Master CPS - Musculoskeletal
for MSRA
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Core Concepts
Key musculoskeletal pathologies for MSRA:
- Degenerative: Osteoarthritis (OA) – "wear and tear."
- Inflammatory:
- Rheumatoid Arthritis (RA) – autoimmune, symmetrical polyarthritis.
- Gout/Pseudogout – crystal deposition.
- Septic Arthritis – joint infection (MEDICAL EMERGENCY).
- Traumatic: Fractures, sprains/strains.
- Spinal: Non-specific back pain, sciatica, Cauda Equina Syndrome (SURGICAL EMERGENCY).
- Metabolic: Osteoporosis – fragile bones.
Clinical Presentation
- Osteoarthritis (OA):
- Gradual, activity-related pain.
- Morning stiffness <30 min, crepitus.
- Asymmetrical, weight-bearing joints (knees, hips, spine, hands).
- Rheumatoid Arthritis (RA):
- Symmetrical polyarthritis (small joints: MCPs, PIPs).
- Morning stiffness >30 min, fatigue, systemic symptoms.
- Swelling, warmth, tenderness, rheumatoid nodules.
- Gout:
- Acute, severe monoarthritis (often big toe).
- Rapid onset of pain, redness, swelling, warmth.
- Septic Arthritis:
- Acute, hot, swollen, exquisitely painful monoarthritis.
- Fever, chills, inability to move joint (passive or active).
- Fractures:
- Trauma, sudden pain, swelling, deformity, loss of function.
- Hip fracture: shortened, externally rotated leg.
- Back Pain:
- Non-specific: Mechanical, no red flags.
- Sciatica: Radicular leg pain, neurological deficit (dermatome/myotome).
- Cauda Equina Syndrome: Saddle anaesthesia, bilateral leg weakness, new bladder/bowel dysfunction.
Diagnosis (Gold Standard)
- OA: Clinical + X-ray (joint space narrowing, osteophytes).
- RA: Clinical (ACR/EULAR) + Bloods (RF, anti-CCP, ESR, CRP) + X-ray (erosions).
- Gout/Pseudogout: Joint aspiration for synovial fluid microscopy (Gout: neg. birefringent urate; Pseudogout: pos. birefringent CPPD).
- Septic Arthritis: Joint aspiration for Gram stain, MCS. Bloods (FBC, CRP, ESR).
- Fractures: Plain X-ray. CT for complex/occult.
- Back Pain:
- Non-specific/Sciatica: Clinical. MRI for red flags or persistent symptoms.
- Cauda Equina: Urgent MRI spine.
Management (First Line)
- OA: Physiotherapy, weight loss. Paracetamol, NSAIDs (oral/topical). Intra-articular steroids for flares.
- RA: Prompt DMARDs (e.g., Methotrexate). NSAIDs for symptoms, oral steroids for flares.
- Gout: Acute: NSAIDs, Colchicine, oral steroids. Prophylaxis: Allopurinol (after acute resolves).
- Septic Arthritis: Urgent IV antibiotics + surgical washout/drainage.
- Fractures: Analgesia, immobilisation, reduction (closed/open), fixation (internal/external). Urgent surgery for open, neurovascular compromise, or unstable fractures (e.g., hip).
- Back Pain:
- Non-specific/Sciatica: Analgesia, stay active, physiotherapy.
- Cauda Equina: Immediate neurosurgical referral + urgent decompression surgery.
Exam Red Flags
- Septic Arthritis: Hot, swollen, very painful monoarthritis + fever + inability to move joint.
- Cauda Equina Syndrome: New/worsening bilateral leg weakness, saddle anaesthesia, new bladder/bowel dysfunction, reduced anal tone.
- Neurovascular Compromise: Pallor, pulselessness, paraesthesia, paralysis, pain distal to injury. Compartment syndrome.
- Open Fracture: Skin breach over fracture.
- Back Pain Malignancy/Infection: Unexplained weight loss, night pain, fever, history of cancer, IVDU, new onset >50 or <20, unremitting pain.
- Non-Accidental Injury (NAI) in Children: Inconsistent history, multiple fractures, spiral fractures in non-ambulatory.
Sample Practice Questions
A 58-year-old carpenter presents with a 3-month history of right shoulder pain, worse with overhead activities and at night. He finds it difficult to reach for items on high shelves. On examination, there is pain on active abduction and external rotation, but passive range of movement is full. No neurological deficits.
A 48-year-old male presents with sudden onset of excruciating pain, redness, swelling, and warmth in his right great toe. The symptoms started overnight and are now so severe he cannot bear to have anything touch the toe. He admits to consuming a large meal with red meat and alcohol the previous evening. He has a history of hypertension and is on a thiazide diuretic. What is the most likely diagnosis?
An 80-year-old female complains of bilateral knee pain, gradually worsening over the past few years. The pain is worse with activity and relieved by rest. She reports morning stiffness lasting about 15 minutes. On examination, crepitus is noted with knee movement, and there is mild limitation of full extension. Inflammatory markers are normal. What is the most likely diagnosis?
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