing osteoporosis risk
Osteoporosis Mx? Using bisphosphonates –> jaw pain & swelling?
0 to -2.5 DEXA:
- Conservative - exercise, reduce alcohol, balanced diet, Tx underlying causes
- Repeat DEXA @2yrs
- 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
Fall on outstretched hand & “dinner fork” deformity - Dx?
Colle’s fracture
- Dorsal angulation of the distal bone fragment
Normal Ca/PO4 but raised ALP - Dx?
Paget’s disease of the bone
Red, scaly legions on finger joints - Dx?
Gottron’s papules = Dermatomyositis
Episodes of white, cold hands - Dx?
Raynaud’s phenomenon
Telescopic digits - Dx?
Arthritis mutilans (Psoriatic disease pattern)
Septic arthritis - presentation? Mx?
Presentation - hot swollen joint with reduced range of motion
Mx: needle aspiration before abx –> fluids for 3Cs & G (cells, culture, crystals, gram stain) –> empirical IV abx (based on aspiration)
- S. aureus is most common
- NOTE: if prosthetic joint - biofilm can be created - early (<3m post-surgery)/delayed (>3m) –> more complicated, coag neg staph more common
Urethritis, conjunctivitis, arthritis - Dx?
Reactive arthritis (can’t pee, can’t see, can’t climb a tree)
Asymmetrical polyarthralgia, tenosynovitis, skin lesions
Gonococcal arthritis
HLA-B27 - Dx?
Seronegative spondyloarthropathies (ank spond, PsA, reactive arthritis, IBD-associated arthritis)
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
Segond fracture (lateral tibial plateau) - associated with what?
75% = ACL rupture
Strong lateral blow to knee
Suspect unhappy triad (ACL, MCL, medial meniscus tears)
Anterior drawer test for ankle - what is it testing?
Tests talofibular ligament stability
Light bulb sign on shoulder X-ray?
posterior dislocation of shoulder
Pain in anatomical snuffbox? Why is this worrying? What is another common carpal bone trauma?
Scaphoid fracture
- Blood supply is distal to proximal (retrograde) –> high-risk of AVN –> refer as orthopaedic emergency
Common trauma: lunate dislocation = another orthopaedic emergency
Paradoxical breathing after chest trauma?
flail segment
Heavy smoker + recurrent digit ischaemia?
Thromboangiitis Obliterans (Buerger’s disease)
Haemoptysis, haematuria & anti-GBM - Dx?
Goodpasture’s syndrome (abs attack lungs & kidneys)
New agitation + hallucinations after pred?
Steroid-induced psychosis
Primary Sjogren’s syndrome - presentation? Abs?
Dry eyes & mouth - the destruction of salivary glands
Abs:
- ANA +ve
- Anti-Ro/La, anti-RF
Principles of orthopaedic Mx
- Reduce – putting the bone back in the right position:
- Closed (don’t need to open) – manipulate/traction (skin/skeletal – pins)
- Open – mini-incision or full exposure
- Fixation – keeping the bone in the right place
- Internal – intra (pins, nails)/extramedullary (plate/screws, pins)
- External – mono/multiplanar
- Rehabilitation – regaining normal movement
- Use (pain relief, retrain)
- Move
- Strengthen
- Weight bear
Fracture complications
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)
OA X-ray changes
Wrist fracture - types? Mx?
Types:
- Colles’ fracture - common in A&E, fall on an outstretched hand –> fracture of distal radius, displaced dorsaly (dorsum of the wrist)
- Smith fracture - fall on flexed wrist, displaced in a palmar direction (palm of the wrist)
- NOTE: displaced in the direction that is facing upwards (e.g. in Colles’ the dorsal aspect is facing the sky; in Smith’s the palmar aspect is facing the sky)
Mx:
- Check neurovascular intact
- Imaging (visualise fracture)
- Reduction under haematoma block > Hold (e.g. cast) > Rehabilitate
- NOTE: Smith’s fracture is often more complicated –> surgical intervention
RA Hand X-ray findings?
- Joint erosion
- Periarticular osteopenia
- Ulnar deviation
- Z-thumb
- Swan neck
Fracture Mx?
- Reduce (aligning fracture components) e.g. chole’s fracture - haematoma block (provides anaesthesia as you manipulate different parts of the fracture) –> traction/counter-traction
- Hold e.g. with cast
- Rehabilitate - regain function e.g. physio
Knee anatomy & examination tests for relevant injuries?
Ligaments supporting knee joint (outside –> in):
-
Lateral & medial collateral ligament (LCL & MCL) - prevent excessive varus/valgus force (respectively)
- MCL - prevent excessive valgus mov of tibia relative to femur
- Valgus stress test (hold leg straight, support knee & provide valgus force distal to the knee): +ve = excessive valgus movement
- LCL - prevent excessive varus mov of tibia relative to femur
- Varus stress test (as above but opposite): +ve = excessive varus movement
- MCL - prevent excessive valgus mov of tibia relative to femur
- Lateral & medial meniscus - cuffs of cartilage cushioning the distal end of femur as it sits on top of the tibia –> McMurray’s test
-
Anterior & posterior cruciate ligaments (ACL & PCL) - prevent end of the femur from sliding around on top of the tibia
- NOTE: ACL & PCL injuries are often sport-related
- ACL - prevent anterior movement of the tibia relative to the femur
- Anterior Drawer test (gripping calf –> tug forward): +ve = anterior displacement of the tibia
- Lachman test (knee flexed 30 degrees, hand above knee pushing down & hand below-knee pulling up): +ve = anterior displacement of the tibia
- PCL - prevent posterior movement of the tibia relative to the femur
- Posterior Sag (flex knee to 90 degrees): sign +ve = posterior displacement of the tibia (tibia sags slightly relative to the femur)
- Posterior Drawer test (grip calf –> push away): +ve = posterior displacement of the tibia
Mx ligament tear:
- Conservative - analgesia & physiotherapy
- Surgical e.g. Semitendinosus used to reconstruct new ACL
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
Overview of MSK exams
Buzzwords for hip exam - split by look, feel, move
OA findings on knee X-ray
- Loss of joint space
- Osteophyte formation (side of joint surfaces)
- Subchondral cysts (area of lucency = dark)
- Subchondral sclerosis (very white joint margin)
Common findings on knee exam?
Meniscal injury - tenderness over joint line (+ McMurray’s)
Gout/pseudogout - swollen, erythematous, tender joint
OA - pain, crepitus, limited RoM
Ligament injury based on special tests/mov
Common findings on shoulder exam?
- Deformed shoulder + internal rotation –> posterior shoulder dislocation
- Winging of scapula –> long thoracic nerve injury (e.g. from axillary LN clearance)
- Tender on palpation –> humeral neck fracture
- Pain, crepitus, reduced ROM –> OA
- Stiff, limited RoM (passive, active) esp external rotation –> frozen shoulder (adhesive capsulitis)
- Supraspinatus impingement –> painful arc (60-120 degrees)
- Positive special tests = rotator cuff injury (pain up to 60 degrees in arc):
- Pain but function = tendonopathy
- pain + reduced function = tear
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
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
Dupuytren’s contracture - def? causes? image?
Def: hypertrophy & contracture of palmar aponeurosis (fascia retinaculum)
Causes:
- Idiopathic, age, trauma, familial (AD)
- Alcoholic liver disease
- Epilepsy & anti-epileptics (e.g. phenytoin)
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
What is Erb’s palsy?
Waiters tip - left arm flexed with extension @elbow, flexion @wrist/fingers
Cause: traumatic birth/high impact injuries to shoulder –> traumatic lesion on superior trunk of brachial plexus
What is the ulnar paradox?
Ulnar nerve damage –> paralyses lumbricals of 4th/5th fingers –> Hyperextension @MCPs, flexion @IPs
Ulnar paradox: in proximal lesion = less claw-like than distal lesion as weakens flexion of IP joints
Landmarks on pelvic XR (hip)? How can I see if hip fracture?
Look at Shenton’s line (inferior pubic rami) = NoF fracture
