Musculoskeletal_Medicine Flashcards
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
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
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
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
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
Gout - presentation? Ix? Mx?
Presentation: 1st MTP joint, monoarticular (can be poly)
Ix: Bloods (FBC, CRP, Urate), X-ray (errosive)
Mx:
- Acute:
- NSAIDs
- Colchicine
- Oral Pred (5 days), steroid joint injection
- Chronic:
- Dietary advice - low purine, weight loss
- Xanthine oxidase inhibitor e.g. allopurinol/febuxostat
- Consider - uricosuric agents e.g. sulphinpyrazone, probenicid, benzbromarone
- (NOTE: Rasburicase - tumour lysis syndromes)
Ankylosing Spondylitis is a type of what? Ix? Mx?
Axial spondylitis
Ix:
- Spinal exam: Schober’s test - gross restriction <3cm (should be 8-10cm)
- X-ray:
- Sacroiliitis
- Sclerosis
- Erosive damage
- Widening joint space
- (Fusion)
- MRI scan whole spine & sacroiliac joints - detect pre-radiographic axial spondylitis
- Sacroiliitis
- Shiny corners (Romanus lesions)
Mx:
- Analgesics + NSAIDs
- TNF-alpha blocker (or IL-17 blocker)
Systemic sclerosis (scleroderma) - def? Subsets? Presentation? Ix? Raynaud’s Mx?
Def: multisystem disease - inflammation, vascular abn, fibrosis
Presentation: digital ulcers, tight skin around hands/mouth
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
- 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)
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
Polymyalgia Rheumatica (PMR) - def? presentation? Associated condition? Dx & Ix? Mx?
Def: inflammatory rheumatological condition
Presentation: muscle aches and joint stiffness (takes 2-3hrs to loosen up in the morning)
- Profile: elderly woman (>70yrs)
- Difficult to rise from seated/prone position
- Shoulder/hip stiffness & bursitis
- muscle tenderness & oligoarthritis
Associated with GCA (15-20% have GCA; 40-60% GCA have PMR)
- GCA is most common primary vasculitis
- Can have amaurosis fugax, blindness if vision not treated within hrs
- Ix: bilateral temporal artery biopsies - up to 2wks after high-dose steroids
Dx: clinical + ESR, CRP, FBC (to rule out haem disorders)
Mx: prednisolone + osteoporosis prevention (Ca, Vit D, Bisphosphonates)
- Other: methotrexate + folic acid
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
Overview of MSK exams
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
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
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
Special tests on spine?
Schober’s test: gross restriction <3cm = Ankylosing Spondylitis (fusion of sacro-iliac & lower spine)
- Mark midline between dimples of venus & 10cm above –> ask to touch toes –> measure distance between 2-points
- Should increase by 8-10
Sciatic stretch test: pain in thigh & buttocks = sciatica (L3-S3 nerve root irritation)
- Patient supine, straight leg raise while ankle dorsiflexion
Femoral nerve test: pain in thigh & buttocks = L2-4 nerve root irritation
- Patient prone, extend hip
Landmarks on pelvic XR (hip)? How can I see if hip fracture?
Look at Shenton’s line (inferior pubic rami) = NoF fracture
Fibromyalgia
Def: chronic pain syndrome diagnosed by the presence of widespread body pain ≥ 3 months
Presentation:
- RFs: AI rheum condition (RA, SLE), female
- Chronic widespread body pain
- Diffuse tenderness on physical exam
- Fatigue, memory problems, sleep & mood disturbance
Ix: clinical Dx
- To exclude other causes: FBC, TFT, ESR/CRP, vit-D, Ab-testing (RF, anti-CCP, ANA)
Mx:
- 1st - TCA e.g. amitryptiline
- Non-pharm: education, exercise, CBT ± referral to psych
