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Year 3 - GP > SLA 2 - Musculoskeletal Disease > Flashcards

SLA 2 - Musculoskeletal Disease Flashcards

1
Q

Which area of the back is affected in lower back pain?

A

Lumbosacral area of the back, between the bottom of the ribs and the top of the legs.

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2
Q

What is the prevalence of lower back pain in the adult population per month?

A

Affects around one third of the adult population each month.

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3
Q

What are some complications of lower back pain?

A
  • development of chronicity and depression
  • disability
  • loss of employment
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4
Q

Which causes of lower back pain warrant particular concern?

A
  • cauda equina syndrome
  • cancer of the spine
  • spinal fracture due to trauma or osteoporotic collapse
  • spinal infection
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5
Q

What is cauda equina syndrome (CES)?

A

CES is caused by compression of the nerve roots caudal to the level of spinal cord termination (@L2), which left untreated can lead to paralysis.

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6
Q

What are the red flags of cauda equina syndrome?

A
  • incontinence
  • saddle anaesthesia
  • bilateral neurological deficit of the legs
  • unexpected laxity of the anal sphincter

NOTE if CES is suspected, a DRE should be performed to assess tone of anal sphincter.

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7
Q

How is CES managed in primary care?

A

Send to A&E.

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8
Q

What are the red flags of spinal fracture?

A
  • sudden onset of severe central spinal pain, relieved by lying down
  • history of major trauma
  • structural deformity of the spine
  • point tenderness over vertebral body
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9
Q

What are the red flags of spinal cancer?

A
  • age > 50yrs
  • aching night pain that prevents or disturbs sleep
  • localised spinal tenderness
  • unexplained weight loss
  • past history of cancer
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10
Q

List 5 primary cancers that are most likely to metastasise to the spine.

A
  • lung
  • gastrointestinal
  • prostate
  • renal
  • thyroid
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11
Q

What are the red flags of spinal infection?

A
  • fever
  • tuberculosis
  • recent UTI
  • diabetes
  • history of IV drug use
  • immunosuppression (e.g. HIV infection, use of immunosuppressants)
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12
Q

Suggest gastrointestinal pathology that may cause lower back pain.

A
  • peptic ulceration
  • pancreatitis
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13
Q

Suggest genitourinary pathology that may cause lower back pain.

A
  • pyelonephritis
  • prostatitis
  • pelvic inflammatory disease
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14
Q

Presentation of mechanical back pain.

A
  • sudden onset
  • worse on moving
  • tenderness to paraspinal muscles
  • hard to get into comfortable position
  • relieved by rest
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15
Q

Presentation of ankylosing spondylitis.

A
  • pain at night that is not relieved when supine
  • stiffness in the morning that is relieved with movement
  • gradual onset of sx
  • sx > 3/12
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16
Q

Presentation of osteoporosis of the spine.

A
  • non-specific back pain
  • localised tenderness (ie. vertebral fracture)
  • female sex
  • advancing age
  • smoking history
  • use of corticosteroids
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17
Q

Presentation of shingles.

A
  • unilateral back pain
  • rash in the distribution of a dermatome
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18
Q

What is sciatica?

A

A common problem describing radiating leg pain caused by inflammation or compression of the lumbosacral nerve roots (L4-S1) forming the sciatic nerve.

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19
Q

Presentation of sciatica.

A
  • unilateral leg pain radiating below the knee to the foot or toes
  • lower back pain
  • paraesthesia in a dermatomal distribution
  • weakness or reflex changes
  • positive result in a straight leg raise test

Note positive straight leg raise test means with the person lying supine - and the hip flexed gradually with the knee extended - pain will be reproduced on the ipsilateral side.

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20
Q

NICE recommends a stepwise strategy for managing mild-to-moderate pain (5 steps):

A
  1. paracetamol
  2. ibuprofen
  3. ibuprofen + paracetamol
  4. naproxen + paracetamol
  5. weak opioid + paracetemol
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21
Q

What self-management advice can be given to help with sciatica?

A

Encourage the person to stay active and return to work as soon as possible.

  • prolonged bed rest NOT recommended
  • application of local heat (muscle relaxing effect)
  • work adjustments to help early return to work
  • exercise regularly
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22
Q

Which analgesic options can be offered to pts with non-specific low back pain?

A

First line: NSAID + PPI

Second line: Codeine with or without paracetamol.

NOTE paracetamol should not be offered alone to manage lower back pain.

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23
Q

Which drug can be offered if back pain is associated with muscle spazms?

A

Diazepam

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24
Q

Which joints are most commonly affected by osteoarthritis?

A
  • hip
  • knees
  • small joints of the hands (1st MCPJ and DIP)
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25
Q

Suggest risk factors for OA.

A
  • FHx
  • increasing age
  • female
  • obesity
  • PMHx joint injury
  • occupational / recreational stresses on joints
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26
Q

Presentation of osteoarthritis.

A
  • age > 45yrs
  • activity related joint pain
  • morning stiffness lasting no longer than 30 minutes
  • functional impairment

NOTE there may be no morning joint-related stiffness in OA.

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27
Q

Give three examination findings of OA.

A
  1. Bony swelling and joint deformity
  2. Joint warmth and/or tenderness
  3. Restricted and painful range of joint movement (incl. crepitus)
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28
Q

Where is hip OA pain often felt?

A

Groin and anterolateral thigh.

Note in males pain may be referred to the testicle on the ipsilateral side.

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29
Q

List the typical radiological features of OA.

A
  • subchondral bone thickening / cysts
  • osteophyte formation
  • loss of narrowing of joint space
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30
Q

Suggest some differentials of OA.

A
  • rheumatoid arthritis
  • psoriasis
  • gout
  • fracture
  • malignancy (incl. bony metastases)
31
Q

Suggest some differentials of hand OA.

A
  • OA of wrist
  • scapholunate ligament injury
  • ganglion
  • De Quervain’s tenosynovitis
  • trigger thumb
32
Q

Suggest some differentials of hip OA.

A
  • greater trochanteric pain syndrome
  • sciatica
  • spinal stenosis
  • meralgia paraesthetica
33
Q

Suggest some differentials of knee OA.

A
  • meniscal tear
  • anterior cruciate ligament tear
  • iliotibial band syndrome
34
Q

Suggest some differentials of knee OA.

A
  • meniscal tear
  • anterior cruciate ligament tear
  • iliotibial band syndrome
35
Q

What self-care management strategies can be used for symptom relief of OA?

A
  • weight loss (if overweight or obese)
  • local muscle strengthening exercises
36
Q

Which analgesic options can be offered to pts with OA?

A
  1. Paracetamol or topical NSAIDs (e.g. voltarol)
  2. Oral NSAIDs (e.g. ibuprofen) + PPI
  3. Opioids (e.g. codeine)
37
Q

Which specific genetic mutations are a risk factor for rheumatoid arthritis?

A

HLA DR4 or HLA DR1

Therefore FMHx (RA) is strong risk factor.

38
Q

Presentation of rheumatoid arthritis.

A

Symmetrical synovitis of the small joints of the hands and feet:

  • pain, which is worse at rest
  • swelling around the joint
  • early morning stiffness lasting over 1hr
  • rheumatoid nodules

Systemic features of malaise, fever, fatigue, sweats and weight loss may also be present.

39
Q

Give some extra-articular features of RA.

A
  • eyes (e.g. scleritis)
  • skin (e.g. leg ulcers, rashes)
  • respiratory (e.g. pulmonary fibrosis)
  • cardiovascular (e.g. myocardial fibrosis)
  • liver (hepatomegaly)
  • depression
  • thyroid disorders
  • susceptibility to infections
40
Q

Which tests can be ordered to support a diagnosis of rheumatoid arthritis?

A
  • rheumatoid factor
  • anti-CCP
  • X-ray of hands and feet
  • inflammatory markers (CRP / ESR)
41
Q

How should suspected rheumatoid arthritis be managed in primary care?

A

3-week referral to rheumatology.

NSAIDs + PPI can be offered for analgesia.

42
Q

Give 3 examples of DMARDs that may be prescribed by a specialist in the management of RA.

A
  1. Methotrexate
  2. Leflunomide
  3. Sulfasalazine
43
Q

What is osteoporosis?

A

A disease characterised by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.

44
Q

Give some risk factors of osteoporosis.

A
  • female sex
  • calcium / vitamin D deficiency
  • increasing age
  • menopause
  • oral corticosteroids
  • smoking
  • alcohol
  • rheumatoid conditions
  • BMI < 18.5 kg/m2
45
Q

What is the mechanism of action of bisphosphonates in treating osteoporosis?

A

Inhibit bone resorption by altering osteoclast activation and function.

46
Q

Which bisphosphonates are generally the first-line treatments for osteoporosis in primary care?

A

Alendronate or risedronate

47
Q

What are the adverse effects of oral bisphosphonates?

A
  • oesophagitis (ask patient to stand or sit upright for at least 30mins after taking medication)
  • osteonecrosis of the jaw (encourage dental check-up)
  • gastrointestinal symptoms (nausea, dyspepsia - most common and typically resolve after 1/12)
48
Q

What advise should be given to a person taking bisphosphonate?

A
  • take on an empty stomach as absorption is affected by food, drink and other drugs (take first thing in morning - NEVER at bedtime)
  • take while in upright position and remain upright for 30 mins to reduce risk of oesophagitis
49
Q

Before commencing medication for treatment of osteoporosis:

a) which screening tool can be used to estimate 10-year fracture risk?

b) which scan can be used to measure bone mineral density (BMD)?

A

a) QFracture

b) dual-energy X-ray absorptiometry (DXA) - result presented as T-score.

50
Q

What are the respective T-score ranges for:

a) normal BMD

b) low BMD

c) osteoporotic BMD

A

a) > (-1.0)

b) (-1.0) - (-2.5)

c) < (-2.5)

NOTE T-score of < (-2.5) BMD required to make a diagnosis of osteoporosis.

51
Q

What is greater trochanteric pain syndrome?

A

Inflammation of the trochanteric bursa (ie. trochanteric bursitis) that causes pain over the lateral hip.

52
Q

What is the management of a patient with greater trochanteric pain syndrome?

A
  • reassure that the condition is usually self-limiting
  • advise to avoid repetitive hip movements or lying on affected hip
  • apply ice-pack several times per day
  • offer analgesia (e.g. paracetemol / ibuprofen)

Note if conservative measures fail to provide adequate improvement in symptoms, a corticosteroid injection and referral to physiotherapy can be offered.

53
Q

What is gout?

A

A type of arthritis caused by monosodium urate crystals forming inside and around joints, causing sudden flares of severe pain, heat and swelling.

54
Q

Give some risk factors of gout.

A
  • hyperuricaemia
  • CKD
  • hypertension
  • excessive alcohol, sugary drinks, meat
  • obesity
  • male sex
  • menopause
  • increasing age
55
Q

Presentation of gout.

A

Acute onset of severe pain together with redness and swelling in joints (typically MTPJ).

Gouty tophi may be present - hard, cutaneous nodules of sodium urate crystals.

56
Q

Which investigations can be organised in primary care to diagnose gout?

A
  • measure serum urate level
  • joint aspiration and microscopy of synovial fluid
57
Q

How can a pt with acute gout be managed?

A
  1. NSAID (e.g. ibuprofen / naproxen) + PPI
  2. Short course of oral corticosteroid (e.g. prednisolone)
  3. Colchicine

NOTE aspirin is not indicated for gout.

58
Q

What is ‘synovitis’ and what does it indicate?

A

Synovitis is inflammation of a synovial membrane, typically a feature of arthritis.

Common causes include rheumatoid arthritis and gout. It can also sometimes occur in osteoarthritis where the degenerative process has caused some inflammation.

59
Q

Define ‘stiffness’ and explain the clinical significance of early morning stiffness.

A

Stiffness is the slowness or difficulty moving one or more joints.

Early morning stiffness is an indicator of inflammatory arthritis.

Stiffness that is generalised and lasts >30mins on waking is a feature of rheumatoid arthritis.

60
Q

What are the likely caused of limited or painful active movement but with full, pain-free passive movement?

A

As passive movement does not require the person to use their own nerves, muscles and tendons to produce a movement, a reduction in passive range or pain on passive movements indicates a problem with the joint itself.

Conversely, if there is painful active movement but pain-free passive movement, pathology is likely to lie within the muscles or tendons rather than the joint itself.

61
Q

What is the WHO pain ladder?

What cautions are needed in applying this to chronic MSK pain?

A

WHO ladder advocates a stepwise use of simple analgesia, NSAIDs and stronger analgesics to manage chronic pain (e.g. cancer pain).

It can be problematic in chronic pain however due to:

i) risks of side-effects and tolerance with prolonged regular use

ii) risk or addiction to opiates

iii) risk of neglecting non-pharmacological options in treatment and rehabilitation (e.g. physiotherapy)

62
Q

What are mechanical symptoms of the knee?

A

Symptoms such as locking or catching of the knee on movement, which are common in knee disease even without any obvious obstruction (e.g. meniscal tear).

63
Q

How can bursitis of the knee be differentiated from a knee effusion?

A

In a knee effusion, fluid can be moved across the knee (ie. bulge test) and pressure over the patella causes the fluid to move (ie. patellar tap).

In bursitis, the swelling is located to the bursa that is affected and would not produce a positive bulge test or patellar tap.

64
Q

Which causes of hip pain would tend to produce pain in the:

a) anterior area

b) lateral area

c) posterior area

A

a) osteoarthritis

b) greater trochanteric pain syndrome (GTPS)

c) lumbosaral spine or gluteal muscle pathology

65
Q

What are the clinical features of plantar fasciitis?

A

Typically causes pain at the insertion of the plantar fascia into the calcaneum (ie. medial heel).

It tends to occur in people who spend a lot of time on their feet; often the pain is marked with the first few steps on getting out of bed and then worsens towards the end of the day.

66
Q

What are the clinical features of metatarsalgia?

When would you suspect a Morton’s neuroma?

A

Metatarsalgia is pain in the mid-food and has a wide range of causes.

In Morton’s neuroma (ie. thickening of tissue around a nerve in the foot causing irritation or damage), the classic finding is tenderness in the inter-digital space where the neuroma is located.

67
Q

What is a ‘painful arc’ in the shoulder and what does this indicate?

A

Pain in the midrange (45° - 120°) of abduction of the shoulder, easing at abduction >120°.

It indicated impingement of the shoulder (e.g. catching of rotator cuff tendons or shoulder bursae) in the sub-acromial space with movement.

68
Q

Besides shoulder pathology, which other problems might present with pain in one or both shoulders?

A
  • referred pain from the neck (ie. cervical spine radiculopathy)
  • cardiac problems (e.g. MI, angina)
  • lung problems (e.g. Pancoast’s tumour)
  • diaphragmatic pain (e.g. right shoulder pain from liver enlargement)
  • polymalgia rheumatica (bilateral)
69
Q

What are the commonest signs of osteoarthritis in the hands?

A
  • Herberden’s nodes (DIPJ)
  • Bouchard’s nodes (PIPJ)
70
Q

What are the commonest signs of rheumatoid arthritis in the hands?

A
  • ulnar deviation of fingers
  • ‘swan neck’ deformity
  • boutonniere’ deformity
71
Q

In the elbow, when would you diagnose:

a) tennis elbow

b) golfer’s elbow

c) olecranon bursitis

A

a) lateral epicondylitis - suspect if pain in lateral elbow with tenderness over the common extensor origin

b) medial epicondylitis - suspect if pain in medial elbow with tenderness over the common flexor origin

c) suspect if fluctuant, non-painful swelling over the olecranon process of the elbow.

72
Q

Define:

a) sprain

b) strain

A

a) overstretching or tearing of a ligament

b) overstretching or tearing of muscles or tendons

73
Q

What are the common symptoms of strains and sprains.

A
  • pain around affected joint
  • swelling
  • limited flexibility
  • reduced ROM

Note in a sprain bruising is likely to be observed; in a strain muscle spasms may be present.

74
Q

Outline the management of strains and sprains.

A

Rest
Ice
Compression
Elevation

Note avoid heat, alcohol, running and massage (HARM) as this can increase inflammation.

Analgesia as required.

Note if fracture is suspected or the joint is unstable, referral to fracture clinic and physiotherapy may be indicated.

Year 3 - GP (17 decks)

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