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Musculoskeletal > Spine and Upper Limb > Flashcards

Spine and Upper Limb Flashcards

1
Q

Describe mechanical back pain?

A

This is lower lumbar back pain

Better on rest, worse on movement

No neurological symptoms or red flags

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2
Q

Cause of mechanical back pain?

Who gets it?

A

Patients tend to be between 20-60

Result of awkward twisting or lifting

Other causes include poor posture, obesity, lack of activity, degenerative disc prolapse, facet joint OA and spondylosis

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3
Q

What is Spondyliosis?

A

Loss of water from vertebrae

Due to age

Results in less cushioning and increased pressure on facet joints leading to secondary OA

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4
Q

Symptoms and signs of mechanical back pain?

A

Pain

  • Worse on movement
  • Relieved on rest
  • Lumbar pain

History of flare ups

Generally well patients

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5
Q

Treatment of mechanical back pain?

A

Reassurance this isn’t something more severe

Analgesia

Physiotherapy

NOT BED REST

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6
Q

Describe an acute disc tear?

A

This is a tear in the outer annulus fibrosus of an intervertebral disc

Often follows heavy lefting

Causes severe pain

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7
Q

Signs and symptoms of disc tear?

A

History of heavy lifting

Severe pain

Pain worse on coughing

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8
Q

Treatment of acute disc tear?

A

Analgesia

Physiotherapy

Symptoms should resolve in 2-3 months

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9
Q

What is Sciatica?

A

Disc tears can cause the gelantinous nucleus pulposus to herniate through the tear and impinge on nerve roots

This causes sciatica - pain radiating through buttocks to below the knee, altered sensation

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10
Q

Where does Sciatica normally occur? (Which nerve roots)

A

L4, L5, S1 (Causes pain in the sensory distribution of the sciatic nerve)

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11
Q

Describe the signs and symptoms of sciatica

A

Pain

  • Burning/tinlging
  • Radiates through buttocks, back of thigh, below knee

Reduced muscle power

Reduced ankle/knee jerk

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12
Q

Treatment of Sciatica?

A

Analgesia

Maintain Mobility

Physiotherapy

  • Most treated by GP and resolve within 3 months -

Occasionaly neuropathic drugs Eg: Gabapentin

VERY RARELY disectomy

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13
Q

What causes bony nerve root entrapment?

A

OA of the facet joints

Leads to osteophytes

These can impinge on nerve roots

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14
Q

Symptoms of bony nerve root entrapment?

A

Nerve root symptoms

Sciatica

Osteoarthritis symptoms

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15
Q

Treatment of bony nerve root entrapment?

A

Osteophyte trimming (surgery)

In suitable candidates only

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16
Q

What is spinal stenosis?

Causes?

A

Narrowing and compression of the spinal cord

Many causes - bulging discs, spondylosis, osteophytes (from OA)

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17
Q

Describe the symptoms of spinal stenosis?

A

Intermittent leg claudication

  • On variable distance
  • Better going uphill
  • Burning pain
  • Pedal Pulses are present
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18
Q

Describe the difference between peripheral vascular disease and spinal stenosis?

A

PVD Spinal Stenosis

Same distance Intermittent Distance

Cramping Burning

Worse uphill Better uphill

Pedal pulses lost Pedal pulses preserved

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19
Q

Treatment of spinal stenosis?

A

Physiotherapy

Weight Loss

Spinal Decompression Surgery

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20
Q

What is Cauda Equina syndrome?

A

Large central disc compressing on the all of the nerve roots of the cauda equina

Surgical emergency

Needs immediate surgical intervention

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21
Q

Symptoms of cauda equina syndrome?

A
  • Bilateral leg pain
  • Bowel incontinence
  • Urinary incontinence
  • Saddle Anaesthesia
  • Urinary Retention
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22
Q

A patient with bilateral leg symptoms and any suggestion of altered bowel/bladder function has XXXXX until proven otherwise?

A

Cauda Equina Syndrome

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23
Q

Investigation of cauda equina syndrome?

Treatment of Cauda Equina?

A

Investigation = MRI, PR

Treatment = Prompt surgical intervention

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24
Q

Red flag or non-red flag?

  • Back pain in under 20s
  • New back pain in edlerly
  • Constant severe pain
  • Worse on movement
  • Worse on rest
  • Systemic upset
A

Red flags:

  • Back pain in under 20s
  • New back pain in elderly (>60)
  • Constant severe pain
  • Worse on rest
  • Systemic Upset
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25
Q

Describe osteoporotic crush fractures?

Treatment?

A

In severe osteoporosis, crush fractures of the vertebral body can occur

Causes acute pain

Kyphosis

Treatment is conservative

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26
Q

Describe Cervical Spondylosis?

A

Degenerative osteoarthritis between vertebral joints in the cervical region

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27
Q

Signs and symptoms of cervical spondylosis?

A

Slow onset neck pain
Stiffness which may radiate to shoulders and occipit

May have impingement due to osteophytes

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28
Q

Treatment of cervical spondylosis?

A

Physiotherapy

Analgesia

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29
Q

Describe cervical disc prolapse?

Symptoms?

A

Can be acute or degenerative

Causes neck pain and nerve root copression

Symptoms:

  • Neck pain
  • Shooting neuralgic pain in dermatomal distribution
  • Weakness
  • Reflex Loss
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30
Q

Describe treatment of cervical disc prolapse?

A

Analgesia

Physiotherapy

Surgery for cases resistant (Disectomy)

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31
Q

MRI shows a cervical disc prolapse.

This patient is asymptomatic

Treatment?

A

Don’t treat

Only treat if MRI findings and clinical findings correlate

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32
Q

Describe atraumatic cervical spine instability?

A

Cervical spine instability can occur without history of trauma in those with Down’s and Rheumatoid Arthritis

In down’s there is a high risk of atlanto-axial instability (C1/C2) and subluxation

In Rheumatoid arthritis there is also a risk of atlanto-axial subluxation which can compress the spinal cord and be fatal

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33
Q

Treatment of atraumatic cervical spine instability?

A

Minor Instability = Prevent children playing contact sports

Collar (to stabilise)

Severe Instability = May require surgical fusion

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34
Q

Describe the complications of atlanto-axial subluxation due to atraumatic cervical spine instability?

Who is this seen in?

A

Subluxation can compress the spinal cord and be fatal

Seen in children with Down’s syndrome, those with rheumatoid arthritis

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35
Q

Name the rotator cuff muscles?

A

Subscapularis

Suprapsinatus

Infraspinatus

Teres Minor

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36
Q

Shoulder problems are often age related. What problems are seen in:

  • Young?
  • Middle aged?
  • Elderly?
A

Young = Instability

Middle Aged = Rotator cuff tears, frozen shoulder

Elderly = Osteoarthritis

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37
Q

What is impingement syndrome?

A

This is when the rotator cuff tendons are compressed in the tight acromial space during movement causing pain

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38
Q

What causes impingement?

A

Osteophytes

Inflammation of tendon (injury or overuse)

Bursitis (Subacromial bursitis)

Hooked acromion rotator cuff tear

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39
Q

Signs and symptoms of impingement?

A

Painful arc

  • Pain between 60 to 120 degrees

Pain radiates to deltoid and upper arm

Tenderness

Positive Hawkins Kennedy test

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40
Q

Treatment of impingement?

A

Conservative:

  • NSAIDs
  • Analgesia
  • Physiotherapy
  • Subacromial Steroid Injection (up to 3)

If resistant then surgical decompression

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41
Q

Describe rotator cuff tears?

A

Tearing of the rotator cuff muscles - can be due to trauma or atraumatic due to degenerative changes

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42
Q

Who gets rotator cuff tears?

How?

A

Seen in those over 40

Minor trauma

Can be asymptomatic in elderly

Caused by degeneration of the rotator cuff

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43
Q

Sign and symptoms of rotator cuff tears?

A

Pain

Weakness

  • of abduction = Supraspinatus (most common)
  • of internal rotation = Subscapularis
  • of external rotation = Infraspinatus
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44
Q

Treatment of rotator cuff tear?

A

Conservative: Physiotherapy, subacromial steroid injection

Surgery - Repair (fails in about 1/3rd)

45
Q

What is Adhesive Capsulitis?

A

This is frozen shoulder

Progressive pain and stiffness of the shoulder in adults, should resolve in 18-24 months

46
Q

Who gets adhesive capsulitis?

A

Adults aged 40-60

Diabetics

May be following surgery or triggering injury

47
Q

Signs and symptoms of adhesive capsulitis?

A

Pain (subsides after 2-9months)

Stiffness (increases around 4-12 months)

Stiffness thaws out

Loss of external rotation

48
Q

Treatment of adhesive capsulitis?

A

Analgesia

Physiotherapy

Intra-arituclar steroid injections

Should resolve within 2 years

If not, consider manipulation under anaesthesia or surgical capsular release

49
Q

Describe acute calcific tendonitis?

Treatment?

A

Tendonitis caused by calcium deposit in the supraspinatus tendon

Causes severe pain

Great relief from subacromial steroid/anaesthetic injection

Self limiting (pain eases as calcification is reabsorbed)

50
Q

Describe shoulder instability?

A

Involves painful abnormal movement of the shoulder

Recurrent subluxation and dislocation

Can be traumatic or atraumatic

51
Q

Describe traumatic shoulder instability?

A

Follows traumatic anterior dislocation

Shoulder does not stabilise

There may be repeat anterior dislocations

Treatment is Bankart Repair (of glenoid labrum)

52
Q

Describe atraumatic shoulder instability?

A

Seen in patients with generalised ligament laxity

  • Idiopathic
  • Ehler Danos
  • Marfans

Causes recurrent subluxations and dislocations (painful)

Treatment is difficult as soft tissue procedures don’t often work due to underlying problem

53
Q

Describe biceps tendonitis?

A

Inflammation of the tendon of the long head of biceps

Causes anterior shoulder pain, pain on resisted shoulder contraction and tenderness on palpation

Can rupture spontaneously causing popeye deformity

Surgery may be required

54
Q

What kind of deformity is this?

What is the underlying cause?

A

Popeye Deformity

Biceps Tendonitis

55
Q

Describe a SLAP lesion?

Cause?

Symptoms?

Treatment?

A

This is a tear in the glenoid labrum

Caused by repetitive shoulder motion (Eg: Atheletes who use overhead motions) or trauma (Eg: Car accident)

Painful

Sensation of popping/locking/grinding

Treatment: Conservative, Arthroscopic Repair

56
Q

Name some non-shoulder related causes that can present as shoulder pain?

A

Neck Pain

Angina

BIliary Colic

Hepatic Abscess

57
Q

Describe carpal tunnel?

A

Caused by the compression of the median nerve in the carpal tunnel (at the wrist)

Presents as paraesthesia to the radial 21/2 fingers and thumb

58
Q

Who is carpal tunnel commonly seen in?

A

Women more than men

May be secondary to rheumatoid arthriti, pregnancy, renal failure, diabetes, hypothyroidism, colles fracture)

59
Q

Describe the presentation of carpal tunnel?

A

Paraesthesiae to thumb and radial 2 1/2 fingers

Worse at night

Loss of sensation/weakness

Wasting over thenar eminence

Symptoms reproduced by Tinel’s test (compressing on median nerve)

60
Q

Treatment of Carpal tunnel?

A

Wrist splints for night

Corticosteroid Injection

Surgery: Carpal Tunnel Decompression

61
Q

Describe cubital tunnel?

A

This is compresion of the ulnar nerve in the cubital tunnel

Causes paraesthesiae to the ulnar 1 and 1/2 fingers

62
Q

Describe the symptoms of cubital tunnel?

A

Paraesthesia over ulnar 1 and 1/2 fingers (ring and pinky)

Weakness of muscles

  • 1st dorsal interosseus (abduction of index finger)
  • Abductor Pollicis

Compression of ulnar nerve causes symptoms

63
Q

Treatment of cubital tunnel?

A

Conservative - Eg: Splinting

Surgical Release of tight structures

64
Q

Cubital tunnel syndrome can be caused by a tight band of fascia forming the roof the tunnel. What is this fascia called?

A

Osborne’s Fascia

65
Q

Where does the triceps muscle insert onto?

A

The Olecranon Process

66
Q

Describe elbow arthritis?

Treatment?

A

Primary osteoarthritis of the elbow is uncommon

However, elbow arthritis can be seen due to Rheumatoid arthritis or secondary due to trauma

Treatment is conservative, surgical excision of radial head and total elbow replacement

67
Q

Describe lateral epicondylitis?

A

Inflammation of the extensor origin attachment

Also called Tennis Elbow

Due to repetitive strain injury on the extensor origin

68
Q

Symptoms of lateral epicondylitis?

A

Painful, tender lateral epicondyle

Pain on extension

  • Resisted middle finger
  • Wrist
69
Q

Treatment of lateral epicondylitis?

A

Self Limiting

Rest from activities

Physiotherapy

NSAIDs

Steroid Injection

Brace

70
Q

Describe medial epicondylitis?

A

Inflammation of the common flexor origins attachment to the elbow

Caused by repeated strain or degeneration

Causes pain

Golfers Elbow

71
Q

Is lateral or medial epicondylitis more common?

A

Lateral (Tennis) is more common than medial (Golfers)

72
Q

Treatment of medial epicondylitis?

A

Conservative:
- Rest

  • Physiotherapy
  • NSAIDs

Injection into this area carries a risk of ulnar nerve damage

73
Q

What is Duputyren’s Contracture?

Pathophysiology?

A

Connective tissue disorder where palmar fascia undergoes hyplerplasia

Bands of fascia form nodules and cords which progress to contractures

At MCPJs and DIPJs

Proliferation of myofibroblast cells and production of abnormal collagen (Type 3 rather than type 1)

74
Q

Describe the signs and symptoms of Duputyren’s contracture?

A

Palpable nodules

Puckered skin

Contractures of ring and little fingers

75
Q

Who is Duputyren’s contracture seen in?

Inheritance pattern?

A

Males

Family History (Autosomal Dominant)

Northern euroopean

Also seen in alcoholic cirrhosis and diabetes

76
Q

Treatment of Duputyren’s contractures?

A

Mild contractures can be tolerated

Surgery (especially if PIPJ affected)

  • Fasciotomy
  • Fasciectomy
  • Amputation (if very severe)
77
Q

Describe trigger finger?

Which fingers does this commonly affected?

A

This is tendonitis of a flexor tendon

Becomes trapped under the A1 pulley

May produce a clicking sound and may catch (needs to be forced to extend)

Commonly affects middle and ring finger

78
Q

Treatment of trigger finger?

A

Steriod injection - into sheath

Surgery (Incise A1 pulley)

79
Q

Describe a ganglion cyst?

  • Where are these seen?
  • Symptoms/appearance?
A

Mucinous filled cyst found next to a tendon or synovial joint

Commonly seen in hand and wrist

Can cause localized pain and irritation

Firm, hard, rubbery cyst that should transilluminate

80
Q

Treatment of a ganglion cyst?

Historical treatment?

A

Usually left alone

  • Surgery can be done
  • Caution if performing surgery for cosmesis - swapping a cyst for a scar

Historical treatment: Hit it with a bible

81
Q

Describe a giant cell tumour of the tendon sheath?

Where is it found?

Symptoms?

What cells are within it?

Treatment?

A

2nd most common soft tissue swelling of the hand

Usually on palmar surface, around PIPJ and middle finger

May or may not cause pain (erosion into bone)

Contains multi-nucleated giant cells

Treatment is excision

82
Q

Describe osteoarthritis of the hand?

A

Degenerative arthritis caused by wear and tear of the joints

Commonly seen in the elderly (or younger following trauma)

83
Q

Who gets osteoarthritis of the hand?

A

Elderly

Younger if post injury

Post menopausal women

Occupational stress (eg: Labourers)

84
Q

Signs and symptoms of hand osteoarthritis?

A

Painful

Tender

Bony Thickening

DIPJs affected

Stiffness

85
Q

Describe the two types of nodes seen in osteoarthritis?

A

Heberden’s Nodes (More common)

  • DIPJs

Bouchard’s Nodes (Less Common)

PIPJs

86
Q

Describe the X-Ray findings of osteoarthritis of the hands?

A

Loss of joint space

Osteophytes

Subchondral Sclerosis

Subchondral Cysts

Bouchard’s Nodes (PIPJs, less common)

Heberden’s Nodes (DIPJs, more common)

87
Q

Describe hand osteoarthritis treatment?

A

NSAIDs

Osteophyte Reomval

Arthrodesis (Fusion)

Joint Replacement

88
Q

Describe OA of the metacarpalphalangeal joints?

A

This is uncommon

Usually preceeded by injury, occupational stress, gout or infection

Treatment can involve replacement

89
Q

Describe rheumatoid arthritis of the hand?

A

Autoimmune inflammatory condition causing soft tissue swelling, joint erosions and pain

90
Q

Who gets rheumatoid arthritis of the hand?

A

Women is more common than men

Can happen at any age but peak about 40-50

91
Q

Describe the pathophysiology of rheumatoid?

A

Autoimmune

Inflammatory process - synovium hypertrophy, pannus formation, macrophages, inflammatory infiltrate

Causes destruction of articular cartilage

92
Q

Describe the signs and symptoms of hand rheumatoid arthritis?

A
  • DIPJs spared
  • Swelling
  • Hot
  • Redness
  • Tenderness and pain
  • Stiffness

May be systemic weight loss, fever and tiredness

93
Q

Describe the deformities seen in rheumatoid arthritis of the hand?

A

MCPJ subluxation

Swan Necking

Boutonniere

Z Shaped Thumb

Ulnar Deviation

94
Q

What does A show?

What does B show?

What condition caused this?

A

A = Boutonniere’s

B = Swan Necking

Caused by rheumatoid arthritis

Boutonniere’s is Bent at the PIPJs, Swan neck is Straight at PIPJs

95
Q

Investigation of rheumatiod arthritis of the hand?

A

Physical Examination (Swelling, tenderness)

Blood Tests; Raised ESR, Raised CRP, Anaemia, Anti-CCP antibody, RF

X-Ray

MRI

Ultrasound (soft tissue swelling)

96
Q

Treatment of rheumatoid arthritis of the hand?

A

DMARDS

Surgery - Tenosynovectomy

Soft Tissue Release

Fusion

Resection of distal ulna

97
Q

Shoulder impingement isn’t a diagnosis, it is a syndrome. Give some of the differential diagnoses?

A
  • Rotator Cuff Tear
  • Frozen Shoulder
  • Instability
98
Q

What does this photo show?

A

Shoulder Arthritis (Loss of joint space)

99
Q

Describe reverse shoulder arthroplasty?

A

This is when the ball is now where the glenoid was

The socket is now on the humerus

This changes the muscles that move the arm from rotator cuff to deltoid - good for use in irrepairable rotator cuff tear

100
Q

How would patients present if calcium for calcific tenderness had ruptured into the joint space?

Treatment?

A

Grey

Sweating

In agony

Unable to move shoulder due to pain
Young patient

Steroid Injection

101
Q

Treatment of shoulder impingement?

A

Physiotherapy

Steroid Injections

Surgery (Trim bone, either arthroscopic or open)

102
Q

What is a Hill Sachs Lesions?

A

In dislocation (instability) the humeral head is wedged under the glenoid

The glenoid knocks a wedge out of the humeral head - this is a Hill Sachs Lesion

Can lead to recurrent dislocation

103
Q

What is Bankart Lesion?

A

This is when the glenoid labrum has been torn off

Leads to instability and recurrent dislcoations/subluxations

104
Q

What does the sulcus sign suggest?

A

Shoulder Instability

105
Q

What are the four types of upper limb arthritis?

A

Degenerative (OA)

Inflammatory (RA, Psoariatic, Gout)

Septic

Post Traumatic

106
Q

Describe the treatment for sternoclavicular joint arthritis?

A

Physiotherapy

Steroid Injection

Excision (very rarely due to posterior anatomy)

107
Q

Describe acromioclavicular arthritis

  • What examination shows this?
  • Treatment?
A

Scarf Test

Treatment invovles injection (steroid) and excision

108
Q
A

Musculoskeletal (23 decks)

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