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 55-year-old male presents with sudden onset of severe low back pain, radiating down both legs. He reports numbness in his groin and difficulty initiating urination for the past 6 hours. On examination, perianal sensation is reduced. What is the most appropriate immediate next step in management?
A 32-year-old male presents to the emergency department after twisting his ankle during a football match. He reports immediate pain and swelling and is unable to bear weight on the affected foot. On examination, there is tenderness over the posterior edge of the lateral malleolus and the base of the fifth metatarsal. According to the Ottawa Ankle Rules, what is the most appropriate initial investigation?
A 6-year-old boy presents with a 2-day history of a painful limp, refusing to bear weight on his right leg. His mother denies any history of trauma. He has had no fever, chills, or recent illness. On examination, he is afebrile, and his vital signs are normal. His right hip has a restricted range of movement, particularly internal rotation, which is painful. There is no erythema or warmth over the hip joint.
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