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Musculoskeletal 1.5.25 Dr Katherine Wostenholme and Dr Sophia HwaiLearningOutcomes To revise the main presentations within MSK including: ● Osteoarthritis: Diagnosis, management, and treatment options ● Rheumatoid arthritis: Diagnosis, treatment, and disease-modifying agents ● Fractures: Diagnosis, management, and complications (e.g., compartment syndrome) ● Back pain: Differential diagnosis, red flags, management ● Soft tissue injuries: Sprains, strains, tendinitis ● Osteoporosis: Diagnosis, prevention, and managementLearningOutcomes LearningOutcomes 1. Back pain - cauda equina 2. Chronic joint pain/ stiffness (OA vs RA) 3. Traumatic fracture 4. Pathological fracture (OP) 5. Soft tissue injuries 6. The limping child 7. Non-accidental injury 8. Congenital abnormalities 9. Bone pain - tumours 10. Osteomyelitis/ septic arthritisQuestion 1 A 45-year-old man presents to the emergency department with severe lower back pain that started 24 hours ago after lifting a heavy box. He also reports difficulty urinating and numbness in the perianal region. On examination, there is reduced anal tone and decreased sensation in the saddle area. What is the most appropriate next step in management? A) Oral morphine and discharge with GP follow-up B) Physiotherapy referral C) Urgent MRI spine D) Lumbar X-ray E) Blood cultures and broad-spectrum antibioticsQuestion 1 A 45-year-old man presents to the emergency department with severe lower back pain that started 24 hours ago after lifting a heavy box. He also reports difficulty urinating and numbness in the perianal region. On examination, there is reduced anal tone and decreased sensation in the saddle area. What is the most appropriate next step in management? A) Oral morphine and discharge with GP follow-up B) Physiotherapy referral C) Urgent MRI spine D) Lumbar X-ray E) Blood cultures and broad-spectrum antibioticsQuestion 1-Explanation-Cauda Equina Syndrome This patient presents with red flag signs of cauda equina syndrome (CES): • Severe back pain • Urinary retention • Saddle anaesthesia • Decreased anal tone CES is a neurosurgical emergency caused by compression of the cauda equina nerve roots, most commonly due to a decompression can lead to permanent neurological deficits including incontinence and paralysis. Oral analgesia and physiotherapy are inappropriate, and X-rays are not helpful for soft tissue evaluation. Blood cultures and antibiotics are irrelevant unless infection (e.g., epidural abscess) is suspected, which isn’t the case here.Question 2 A 62-year-old woman presents with gradually worsening pain and stiffness in her knees and hips over the last few years. The stiffness lasts less than 30 minutes in the morning and improves with movement. Examination reveals crepitus and bony enlargement of the distal interphalangeal joints. What is the most likely diagnosis? A) Rheumatoid arthritis B) Osteoarthritis C) Gout D) Psoriatic arthritis E) Reactive arthritisQuestion 2 A 62-year-old woman presents with gradually worsening pain and stiffness in her knees and hips over the last few years. The stiffness lasts less than 30 minutes in the morning and improves with movement. Examination reveals crepitus and bony enlargement of the distal interphalangeal joints. What is the most likely diagnosis? A) Rheumatoid arthritis B) Osteoarthritis C) Gout D) Psoriatic arthritis E) Reactive arthritisQuestion 2-Explanation This is classic osteoarthritis (OA), characterized by: In contrast, rheumatoid arthritis (RA) usually presents with: • Chronic joint pain and stiffness • Symmetrical joint involvement • Morning stiffness < 30 minutes • Morning stiffness > 30 minutes • Worse with activity and relieved by rest • Involvement of small joints (MCP, PIP) • Bony enlargement (e.g., Heberden’s nodes in DIP joints) • Systemic features • Often affects weight-bearing joints (knees, hips) • Autoantibody positivity (RF, anti-CCP)Question 3 A 30-year-old male presents after a road traffic accident. His right leg is shortened and externally rotated. X-ray shows a displaced femoral shaft fracture. What is the most appropriate immediate management? A) Intravenous bisphosphonates B) Internal fixation surgery C) Full weight-bearing mobilization D) Urgent reduction and splinting E) Bed rest for 6 weeksQuestion 3 A 30-year-old male presents after a road traffic accident. His right leg is shortened and externally rotated. X-ray shows a displaced femoral shaft fracture. What is the most appropriate immediate management? A) Intravenous bisphosphonates B) Internal fixation surgery C) Full weight-bearing mobilization D) Urgent reduction and splinting E) Bed rest for 6 weeksQuestion 3-Explanation In the acute management of a traumatic fracture, the priorities are: 1. Pain control 2. Stabilisation of the fracture to prevent further injury (neurovascular compromise, bleeding, etc.) 3. Definitive surgical fixation if needed A displaced femoral shaft fracture is an emergency due to the risk of major blood loss and soft tissue damage. Immediate reduction and splinting (e.g., traction splint) is crucial before definitive surgical fixation. Bisphosphonates are not indicated here. Bed rest and early full weight-bearing are inappropriate and dangerous in an unstable fracture.Question 4 An 82-year-old woman falls from standing height and sustains a fractured neck of femur. She has a history of multiple similar fractures. A DEXA scan shows a T-score of -2.9. What is the most likely underlying cause of her fracture? A) Bone metastasis B) Primary hyperparathyroidism C) Paget’s disease of bone D) Osteoporosis E) OsteomalaciaQuestion 4 An 82-year-old woman falls from standing height and sustains a fractured neck of femur. She has a history of multiple similar fractures. A DEXA scan shows a T-score of -2.9. What is the most likely underlying cause of her fracture? A) Bone metastasis B) Primary hyperparathyroidism C) Paget’s disease of bone D) Osteoporosis E) OsteomalaciaQuestion 4-Explanation According to the World Health Organization, osteoporosis is defined based on the following bone density levels: This is a classic fragility fracture, which occurs from low-impact trauma in someone with osteoporosis. A T-score ≤ -2.5 on DEXA confirms the diagnosis. - A T-score within 1 SD (+1 or -1) of the young Osteoporosis is especially common in postmenopausal adult mean indicates normal bone density women and elderly individuals and typically affects the vertebrae, hip, and wrist. - A T-score of 1 to 2.5 SD below the young adult While bone metastases, osteomalacia, and Paget’s mean (-1 to -2.5 SD) indicates low bone mass. disease can also cause pathological fractures, they typically present with additional features (e.g., bone pain, deformities, abnormal lab results). The clinical - A T-score of 2.5 SD or more below the young context and DEXA scan make osteoporosis the best adult mean (more than -2.5 SD) indicates the answer. presence of osteoporosis.Question 5 A 24-year-old footballer presents with sudden pain and swelling in his right ankle after landing awkwardly during a match. On examination, there is tenderness over the lateral malleolus and minimal bruising. He can bear weight with some discomfort. What is the most appropriate initial management? A) Immediate MRI to assess ligament damage B) Arthroscopy of the ankle joint C) RICE (Rest, Ice, Compression, Elevation) and simple analgesia D) Plaster cast immobilisation for 6 weeks E) Urgent surgical ligament repairQuestion 5 A 24-year-old footballer presents with sudden pain and swelling in his right ankle after landing awkwardly during a match. On examination, there is tenderness over the lateral malleolus and minimal bruising. He can bear weight with some discomfort. What is the most appropriate initial management? A) Immediate MRI to assess ligament damage B) Arthroscopy of the ankle joint C) RICE (Rest, Ice, Compression, Elevation) and simple analgesia D) Plaster cast immobilisation for 6 weeks E) Urgent surgical ligament repairQuestion 5-Explanation This is a soft tissue injury, likely an ankle sprain (most commonly involving the anterior talofibular ligament). The Ottawa Ankle Rules suggest imaging is unnecessary if the patient can bear weight and there is no bony tenderness. RICE (Rest, Ice, Compression, Elevation) and NSAIDs/paracetamol are appropriate first-line treatment. MRI and surgery are not necessary unless there is suspicion of severe ligament tear or persistent symptoms. Plaster immobilisation is excessive for mild/moderate sprains.Question 6 An 8-year-old boy presents to A&E with a sudden-onset painful right knee. When asked to walk, he cries whenever he tries to take a step. His mother states he fell off his bike 1 week ago but was able to walk fine immediately after getting up. He has no preceding illness and is otherwise well. On examination, his body temperature is 38.6 °C, and slight swelling and tenderness localised over the right knee with a few bruises on both of the shins. He also has a soft systolic cardiac murmur that has never been documented before.. What is the most likely diagnosis of his condition? A) Infective endocarditis secondary to superficial bacterial infection in the knee B) Acute rheumatic fever C) Septic arthritis D) Inflamed medial meniscus E) Latent fractureQuestion 6 An 8-year-old boy presents to A&E with a sudden-onset painful right knee. When asked to walk, he cries whenever he tries to take a step. His mother states he fell off his bike 1 week ago but was able to walk fine immediately after getting up. He has no preceding illness and is otherwise well. On examination, his body temperature is 38.6 °C, and slight swelling and tenderness localised over the right knee with a few bruises on both of the shins. He also has a soft systolic cardiac murmur that has never been documented before.. What is the most likely diagnosis of his condition? A) Infective endocarditis secondary to superficial bacterial infection in the knee B) Acute rheumatic fever C) Septic arthritis D) Inflamed medial meniscus E) Latent fractureQuestion 6-Explanation Always think about septic arthritis in a swollen, hot isolated joint. The most commonly affected joint is the knee.The limping child Source: American Family Physician FoundationSepticarthritis Acute bacterial infection of a joint, typically via hematogenous spread of staph.aureus. Immunocompromised patients and IVDU are at greater risk of other organisms eg. pseudomonas aeruginosa. Orthopaedic emergency due to risk of joint destruction. Clinical features:- Joint pain, swelling, warmth, ↓ movement , Fever (may be absent in infants), Limp or refusal to weight-bear, Irritability, systemic signs Investigations: Bloods ( ↑ CRP, ESR, WBC), Blood cultures, Joint aspiration: purulent fluid, ↑ WBC, ↓ glucose, Ultrasound: joint effusion, X-ray/MRI if needed Management:- Urgent surgical drainage, Empirical IV antibiotics tailored post-culture, Pain relief, physiotherapy , IV → oral antibiotics over 3–6 weeks DDx: transient synovitis, osteomyelitis, JIAQuestion 7 A 2-year-old child is brought to A&E with a swollen leg and bruising. The caregiver reports the child fell off the sofa while she was in front of the TV. An X-ray shows a metaphyseal fracture of the distal femur. What is the most appropriate next step? A) Cast and advise NWB for 6 weeks B) Surgical pinning of the fracture C) Ponseti casting and bracing D) Apply gallows traction for 7 days E) Refer to seniorQuestion 7 A 2-year-old child is brought to A&E with a swollen leg and bruising. The caregiver reports the child fell off the sofa while she was in front of the TV. An X-ray shows a metaphyseal fracture of the distal femur. What is the most appropriate next step? A) Cast and advise NWB for 6 weeks B) Surgical pinning of the fracture C) Ponseti casting and bracing D) Apply gallows traction for 7 days E) Refer to seniorQuestion 7-Explanation Metaphyseal fractures are pathognomonic for non-accidental injury.Non-accidental injury Fractures highly suggestive of NAI: Classic metaphyseal lesions (CML): Also called "corner" or "bucket-handle" fractures; result from shearing forces during pulling, twisting, or shaking. Posterior rib fractures: Rarely caused by CPR or simple falls; suggest squeezing injuries.Non-accidental injury Scapular fractures: Uncommon without major trauma Spinous process fractures: Require significant force Sternal fractures: Rare outside of severe blunt traumaNon-accidental injury - Bilateral fractures - Presence of burns or scalds - Bruises: - To any part of the body in an - History - Predominantly occurs in children under infant - Bruises on the head and face most common sites of abusive bruising - 2 years old Consistent with gripping - Often delayed presentation following - Subconjunctival haemorrhage injury - Retinal haemorrhage - Inconsistencies in the caregiver's - Human bite marks narrative, including: - Changing stories - - Immersion scalds: most commonly on Severity/type of injury not lower limbs. This may spare the buttocks corresponding to the narrative - Injuries if they were pressed against the bottom in a child not yet independently mobile of the bath. - Torn frenum: Associated with head - Unwitnessed injuries injuries or force-feeding of an infant. - Evidence of drug or alcohol use in the - Cigarette burns household - Female genital mutilation - Injuries of varying agesNon-accidental injury Management: - Always refer to senior - Admit to paeds for safeguarding - Explain to parents - Refer to social - Full skeletal survey + bleeding investigationsQuestion 8 A newborn is noted to have asymmetrical thigh skin creases and limited abduction of the left hip during routine examination. The birth was smooth. Which of the following is the most likely diagnosis? A) Congenital talipes equinovarus B) Developmental dysplasia of the hip (DDH) C) Slipped capital femoral epiphysis (SCFE) D) Perthes disease E) Osteogenesis imperfectaQuestion 8 A newborn is noted to have asymmetrical thigh skin creases and limited abduction of the left hip during routine examination. The birth was smooth. Which of the following is the most likely diagnosis? A) Congenital talipes equinovarus B) Developmental dysplasia of the hip (DDH) C) Slipped capital femoral epiphysis (SCFE) D) Perthes disease E) Osteogenesis imperfectaQuestion 8-Explanation Likely DDH due to age and presentation findings.DDH DDH refers to a spectrum of abnormalities where the femoral head and the acetabulum are not properly aligned. It ranges from mild instability to complete hip dislocation. Risk factors: - Female (4:1 ratio), Breech, FH DDH, Oligohydramnios Clinical features: - +ve Ortolani (clunk as femoral head is relocated into the acetabulum) - +ve Barlow (dislocation when pressure applied to a flexed, adducted hip) - Asymmetrical thigh or gluteal folds - Limited hip abduction - Apparent limb shortening (Galeazzi sign) - Limp or toe-walking once ambulating Investigations: - Ultrasound of hips - X-ray useful after 4-6 months once ossification begins. Management: - Pavlik harness for 6-12 months: Maintains the hips in flexion and abduction (for infants <6 months). - Surgical intervention: Closed or open reduction may be necessary if harness treatment fails or if diagnosed late.DDHQuestion 9 A 14-year-old boy presents with persistent left knee pain and swelling. The pain has worsened over the last month and is worse at night. An X-ray shows a mixed lytic and sclerotic lesion in the metaphysis of the distal femur with a "sunburst" pattern of periosteal reaction. What is the most likely diagnosis? A) Osteoid osteoma B) Osteosarcoma C) Ewing sarcoma D) Chondrosarcoma E) OsteomyelitisQuestion 9-Explanation Osteosarcomas are the most common type of bone tumours.Question 9 A) Osteoid osteoma B) Osteosarcoma C) Ewing sarcoma D) ChondrosarcomaQuestion 9-ExplanationBone tumours Lesions in the bone can be primary or secondary. Clinical features: - Hypercalcaemia (stones, groans, thrones, psychiatric moans), pain, infection-like symptoms, consider multiple myeloma Investigations: - Xray, MRI entire bone, Bone scan, biopsy Management: - A-E resuscitation - Correct electrolyte abnormalities eg. hypercalcaemia - Analgesia - Refer to orthopaedics if associated fracture or suspected primary - Bisphosphonates, radiotherapy, chemotherapy, excision +/- implantBone tumoursQuestion 10 68-year-old man presents with worsening pain in his right foot. The pain has been getting worse over the past two days and he now feels generally unwell with a fever. He was admitted two weeks ago with an infected arterial ulcer on the base of his right heel and has a history of T2DM. The ulcer is now very deep and there is exposure of bone. What investigation is required for a definitive diagnosis? A) X-ray foot B) CT foot C) MRI foot D) Blood cultures E) Bone biopsyQuestion 10 68-year-old man presents with worsening pain in his right foot. The pain has been getting worse over the past two days and he now feels generally unwell with a fever. He was admitted two weeks ago with an infected arterial ulcer on the base of his right heel and has a history of T2DM. The ulcer is now very deep and there is exposure of bone. What investigation is required for a definitive diagnosis? A) X-ray foot B) CT foot C) MRI foot D) Blood cultures E) Bone biopsyQuestion 10-Explanation He likely has osteomyelitis. Both MRI and bone biopsy can diagnose OM, but bone biopsy is the gold standard.Condition Infection of bone, usually bacterial (staph, aureus, salmonella (sickle cell patients), Kingella kingae (children) Clinical features: - Bone pain, swelling, warmth - Fever, generally unwell] Investigations: - Bloods, cultures, X-ray, MRI, Bone biopsy Management: - IV antibiotics (2 weeks minimum -> IVOST for 4 weeks) - Surgical debridement SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! Sign up to our next session on MedAll Take part in our research survey See all our upcoming events www.medticteaching.com | Email: medticteaching@gmail.com | Youtube @medtic | Instagram @medtic.teaching | Tiktok @medticteaching