MSK Flashcards

Question

Knee pain meniscal tears

Answer 1

Typically result from twisting injuries. Features: - pain worse on straightening the knee - knee may 'give way' - displaced meniscal tears may cause knee locking - tenderness along the joint line - Thessaly's test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee

Answer 2

Inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions. May be idiopathic or associated with connective tissue disorders or underlying malignancy (typically ovarian, breast and lung cancer, found in 20-25% - more if patient older). Screening for an underlying malignancy is usually performed following a diagnosis of dermatomyositis. Skin features: - macular rash over back and shoulder. - heliotrope rash in the periorbital region. - Gottron's papules - roughened red papules over extensor surfaces of fingers. - 'mechanic's hands': extremely dry and scaly hands with linear 'cracks' on the palmar and lateral aspects of the fingers. Other features: - proximal muscle weakness +/- tenderness - Raynaud's - respiratory muscle weakness - Interstitial lung disease: e.g. Fibrosing alveolitis or organising pneumonia dysphagia, dysphonia

Answer 3

Baker's cysts (also known as a popliteal cyst) are not true cysts but rather a distension of the gastrocnemius-semimembranosus bursa. They may be primary or secondary: - Primary: no underlying pathology, typically seen in children. - Secondary: underlying condition such as osteoarthritis, typically seen in adults. They present as swellings in the popliteal fossa behind the knee. A child with a suspected Baker's cyst requires an USS to confirm the diagnosis!!!

Answer 4

Pain and tenderness localised to the lateral epicondyle. Pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended. Episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks. Management options - advice on avoiding muscle overload - simple analgesia - steroid injection - physiotherapy

Answer 5

Topical NSAIDs are first-line analgesics. Topical NSAIDs may be particualrly beneficial for patients with OA of the knee or hand. Second-line treatment is oral NSAIDs a proton pump inhibitor should be co-prescribed with NSAIDs. NICE recommend we do not offer paracetamol or weak opioids, unless: - they are only used infrequently for short-term pain relief and all other pharmacological treatments are contraindicated, not tolerated or ineffective. - glucosamine and strong opioids are not recommended. - non-pharmacological treatment options include walking aids for knee and hip OA. - Intra-articular steroid injections may be tried if standard pharmacological treatment is ineffective. Patients should be aware that they only provide short-term relief (2-10 weeks). If conservative methods fail then refer for consideration of joint replacement.

Answer 6

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

Answer 7

- 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 - captopril is typically used due to its rapid onset and short half-life, allowing for dose titration ACE inhibitors target the underlying mechanism by reducing efferent arteriolar vasoconstriction and limiting renin-angiotensin system activation. Poor prognosis

Answer 8

Olecranon bursitis describes inflammation of the fluid-filled bursa overlying the olecranon process at the proximal ulna. The bursa reduces friction between the elbow and overlying tissues. Causes: - Repetitive trauma - writers and students leaning on elbows, plumbers, miners - Direct trauma - Infection – usually Staphylococcus aureus; more common in patients with diabetes, alcohol misuse, steroid use or renal impairment - Gout, rheumatoid arthritis, or idiopathic causes - Fluctuant, well-circumscribed swelling at the posterior elbow. - sometimes described as a 'golf ball on the end of the elbow'. - Tenderness and warmth over the bursa. - Fever and overlying skin changes suggest possible infection - Tophi or joint effusions if due to gout or rheumatoid arthritis - Non-septic: conservative management with rest, ice, compression, and NSAIDs - Septic: aspirate and treat empirically with oral flucloxacillin; consider admission for IV antibiotics if systemically unwell. Avoid further trauma to the area; use elbow pads if needed. Surgical drainage may be necessary if aspiration fails or infection persists.

Answer 9

Iliotibial band syndrome is a common cause of lateral knee pain in runners. - Tenderness 2-3cm above the lateral joint line Management: - Activity modification and iliotibial band stretches - if not improving then physiotherapy referral

Answer 10

Fibromyalgia is a syndrome characterised by widespread pain throughout the body with tender points at specific anatomical sites. Cause is unknown.women are around 5 times more likely to be affected typically presents between 30-50 years old. - Chronic pain: at multiple site, sometimes 'pain all over' - Lethargy - Cognitive impairment: 'fibro fog' - Sleep disturbance, headaches, dizziness are common Ix: Diagnosis is clinical and sometimes refers to the American College of Rheumatology. classification criteria which lists 9 pairs of tender points on the body. If a patient is tender in at least 11 of these 18 points it makes a diagnosis of fibromyalgia more likely. - aerobic exercise: has the strongest evidence base - cognitive behavioural therapy - medication: pregabalin, duloxetine, amitriptyline GPSELF TEST: Amitriptyline can be used for primary chronic pain syndromes in over 18s. Opiates, paracetamol, non-steroidal anti-inflammatories, gabapentin, pregabalin and corticosteroid injections are not advised!!

Answer 11

Sjogren's syndrome is an autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces. It may be primary (PSS) or secondary to rheumatoid arthritis or other connective tissue disorders, where it usually develops around 10 years after the initial onset. Sjogren's syndrome is much more common in females (ratio 9:1). There is a marked increased risk of lymphoid malignancy (40-60 fold). - Dry eyes: keratoconjunctivitis sicca - Dry mouth - Vaginal dryness - Arthralgia Raynaud's, myalgia sensory polyneuropathy recurrent episodes of parotitis - Rheumatoid factor (RF) positive in nearly 50% of patients - ANA positive in 70% - Anti-Ro antibodies in 70% of patients - Anti-La antibodies in 30% of patients. - Extractable nuclear antigen (ENA) Schirmer's test: filter paper near conjunctival sac to measure tear formation. Artificial saliva and tears. Pilocarpine may be helpful to stimulate saliva production.

Answer 12

HLA-B27 is a class I MHC antigen strongly associated with the seronegative spondyloarthropathies . “Seronegative” means rheumatoid factor (RF) and anti-CCP are negative. 👉 Remember the mnemonic “PAIR” P Psoriatic arthritis A Ankylosing spondylitis I Inflammatory bowel disease–associated arthritis R Reactive arthritis

Answer 13

- Sensory loss over anterior thigh - Weak hip flexion, knee extension and hip adduction - Reduced knee reflex - Positive femoral stretch test

Answer 14

- Sensory loss anterior aspect of knee and medial malleolus - Weak knee extension and hip adduction - Reduced knee reflex - Positive femoral stretch test

Answer 15

- Sensory loss dorsum of foot - Weakness in foot and big toe dorsiflexion - Reflexes intact - Positive sciatic nerve stretch test

Answer 16

- Sensory loss posterolateral aspect of leg and lateral aspect of foot - Weakness in plantar flexion of foot - Reduced ankle reflex - Positive sciatic nerve stretch test

Answer 17

Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 3:1) aged 20-30 years old. - Typically a young man who presents with lower back pain and stiffness of insidious onset. - Stiffness is usually worse in the morning and improves with exercise the patient may experience pain at night which improves on getting up. - 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 Other features - the 'A's Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis and cauda equina syndrome peripheral arthritis (25%, more common if female)

Answer 18

L – loss of joint space E – erosions S – soft tissue swelling S – soft bones (osteopenia)

Answer 19

C Coagulation defect (thrombosis) Recurrent arterial or venous thromboses L Livedo reticularis O Obstetric complications Recurrent miscarriages T Thrombocytopenia Low platelets S (prolonged) aPTT Paradoxical prolongation of APTT despite being hypercoagulable Investigations: - Anticardiolipin antibodies - Anti-beta2 glycoprotein I (anti-beta2GPI) antibodies - lupus anticoagulant - Thrombocytopenia - Prolonged APTT

Answer 20

Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. 1. NSAIDs or colchicine are first-line - the maximum dose of NSAID should be prescribed until 1-2 days after the symptoms have settled - gastroprotection (e.g. a proton pump inhibitor) may also be indicated. Colchicine Has a slower onset of action may be used with caution in renal impairment: the BNF advises to reduce the dose if eGFR is 10-50 ml/min and to avoid if eGFR < 10 ml/min BNF. the main side-effect is diarrhoea 2. Oral steroids may be considered if NSAIDs and colchicine are contraindicated. a dose of prednisolone 15mg/day is usually used. another option is intra-articular steroid injection. If the patient is already taking allopurinol it should be continued!!

Answer 21

British Society of Rheumatology Guidelines now advocate offering urate-lowering therapy to all patients after their first attack of gout. Allopurinol is first-line. initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 360 µmol/l. a lower initial dose of allopurinol should be given if the patient has a reduced eGFR. Colchicine cover should be considered when starting allopurinol. Allopurinol can precipitate acute flares of gout due to changes in uric acid levels in the serum and tissues NSAIDs can be used if colchicine cannot be tolerated. The BSR guidelines suggest this may need to be continued for 6 months. The second-line agent when allopurinol is not tolerated or ineffective is febuxostat (also a xanthine oxidase inhibitor). Consideration should be given to stopping precipitating drugs (such as thiazides).

Answer 22

Greater trochanteric pain syndrome is also referred to as trochanteric bursitis. It is due to repeated movement of the fibroelastic iliotibial band and is most common in women aged 50-70 years. - Pain over the lateral side of hip/thigh - Tenderness on palpation of the greater trochanter

Answer 23

An examination should be conducted using Simmond's triad, to help exclude Achilles tendon rupture. This can be performed by asking the patient to lie prone with their feet over the edge of the bed. The examiner should look for an abnormal angle of declination; Achilles tendon rupture may lead to greater dorsiflexion of the injured foot compared to the uninjured limb. They should also feel for a gap in the tendon and gently squeeze the calf muscles if there is an acute rupture of the Achilles tendon the injured foot will stay in the neutral position when the calf is squeezed. Ultrasound is the initial imaging modality of choice for suspected Achilles tendon rupture. An acute referral should be made to an orthopaedic specialist following a suspected rupture.

Answer 24

A syndrome of paraesthesia or anaesthesia in the distribution of the lateral femoral cutaneous nerve (LFCN). Patients typically present with the following symptoms in the upper lateral aspect of the thigh: - Burning, tingling, coldness, or shooting pain - Numbness - Deep muscle ache - Symptoms are usually aggravated by standing, and relieved by sitting - They can be mild and resolve spontaneously or may severely restrict the patient for many years. Signs: - Symptoms may be reproduced by deep palpation just below the ASIS (pelvic compression) and also by extension of the hip. - There is altered sensation over the upper lateral aspect of the thigh. - There is no motor weakness. Investigations: - The pelvic compression test is highly sensitive, and often, meralgia paraesthetica can be diagnosed based on this test alone. Injection of the nerve with local anaesthetic will abolish the pain. Using ultrasound is effective both for diagnosis and guiding injection therapy in meralgia paraesthetica.

Answer 25

Medial epicondylitis is also known as golfer's elbow. Features: - Pain and tenderness localised to the medial epicondyle. - Pain is aggravated by wrist flexion and pronation. - Symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement.

Answer 26

Adverse effects: - Oesophageal reactions: oesophagitis, oesophageal ulcers (especially alendronate). - osteonecrosis of the jaw substantially greater risk for patients receiving IV bisphosphonates in the treatment of cancer than for patients receiving oral bisphosphonates for osteoporosis or Paget's disease. poor dental hygiene/prior dental procedures are also a risk factor. - All patients with cancer and patients with poor dental status should have a dental check-up before bisphosphonate treatment. - Increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate. - Acute phase response: fever, myalgia and arthralgia may occur following administration. hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking tablet. Hypocalcemia/vitamin D deficiency should be corrected before giving bisphosphonates. However, when starting bisphosphonate treatment for osteoporosis, calcium should only be prescribed if dietary intake is inadequate. Vitamin D supplements are normally given. The duration of bisphosphonate treatment varies according to the level of risk. Some authorities recommend stopping bisphosphonates at 5 years if the following apply: - patient is < 75-years-old - femoral neck T-score of > -2.5 - low risk according to FRAX/NOGG

Answer 27

Perthes disease is a degenerative condition affecting the hip joints of children, typically between the ages of 4-8 years. It is due to avascular necrosis of the femoral head. Perthes disease is 5 times more common in boys. Around 10% of cases are bilateral. ******************* - Hip pain: develops progressively over a few weeks - Limp - Stiffness and reduced range of hip movement!!! - X-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening

Answer 28

- Typical age group = 10-15 years. - More common in obese children and boys. - Displacement of the femoral head epiphysis postero-inferiorly. - Bilateral slip in 20% of cases. May present acutely following trauma or more commonly with chronic, persistent symptoms. - Knee or distal thigh pain is common - Loss of internal rotation of the leg in flexion NOTE AGE OF SUFE vs PERTHES DISEASE

Answer 29

Describes arthritis occurring in someone who is less than 16 years old that lasts for more than three months. Pauciarticular JIA refers to cases where 4 or less joints are affected. It accounts for around 60% of cases of JIA. Features of pauciarticular JIA: - joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows - limp - ANA may be positive in JIA - associated with anterior uveitis

Answer 30

De Quervain's tenosynovitis is a common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged 30 - 50 years old. - Pain on the radial side of the wrist. - Tenderness over the radial styloid process. - Abduction of the thumb against resistance is painful - Finkelstein's test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus. Mx: - analgesia - steroid injection - immobilisation with a thumb splint (spica) may be effective - surgical treatment is sometimes required

Answer 31

Dupuytren's contracture has a prevalence of about 5%. It is more common in older male patients and around 60-70% have a positive family history. The ring finger and little finger are the fingers most commonly affected. Specific causes include: - manual labour - phenytoin treatment - alcoholic liver disease - diabetes mellitus - trauma to the hand Consider surgical treatment of Dupuytren's contracture when the metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table.

Answer 32

Paget's disease is a disease of increased but uncontrolled bone turnover. It is thought to be primarily a disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity. The skull, spine/pelvis, and long bones of the lower extremities are most commonly affected. - the stereotypical presentation is an older male with bone pain and an isolated raised ALP. - Bone pain (e.g. pelvis, lumbar spine, femur). - Classical, untreated features: bowing of tibia, bossing of skull Ix: - Raised alkaline phosphatase (ALP) calcium and phosphate are typically normal. Hypercalcaemia may occasionally occur with prolonged immobilisation. x-rays plain radiographs are the first-line investigation and are usually diagnostic. - osteolysis in early disease → mixed lytic/sclerotic lesions later - skull x-ray: thickened vault, - osteoporosis circumscripta bone scintigraphy: increased uptake is seen focally at the sites of active bone lesions

Answer 33

Management: - Bisphosphonate (either oral risedronate or IV zoledronate) - Calcitonin is less commonly used now Complications: - deafness (cranial nerve entrapment) - bone sarcoma (1% if affected for > 10 years) - fractures - skull thickening - high-output cardiac failure

Answer 34

Temporal arteritis (GCA) is a vasculitis of unknown cause that affects medium and large-sized vessels arteries. Occurs in those over 50 years old with peak incidence in patients who are in their 70s. Overlap between temporal arteritis and PMR around 50% of patients will have features of PMR. - Typically patient > 60 years old - Rapid onset (e.g. < 1 month) - Headache (found in 85%) - Jaw claudication (65%) Anterior ischemic optic neuropathy accounts for the majority of ocular complications. It results from occlusion of the posterior ciliary artery (a branch of the ophthalmic artery) → ischaemia of the optic nerve head. Fundoscopy typically shows a swollen pale disc and blurred margins. - May result in temporary visual loss - amaurosis fugax - Permanent visual loss is the most feared complication of temporal arteritis and may develop suddenly. - Tender, palpable temporal artery - Around 50% have features of PMR: aching, morning stiffness in proximal limb muscles (not weakness). also lethargy, depression, low-grade fever, anorexia, night sweats

Answer 35

- Raised inflammatory markers ESR > 50 mm/hr (note ESR < 30 in 10% of patients) - CRP may also be elevated - Temporal artery biopsy: considered the gold standard diagnostic test for GCA used to confirm the presence of granulomatous inflammation with multinucleated giant cells in the temporal artery wall. a positive biopsy supports the diagnosis of GCA and justifies continued corticosteroid therapy, particularly in cases with atypical or isolated symptoms. if the biopsy is negative, GCA cannot be ruled out due to the possibility of skip lesions; clinical judgement prevails, and treatment should be continued if the pre-test probability remains high. temporal artery colour Doppler ultrasound is a diagnostic alternative to temporal artery biopsy. Note creatine kinase and EMG normal!!

Answer 36

1. Urgent high-dose glucocorticoids. - should be given as soon as the diagnosis is suspected and before temporal artery biopsy, - if there is no visual loss then high-dose prednisolone is used. - if there is evolving visual loss IV methylprednisolone is usually given prior to starting high-dose prednisolone. there should be a dramatic response, if not the diagnosis should be reconsidered. 2. Urgent ophthalmology review - patients with visual symptoms should be seen the same-day by an ophthalmologist - visual damage is often irreversible 3. Bone protection with bisphosphonates is required as long, tapering course of steroids is required.

Answer 37

Marfan's syndrome is an autosomal dominant connective tissue disorder. It is caused by a defect in the FBN1 gene on chromosome 15 that codes for the protein fibrillin-1. - Tall stature with arm span to height ratio > 1.05 - High-arched palate - Arachnodactyly - Pectus excavatum - Pes planus - Scoliosis of > 20 degrees Heart: - Dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation. - Mitral valve prolapse (75% Lungs: repeated pneumothoraces Eyes: - upwards lens dislocation (superotemporal ectopia lentis) - blue sclera - myopia - dural ectasia (ballooning of the dural sac at the lumbosacral level)

Answer 38

Caused by compression of median nerve in the carpal tunnel. - Pain/pins and needles in thumb, index, middle finger - unusually the symptoms may 'ascend' proximally - Patient shakes his hand to obtain relief, classically at night Examination: - Weakness of thumb abduction (abductor pollicis brevis) - Wasting of thenar eminence - Tinel's sign: tapping causes paraesthesia - Phalen's sign: flexion of wrist causes symptoms Causes: - idiopathic - pregnancy - oedema e.g. heart failure - lunate fracture - rheumatoid arthritis Electrophysiology: Motor + sensory: prolongation of the action potential Tx: NICE recommends a 6-week trial of conservative treatments if the symptoms are mild-moderate, - Corticosteroid injection - Wrist splints at night: particularly useful if transient factors present e.g. pregnancy if there are severe symptoms or symptoms persist with conservative management: - Surgical decompression (flexor retinaculum division)

Answer 39

Beta blockers, diuretics, ACE inhibitors and aspirin increase serum urate levels and may trigger gout. Sodium glucose cotransporter 2 inhibitors, calcium channel blockers, fenofibrate and losartan all decrease urate levels.

Answer 40

NICE recommends a targeted assessment of fracture risk of all women from the age of 65 and all men from the age of 75. Women and men under 65 can have a fracture risk assessment if they have additional risk factors present such as low BMI, previous fragility fracture, family history of osteoporosis, high alcohol intake and smoking.

Answer 41

Topical nonsteroidal anti-inflammatory drugs (NSAIDs) are recommended as first line management for knee osteoarthritis. However, if these are not effective then oral NSAIDs are the next step.

Answer 42

Bone mineral density is usually expressed as the number of standard deviations from the young adult mean. This is known as the T score. Normal bone density is within 1 SD of the young adult mean (i.e. T score > -1). Osteopenia is defined by a T score between -1 and -2.5. Osteoporosis is defined as a T score < -2.5. BMD can also be expressed as the number of standard deviations from the age-related mean. This is the Z score, which enables a patient's risk to be compared to other patients of the same age.

Answer 43

There are some differences in the risk factors included in FRAX and QFracture algorithms. QFracture includes history of falls but FRAX does not. In addition, FRAX can incorporate data on bone mineral density (BMD) if a dual energy X-ray absorptiometry (DEXA) scan has been performed, whereas QFracture cannot. Ethnicity is included in the QFracture algorithm but not FRAX. All the other factors feature in both tools. QFracture has been extensively validated in the UK population and is recommended by the Scottish Intercollegiate Guidelines Network (SIGN) guidance in preference to FRAX.

Answer 44

Compression neuropathy of the radial nerve, typically occurring when the arm is compressed for a prolonged period (often during deep sleep, intoxication, or unconsciousness). - Wrist drop: inability to extend wrist and fingers. Paralysis of wrist and finger extensors. - Weak grip - Numbness over dorsum of hand, particularly first web space (between thumb and index finger)

Answer 45

Anterior cruciate ligament injuries are often non-contact, twisting injuries characterised by an audible pop or crack and a large immediate swelling. Posterior cruciate ligament injuries are less common and rarely occur in isolation, they usually occur from direct impact to the flexed knee.

Answer 46

Hyperuricaemia is a classic feature of gout, although gout occurs nearly half of the time without hyperuricemia, and most people with raised uric acid levels never develop gout. Thus, the diagnostic usefulness of measuring a uric acid level during the acute attack is limited. During acute attack urate levels are frequently normal. Current guidance suggests that if serum urate level is below 360 micromol/litre (6 mg/dl) during a flare and gout is strongly suspected, repeat the serum urate level measurement at least 2 weeks after the flare has settled.

Answer 47

Chronic pain is defined as pain lasting more than twelve weeks. Approaches to management of chronic pain are often very different from those used for acute pain.

Answer 48

DAS28 is a composite scoring system used to assess and monitor disease activity in rheumatoid arthritis (RA) by evaluating 28 specific joints for inflammation. The DAS28 is calculated using a complex mathematical formula that takes into account whether the 28 joints examined are swollen or tender, the CRP or ESR, and the patient’s global assessment of their health.

Answer 49

Reactive arthritis is defined as an arthritis that develops following an infection where the organism cannot be recovered from the joint. Features - typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months - arthritis is typically an asymmetrical - oligoarthritis of lower limbs - dactylitis - symptoms of urethritis - conjunctivitis (seen in 10-30%) - anterior uveitis - skin - circinate balanitis (painless vesicles on the coronal margin of the prepuce) - keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles) ************** - Post-enteric: the three most commonly associated enteric pathogens are Campylobacter, Salmonella and Shigella species. - Post-venereal: following Chlamydia trachomatis infection or with human immunodeficiency virus (HIV).

Answer 50

Patients taking methotrexate should initially have full blood count and renal and liver function tests repeated every 1–2 weeks until therapy is stabilised. Thereafter, patients should be monitored every 2–3 months.

Answer 51

👉 Mnemonic: CHARTS C – Coal workers’ pneumoconiosis H – Histiocytosis (Langerhans cell) A – Ankylosing spondylitis R – Radiation T – Tuberculosis S – Sarcoidosis RA is lower lobe fibrosis!

Answer 52

Osteomalacia causes proximal muscle weakness, which is suggested by the difficulty rising from a chair, and is associated with low serum calcium and elevated alkaline phosphatase.

Answer 53

NICE advise that GPs should offer a dual-energy X-ray absorptiometry (DXA) scan to measure bone mineral density (BMD) without calculating the fragility fracture risk in people: - Over 50 years of age with a history of fragility fracture. - Younger than 40 years of age who have a major risk factor for fragility fracture

Answer 54

Lumbar spinal stenosis without red flags is a routine referral to spinal/orthopaedic services. Spinal stenosis is a common cause of low back pain that radiates to the legs, and it is more common in adults aged over 50 years. Imaging such as magnetic resonance imaging (MRI) of the lumbar spine would be helpful to rule out alternative diagnoses and are used to determine the extent and location of the nerve compression but ideally this may be better done in specialist settings of care where treatment options including surgical or nonsurgical can be discussed.

Answer 55

Pre-patellar bursitis is the most common site of bursitis in the knee. Most cases occur in males aged 40-60 years of age. It presents with knee pain, especially on kneeling and mild swelling over the anterior aspect of the knee overlying the patella. There will usually be a history of excessive kneeling for example those working as roofers, gardeners, or carpenters.

Answer 56

The Ottawa ankle rule shows areas of tenderness to be evaluated in ankle trauma patients to determine need for imaging. An ankle X-ray is required only if there is pain in the malleolar area, associated with any of the following: - Pain on palpation over the posterior tip/edge of the lateral malleolus. - Pain on palpation over the posterior tip/edge of the medial malleolus. - Inability to weight bear both immediately after the injury and in the emergency department.

Answer 57

Ottawa knee rule, knee X-ray is only required after a knee injury for people with any of these findings: - Age 55 years or older - Isolated tenderness of the patella (no bone tenderness of the knee other than the patella) - Tenderness of the head of the fibula - Inability to flex the knee to 90° - Inability to weight bear both immediately and during the consultation for four steps (inability to transfer weight twice onto each lower limb regardless of limping) - In addition, offer an X-ray of the knee if there was rapid onset (within two hours of the injury) of a large effusion, which suggests haemarthrosis.

Answer 58

One of the leading causes of heel pain is plantar fasciitis which is caused by inflammation of the plantar fascia as it inserts to the medial calcaneal tubercle. It affects both overweight and highly active people. The management is largely conservative. Initial treatment involves analgesia using a non-steroidal anti-inflammatory (NSAIDs), eccentric stretching and ice packs. If symptoms do not improve referral to physiotherapy should be considered. Prolotherapy also has a role in treatment of plantar fasciitis. If the symptoms are refractory to conservative management, referral to an orthopaedic surgeon should be made for consideration of surgical management. Worse with first steps in the morning or after rest (“start-up pain”), improves with movement, may recur after prolonged activity.

Answer 59

Osgood–Schlatter syndrome is an example of an overuse syndrome associated with physical exertion before skeletal maturity. Patients, usually boys, complain of pain, tenderness and a lump over the tibial tubercle. Pain follows activity and may be bilateral. Seen in sporty teenagers Pain, tenderness and swelling over the tibial tubercle.

Answer 60

- Softening of the cartilage of the patella - Common in teenage girls - Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting - Usually responds to physiotherapy

Answer 61

77% of ankle injuries are lateral ligaments strains with the majority to the anterior talofibular ligament. Fractures are the second most common ankle injury, accounting for 16.3%.

Answer 62

The T-score compares the patient’s BMD result with that of a healthy 30-year-old adult of the same gender and ethnicity. - A T-score from +1.0 to -1.0 is considered within the normal range. - A T-score of -1.0 to -2.5 is considered osteopenia. - A T-score of -2.5 or less represents osteoporosis. The Z-score compares the patient’s BMD to that of a healthy person of the same age, gender and ethnicity. T = Thirty-year-old reference (used for diagnosis)

Answer 63

It is important to maintain a high level of clinical suspicion for scaphoid fractures as these often masquerade as wrist sprains and X-rays undertaken close to the time of injury can be falsely reassuring. A missed or delayed diagnosis can lead to non-union of this poorly vascularized bone with subsequent avascular necrosis, subluxation and osteoarthritis. It is important to arrange a plain radiograph and an orthopaedic assessment for any patient with tenderness in the anatomical snuff box following a wrist injury.

Answer 64

Fracture risk appears to be increased in people taking antidepressant medications, particularly SSRIs.

Answer 65

The maximum daily dose of allopurinol in patients with renal impairment is 100 mg. Although the BNF does not specify at which eGFR level this change should take place but mentions that in severe impairment the daily dose should either be reduced to below 100 mg or increase the dose interval.

Answer 66

NICE recommends topical NSAIDs as first line in knee OA (e.g.: 5% topical ibuprofen gel). If this is not sufficient then oral NSAIDS should be considered, providing there are no contraindications.

Answer 67

Pain in the leg and lower back between 30-70 degrees of straight leg raising is indicative of lumbar disc herniation. Pain at more than 70 degrees may be indicative of hip pathology. Pain at less than 30 degrees may indicate a range of possibilities including acute spondylolisthesis, gluteal abscess or acute dural inflammation. Pain that increases with neck flexion or foot dorsiflexion may indicate a lesion in the spinal cord. Pain that does not increase with neck flexion may indicate a lesion in the hamstring area or in the lumbosacral or sacroiliac joint.

Answer 68

Infective olecranon bursitis. Patient can be treated empirically with flucloxacillin (or a macrolide if they are allergic to penicillin).

Answer 69

- Sudden painful, swollen joint (often knee) - Warm, tender, limited movement Calcium pyrophosphate crystals. Diagnostic test — synovial fluid shows rhomboid-shaped, positively birefringent crystals under polarized light.

Answer 70

Trigger finger is a common condition associated with abnormal flexion of the digits. It is thought to be caused by a disparity between the size of the tendon and pulleys through which they pass. In simple terms the tendon becomes 'stuck' and cannot pass smoothly through the pulley. Associations* (idiopathic in the majority) more common in women than men rheumatoid arthritis diabetes mellitus Features - more common in the thumb, middle, or ring finger - initially stiffness and snapping ('trigger') when extending a flexed digit a nodule may be felt at the base of the affected finger Management********** - Steroid injection is successful in the majority of patients. A finger splint may be applied afterwards. surgery should be reserved for patients who have not responded to steroid injections

Answer 71

99% are ANA positive - this high sensitivity makes it a useful rule out test, but it has low specificity. Anti-dsDNA: highly specific (> 99%), but less sensitive (70%)

Answer 72

A child with a suspected Baker's cyst requires an USS to confirm the diagnosis. Routine if no increasing in size. Urgent if increasing in size

Answer 73

Raynaud's phenomenon is characterised by an exaggerated vasoconstrictive response of the digital arteries and cutaneous arteriole to the cold or emotional stress. It may be primary (Raynaud's disease) or secondary (Raynaud's phenomenon). All patients with suspected secondary Raynaud's phenomenon should be referred to secondary care. - First-line: calcium channel blockers e.g. Nifedipine IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months

Answer 74

No visual symptoms = 40–60 mg oral prednisolone Visual symptoms or visual loss (amaurosis fugax, diplopia, vision loss) = Immediate high-dose IV methylprednisolone 500–1000 mg daily for 3 days

Answer 75

It is most common in middle-aged females. Up to 20% of diabetics may have an episode of frozen shoulder. Features typically develop over days: - EXTERNAL rotation is affected more than internal rotation or abduction both active and passive movement is affected. - patients typically have a painful freezing phase, an adhesive phase and a recovery phase - Bilateral in up to 20% of patients - Episode typically lasts between 6 months and 2 years The diagnosis is usually clinical although imaging may be required for atypical or persistent symptoms. Management - No single intervention has been shown to improve outcome in the long-term. - Treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids.

Answer 76

Due to the compression of the ulnar nerve. Features: - Initially intermittent tingling in the 4th and 5th finger. - May be worse when the elbow is resting on a firm surface or flexed for extended periods. - Later numbness in the 4th and 5th finger with associated weakness.

Answer 77

Osteochondritis dissecans (OCD) is a pathological process affecting the subchondral bone (most often in the knee joint) with secondary effects on the joint cartilage, including pain, oedema, free bodies and mechanical dysfunctions. It generally affects children and young adults. OCD may progress to degenerative changes if untreated. Patients typically present with a subacute onset of: Knee pain and swelling, typically after exercise Knee catching, locking and/or giving way: more constant and severe symptoms are associated with the presence of loose bodies Feeling a painful 'clunk' when flexing or extending the knee - indicating the involvement of the lateral femoral condyle Signs: Joint effusion Tenderness on palpation of the articular cartilage of the medial femoral condyle, when the knee is flexed Wilson's sign for detecting medial condyle lesion - with the knee at 90° flexion and tibia internally rotated, the gradual extension of the joint leads to pain at about 30°, external rotation of the tibia at this point relieves the pain Investigations: X-ray (anteroposterior, lateral and tunnel views) - may show the subchondral crescent sign or loose bodies MRI - used to evaluate cartilage, visualise loose bodies, stag

MSK Flashcards

(101 cards)