ortho/msk

Question 1

red flags for back pain?

Answer 1

tuna fish 
trauma 
unexplained wt loss 
neurological symps (radiating pain, incontinence) 
age >50/55, <20y 
fever
IVDU (osteomylitis) 
steroid use/immunosuppressed 
Hx of ca (breast, lung, prostate, kidney, GI, thyroid)

Question 2

Cauda equina syndorme pC?

Answer 2

• severe or progressive B/L neuro deficit of legs (motor weakenss with knee extension, ankle eversion, foot dorsiflexion)
• recent onset urinary retention ± urinary incontinence
• recent onset faecal incontinence
• perianal or perineal sensory loss (saddle anaesthesia or paraesthetisa)
• unexpected laxaty of anal sphincter

Question 3

Spinal # pc?

Answer 3

• sudden onset central spinal pain which is relieved by lying down
• Hx of trauma, wt lifiting if steroids.
• structural deformity of spine (eg. step)
  point tenderness of vertebral body

Question 4

back pain pointing to ca PC?

Answer 4

• > 50y
• gradual onset symps
• severe unrelenting pain remining when supine, aching night pain preventing or disturbing sleep, pain aggravated by staining and thoracic pain
• localised spinal tenderness
• unexplained wt loss
• hx of ca

Question 5

Infection + backpain pc ?

eg. discitis, vertebral osteomylitis, spinal epidural abscess

Answer 5

• fever
• TB or recent UTI
• DM
  Hx of IVDU
• HIV, immmunosuppressed.

Question 6

Back pain Mx?

Answer 6

• rule out red flags, fix any underlying issue
• STarT back risk stratification tool (<3 low risk, medium risk - physio, >4 high riskhsopital referral)
• simple analgesia for pain
  NSAIDs first line + PPI
  if CI, codeine with paracetamol ; do not give paracetamol alone.
  BDZ (diazepam 2mg qds for 5/7) for muscle spasm
• referral to physio
• CBT
• self management advice0 keep active.

Question 7

commonest mets to bone ?

Answer 7

breast, lung, prostate, thyroid, kidney

Question 8

benign bone tumour - osteochondroma?

Answer 8

• most common benign tumour
• cartilaginous capped outgrowth of bone from cortex, normally near epiphysis. lesion grows till skeletal maturity.
• pain free and PC as lump. if painful, inflamm of overlying bursa.
• usually solitary. multiple lumps need f/u (hereditary)
• any sudden increase in size = malignant transform to chondrosarcoma

Question 9

benign bone tumour - chondroma

Answer 9

non calcified cartilaginous growth in medulla or crtex of tubular bones eg. phalanges, metacarpals, tarsals, etc.

Question 10

benign bone tumour - osteoid osteoma

Answer 10

• young (5-30y)
• progressive night pain of long bones, referred to other joints, RELIEVED by NSAIDS
• commonly long bones (diaphysis) , cause of painful scoliosis
• XR shows ‘nidus’ - small osteolytic area surrounded by rim of dense sclerosis. look for periosteal reaction

Question 11

benign bone tumour - non ossyfing fibroma

Answer 11

• fibrous tissue tumour on radiology as an oval cortical defect with sclerotic rim. incidental finding. no tx.

Question 12

primary malignant bone tumours - osteosarcoma

Answer 12

• commonest bone primayr
• long bones of young adults or as complication of paget’s disease in elderly.
• PC with progressive pain (night/rest), refractory to analgesia
• swelling, reduced joint movement, limp
• xr = bone destruciton, soft tissue invasion, radiating spicules (sunray appearance); subperiosteal elevation with new bone (codman’s triangle)
• MRI for staging
• mets via blood to lungs and bone.
• Tx = neoadjuant chemo and surgical resection.

Question 13

primary malignant bone tumours - chondrosarcoma

Answer 13

• common in older
• on flat bone eg. ilium of pelvis, ribs, scapula
• tx ranging from WLE to amputation.
  less role for chemo/radio

Question 14

primary malignant bone tumours - Ewing’s sarcoma

Answer 14

• children and young adult (<20)
• pain, assos with hot/red swelling with fever ; ddx osteomyelitis
• commonly pelvis, long bones, scapula
• high ESR, high WCC
• XR - lytic bone destruction with periosteal reaciton in multiple layer s(onion skin appearance)
• MRI shows soft tissue involvement (not seen with osteomylitis)
• mets to lungv fast, usual PC with this
• tx chemo radio, resection/amputation. response to chemo decides prognosis

Question 15

primary malignant bone tumours - Giant cell tumour (osteoclastoma)

Answer 15

• rare before 20y
• usually benign but may undergo malignant transformation
  rx is local excision and filling defect with cement
• recurrance common