Ortho + MSK Flashcards
Reflexes eponym
1,2 buckle my shoe, 3,4 kick the door, 5,6 pick up a stick, 7,8 open the gate
S1 & S2 = Ankle reflex
L3 & L4 = Patellar reflex
C5 & C6 = Biceps reflex
C7 & C8 = Triceps reflex
L3 Radiculopathy
Sensory loss to Anterior thigh
Quadricep weakness
Reduced Knee reflex
Test = +ve Femoral stretch test
Which nerve roots does the femoral nerve arise from
L2-L4
L4 radiculopathy
Sensory loss to anterior Knee
Quad weakness
Reduced knee reflex
+ve femoral stretch test
L5 radiculopathy
Anterolateral shin + dosrum of foot sensory loss
Weakness of dorsiflexion (foot drop)
Reflexes intact
+Ve sciatic stretch test
S1 radiculopathy
Sensory loss = posterolateral leg
Weakness = Plantarflexion
Reduced ankle reflex
+Ve sciatic stretch test
In which spinal roots does the sciatic nerve originate
L4-S3
Cauda equina
Surgical emergency where the nerve roots of the cauda equina (L2/L3) are compressed.
Causes = Disc prolapse / Tumor / Spondylethesis / Abscess / Trauma
Features;
* Saddle anaesthesia
* Loss of sensation in bladder + rectum = urinary/fecal incontinence + loss of sphincter tone
* Bilateral sciatica / Bilateral motor weakness in legs
* Sexual dysfunction.
Diagnosis;
* PR - for anal sphincter tone
* Emergency MRI scan
Management = Surgery ASAP
Sciatica
Cause = Any compression of the nerve roots of the sciatic nerve (L4-S3) e.g disc herniation / Spinal stenosis / RA / AS / Tumor / Piriformis syndrome / Wallet sciatica / Pregnancy
Sciatic nerve innervates the hamstrings & then splits into the Tibial + Common fibular nerve
Features;
* Sharp shooting pain down posterior leg + back pain
* Unilateral
* Worse on sitting / standing
O/E = +ve sciatic nerve stretch test.
Management = Analgesia + physio. Only MRI if there is signs of UMNL or cauda equina Red Flags.
90% resolve in 6 weeks.
Spondylethesis
Displaced vertebral body (typically L5)
Causes - Spondylosis / Degeneration / Malignancy / Trauma / Congenital
Common in younger or much older patients.
Poorly localised back pain which is worse on activity.
Stiffness + waddling gait + Palpable ‘step’ of the spine.
Diagnosis = Xray - shows collaged scotty dog deformity
Management = physio + analgesia + orthotics. May require fusion surgery or decompression.
Spinal stenosis
Typically pt >50yrs with sharp lower back pain + tingling down the legs which improves upon rest.
Pain eases when walking up hill and when leaning forward / sitting.
Diagnosis = MRI scan
Management = Physio + Analgesia + Epidural steroids
Weight loss will help
If neurological comprise then laminectomy can be done
How to differentiate between neurogenic claudication and vascular claudication
Neurogenic claudication = often alleviated by walking uphill and eased when sitting. pulses intact
Vascular claudication = Worse on walking uphill and pulses may be abnormal.
Schuermanns disease
A condition of hyperkyphosis of atleast 3 vertebrae - due to epiphysitis of vertebral joints (cartilage –> bone)
Features;
* Typically presents in adolescence with back pain + stiffnss + progressive kyphosis
Diagnosis = Xray shows epiphyseal plate disturbance + anterior wedging.
Cervical spondylotic myelopathy
= Posterior disc protrusion in the cervical spine. Often secondary to spondylosis
Features;
* Neck pain & stiffness
* Slow progression of motor weakness - difficulty walking, spastic paraparesis + reduced hand dexterity.
* May have radiculopathy too
* Autonomic dysfunction can occur e.g incompetence.
Examination findings; +ve hoffman + babinski’s
Invx = MRI
Management = decompression might be needed
Pott’s disease
This is TB induced spondylitis due to haematogenous spread.
High risk of disc collapse from caseous necrosis - may cause pott’s paraplegia
What is the most common causative organisms in Discitis
Staph aureus - most common
Pseudomonas - in IVDU
What other investigations should be done if Staph aureus discitis is found
Echocardiogram - to look for infective endocarditis due to haematogenous spread. (Septic emboli most common cause of discitis / psoas abscess in non IVDU)
Epidural abscess
Often forms secondary to discitis
Features;
* Severe localised back pain & tenderness on palpation
* Systemic infection - high fever etc
* Focal neurological deficit possible
Invx = Sepsis screen. MRI is best radiological invx
Consider echo + dental Xray
Management = Long term broad spec antibiotics (IV)
Osteomyelitis
Types;
1. Haematogenous - results from a bacteria, more common if immunosupressed / infective endocarditis
2. Non-haematogenous = local spread of infection e.g diabetic foot, PAD - often polymicrobial
Staph aureus most common cause
Salmonella in Sickle cell patients
Invx = MRI
Management = IV antibiotics
Osteopetrosis
Marble bone disease - autosomal recessive
Bone becomes harder and more dense
Typically presents in young adults /children
Radiology shows marble bone - lack of differentiation between cortex & medulla
Monteggias fracture
Ulnar shaft fracture + Dislocated proximal radioulnar joint
Complication = radial nerve palsy
Galeazzis fracture
Radial shaft fracture & Dislocation of the Distal radioulnar joint (DRUJ)
Colles Fracture
Distal radius
Dorsally ungulated
Dorsal displacement
Dinner fork deformity
Complications = Median nerve injury + compartment syndrome + EPL rupture + OA.
Mx = Dorsal plaster slab + slight ulnar deviation
Smiths fracture
Reverse colles fracture = Volar angulation of distal smiths fracture & garden spade deformity.
Mx = open reduction
Which drug is association with duputryens contracture
Phenytoin
NoF fractures
Intracapsular/Subcapital - Displaced fractures need athroplasty, undisplaced ones can have Internal fixation or Hemiarthroplasty
Extracapsular - Intertrochanteric can have dynamic hip screw. If displaced or subtrochanteric then intermedullary device is needed.
Salter-Harris Classification
I - Straight across growth plate (physis only - Xray may look normal)
II - Above (Physis + metaphysis)
III - Lower or below (physis + epiphysis and includes joint)
IV - Two or through (physis + metaphysis + epihysis)
V - Erasure of growth plate or crush injury (Xray may look normal)
Greenstick fracture
Unilateral cortical breech only
Buckle / Torus fracture
Incomplete cortical distruption resulting in periosteal haematoma only (looks like bilateral swelling on the bone)
Barton’s fracture
Intra-articular fracture of the distal radius (colles/smiths) with associated radiocarpal dislocation
Which is the most common site for a metatarsal stress fracture
shaft of 2nd metatarsal
Bennets fracture
Intra-articular fracture to the base of the thumb
Xray shows a triangular fragment off the base of the thumb
Commonly from fist fights
Boxers fracture
Fracture to the neck of the 5th metacarpal caused by fist fight usually.
Skiers thumb
Partial or complete rupture of the Ulnar collateral ligament at the MCPJ joint.
Cause = forced abduction of the thumb
Clinically = tenderness over the UCL. Instability of thumb joint. Can cause a weak pinch grip.
Extensor tendon injury
Clinically depends on where it is injured - if injured at the wrist then loss of extension at the MCP joint (= drooping of the digit, PIP and DIP compensates)
If injured over the PIP = Boutonniere’s
If injured over the DIP = Mallet finger
De Quervains tenosynovitis
Inflammation of the tendon sheath containing the APL and EPB at the location of the radial styloid process.
Common in 30-50 year olds.
Associated with RA and pregnancy.
Features;
* Pain over the wrist + Localised tenderness over the anatomical snuffbox + radial styloid process
* Pain worsened by gripping and resisted thumb abduction.
Test = Finkelstein’s test -
Side effects of intra-articular steroid injections
Pain + swelling (cortisone flare, settles in 1-2days)
Skin discolouration
Hyperglycemia
Infection
Allergic reaction
Subcut skin atrophy
Perihera nerve dysfunction
may lead to cardiac arrythmias if inserted wrong.
Axillary nerve palsy
Axillary nerve originate from posterior cord of brachial plexus (C5,C6)
Commonly caused by humeral head / anterior shoulder dislocations.
Regimental patch reduced sensation + weakness to teres minor + deltoid. (cannot abduct arm past 15 degrees + loss of contour over shoulder).
Radial nerve palsy
Radial nerve = posterior cord of brachial plexus (C5-T1)
Common caused by humerus midshaft fracture, drunk arm, handcuffs and monteggia’s fracture
Features;
* Weakness of triceps
* Wrist drop + Weak grip (weakness of finger extension)
* Sensory loss over posterior forearm and dorsolateral hand
Musculocutaneous nerve palsy
Origin = lateral cord of brachial plexus
Injury is rare as it runs deep in the anteror comparment of arm. Usually results from a brachial plexus injury
Features;
* Weak flexion + supination of arm
* Sensory loss to lateral forearm
Median nerve palsy
Features depend on where the injury is.
If at wrist level;
* Carpal tunnel syndrome - Thenar wasting & paralysis of opponens pollices (ape hand deformity/hand of benedictin)
* Sensory loss to palmar aspect of lateral 2.5 fingers
If at elbow;
* Same as above +
* Inability to pronate the forearm
* weak flexion of wrist
* ulnar deviation of the wrist
Ulnar nerve palsy
Originates from medial cord (C8-T1)
Cause of injury = handlebar palsy (cycling) + medial epicondyle fracture + cubital tunnel syndrome.
Features
* Claw hand (if injury to the wrist)
* Intrinsic hand muscle wasting (*except lateral 2 lumbricas - median nerve *) causing weakness in Abduction + Adduction of fingers
* Hypothenar wasting
* Inability to adduct the thumb
O/E = +ve Froment’s sign (difficulty holding paper - they will basically bend their thumb to compensate - flex the FPL)
Median nerve motor supply to the hand
LOAF
Lateral 2 lumbricals
Opponens pollices
APB
FPB
Erb’s palsy
= upper brachial plexus injury. (C5/C6)
Common complication of forcep use or shoulder dystocia. Also common in RTAs.
Injuries to the axillary nerve, suprascapular nerve, Musculocutaneous nerve + Long thoracic nerve
Features;
* Adducted extended, internally rotated, pronated arm with flexed wrist (waiters tip)
* Winging of the scapula
* May have diaphragmatic paralysis if phrenic nerve is damaged.
Klumpke’s paralysis
Lower brachial plexus injury (C8-T1)
Injuries to the radial, ulnar and median nerves
Commonly caused by breech delivery or when grabbing something from a height
Features;
* Paralysis of the intrinsic muscles of the hand
* claw hand
* Horner’s syndrome (if T1 is involved)
Carpal tunnel syndrome
Compression of the median nerve in the carpal tunnel. More common in females.
Causes = Obesity / Pregnancy / Hypothyroidism / Stress injury / RA / Radial fracture / Oedema / Acromegaly / Lunate fracture
Features;
* Pain or pins and needles in the thumb, index and middle finger. Worse at night. Pt shakes hands to relieve pain.
Signs;
* Weakness of thumb abduction
* Thenar wasting
* Tinel’s sig = tapping causes parasthesia
* Phalen’s = Flexion of the wrist causes symptoms
Management = 6 week conservative treatments (corticosteroid injections + wrist splint at night). If symptoms persist consider surgery.
Meralgia paresthetica
Entrapment of the lateral femoral cutaneous nerve by the ASIS.
More common in women aged 30-40yrs
RF = Prengnacy / obesity / Surgery / Neuroma / DM / Trauma / Tense ascites
Clinical features;
* Anterolateral thigh pain
* Burning or tingling dysthesia (light touch is painful - allodynia)
* Deep muscle ache in thigh
* Pain worse on standing, relieved by sitting.
O/E - pelvic compression test - compress lateral thigh for 45s with pt lying on side. If painful then +ve test.
Management = LA ultrasound guided injection.
Obturator nerve palsy
Typically injured from anterior hip dislocation.
Reduced sensation to medial thigh & weakness in Adduction of the thigh.
Clinically = exercise induced medial thigh pain + leg adduction weakness with +ve trendelenburg.
Femoral nerve palsy
Cause of injury usually hip/pelvic fractures. Femoraly artery/vein catheterisation/ Forceps delivery.
Features;
* Weakness of hip flexion + knee extension
* Loss of patellar reflex
* Sensory changes to anteromedial thigh
Sciatic nerve palsy
Common injured in hip fracture or surgery
Features;
* Foot drop
* Weak eversion/inversion
* loss of knee flexion
* loss of ankle jerk
Main differentiator from common peroneal palsy and sciatic palsy
The ankle jerk remains in common peroneal palsy + There will be sensory loss over dorsum of foot.
Whilst both have footdrop
Types of peripheral polyneuropathies
- Axonal - mild-moderate reduction in conduction velocity. Big reduction in amplitude
- Demyelinating - significant reduction in velocity but mild reduction in amplitude E.g GBS, Myeloma, Vasculitis.
Which polyneuropathies are predominantly motor?
CMT
GBS
Diptheria
Lead poisoning
CIDP
Which polyneuropathies are predominantly sensory
DM
Uremia
Alcoholism
B12
Amyloidosis
Leprosy
Diabetic neuropathy
Most common metabolic neuropathy. 50% of diabetics get it after 25years.
Features;
* Symmetrical glove + stocking distribution - initially sensiry but can become motor + autonomic as it progresses.
* Acute painful neuropathy
* Gastroparesis - causes bloating + vomitting and may worsen BM.
1st line treatment = amitriptyline, gabapentin, pregabalin or duloxetine
Thiamine deficiency
= B2
Causes = dietary (dry beri-beri) or Alcoholism
Management = parenteral thiamine
Note = wet beri-beri causes dilated caridomyopathy
Charcot marie tooth disease
Heriditary sensorimotor neuropathy
Commonly caused by the PMP22 duplication - responsible for the protein in myelin sheaths
Clinical presentation;
* Symmetrical distribution of motor loss - gradual progression over time
* typically occurs in younger adults with an onset of clumsiness, falling, tripping etc
* LMNL signs = *Foot drop + high stepping gait. Weak ankle dorsiflexion, Absent ankle jerk reflex, Leg weakness, Atrophy of calf muscles. *
* Deformities = Claw hammer toes, pes cavus, stork leg deformity.
* Sensory changes - parasthesia, tingling/burning in hands and feed.
Guillian barre syndrome
Immune mediated demyelination of the peripheral nervous system. Typically triggered by Campylobacter, CMV, or EBV.
Features;
* progressive, ascending symmetrical weakness of limbs starting in legs.
* Reduced/absent reflexes
* Distal parasthesia (glove + stocking distribution)
* Respiratory muscle weakness
* Autonomic involvement = urinary retention, diarrhoea etc
* Cranial nerve involvement = diplopia, bilateral facial nerve palsy, OPA weakness.
Investigations;
* LP = rise in CSF protein but normal WBC
* Nerve conduction sutdies = Inc F wave, Prolonged distal motor latency, Decreased velocity.
* CXR = to rule out sarcoidosis as cause
* Spirometry = to measure disease progression. Respiratory muscle involvement is bad sign. Early intubation needed.
Management;
*Plasma exchange or IV immunoglobulins
Gabapentin / carbamazepine if neuropathic pain
Miller-fisher syndrome
Sub type of GBS characterised by;
1. ataxia
2. Areflexia
3. Opathalmoplegia
4. Anti-GQB1 antibodies
Osteoporosis risk factors
I
Increased age
Post menopausal women
Corticosteroid use (equivelant to 7.5mg prednisolone for >3months)
Low BMI
RA
Smoking
Alcohol
Which medications can worsen osteoporosis
Steroids
PPIs
Heparin
Glitazones
Antiepileptics
SSRIs
What is the 1st line treatment in patients with DEXA < -2.5?
Alendronate
Bisphosphonates
MOA = Pyrophosphate analogues. Work by inhibiting osteoclasts therefore preventing bone lysis.
Indications = prevention/treatment of osteoporosis / Pagets disease / Hypercalcemia
SE;
* Osteonecrosis of the jaw
* Atypical stress fractures of the femur proximal shaft
* Hypocalcemia
* Acute phase flu like symptoms
* Oeophageal upset & GI side effects
Contraindications = eGFR < 35
Management of osteoporosis
- Alendronate
- Risodronate or Etidronate - 2nd line, only if alendronate can’t be tolerated.
- Strontium Ranelate/Raloxifene - 3rd line, have v strict T score criteria i.e may need T < -3.5
- Denosumab - strictest criteria. 6 monthly subcut injection.
Raloxifene
SERM (selective oestrogen receptor modulator)
MOA = Binds to oestrogen receptors activating estrogenic patwhays (inhibits bone remodelling & reabsorption) - particularly useful in the spine (not shown use for non-vertebrae yet)
SE = may worsen menopausal symptoms / Inc risk of VTE / May decrease risk of BC
Strontium ranelate
moa = Decreases osteoclast differentiation + increases apoptosis. (inhibits bone reabsorption)
Only use in those with no other options.
SE = inc risk of CVD (any existing disease is major contraindication) / inc VTE risk / Steven johnsons syndrome
Denosumab
moa = human monoclonal antibody that inhibits RANK ligand - inhibiting maturation of osteoclasts.
Duration of antibiotic therapy in septic arthritis
4-6 weeks
