Red flags for MSK conditions

Question 1

3 things to consider serious pathology in MSK presentation

Answer 1

• Escalating pain and progressively worsening symptoms that do not respond to conservative management/medication as expected
• Systemically unwell - fever, weight loss
• Night pain that prevents sleep due to escalating pain +/- difficulty lying flat

Question 2

Emergency MSK conditions

Answer 2

• Cauda equina syndrome
• Metastatic spinal cord compression
• Spinal infection
• Septic arthirits
• Giant cell arteritis

Question 3

CES presentation

Answer 3

• Spinal and leg pain
• Neurological symptoms
• Changes in bladder or bowel function
• Saddle sensory disturbance

Question 4

Metastatic spinal cord compression presentation

Answer 4

• Consequence of mets to spine
• Can lead to irreversible neurological damage
• Spinal pain, band like referral
• Escalating pain
• Gait disturbance

Question 5

Spinal infection presentation

Answer 5

• Fever
• Spinal pain
• Worsening neurological symptoms
• Consider RF inc immunosupressed, primary source infection, personal or FH of TB)

Question 6

Septic arthiritis presentation

Answer 6

• Unwell person
• With or without fever
• Sudden onset of hot, swollen painful joint
• Multidirectional movement restriction
• Suspect this until proven otherwise
• Movement IMPORTANT in children - painful limp or loss of function in upper limb, don’t always have hot, swollen painful joint

Question 7

GCA presentation

Answer 7

• New onset headache
• Primarily temples
• +/- jaw claudication, shoulder or pelvic girdle pain, visual symptoms
• Accompanied by raised ESR/CRP in people usually over 50

Question 8

Urgent MSK conditions

Answer 8

• Primary/secondary cancers
• Insufficiency fractures
• Major spinal related neurological deficit
• Cervical spondylotic myelopathy
• Inflammatory arthirits suspected

Question 9

Primary/secondary cancers presentation

Answer 9

• Escalating pain and night pain
• Unfamiliar symptoms and eventually become systemically unwell
• If unwell –> emergency

Question 10

Insufficneicy fracture presentation

Answer 10

• Sudden onset pain
• Most often thoracolumbar region following low impact trauma
• Pain varies but often severe and localised to area of fracture
• Consider RF eg OP

Question 11

Major spinal related neurological deficit presentation

Answer 11

• Spinal pain, associated limb symptoms
• New onset or progressively worsening limb weakness
• Present for days/weeks
• Less than grade 4 on oxford muscle grading scale
• Associated with one or more myotome

Question 12

Cervical sponylotic myelopathy presentation

Answer 12

• Cervical spondylosis in rare cases can progress to this
• Worsening pain
• Lack of co-ordination (buttoning shirt etc)
• Heaviness/weakness in arms/legs
• Pins and needles and pain in arms
• Problems walking
• Loss of bladder/bowel control

Question 13

When to suspect inflammatory arthirits or refer to rheumatology?

Answer 13

• Persistent synovitis - esp if small joints in hands +/- feet, early morning stiffness lasting more than 30mins even if CRP/ESR normal and normal RF and anti-CCP
• Suspected new onset of autoimmune CT disease eg lupus, scleroderma or vasculitis
• Myalgia - not secondary to viral infection/fibromyalgia but worsens proximally, symmetrical, more than 30mins morning stiffness and raised ESR/CRP
• Suspected inflammatory spinal pain

Question 14

Red flags for MSK presentation

Answer 14

• Age under 25 or over 55
• Nature of pain - thoracic, non-mechanical (not provoked by movement/alleviated), constant and unremitting, night pain, morning stiffness more than 1hr
• Patient unwell
• Prolonged steroid therapy
• Diabetes - abscess more common
• HIV
• Known OP, low BMI etc
• Structural deformity
• Previous history of cancer
• Trauma