GP - MSK

Question 1

What does an x-ray show in patients with OA?

Answer 1

LOSS:
- Loss of joint space
- Osteophytes forming at joint margins
- Subchondral sclerosis
- Subchondral cysts

Question 2

Which joints are usually affected in OA?

Answer 2

• Large weight-bearing joints (hip/knee)
• Carpometacarpal joints
• DIP/PIP joints

Question 3

What are the clinical features of OA?

Answer 3

• Pain following activity - improves with rest
• Unilateral symptoms
• No systemic upset

Question 4

What is the management for OA?

Answer 4

• Lifestyle changes = weight loss/muscle strengthening exercises/aerobic fitness
• Topical NSAIDs (first line)
• Oral NSAIDs + PPI
• Intra-articular steroid injections
• Joint replacement

Question 5

What will an x-ray show in RA?

Answer 5

LOSE
- Loss of joint space
- Osteopenia
- Soft tissue swelling
- Erosions

Question 6

What are the clinical features of gout?

Answer 6

• Maximal intensity develops within 12 hours
• Pain
• Swelling
• Erythema
• Often 1st MTP joint or ankle/wrist/knee

Question 7

What are the investigations for gout?

Answer 7

• Bloods = uric acid levels (>360 umol/L)
• Synovial fluid analysis = needle shaped negatively birefringent monosodium urate crystals under polarised light
• X-ray = joint effusion/well-defined ‘punched-out’ erosions with sclerotic margins with overhanging edges/preservation of joint space

Question 8

What is the management for gout?

Answer 8

• FIRST LINE = NSAIDs/colchicine (+PPI)
• Lifestyle changes = reduce alcohol/lose weight/avoid food high in purines
• Oral steroids e.g. prednisolone
• Intra-articular steroid injection
• Urate-lowering therapy (allopurinol/febuxostat)

Question 9

What are the clinical features and investigations for pseudogout?

Answer 9

• Knee/wrist/shoulders most commonly affected
• Pain
• Swelling
• Erythema
• Joint aspiration = weakly-positive birefringent rhomboid-shaped crystals
• X-ray = chondrocalcinosis

Question 10

What is the management for pseudogout?

Answer 10

• Aspiration of joint fluid (rule out septic arthritis)
• NSAIDs
• Intra-articular/intra-muscular/oral steroids

Question 11

What are the clinical features of polymyalgia rheumatica?

Answer 11

• Typically >60 years
• Rapid onset (<1 month)
• Aching/morning stiffness in proximal limb muscles
• Polyarthralgia
• Lethargy/depression
• Low-grade fever/anorexia/night sweats

Question 12

What are the investigations for polymyalgia rheumatica?

Answer 12

• Bloods = ESR raised
• CK and EMG normal

Question 13

What is the management for polymyalgia rheumatica?

Answer 13

Prednisolone

Question 14

What are red flags for lower back pain?

Answer 14

• Age <20 or >50 years
• History of previous malignancy
• Night pain
• History of trauma
• Systemically unwell

Question 15

What are the clinical features of facet joint pain?

Answer 15

• May be acute or chronic
• Pain worse in morning and on standing
• Pain over facets
• Pain worse on extension of back

Question 16

What are the clinical features and investigations for spinal stenosis?

Answer 16

• Gradual onset
• Unilateral/bilateral leg pain +/- back pain
• Numbness/weakness which is worse on walking
• Pain relieved on sitting down/leaning forwards/crouching down
• MRI needed to confirm

Question 17

What are the clinical features of ankylosing spondylitis?

Answer 17

• Typically young man with lower back pain and stiffness
• Usually worse in morning and improves with activity

Question 18

What are the clinical features of peripheral arterial disease?

Answer 18

• Pain on walking - relieved by rest
• Absent/weak foot pulses and other signs of limb ischaemia
• Past history may include smoking/vascular diseases

Question 19

What are the clinical features of a prolapsed disc?

Answer 19

• Dermatomal leg pain associated with neurological deficits
• Leg pain usually worse than back
• Pain often worse when sitting

Question 20

What is the investigation for lower back pain?

Answer 20

MRI - only if:
- Non-specific back pain
- Result will likely change management
- Malignancy/infection/fracture/cauda equina/ankylosing spondylitis suspected

Question 21

What is the management for lower back pain?

Answer 21

• FIRST LINE = NSAIDs (+PPI)
• Encourage self-management and to stay physically active/exercise

Question 22

What are the clinical features of a hip fracture?

Answer 22

• Pain
• Shortened and externally rotated leg
• May/may not be able to weight bear

Question 23

What is the management for hip fractures?

Answer 23

• Intracapsular = internal fixation/hemiarthroplasty/total hip replacement
• Extracapsular = dynamic hip screw/intramedullary device

Question 24

What is a complication of hip fractures?

Answer 24

Avascular necrosis

Question 25

What is the general management for fractures?

Answer 25

- Immobilise fracture including proximal and distal joints - Monitor and document neurovascular status - Tetanus prophylaxis - IV broad spectrum abx for open injuries - Open fractures = emergency = thoroughly debrided and lavaged within 6 hours of injury

Question 26

What are the most common causes of septic arthritis?

Answer 26

- Staph. aureus - Sexual health history - neisseria gonorrhoea - IVDU - pseudomonas aeruginosa