1
Q
duIT band sx and mx
A
tenderness 2-3cm above the lateral joint line
Common in runners
Management
activity modification and iliotibial band stretches
if not improving then physiotherapy referral
2
Q
Red flags back pain
A
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever
Thoracic back pain
3
Q
Hip disclocation sx
A
shortened and internally rotated leg
4
Q
Mx and complications of hip dislocation
A
A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.
Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients.
Recurrent dislocation: due to damage of supporting ligaments
5
Q
calcification of the articular cartilage dx
A
Pseudogout
Chondrocalcinosis
6
Q
Spinal stenosis
A
Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis
7
Q
Signs of scaphoid fracture
A
Point of maximal tenderness over the anatomical snuffbox
This is a highly sensitive (around 90-95%), but poorly specific test (<40%) in isolation
2. Wrist joint effusion
Hyperacute injuries (<4hrs old), and delayed presentations (>4days old) may not present with joint effusions.
3. Pain elicited by telescoping of the thumb (pain on longitudinal compression)
8
Q
Infrapatella bursitis
A
associated with kneeling as seen in clergymen
Swelling and tenderness
9
Q
Psoriatic arthritis sx
A
symmetric polyarthritis
very similar to rheumatoid arthritis
30-40% of cases, most common type
asymmetrical oligoarthritis: typically affects hands and feet (20-30%)
Dactylitis, sometimes described as ‘sausage fingers’
periarticular disease - tenosynovitis and soft tissue inflammation resulting in:
enthesitis: inflammation at the site of tendon and ligament insertion e.g. Achilles tendonitis, plantar fascitis
tenosynovitis: typically of the flexor tendons of the hands
dactylitis: diffuse swelling of a finger or toe
nail changes
pitting
onycholysis
10
Q
X ray psoriatic arthritis
A
‘pencil-in-cup’ appearance
11
Q
Dermatomyositis sx
A
Skin features
photosensitive
macular rash over back and shoulder
heliotrope rash in the periorbital region
Gottron’s papules - roughened red papules over extensor surfaces of fingers
proximal muscle weakness +/- tenderness
ANA+
Anti Jo
12
Q
Right-sided hip pain radiating to knee and joint instability, post THR
A
Aseptic loosening
13
Q
If UGI SE from alendronate
A
Change to risedronate
14
Q
Acute mx of gout
A
NSAID
Colchicine - reduce the dose if eGFR is 10-50 ml/min and to avoid if eGFR < 10 ml/min
Oral steroids if others CI
15
Q
SE of entanjrcept
A
Reactivation of TB
16
Q
AS mx
A
Ibuprofen
17
Q
AS XR
A
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
18
Q
Clubfoot findings
A
Inverted + plantar flexed foot which is not passively correctable.
19
Q
PMR sx and mx
A
typically patient > 60 years old
usually rapid onset (e.g. < 1 month)
aching, morning stiffness in proximal limb muscles
ESR>40
Pred 15mg- 1 week then reassess
20
Q
Sjogren AB
A
Positive anti-Ro and anti-La antibodies
21
Q
Sjogren’s syndrome sx
A
dry eyes: keratoconjunctivitis sicca
dry mouth
vaginal dryness
arthralgia
Raynaud’s, myalgia
sensory polyneuropathy
recurrent episodes of parotitis
positive Schirmer’s test
22
Q
Mx of hip fracture
A
Undisplaced Fracture:
internal fixation, or hemiarthroplasty if unfit.
Displaced Fracture:
arthroplasty (total hip replacement or hemiarthroplasty) to all patients with a displaced intracapsular hip fracture
total hip replacement is favoured to hemiarthroplasty if patients:
were able to walk independently out of doors with no more than the use of a stick and
are not cognitively impaired and
are medically fit for anaesthesia and the procedure.
stable intertrochanteric fractures: dynamic hip screw
if reverse oblique, transverse or subtrochanteric fractures: intramedullary device
23
Q
AS features
A
reduced lateral flexion
reduced forward flexion - Schober’s test
Pain at night
Reduced chest expansion
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
24
Q
Prepatellar bursitis
A
Associated with more upright kneeling
25
Bone protection if started on long term steroids
Immediate bisphosphonate prescription
26
Phalen sign
Flexion of wrist produces carpal tunnel signs
27
Sickle cell osteomyelitis organism
Salmonella- noon typhi
28
When is colchicine CI
he BNF advises to reduce the dose by up to 50% if creatinine clearance is less than 50 ml/min and to avoid if creatinine clearance is less than 10 ml/min.
29
Mx of prolapsed disc
irst-line is NSAIDs +/- proton pump inhibitors rather than using neuropathic analgesia (e.g. duloxetine)
if symptoms persist e.g. after 4-6 weeks) then referral for consideration of MRI is appropriate
30
High risk group of fragility fractures
Age >75
Glucocorticoid therapy
(People who are taking high doses of oral corticosteroids (more than or equivalent to prednisolone 7.5 mg daily for 3 months or longer)
Previous hip/vertebral fractures
Further fractures on treatment
High risk on FRAX scoring
T score <-2.5 after treatment
31
When should you continue/stop bisphosphonates
Any high risk- continue indefinitely
Low risk- repeat DEXA, 2 year break if >-2.5
32
Taking bisphosphonates
swallowed with plenty of water while sitting or standing on an empty stomach at least 30 minutes before breakfast (or another oral medication); the patient should stand or sit upright for at least 30 minutes after taking
33
Limited scleroderma sx
Raynaud's may be the first sign
scleroderma affects face and distal limbs predominately
associated with anti-centromere antibodies
a subtype of limited systemic sclerosis is CREST syndrome: Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
34
Diffuse cutaneous systemic sclerosis
scleroderma affects trunk and proximal limbs predominately
associated with anti scl-70 antibodies
the most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)
other complications include renal disease and hypertension
patients with renal disease should be started on an ACE inhibitor
poor prognosis
35
Hydroxycholorqiune SE
bull's eye retinopathy - may result in severe and permanent visual loss
Corneal opacities
36
Mx of GCA with temporal arteritis
Oral pred
IV if visual loss
37
Allopurinol during gout attacks
If already on it- continue
Just do not start on it on first attack
38
X ray sign of rheumatoid
loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
periarticular erosions
subluxation
39
Tx of osteoporosis in stage 4 CKD
Denosumab
BP CI
40
Movement making lateral/medial epicondylitis worse
Lateral epicondylitis: worse on resisted wrist extension/suppination whilst elbow extended
Medial -wrist flexion and pronation
41
Medications causing gout
diuretics: thiazides, furosemide
ciclosporin
alcohol
cytotoxic agents
pyrazinamide
42
Nerve root of triceps
Main C7
43
Osteosarcoma features
x-ray shows Codman triangle (from periosteal elevation) and 'sunburst' pattern
metaphyseal region of long bones prior to epiphyseal closure
44
Ewing sarcoma
x-ray shows 'onion skin' appearance
45
Baker Cyst
Foucher's sign describes the increase in tension of the Baker's cyst on extension of the knee.
More likely to develop in patients with arthritis or gout and following a minor trauma to the knee
46
Dermatomyositis features
Skin features
photosensitive
macular rash over back and shoulder
heliotrope rash in the periorbital region
Gottron's papules - roughened red papules over extensor surfaces of fingers
Other features
proximal muscle weakness +/- tenderness
Raynaud's
47
Radial tunnel syndrome
tenderness distal to the common extensor origin in comparison to lateral epicondylitis where there is pain over the common extensor origin. It is most common in gymnasts, racquet players and golfers who frequently hyperextend at the wrist or carry out frequent supination/pronation. Patients can also complain of hand paraesthesia or aching at the wris
48
Sulfasalazine SE
Oliospermia
Rashes
49
Gold SE
Proteinuria
50
Antiphospholipid sx bloods
Antiphospholipid syndrome leads to a raised APTT and normal PT and can result in thrombocytopenia.
51
Nerve likely to be injured ion TKR
Common Peroneal nerve
52
Etanercept SE
Demyelination
Reactivation of TB
53
Methotrexate SE
Myelosuppression
Liver cirrhosis
Pneumonitis
54
Mx of Raynaud's
Oral nifedipine
55
What do you have to do before giving bisphosphonates
Hypocalcemia/vitamin D deficiency should be corrected before giving bisphosphonates
56
Drug induced lupus causes
Proncainamide
Hydralazine
57
Plantar fascitis sx
The pain is usually worse around the medial calcaneal tuberosity.
Gradual onset of sharp pain in the heel or medial arch of the foot.
Pain is worse when you ask them to walk on their toes.
Pain is usually worst with the first steps in the morning or after periods of rest (post-static dyskinesia
RF- pes Planus and obestiy
58
L3 vs L4 compression
L3 nerve root compression
Sensory loss over anterior thigh
Weak hip flexion, knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
L4 nerve root compression Sensory loss anterior aspect of knee and medial malleolus
Weak knee extension and hip adduction
Reduced knee reflex
Positive femoral stretch test
59
Pencillamine SE
Proteinuria
Exacerbation of MG
60
Femeroacetabular impingement
presents with hip/groin pain worse on prolonged sitting and associated with snapping, clicking or locking of the hip. There is an association between FAI and prior hip pathology eg Perthes in childhood.
61
Adhesive capsulitis sx
External rotation (on both active and passive movement) is classically impaired
Age 40–60, often female.
Strong association with diabetes and hypothyroidism.
Pain (especially at night) followed by progressive stiffness.
Loss of both active and passive range of motion in all planes (distinguishing it from tendinopathy).
62
Mx of RA false
IM or oral pred
63
Drug induced lupus AB
Antihistone
64
Cough, dyspnoea and fever on methotrexate
Drug induced pneumonitis
65
Greater trochanteric pain syndrome
Pain and tenderness over the lateral side of thigh
Most common in women aged 50-70 years
(trochanteric bursitis)
Worsens with:
Lying on affected side
Can have +ve trendenleburg
66
Sjogrens AB
Anti Ro
67
Dermatomyositis AB
Anti Jo
68
Myxoid cyst
digital mucous cysts, are benign lesions that typically occur on the fingers or toes, particularly around the nail bed.
Associated With OA
69
Risk of stress factures
Inadequate calories
Menstrual irregularities
Increased/new intensity sports
70
Dupuytrens contracture causes
manual labour
phenytoin treatment
alcoholic liver disease
diabetes mellitus
trauma to the hand
71
Tx of reactive arthritis
NSAIDs
72
Test before adalimumab
CXR
73
Pancytopaenia with methotrexate cause
Taking with trimethoprim
74
CKD biochem on Ca, P , ALP
High P, high ALP, high PTH
75
Chronic fatigue diagnosis
Diagnosed after at least 3 months of disabling fatigue affecting mental and physical function more than 50% of the time in the absence of other disease which may explain symptoms
76
Adivse post hip replacement
avoiding flexing the hip > 90 degrees
avoid low chairs
do not cross your legs
sleep on your back for the first 6 weeks
77
Mx of achilles tendonitis
Achilles tendonitis management: rest, NSAIDs, and physio if symptoms persist beyond 7 days
78
Poor prognostic features of RA
rheumatoid factor positive
anti-CCP antibodies
poor functional status at presentation
X-ray: early erosions (e.g. after < 2 years)
extra articular features e.g. nodules
HLA DR4
insidious onset
79
Reactive arthritis sx
Arthritis
Eye pain
Dactylitis
Dysuria
80
Skin disorder with antiphospholipid syndrome
Lived reticularis
81
Osteomalacia sx
Low Ca, P, raised ALP
Proximal myopathy
82
If allergic to aspirin which RA drug are you likely allergic to
Sulfalazine
83
Inversion ligament damage
anterior talofibular ligament is the most commonly sprained
84
Antibodies associated with each condition
A: Anti-centromere antibodies
Limited cutaneous systemic sclerosis (CREST Syndrome)
B: Anti-Scl70 antibody
Diffuse systemic sclerosis
(Scleroderma)
C: Anti-Jo antibodies
-myositis
e.g. Polymyositis, dermatomyositis
D: Anti-mitochondrial antibodies
Primary biliary cholangitis (PBC)
E: Anti-neutrophil cytoplasmic antibodies (ANCA)
Small vessel vasculitis
F: Anti-nuclear antibodies (ANA)
Autoimmune conditions
e.g. SLE, RA, Sjogrens
G: Anti-phospholipid antibodies
Blood clots & Miscarriages
H: Anti-Ro antibodies
SLE or Sjogrens
I: Parietal cell antibodies
Pernicious anaemia
J: Anti-gliadin antibodies
Coeliac disease
K: Anti-histone antibodies
Drug-induced lupus
85
Ix and tx of sciatica
NICE recommends first-line treatment: NSAIDs (± PPI), not neuropathic agents like duloxetine
If symptoms persist after 4-6 weeks: consider referral for MRI
86
What muscles does ulnar innervate
medial two lumbricals
(Flexion at the metacarpophalangeal (MCP) joints and extension at the proximal and distal interphalangeal (PIP and DIP) joints of digits 4 and 5)
§
aDductor pollicis
interossei
hypothenar muscles: abductor digiti minimi, flexor digiti minimi
flexor carpi ulnaris
87
Ulnar damage patterns
Damage at wrist
'claw hand' - hyperextension of the metacarpophalangeal joints and flexion at the distal and proximal interphalangeal joints of the 4th and 5th digits
wasting and paralysis of intrinsic hand muscles (except lateral two lumbricals)
wasting and paralysis of hypothenar muscles
sensory loss to the medial 1 1/2 fingers (palmar and dorsal aspects)
Damage at elbow
as above (however, ulnar paradox - clawing is more severe in distal lesions)
radial deviation of wrist
88
Skin condition associated with reactive arthritis
Keratoderma blennorrhagica
89
Muscles innervated by ulnar nerve
⚙️ Forearm (1.5 muscles):
Flexor carpi ulnaris
Medial half of flexor digitorum profundus (to digits 4 & 5)
✋ Hand (Most intrinsic hand muscles):
Hypothenar muscles (Abductor, Flexor, Opponens digiti minimi)
3rd and 4th lumbricals (for digits 4 & 5)
All interossei (palmar & dorsal)
Adductor pollicis
Palmaris brevis
90
Muscles innervated by median nerve
⚙️ Forearm (6.5 muscles):
Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Lateral half of flexor digitorum profundus (digits 2 & 3)
Flexor pollicis longus
Pronator quadratus
✋ Thenar + 1st & 2nd lumbricals (via recurrent branch of median nerve):
Abductor pollicis brevis
Flexor pollicis brevis (superficial head)
Opponens pollicis
Lumbricals 1 & 2 (digits 2 & 3)
91
Muscle innervated by radial nerve
💪 Arm:
Triceps brachii (elbow extension)
Anconeus
⚙️ Forearm (posterior compartment – all extensors):
(via deep branch → posterior interosseous nerve)
Brachioradialis (flexes elbow in mid-pronation)
Extensor carpi radialis longus & brevis
Extensor digitorum
Extensor digiti minimi
Extensor carpi ulnaris
Supinator
Abductor pollicis longus
Extensor pollicis brevis & longus
Extensor indicis
92
OP management post fragility fracture
Osteoporosis management following a fragility fracture:
Patients ≥ 75 years: Presumed osteoporosis; start oral bisphosphonate treatment without routine DEXA, as per NICE NG212, unless results would change management.
Patients < 75 years: Consider DEXA if it will influence treatment decisions. Treatment may begin without DEXA if clinical suspicion is high. Use FRAX (with or without BMD) to assess fracture risk and guide therapy.
93
Nodes from OA
Hebedens - distal IP
Bouchards - proximal IP
94
Damage to which nerve causes positive trendenleberg
Superior gluteal
95
Dermatomes upper limb
C4 Over the shoulder (clavicle area)
C5 Lateral upper arm (deltoid region)
C6 Lateral forearm, thumb, and index finger
C7 Middle finger (sometimes includes index & ring)
C8 Medial forearm, ring and little fingers
T1 Medial upper arm (above the elbow)
T2 Axilla and upper medial arm (near armpit)
96
Dermatomes lower limb
L1 – Groin
L2 – Upper anterior thigh
L3 – Lower anterior thigh / knee
L4 – Medial leg & medial malleolus
L5 – Dorsum of foot & big toe
S1 – Lateral foot & little toe
S2 – Posterior thigh
S3–5 – Perianal (“saddle area”)
97
Disc prolapse vs facet joint pain
Facet Joint Pain
Typically presents with localised lower back pain, often worse in the morning and on standing.
Pain exacerbated by lumbar extension and rotation.
On examination, tenderness over the affected facet joints may be present.
No radicular symptoms (no leg pain, numbness or weakness).
Usually no neurological deficits.
Imaging (X-ray/MRI) may show degenerative changes but is not diagnostic.
Disc Prolapse
Often presents with acute onset of back pain radiating down one leg (sciatica), following a dermatomal pattern.
Associated with neurological symptoms: numbness, paraesthesia, weakness in affected myotomes.
Pain worsened by sitting, bending forward, coughing or straining.
Positive straight leg raise test may be present.
MRI is the investigation of choice to confirm diagnosis.
May have signs of nerve root compression on neurological examination.
98
Mx of bow leg in children
Bow legs in a child < 3 is a normal variant and usually resolves by the age of 4 years
beyond this age without improvement warrants specialist input.
99
Kocher Criteria
Non-weight bearing - 1 point
Fever >38.5ºC - 1 point
WCC >12 * 109/L - 1 point
ESR >40mm/hr
2 points = 40% probability of septic arthritis
3 points = 93% probability of septic arthritis
4 points = 99% probability of septic arthritis
100
Prepatellar bursitis vs Infrapatellar bursitis
Cause:
- Prepatellar bursitis: Caused by repetitive direct pressure or trauma to the anterior aspect of the knee, typically from prolonged upright kneeling.
- Infrapatellar bursitis: Results from repetitive kneeling with pressure on the area just below the patella, often associated with kneeling on bent knees.
Presentation:
- Prepatellar bursitis: Presents with swelling and tenderness over the prepatellar bursa (anterior to the patella). The swelling is superficial and may be fluctuant.
- Infrapatellar bursitis: Presents with swelling and tenderness over the infrapatellar bursa, located just below the patella. It is often more distal compared to prepatellar bursitis.
Prepatellar bursitis (Housemaid's knee): Typically seen in occupations involving prolonged upright kneeling, such as:
Housemaids/cleaners
Carpet layers
Floor installers
Roofers
Infrapatellar bursitis (Clergyman's knee): Associated with jobs requiring kneeling on bent knees or frequent pressure below the patella, such as:
Clergy (historically from prolonged kneeling during prayer)
Plumbers
Gardeners
Tilers
101
Those requiring bone protection
aged ≥65 years on ≥7.5mg prednisolone daily for ≥3 months
Any age with previous fragility fracture on glucocorticoids
Patients <65 years with T-score ≤ -1.5 on DXA scan
102
When to DXA scan vs start bisphosphonate
Offer oral bisphosphonates to people taking glucocorticoid therapy without waiting for bone density assessment (which should follow later) if they have any of the following risk factors:
A prior fragility fracture.
Women age 70 years or over.
Postmenopausal women, and men age 50 years or over taking high dose glucocorticoids (7.5 mg or more of prednisolone daily or equivalent over 3 months).
Postmenopausal women, and men age 50 years or over with a FRAX probability of major osteoporotic fracture or of hip fracture exceeding the intervention threshold.
103
Examination of AS
reduced lateral flexion
reduced forward flexion - Schober's test - a line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
reduced chest expansion
104
Femeroacetabular impingement sx
It commonly presents with hip/groin pain worse on prolonged sitting and associated with snapping, clicking or locking of the hip
105
Mx of plantar fasciitis
rest the feet where possible
wear shoes with good arch support and cushioned heels
insoles and heel pads may be helpful
106
Common peroneal nerve lesion sx
weakness of foot dorsiflexion
weakness of foot eversion
weakness of extensor hallucis longus
sensory loss over the dorsum of the foot and the lower lateral part of the leg
107
Risk factors for the development of stress fractures in athletic females?
Women with low calorie intake or menstrual irregularities who have started a new sport or increased their training are at particular risk of stress fractures
108
Differentiating Chondromalacia Patellae, Osgood-Schlatter Disease, and Osteochondritis Dissecans
Chondromalacia Patellae
- Softening and degeneration of the articular cartilage on theurface of the patella.
Presents with anterior knee pain exacerbated by activities that load the patellofemoral joint walking up/down stairs, rising from sitting.
- No swelling or locking.
- Tenderness is usually around the patella.
Osgood-Schlatter Disease
- Traction apophysitis of the tibial tubercle.
- Repetitive strain from the patellar tendon pulling on the immature tibial tuberosity growth plate.
Common in sporty adolescents (both sexes).
- Localised pain, tenderness, and swelling over the tibial tubercle (apophysis).
- Pain worsens with activities involving knee extension against resistance (running, jumping).
Osteochondritis Dissecans
- Localised subchondral bone necrosis due to repetitive microtrauma or vascular insufficiency.
- Activity-related knee pain with intermittent swelling.
- Mechanical symptoms such as locking or catching due to loose bodies
109
Mx of cervical myelopathy
Disc decompression
Early treatment (within 6 months of diagnosis) offers the best chance of a full recovery but at present, most patients are presenting too late. I
110
Analgesia ladder for arthritis
Topical NSAIDs
Oral NSAIDs
If topical treatment is inadequate
Use lowest effective dose, shortest duration
Consider co-prescribing PPI
Paracetamol or codeine
Short-term use only if NSAIDs contraindicated or ineffective
Avoid strong opioids
111
Area of weakness, pain, reflex effected for C5, 6,7,8 radiculopathies
C5- shoulder and lateral arm pain
Weak deltoid and biceps
Bicep reflex
C6- thumb and index pain
Weak brachioradialis and wrist extension
BR reflex
C7- middle finger pain
Tricep and wrist flexion weakness
Tricep reflex
C8- median forearm, little and ring pain
Finger flexion weakness
No reflex
112
Features suggesting carpal tunnel syndrome
Symptoms that are affected by the position of the hand (extremes of flexion or extension) suggest carpal tunnel syndrome.
Hand pain during the night or pain felt just before waking that is relieved by “shaking out” of the hand.
Weakness of the thumb abductor (a late finding in carpal tunnel syndrome).
113
Which muscles are supplied by anterior interosseous nerve
Branch of median
FPL
Flexor digitorium profundus- medial- index and middle
PQ
Flexos pollicus longus
114
Signs of median nerve damage
Hand of benediction (on attempted fist)
Thenar wasting
Sensory loss in Thenar eminence, lateral palm, lateral 3.5 fingers
115
Motor supply of median nerve
Motor: Anterior forearm (flexion, pronation), LOAF hand muscles
116
Test for plantar fascitis
Positive Windlass test: dorsiflexion of the 1st MTP joint reproduces the pain.
117
Morton’s Neuroma
Described as a “pebble in the shoe” sensation.
Most often occurs between the 3rd and 4th metatarsal heads
118
Patellofemoral Pain Syndrome
anterior knee pain, behind patella, in runners, worse on stairs/kneeling
119
Patellar Tendonitis features
Anterior knee pain, worse with running/jumping, especially downhill
Tenderness along patellar tendon
Pain with resisted knee extension
120
Features of Cervical Radiculopathy
Most frequently affected nerve roots:
C7 (most common)
C6 (next most common)
Neck pain
Radiating arm pain
Night pain
Spurling's test positive:
Neck extension, lateral rotation, and axial compression reproduce pain or neurology
C7-
Weakness: elbow extension (triceps) and wrist/finger extension
Reflex loss: diminished triceps reflex
Sensory loss: over the middle finger
121
Mx of cervical radiculopathy
If symptoms < 4–6 weeks and no neurological deficit:
Conservative- analgesia, physio and consider neuro analgesia
If symptoms > 4–6 weeks or objective neurology on exam:
Perform MRI
Refer for specialist management
Consider spinal injections
Consider surgery (e.g. decompression, discectomy) if:
Progressive weakness
Persistent pain despite 6–12 weeks of conservative therapy
122
Red flag features of back pain
Age > 50
Gradual, progressive back pain not improving after 4–6 weeks
Severe night pain, waking from sleep
Pain on valsalva – sneezing, straining
Localised vertebral tenderness
Systemic features – weight loss, fatigue
Known malignancy history
Require urgent MRI spine or spinal referral
123
Radial Tunnel Syndrome
Compression of the posterior interosseous nerve in the radial tunnel (just distal to lateral epicondyle)
Pain with resisted middle finger extension or thumb
Tenderness 3–5 cm distal to lateral epicondyle
124
Septic arthritis mx
Empirical antibiotics (IV) after aspiration:
Flucloxacillin – for 4–6 weeks total
Clindamycin – if penicillin allergy
Vancomycin / Teicoplanin – if MRSA suspected
Cefotaxime – if gonococcal cause suspected
Joint decompression: needle aspiration ± lavage
125
Joint pain that is incredibly painful, after UPSI
Gonnorheoa septic arthritis
126
Mx of DDH
Age < 6/12 Pavlik harness
6-18/12 - spica casting
>18/12 - surgery
127
Rotator Cuff Tendinopathy / Impingement
Lateral shoulder pain (esp. subacromial)
Worse with overhead movement
Night pain common
Painful arc (70–120°)
128
Rotator Cuff Tear
Often post-traumatic (e.g. fall/dislocation)
👀 Features
Severe shoulder pain and marked weakness
Inability to abduct above 90°
Positive drop arm test
129
Glenohumeral Joint Osteoarthritis
Age > 60
Deep joint pain
Markedly reduced ROM
X ray changes
130
Acromioclavicular Joint Disorders
ACJ Osteoarthritis
RF: Age > 60, weightlifting
Pain over ACJ, worse with overhead movement or cross-body adduction
💥 ACJ Injury
Ligament/tendon injury after trauma or fall
Tender ACJ, painful elevation
131
Progressive bone pain, waking in night child
Urgent X ray within 48 hrs
132
Which bones does osteosarcoma vs Ewing effect
Osteosarcoma- metaphysical regions of long bones
especially around knee
Ewing- diaphysis of long bones and pelvis
133
When to offer DEXA
Anyone >50 with a fragility fracture
Anyone <40 with a major risk factor:
Vertebral fracture
High-dose corticosteroids (≥7.5mg prednisolone daily ≥3 months)
≥2 fragility fractures
Calculate QFracture (preferred) or FRAX 10-year risk
If high or borderline risk → proceed to DEXA
134
Pubic symphysis dysfunction
Commonly triggered by pregnancy
Pain over pubic symphysis, radiates into the groins
A ‘waddling’ gait
135
Meralgia paraesthetica.
Burning pain in the anterolateral thigh, worse on standing or walking and relieved by sitting, and pain reproduced by palpation over the ASIS
136
Mx of mechanical back pain
NSAIDs
137
Posterior knee dislocation- nerve affected and symptoms
Tibial nerve
Motor: Plantarflexion + inversion
Sensory: Sole of foot
138
Common perineal nerve injury mechanism and sx
Injury: Fibular neck compression
Motor: Dorsiflexion + eversion (anterior + lateral compartments)
Sensory: Dorsum of foot, lateral leg
Features: High-stepping gait
139
Femoral nerve injury mechanism and sx
Roots: L2–L4
Motor: Anterior thigh → knee extension, hip flexion
Sensory: Anterior + medial thigh, medial leg and foot
Injury: Hip fracture, pelvic trauma
140
Obturator nerve injury mechanism and sx
Roots: L2–L4
Motor: Thigh adduction
Sensory: Medial thigh
Injury: Anterior hip dislocation
141
Sciatic nerve injury mechanism and sx
Roots: L4–S3
Motor: Posterior thigh (knee flexion), all leg and foot muscles
Sensory: Posterior thigh, lateral leg, entire foot
Injury: Posterior hip dislocation, acetabular fracture
142
Superior gluteal nerve injury mechanism and sx
Roots: L4–S1
Motor: Gluteus medius + minimus → hip abduction
Sensory: None
Injury: Pelvic surgery or fracture
Sign: Positive Trendelenburg (pelvic drop on swing side when standing on affected leg)
143
Inferior gluteal nerve injury mechanism and sx
Roots: L5–S2
Motor: Gluteus maximus → hip extension
Sensory: None
Injury: Pelvic trauma/surgery
144
lower back with intermittent shooting pains down the front of his thigh. On examination power is 4/5 on knee extension, there is sensory impairment over the anterior thigh and loss of knee jerk reflex in the left leg.
Give NSAIDs
First line for radiculopathy pain
145
Firm, fixed lump increasing in size in child ix
Very urgent US <48hrs for Ix of sarcoma
146
Ix of MSK cancers in children
Lump increasing in size → ultrasound within 48 hours
Unexplained bone pain or swelling → X-ray within 48 hours
Suspicious imaging → specialist referral within 48 hours
147
Breast cancer/myeloma and bone metastases mx
Bone-modifying agent (either zoledronic acid or denosumab)
Consider in prostate cancer if other analgesia fails
148
Gonnorhoea septic arthritis mx
IV third-generation cephalosporin
149
Spinal fracture sx
Sudden onset, severe central back pain which is worse with loading (e.g. standing)
Examination may reveal point vertebral tenderness.
150
Pain of OA from hip
Pain from hip OA is classically felt in the anterior groin, occasionally radiating to the thigh or knee, and worsens with activity but eases with rest. Loss of internal rotation (especially with hip flexion) is an early sign, and crepitus or stiffness may also be present.
151
Metastatic spinal disease presentation
Progressive, unremitting pain (especially at night)
152
MOA of tibial plateau fracture
struck on the knee by a car bumper
Fall from height
high-energy valgus/axial load causing a tibial plateau fracture.
153
Differentiating knee injuries
ACL tear: audible pop, rapid swelling (<2 hrs), positive Lachman test
PCL tear: dashboard injury, posterior sag sign
Meniscal tear: twisting + locking + joint line tenderness
MCL injury: lateral trauma + medial pain + valgus test positive
LCL injury: medial trauma + lateral pain + varus test positive
Tendon rupture:
Fall or sudden eccentric loading of the knee
can't extend knee or perform straight leg raise
Tibial plateau fracture: severe bruising, often in high-energy injury
154
Metastatic spinal cord compression mx
Bed rest, 16mg Dex + PPI, radiotherapy or surgery if appropriate
155
MSRA
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Decks in class (23)
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