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Um My name is I'm one of the uh S FP doctors at bars. Um I'm on the academic program. Um but I went to Imperial, I may know some of you on the call. Um Hopefully this will be an interactive session. Uh Can I just check that you can hear me and see me? OK. Yeah, we can hear you and see you. OK. Um Yeah, so this session is going to be interactive. So please interact with me either via uh unmute or just writing in the chat. Um This lecture is going to be quite content heavy. Um There were a lot of things I was asked to cover. So we're going to cover the examination technique uh for MSK in room, but also we're going to cover the different pathologies. Um What I also wanted to highlight before I begin is that some of the content, some of the images I've used are not mine and I've referenced them. Um But otherwise the content of the slides are mine just wanted to put that disclaimer out. So, so what we're going to start with are the common presentations and differentials for each joint and we're going to go over hand knee, shoulder examinations with special tests. We're going to look at X ray interpretation for M SK pathologies and then we're going to touch on other rheumatological conditions such as sle polymyalgia, rheumatica, and ankylosing spondylitis. So first F ba Johnny, a six year old child with sickle cell disease presents to P A&E complaining of knee pain. When you see him, you see that he tries avoiding putting weight on his knee and has a temperature of 38.6 degrees. What is the next best step in the management? Please type in the chat. So a obtain a blood sample, including white cell count and CRP B. Conduct joint aspiration and send sample of M CNS and crystals. C prescribe antibiotics. D send join home with simple analgesia. E obtain a joint x-ray. So if you wouldn't mind just all putting an answer in the chart, even if you're not 100% sure. OK. We've got a B Yeah, so far all bees. OK. We've got 27 people on this chat. So I'm waiting for more answers. OK. How many people have answered? Yeah, so far we got six B. OK. Right. For the interest time, I'm going to move on. But please guys, this session will be useful if you interrupt, you'll learn a lot more. So, yeah, B is the correct answer. So let's go through the other answers. So basically this case is a case of septic arthritis. This patient cannot put weight on their knee. So they can't wait there. They've got um knee pain, they have a temperature and they have risk factors. They are sickle cell patient. So you obtaining a blood sample, including white cell count and CRP would be useful at some point. However, it is possible that, that it may not be raised. And the, it's mu it's a much more value to get a joint as for because this is septic arthritis. So there's sepsis within the knee joint. And with this kind of picture, you have to, you have to think septic arthritis, joint aspirate until proven. Otherwise, c prescribe antibiotics is a great move. But that's something you'll do. Eventually you'll first get the joint aspirate. D would be completely unsafe. This is inappropriate and this uh child may get much worse. Um And then E ob obtain a joint X ray. This, this wouldn't really tell you much MRI would be better. However, of course, this is an infection within um essentially the fluid around the knee. It's not within the bone unless it's osteomyelitis as well. And in that case, you'd see it more on MRI. So the most common organisms of uh septic arthritis are staph aureus, strep, pneumo, and then salmonella species. The reason why I've put this patient as sickle cell um is just to remind you that salmonella is more common in patients with sickle cell. And as we said, the cardinal signs of septic arthritis are hot, swollen, painful, knee, inability to weight, bear limited range of motion and temperature of usually above 38. Any questions on this? No question is a stupid question. I'd rather you make these mistakes now than in the exam and in life. So just far away, if you have any questions, right. I'm going to assume that there are no questions. Please let me know if you do so. the most common presentations with knee in the knee joint are joint pain which can be acute and chronic and then reduced range of motion. So, can anybody tell me? So, just unmute? All right. In the chat, some causes of joint pain, either acute chronic or both osteoarthritis, crystal arthritis, Oscar. So, uh, yeah, uh, gout trauma. Great. So, well. So the next picture is graphic, sorry, II need to give that warning. Uh So, yes, acute and chronic. So you have osteoarthritis, which would be more like a pain that gets worse with increased movement gets worse throughout the day. And, um, that's usually, yeah, longstanding, you have crystal arthropathy, especially pseudo gout which affects the knee which can cause acute pain. Um, and it would cause a hot swollen knee ligamentous injury. So ACL, PCL, MCL, um and LCL. Um and then, um, you can have menisc a meniscal injury, um fracture. The top image is that of an open fracture and then septic arthritis. So, can anybody tell me what the image on the left is showing fantastic. Yeah, septic arthritis, you see a knee that's hot, swollen. So you tell it's help because if you put your hand there, you'll see that, that it has increased temperature, it's erythematous and it's swollen compared to the other side. And you also see um some skin lesions almost like cellulitis. So it could be um that the staph aureus on the skin has been introduced um like that i into the knee joint, but maybe not. Um it could also be a patient that has uh vascular disease. They're more at risk or diabetes and they're more at risk of developing infections, poor blood flow, et cetera. Fantastic. So, reduced range of motion. We've said septic arthritis is the main one, painful, swollen knee cannot wait there. However, of course, if you fracture your, any of the bones involved within the knee joint, you will have pain with a reduced range of motion. And with osteoarthritis, you may get a uh painful stiff knee. Um And because of the pain, the range of motion will be reduced. So what you do in all the examinations. So, so let's just let me just say for paces, everything is an act. It's a dance. You need to be able to show off your skills, be a competent doctor that has a nice uh persona, nice, put a nice face onto the patient, be friendly, be polite, uh be well dressed and to all patients at all stations, you'll wash your hands, you'll introduce yourself, you'll confirm the identity of the patient. You will obtain permission for what you are going to do. You'll ask for pain, you'll check the position and you will expose the patient that's for all the stations and I'm not going to repeat it. I'm sure you guys know, but it's very important that you get this done in 30 seconds. Um It really creates a good first impression if you do all these moving on. So to the knee examination, for the knee examination, I appreciate this is quite hard to do over teams. I'm going to try my best and please let me know if you have any questions. What I would recommend right off the bat is for you to look at these on the um on youtube. But also look at the um ones that one of the orthopedic surgeons has done for Imperial on Opto, the name will come to me, but they were really good. And basically that's what they're expecting for the Ortho exams. Um So every exam and also is look for or move special tests plus minus gait. So you'll look for erythema, joint swelling. So erythema can be present in um in septic arthritis, for instance, however, that's unlikely to have the exam, joint, swelling could be that of an injury. It could be a meniscal injury, for instance, it could be meniscal sprain. Um In addition, you may have scars which could indicate previous surgery or trauma. So, for instance, you might have a total knee replacement or a unicompartmental knee replacement or arthroscopic uh scope scars. Do you want to look for any obvious deformity? For instance, do you have a dislocated patella? Um And you can also tell that in patellar tracking, well, I'll tell you about that in a bit. You want to look for muscle wasting, so you want to look at the quads. Um This could indicate a low amount in your own lesion, it could indicate just use atrophy. And in addition to that, if the one knee is injured, they may have used that leg less. So you might get a slight um uh a lesser amount of cords bulk on that side. Um You also want to look posteriorly for any um any raised lesions on the back of the knee, which could indicate a baker cyst or a popliteal aneurysm. However, on uh they're quite rare, the popliteal aneurysms, you want to look for any obvious fixed fraction deformity. Um And then you also want to see if there's any posterior sag, which um which is indicative of the PCL injury. Um And then in terms of feeling, you want to see if you want to do the sweep test and the patella tap to which are both tests to look for a joint effusion you want to feel and of course, move the joint for joint crepitus, um which can present in osteoarthritis. You want to feel for patella tenderness or laxity joint line tenderness. Um So that could be because of fracture, meniscal or collateral ligament injury. You want to feel at the back of the knee for a baker cyst or popliteal aneurysm. You then want to move the knee actively and passively normal flexion of the knee is between 0 to 140 degrees and extension of the knee is usually between minus 10 to 0 degrees. If the patient has a hyperextended knees, that might be a sign that the patient is hypermobile and that puts him um at increased risk of having um uh joint injuries. Then you your, your special test which include your anterior jaw and posterior jaw test which you basically press down and pull up. Um You could see a video on this. You then can the most specific test for ACL injury is the Lachman test where you basically move the femur and the tibia against each other and you see if there's laxity there. Um You want to do the valgus stress test um which is testing. Um You're putting valgus strain to test the MCL varus stress to test the lateral collateral lateral collateral ligament. You want to then put them uh to swing their legs off the bed and you want to look for patella tracking, basically get them. Imagine these are my legs, my calves, um off the bed with my knees at the top. You want to look here if the patella sting in the right position where it's moving out of place, so you might offer to do the MRI test, which is a specific test for me for meniscal injury. However, it's something that you'd only offer because it's a painful test. Um but you can't look at the video on that. I know these are quite, this is quite intense. I'm giving you a lot of information. Does anyone have any questions on this? I've tried to devise the slides so you can use them as a revision aid as well. Um, examinations are something better to do in person but any questions at all. I'm very happy to explain anything. Well, I have a question actually, um, in the Paces M SK station, if you got a knee exam, would you be expected to do all of the special tests and offer them Murray's as well? I would personally do them all. Um, I think you can become very fluent in doing the knee examination. You can do it in 6 to 7 minutes, potentially even 5 to 6 minutes, it's difficult, but when you practice it a lot, it becomes much easier. Just make sure you're very systematic. Um, I think that's it. The, the tip, make sure you practice a lot. However, what I would say is if you don't have time, focus on the ones that are relevant. Uh, for instance, if the patient has scar, which may indicate that they had knee replacement, they're much more likely to have signs like reduced, uh, range of motion rather than any specific positives during in the special tests if that makes sense. So you'd pay more attention to the things in the beginning, um, and moving the knee joint, um, and te testing the one knee joint against the other one because that's the thing, potentially, if there's only a scar on one side, it could be that that one is the one with the replacement. So you want to test it against the potentially other normal side side if that makes sense. I hope that answers your question. Yeah, thank you. No problem. Any other questions, there's nothing in the chart. OK. I'm gonna move on if you do let me know. So can anybody tell me what the uh scar on the left is showing? Fantastic. Yeah. And do you know what type of knee replacement? Ludovica between total and unicompartmental knee replacement? Yeah, it's mo most likely going to be a total knee replacement. You could with the same scar, do a unicompartmental knee replacement, but sometimes the scars are different for unicompartmental knee replacements. Does anyone know what the one on the right is showing? This is a bit harder to tell from the image but pay attention to the angle of the left leg. Um Compared to the right, could this be a fixed flexion deformity? Fantastic. Yeah. Fixed flexion deformity. The patient is unable to fully straighten their leg. You can see that because you could compare it to the other side. Oh, great, fantastic. Moving on. Um So the way you present, so you can do this in many different ways. This is what G medics recommends and I kind of followed this, but you need to be very concise here. This is not the time to to to go on uh you know, huge fields you want to briefly present. So you want to basically say today I examined Mr X on general inspection, the patient appeared, well, no signs of MSK disease and there was no paraphernalia around the bed such as mobility aids. The patient had a normal gait and knee joint appearance. Men, you want to look at their gait, see how they walk, see if they've got um you also want to see how their legs are orientated uh in in terms of if they have any natural va varus or valgus, valgus. So there you'd say there's no joint crepitus range of motion in both knees was, was um both actively and passively within the normal range. Um The special tests were negative. In summary, these findings are consistent with X and I would like to complete the following for um completion. So you do a neuro exam of both limbs. You'd want to examine the joint above and below. So the ankle and the hip and you'd want to ask for further imaging if indicated such an X ray, MRI, if the patient has a positive Lachman's and a positive anterior jaw test, that tells you that potentially this patient has an ACL injury. Um You want to make sure that you get some imaging for that, you're most likely going to do an MRI and you'd probably want to operate on that patient, but you'd want to also look for any other injury. Um In addition to that, of course, you need to add that you want to take a history from the patient because the mechanism of injury is very important. Um, especially for instance, if they injured their, um, knee, um, during football, during a tackle, you're, you're going to say this is probably going to be ACL. Um, whereas there, whereas if there's a lot of twisting involved, um or popping sound might be a meniscal injury, I hope that makes sense. So we're going to move on and we're going to look at some X rays, they're most likely going to show you an X ray of osteoarthritis. And you're going to remember this off the top of your head backwards, forwards. You're going to remember this. They're going to ask you for sure if you have, um, a knee um station and I didn't have a knee station and they showed me this. So the cardinal signs of osteoarthritis are summarized with the acronym, loss, loss of joint space, which you can see on the, um, So the fibula on the left. So you can see on the lateral side of the knee that we're looking at. Um, you can see that there's joint space narrowing. In addition to that, you can see bony spurs which are called osteophytes. You may see some subchondral cysts. I can't see any here, but there are areas of sort of, they look darker and it basically looks like a cyst and then you've got the areas of whitening, which is subchondral sclerosis. So please please please learn this. It's gonna come up, I'm sure about it. So in terms of knee replacements, this is quite um niche I would say, but it might come up on an X ray. So you've got the total knee replacement and then you got the unicompartmental knee replacement. And then basically, there are three components to the knee joint. So compartments which they might ask you about, you've got the medial, the lateral and the patellofemoral compartment. And generally, it's a medial and lateral compartment that you're going to do a unicompartmental knee replacement for. And the reason why you do this, there are many reasons. But basically, if you see, for instance, on the previous X ray, if the medial side had a larger joint space and it was the narrowing was very uh pronounced on the lateral side, you could do a lateral compartment, unicompartmental knee replacement. Um If I'm going into too much detail, please let me know. Also, it's kind of my thing. So I am quite interested in it. So I know some of these things. So let me know if something doesn't make sense. Ok. Um So in terms of why you do eat. So basically, if you've got, if the medial compartment, lateral compartment and patellofemoral compartment have gone due, usually due to osteoarthritis, you're much more likely to do a total knee arthroplasty or total knee replacement. It's the same thing. Um In addition to that, if you think about it, if you do a unicompartmental knee replacement, you're more likely to have to do the other compartment as well at some point, unicom or mental knees are very hard to do. It's super specialist, not every knee surgeon does them. Um However, um it is less invasive and you do preserve the cartilage and bone and you have better knee kinematics. It's much less stiff with quicker rehab. So in sports, um in sportsmen, you'd um or women, you're more likely to do a unicompartmental if that allows. And then you can use special materials which allow for better kinematics of the knee joint, which means the knee moves in a more natural manner. Whereas with the total knee replacement, you more likely you have a stiff knee. Um and you also have slower um rehab more like you need to do more physio. Any questions on this? Ok. I'm gonna assume no questions and I'm going to continue Miss Smith an 80 year old lady presents to A&E complaining of pain in her wrist. Her x-ray indicates a fracture in the distal radius that is dorsally displaced and angulated. What is the diagnosis? The most likely diagnosis? A Smith's fracture? B Barton's fracture. C Collie's Fracture. Duffer's fracture and E sca scaphoid fracture. Please put your answer in the chat. Even if you don't know if you don't know just gas. Ok. Ok. I'm getting lots of CS. Yeah, it is Collies fracture. So these distal radius fractures can make you go crazy. You you may want to learn these for the exam, the written they do sometimes come up. So there are various things that we need to consider. So the most common time that you're gonna get a distal radius fracture in a in a question is falling out stretched hand, especially in the elderly population. So if we take a look at the top right image, you can see the difference between the mechanism of action for a Collies fracture versus a Smith fracture. So that's why you get the different um patterns of injury if that makes sense. So in the collies, you have a dorsally displaced, so backwards, dorsally angulated in the distal radius, a lot of these. So that's how you remember it. Um In addition to that, it's also important to mention that you have intraarticular, extraarticular and displaced and numb, displaced fractures. So basically, if it involves the joint, um it's intraarticular, if it's completely pull if the fracture piece is completely pulled away from the rest of the bone that's displaced. OK. Um So essentially what a collie fracture is that the, the segment, the distal segment of the distal radius is dorsally displaced, so it's moved backwards. Ok. Um And usually a collies fracture is an extra articular fracture. Yeah, you also have some other fractures that I mentioned here. So the Smith fracture is the most co similar one to colleagues in terms that it's the opposite. So you have distal radius fracture with volar. So forward displacement of the fragments. A Barton's fragment is a fracture. Um dislocation of the um radial carpal joint. Um That's com quite common, I believe in fist fights. Um And then uh you've got the college fracture which we've said um she fracture in different and then scaphoid fractures that fractured the radial styloid. So moving on to presenting an X ray. So this is something that you should know how to do for your pa ation. So you always um want to say that this is AP or P um un later view x- taken of patient X at this day at this time, it shows adequate or inadequate um uh part of the joint. So, ideally, you'd want to see the joint proximal and distal. Um And then you'd say the most obvious abnormality is and other features are. So there are various ways that you can present an X ray I like seeing the most obvious abnormality first because if I'm running out of time, they can quickly move me on. You may use the uh acronym old acid to remember the uh bone fractures. So how to it? Um I describe a fracture. So you wanna say if the fracture is open or closed. And so this, you'd also see from the patient if the actual bone is outside the skin or not, you'd want to say where this bone is. You'd want to say if this is a complete fracture or incomplete, you want to talk. If there's any articular involvement, you want to talk about the comminution and pattern. So you can see the different patterns um are on the bottom, right? You might have an oblique transverse spiral comminuted, which means in lots of different pieces. Um you impacted avulsion, green stick, which is very common in Children. You want to talk about the bone quality itself. You want to talk about the bone cortices and then you're going to talk about displacement, angulation and rotation. You're most likely to get transverse fractures with di with a direct blow, oblique, with shearing force. And then whenever you have rotational force that can cause a spiral fracture, so that's known as a simple fracture. If there's one fracture line segmental would be if there are two fracture lines. And if it's comminuted or complex, that's usually after high energy trauma, you'll have different pieces of bone everywhere. And in Children, you're quite uh likely to have green stick where basically the fracture does not go through the whole corte cortex. And the reason for that is that the kid's bones are much more pliable. Um And you're less likely to get full uh a full break. It's almost like um a uh the bark of a tree, uh sorry, a branch of a tree. Um And then there's also buckle fracture, which you can see that's in England bleed. Um I hope this makes sense. It is quite a lot of information. Um However, it's good to know and good to know the different components of presenting an x-ray. So, can anybody tell me what the fracture on the left is spot diagnosis? There's even an arrow pointing it to it guys. Any other takers? I've got one patella fracture. Does anybody agree? Does anybody disagree? So, it is a patella fracture? Don't doubt yourself. You said the correct one. The femur looks fine to me and the tibia and, and um seems fine. Um So, yeah, so this is a uh simple complete fracture of the patella and this is a lateral plain radiograph. Um You'd say that you actually want an ap view as well. Um Of the um so you want a face on view as well of the knee joint. Um But yeah, this is patella fracture. Can anybody tell me what the one on the left is showing? Uh the one on the yeah, anyone know what's on the right? So look specifically at where the fragments are going. Times call. Yeah, it's a collies fracture and sorry, I um you're most likely to get a pa radiograph of the knee joint. Um Not an ap um So, yeah, collies fracture. So, yeah, di fork deformity. You've got dorsal, um you've got dorsal displacement and dorsal angulation. So you see that the fragment has, has moved backwards and is also angulated. So this is the d deformity. It's a collies fracture. Well done. Any questions on this, please let me know if you don't understand and I hope that this is like the correct level. Um I know it might be a bit challenging, but this is trying to prepare you for finals. OK. I'm gonna move on to the shoulder joint. Um I think in order to describe the examination, I need to go through the anatomy with you. A lot of people don't know it that well. So you've got the sternum and you then have the sternoclavicular joint which is between the top of the sternum and the clavicle. You've got the clavicle itself, you then have the acromioclavicular joint which is joined to the acromion. And then you've got a coracoid process, which is a process from the scapula. And then you got the humerus which is the arm bone and then within the arm bone, you'll have the bicipital groove. Um If we look at the scapula from a posterior view, you have the coracoid process, which as we said comes out at the front, I hope you can see my laser. So this Caraco perosis comes out here at the front. You've got the scapular spine which is joined onto the acromion and then you've got the supraspinous fossa and the infraspinous fossa. These are all relevant because you will feel these and look at these. Sorry Daniel. I think you might have muted yourself. What did you not hear? Uh So we heard up to the supraspinous and infraspinous fossa and then we'll feel them on um examination and then you come out great. I don't know how I managed to mute myself. But basically, yeah. So it's relevant because you're going to feel these during the uh the field part of the exam. So basically, you're going to first, do you see my laser? Yeah, great. So you're going to first feel the sternum, you're then going to feel upwards to the sternal clavicular joint all across the clavicle, feel the acromioclavicular joint, paying attention to any pain in the ac joint, you're going to feel the acromium, potentially, you may feel chorros, but unlikely you're going to feel the humerus, you're going to feel the bicipital groove, which is an indentation there. And then from the back, you're going to feel the uh scapular spine and then the borders of the scapula in general. I hope that makes a bit more sense. So, moving on to the writing. I'm sorry that it's a lot of writing. I just want you to have all the information on some slides. But basically, again, look, they'll move special tests. You wanna make sure of course that they're exposed. You can see the both shoulder joints, you can see them, you can see the scapula. Um, you want to look for erythema and joint swelling, which could be a fusion inflammatory arthropathy could be even septic arthritis, uncommon but possible in the shoulder joint, you will look for scars for potential past surgery. Bruit, which could be um a sign of trauma, recent surgery, asymmetry, particularly um present in severe scoliosis fractures and of course dislocation. Um and then you wanna look for any obvious deformity and then you're going to look for muscle wasting. So you may get disuse atrophy, low motor neuron pathology. And then in there are specific nerve injuries to look out for. So, with axillary nerve injury, you'd get deltoid wasting. So your deltoid is the one the muscle that's here. So your deltoid would be uh more wasted if you have auxillary nerve injury if you have spinal accessory nerve lesion. So that's cranial nerve 11. Um The spinal component, you'd have trapezius wasting. Um and then in chronic rotated cuff tears or a suprascapular nerve lesion, you'd get wasting of the supraspinatus and infraspinatus, which are basically would be present in the supraspinous and infraspinous fossa. That's where those um the same named muscles attach essentially. So look for the muscle bulk, look for any obvious deformity. And then you'd want to feel the temperature, you'd want to feel the, the parts of the joints that I was saying. And then you want to test movement, which is active, passive and essentially simple and compound. So flexion, um you basically raise the arms forwards, extension, put the arms back, you'd have abduction and abduction and then you've got internal rotation, which can be done with the hands. I'm trying to show you, but basically that is internal rotation, but also hands towards the back and then external rotation. But you can also do compound movements like this, which is a combination of essentially flexion, um abduction and external rotation. So, um and then the thing to know is you need to know which muscles do certain things. So for instance, with internal rotation, it's, it's largely um conducted by the subscapularis, whereas the external rotation is more infraspinatus, Terracina. Um These are all things that you will learn, but it's good to know what the muscles do of the rotator cuff in order to be able to essentially test what has gone wrong essentially. Um So, and then the other thing and then the, so you basically have four muscles, right? You got the supraspinatus, the infraspinatus, you've got the subscapularis and you've got the pteris minor muscles. So there are special tests that you test for. You'd put the patient's hands towards the wall. Um And that would look for winging of the scapula. So here, this may indicate i ipsilateral serratus anterior muscle weakness, which um is potentially due to long thoracic nerve injury. Then you've got the impingement syndrome tests. Now, this is I'm highlighting this to you because it's quite common to come up. A lot of people have it. I have it myself. So um I have positive signs which is fun during uh paces practice, but practice on your friends. Uh This is going to make paces easier, but basically, you've got various tests. The most common um positive finding in independent syndrome will be a pa painful arc, particularly between the 60 to 100 and 20 degrees. Um In addition to that, you may do the MT A test where you basically get them to put their hand like this with their hand pointing down with the thumb pointing downwards and you press down and essentially that if that causes pain, that is potentially due to impingement syndrome and um more specifically supraspinatus um tear or a weakness, um which can be present in impingement syndrome when you do resistant external rotation and that causes pain or um reduction in the range of motion that would be uh indicate weakness in the infraspinatus and teres minor as those are the ones that, that um essentially conduct that movement. And then in terms of resistant internal rotation, that's we could potentially weakness in subscapularis and then finally the scarf test where you put the hand across the chest and you push it down if that causes pain, that can indicate um a chromic joint pathology such as osteoarthritis. In addition to that, if you only find restriction of movement uh in all movements from one side compared to the other, that could be just due to adhesive capsulitis, which is basically um stiff doing. So I hope that makes sense. So just to just to send them all home. So, adhesive capsulitis, you have stiffness and pain, significant reduction in both active and passive movements. Palpation does not s cause pain. Most of the time and risk factors generally include surgery, prolonged immobility and trauma. You may get auxillary nerve, palsy and shoulder dislocation. Um The axillary nerve has both sensory and motor functions. So, as you remember, potentially from your ACY or APY, you, the axillary nerve supplies a regimental patch in terms of sensation, which is here. Um And then you'd also get um loss of shoulder abduction, particularly the 1st 60 degrees. So 0 to 60 degrees in terms of impingement syndrome. It's a very common pathology, especially in young patients. Inflammation of the rotator cuff tendons is partly the subacromial space. It may be associated with weakness of certain muscles. The most common um is association is with supraspinatus muscle tendonitis. And here you basically have pain, weakness and reduced range of active mo active movement. How, however, the passive range of motion is preserved. So for instance, I've got um impingement syndrome. So if I were to put my hands up, I have a painful arc on the right side. So I can't really lift it. But if someone pushes my shoulder, my hand up, I can do it. Uh however, it's painful. So, so my passive motion um is, is movement is preserved. This comes in contrast with adhesive capsulitis where the active and passive movements are both restricted. You can't push the hand more. Ok. And usually uh the sy symptoms are exacerbated with overhead movements such as abduction between 60 to 120 degrees, which we've talked about, which is known as the painful arc with all these patients. As said before, you wanna examine the cervical spine and elbow, neurological examination and further imaging such as X ray, MRI. Um you'd only really do X ray if you suspect dislocation or fracture. MRI. Most um you do if you're suspecting the tab, the rotator cuff, for instance, um in terms of impingement syndrome, the diagnosis is usually clinical and the um management enclosed in involves intense physiotherapy. Does anybody have any questions about the shoulder joint? I know I've gone through a lot of things quite fast. Does anything not make sense? Can I explain anything better? What I would recommend for all these exams is practice as many times as possible, get really fluent because the thing is that once you see signs, you lag in terms of your timing and you want to make sure that you have enough time and pas to examine the patient swiftly in six minutes for instance and for the rest, ok, I'm gonna assume that there are no questions. Please do, let me know if you have any questions. So X ray findings. So I'm just gonna quickly go over these, but you may get um a plain radiograph of the shoulder joint, um which may indicate fractures, um or dislocations. So here we can see a proximal humerus fracture um below um you can see a fracture and dislocation. So if you see that the, the whole, let me get the laser. So you see that this is meant to sit here. So it's completely moved out of the, out of the way and you have a fracture here. Um And then basically, here you can see. So these are the various parts of the humerus, which you've got the surgical neck, you've got the anatomical neck, you've got the grade tuberosity. So basically, you can get various fracture patterns. Um And you've got the lesser tuberosity as well. So you want to refer to the anatomy, right? So this is the greater tubercle. So the, the there's a fracture between the greater tubercle and the humeral head, for instance. Um Here, you'd also say you've got a fracture, um fracture and dislocation and you've got the dislocation immediately. Ok. So that's how you describe it So, moving on to a bit of room, Samantha, a 72 year old retired seamstress presents to you in the GP clinic, complaining of pain in her hands, her hands looks as follows. What is the most likely diagnosis? A rheumatoid B osteo C osteo and rheumatoid D gout e fracture. Please write your offices in the chat. I like that. There's a bit of debate here. OK. The answer for simplicity's sake is a potentially, there could be some osteoarthritis due to her age and due to her profession. But the most obvious signs here are rheumatoid rather than osteo. So the most common signs are ulnar deviation. So the fingers you see are going that way towards the ulnar side. You have sworn necking of the feet fingers, which is this weird cur um angulation of the fingers, buttons, deformity of the thumb or Z thumb. In terms of oa you'd get Hes and Bouchard's nos which are here and here which the patient didn't really have po potentially. But I would say this is more rheumatoid. OK. Um So yeah, so you have boards nodes and the way I remember it is b uh comes before age. So B is more proximal. So it's the proximal pharyngeal joint rather than the distal internal joint. And these are swollen, heart, painful finger joints. Um And they're a sign of osteoarthritis of the fingers. I know you guys know this, there's a very nice image which showcases the difference between osteo and rheumatoid and their predilection for certain joints. You're usually um with rheumatoid, the history is usually gets better throughout the day. Um rather than worse as with osteo and um you have morning stiffness um with rheumatoid which lasts more than 30 minutes and you're, and you're more likely have symmetrical arthritis rather than asymmetrical with osteo. And osteo is usually because of cartilage loss rather than due to inflammation, which is the cause of rheumatoid. And with rheumatoid, you might get extra articular involvement. So this leads us on nicely to our hand. Examination here, I always ask the patients to put their hands on a pillow. Um And I asked them to expose their um wear a short sleeve top and I also want to put them to put their hair behind their ears. So again, look for you move special tests in the hands. You'll look for all those things that I said. Um the only thing I haven't told you about is the got and papules which are demonstrated in the bottom, right image, which is common in Dermatomyositis. Um You want to look at the nails, particularly for signs of psoriatic arthritis. You may get onycholysis, nail pitting. Um and you also get dactylitis, sausage, like fingers in psoriasis psoriatic arthritis, which can be seen in the top uh image on the right. You want to look under the elbows for signs of psoriasis. Uh So psoriatic plaques, you may get rheumatoid nodules. And you also want to look behind the ears for gouty to which are like yellow deposits which are raised, you'll feel for temperature um nodules and you want to test the gross sensation of the patient. Um You want to move their hands actively and passively. You want to test test wrist extension and flexion, finger, flexion extension, thumb, flexion extension, um and opposition finger abduction and abduction, pincer grip and power grip. Essentially, this test is testing the muscles and the nerves. So, ulnar radial um and then to a certain extent, median, in terms of sensation, you then want to do the salons test um and then which can simulate the median nerve. But also um if you tap the carpal tunnel, you're likely to um get um so that's Tinel sign. If you tap the carpal tunnel, you get um signs of tingling, uh uh symptoms of tingling in the patient that's median nerve. And then you want to do Finkelstein's test where basically you put the thumb in the uh fist and point downwards. And that is known as Devin's penis, sinusitis. So these are very rheumatological uh conditions, very rheumatology, focused conditions that may come up in the hand examination. So, what you'd want to do is uh test other joints. And then according to what the pathology is, you'd offer other tests such as respiratory. If you're um thinking of rheumatoid because they may have extraarticular manifestations such as p uh pulmonary fibrosis and pleural effusions, the abdomen um can be involved. You might get splenomegaly and FTI syndrome, which is neutropenia, splenomegaly and rheumatoid arthritis. These are quite niche, but I'm just mentioning them just for your revision. You do an FBC to get an um you might have signs of anemia of chronic disease in rheumatoid. You would do euts um to check if there's any uh vasculitis. Um and you also wanna know um drug dosing. You do FTS as baseline for meds. ESR and CRP will correlate with disease s conditions. Um And sorry about that. Um I was being Facetimed um and then T FT S if there's any autoimmune concern and then urate if you're considering gout, you may do other tests such as rheumatoid factor, which is not that specific um to rheumatoid but but can help. Anti CP is more specific than rheumatoid factor for rheumatoid arthritis. And it is a predictor of poor prognosis and you may do genetic testing such as HLA B 27 which is common in psoriatic arthritis. You may consider doing a hand X ray and ultrasound to look um at the joints, seeing if there's any uh joint erosion um that may be seen better on ultrasound and you may consider joint as for for infusion. Um If you're concerned of septic um arthritis or uh if you want, if you're suspecting crystal arthropathy, you test it for crystals, any questions on the hand exam anything that I said, we're almost young guys. Um I don't see any questions. I will move on. So carpal tunnel, you may get positive T sign and Phalen's test here. You basically want to offer conservative medical and surgical management. What I'd recommend in general for patients is classify until you die for all your answers. So you won't say if they ask you what is the management of carpal tunnel syndrome? You will turn around and say, well, the car, the management of carpal tunnel syndrome can be c can split into conservative medical and surgical management. Conservative management involves wrist splinting, more frequent breaks and avoidance of tasks. Medical management involves pain relief and corticosteroids which can decrease the inflammation. Finally, surgically, you can do a carpal tunnel release. And essentially what happens in carpal tunnel syndrome is you have compression of the median nerve within the carpal tunnel. You may get wasting of the thenar eminence and prolonged median nerve compression as depicted by the image. So any questions on hands or anything I've talked about before we move on to back pain and then we're almost done. I'm gonna move on just in the interest of time. I'm gonna assume that you don't have any questions. So if someone comes in with back pain, what would you consider? So again, you want to classify? So cause of rheumatological cause, involve ankylosing, spondylitis, psoriatic arthritis. They're both under the seronegative spondyloarthropathies. You may get neurological causes such as spinal stenosis, nerve root compression, radicular compress uh radiculopathy, called equina malignancy such as sarcoma, multiple myeloma or metastasis. And then musculoskeletal such as fracture, muscular pain or sacroiliac joint dysfunction. You've got various differentials in this nice uh table for your revision. Of course, just to know you can get referred pain. So for instance, in aortic dissection in pancreatitis, um an aortic aneurysm, abdominal aortic aneurysm rupture as well. So, se seronegative spondylar arthropathy, um this encompasses various conditions. So, so these are another seronegative arthritis. So it involves reactive arthritis, um enteropathic arthritis, psoriatic arthritis and ankylosing spondylitis. As you know, with ankylosing spondylitis, you have, it's an autoimmune condition associated with the HLA B 27 gene. Um And basically, it attacks the vertebral joints. You um the collagen get destroyed and replaced with fibrin. Um ossification occurs and you basically over time get the bamboo spine which is seen on the right. Let me show you here. But the thing to know is that you get eye involvement, uh you can get involvement of the Ulta um and tendons. So, in terms of that, so you can get enthesitis. So these patients have plantar fasciitis. So you can get uveitis, psoriasis, inflammatory bowel disease, pulmonary fibrosis, aortitis, aortic, insufficiency, heartburn, and rarely amyloidosis. So, basically, this is an autoimmune condition which can cause multiple other um extraarticular um things in terms of the management. It basically depends on the prediction of the disease in that specific individual. So you got axial manifestations which involve back pain and stiffness. And then you got the peripheral manifestations, arthritis, endit and dactylitis. So you're more likely going to give local steroids, steroids and then DMARDS such as sulfaSALAzine to those with the peripheral manifestations with the overlap with arthritis as you would for instance, in rheumatoid. However, those are the actual manifestations, the evidence suggests that DMARDS don't do that much. So you wanna do biological dos, so more likely to give a TNF alpha inhibitor or an il 17 inhibitor. So, if we take you back to pathology in year five, these involve etanercept Adalimumab and then il 17 inhibitors include secukinumab, ixekizumab. These are best better for patients with back pain and um axial involvement. You're going to give them pain, um pain relief if necessary. And very in some cases, you may need to do surgery, especially those that have bamboo spines and then various radiographic findings intensive ankylosing spondylitis. Um The thing to know is that you have sacroiliac uh involvement. That's, that's basically what you get. Um the most common finding in ankylosing spondylitis moving on to. Um again, this is an autoimmune condition which causes various manifestations. Um The most common ones that you come up in the exams are the butterfly rash. Uh You can get Raynaud's, you can have um deposition of the immune complexes in the kidney which causes um deterioration of renal function. Um You can get um other things, lung involvement, pleuritis, pneumonitis, et cetera, and then muscle joint, uh pains, um et cetera. So and then you may get mouth and nose ulcers. So these are quite common. So, manifestation which is usually caused by immune complex def deposition, moving on to the next slide. So as we said, multisystem autoimmune inflammatory disorder, the risk factors involve young females. Um those of a Carribbean or Chinese descent, certain viruses and drugs are associated. Um and there's the American College of Rheumatology criteria, which is summarized by. So, brain MD to remember. So, serositis, oral, nasal ulcers, arthritis, photosensitivity, bloods, particularly at the pen. So you get pancytopenia, low hemoglobin, low white cell count, low platelets, renal disease. You can get nephrotic syndrome because of the immune complex depositions um which involves proteinuria. Sorry about that and then A N A may be raised. Um antidouble stranded DNA is, is the most um specific and then you can um sorry, antitra DNA is common. The most specific is anti Smith antibody. And then you can get um associated um conditions such as anti syndrome where you've got recurrent um miscarriage and you have um recurrent venous and arterial thrombosis. You have neurological disease, sometimes malar rash, which is that butterfly rash and then you can also get discoid rash, which is coin shaped um lesions in terms of management, conservative medical and specialist. So, lifestyle diet flu jab because they're um immunosuppressed medical involves pain relief and then specialists will involve steroids, hydroxychloroquine in which we want them to have regular eye tests because it can cause um complications taken long term cyclophosphamide mmf azaTHIOprine and various biologics. So the various D mus uh the most commonly used one is hydroxychloroquine. We don't want patients on steroids that, that long because of the risk of causing cushing's. So any questions on a ankylosing von lights or? Sae? Ok. I think this is the final question. So and a history of headache and jaw pain, she has a longstanding history of shoulder and neck pain. What is the next best step? A temporal artery biopsy? B, ultrasound, temporal artery C assisted for visual impairment D check the es re prescribed steroids. Please write in the chart. Yeah. OK. So the correct answer is essential for visual impairment. So what this question is trying to get to is giant cell arteritis. Why am I mentioning the longstanding history of shoulder and neck pain? And the question, can anybody quickly tell me on the chart or on you? Fantastic well done guys. So yeah, there's an association between joints, arteritis or temporal arteritis with polymyalgia, rheumatica. So essentially you um in GC you're likely to get um you may essentially get impairment because of um because of the arteritis and because of the potential atheroma there. Um and or shooting off uh thrombi or emboli. So you do want to assess for blindness because this visual loss can be permanent and requires emergency treatment. If for some reason they don't have um visual impairment, then you can just give them steroids. Um sorry is useful. It wouldn't be raised. However, with visual impairment, you want to give them IV steroids and admission and close monitoring high dose steroids. And then in terms of the first two, they are basically to see if this patient has um GCA or temporal arteritis. And basically, and you might, you, you sometimes get skipped lesions with GCA, which is why the temporal artery biopsy may come back as inconclusive symptoms that are common include a headache because you got um uh essentially the um the the blood vessel that it becomes firm and it can become tender, you can get jaw claudication and necrosis of the tongue, um particularly if they chew food, they may um experience this claudication and what it is is basically, you have inflammation of the walls um of larger sized arteries. And this also increases the risk of stroke and heart attack. So it's something to not be missed and we should not take it lightly. As you correctly said, you have uh association with polymyalgia, rheumatica which causes shoulder and pelvic girdle pain. These patients will have to carry a steroid treatment card with them. Um And essentially, it's an condition which is characterized by severe bilateral pain and morning stiffness in the shoulder, neck and pelvic gut with no objective weakness. So it's stiffness, not weakness, 15% of PMR patients will develop GCA, however, 40 to 50% of patients with GCA will have PMR. So if someone comes in with GCA, they're very likely to have PMR common in the elderly or um, so over fifties and you'd the ESR and CRP, so the inflammatory markers would be raised and it's good to monitor these markers for treatment. And of course, since you're starting on the steroids, you want to screen them for metabolic syndrome, risk fractures such as diabetes. Um And if it's just PMR, you're going to give them 15 mg of prednisoLONE. And then of course, because they're starting on the steroids, you'd consider bisphosphonates, Vitamin D PPI to protect other stomach um lining and then conservative, of course, diet and exercise. Um However, when they have uh GCA, you're more likely to start between 30 60 mg of pred. I hope you guys found this useful. I know I've given you a lot of um information and I really hope um you were able to retain some of that. I'm very happy for you to use my slides. Contact me with questions for anything. If you'd like help with the S FP, I'm very happy to help. I'd greatly, greatly appreciate if you could fill in this feedback form. This is very useful for the Med committee, but also myself in terms of how to improve my teaching. Um And yeah, I just hope you guys have fun This is your final year. Um This is your time to um, go out, have fun, make good memories with your classmates. Go to placement, get um, well equipped in terms of skills and knowledge for F one. But don't worry, everything is going to go well, just practice the exam, just know the basics and you'll be fine. Um, yeah, very happy to be convicted or concerns. Um, and yeah, please let me know if you have any questions or else. Thank you for listening. Well, thank you very much. That was a really good talk. And again, you've covered a lot of information of patients, orthopedics and um rheumatology. Um So yeah, thank you for taking your time out and it was a really good talk. It was my pleasure. Thank you so much. Uh Yeah, please fill in the feedback from guys uh uh all the best for everything. Thank you for having me. Yeah. Remember we'll release the feedback. Um, the slides and presentation after enough people have uh filled in the feedback. All right. Take care. Daniella.