Musculoskeletal Medicine

• Upon completion of this problem, students will be able to describe musculoskeletal embryology and normal limb development, and explain the assessment and management of congenital foot abnormalities in children.
• Upon completion of this case, students will be able to describe spinal deformities and their implications in children.
• Upon completion of this case, students will be able to describe the basic anatomical structures of the lower limbs.
• Upon completion of this problem, students will be able to describe the gross anatomy of the upper limb, including bones, muscles and nerves. They will know the functions of the key nerves of the upper limb.
• Upon completion of this problem, students will be able to explain shoulder biomechanics and the etiology of chronic tendon disorders. They should explore how to individualize a treatment plan.
• Upon completion of this problem, students will understand the anatomy and biomechanics of the knee, and explore the mechanisms and pathology of lesions affecting the components.
• Upon completion of this problem, students will be able to describe the structure and function of joints and extra-articular soft tissues and the natural history and pathogenesis of osteoarthritis.
• Upon completion of this problem, students will understand vitamin D physiology, consequences of deficiency, and osteomalacia.
• Upon completion of this problem, students will be able to describe an approach to osteoporosis.
• Upon completion of this problem, students will be able to describe a basic approach to low back pain and identify its common causes and its investigation and management.
• Upon completion of this problem, students will be able to explain the difference between inflammatory and mechanical back pain, and will have explored ankylosing spondylitis as the prototypical inflammatory spine disease.
• Upon completion of this case, students will be able to describe Giant Cell Arteritis as one type of vasculitis.
• Upon completion of this problem, the students will have an overall approach to weakness, and will be able to describe inflammatory muscle disease.
• Upon completion of this case, students will be able to describe gout.
• Upon completion of this problem, students will be familiar with reactive arthritis and recognize that environmental and genetic factors have a significant role in the pathophysiology of rheumatic diseases.
• Upon completion of this problem, students will be able to describe systemic lupus erythematosus.
• Upon completion of this problem, students will be able to describe the diagnosis and management of rheumatoid arthritis and will have an approach to extra-articular manifestations.
• Upon completion of this problem, students will be able to describe the assessment and management of fractures in children.
• Upon completion of this problem, students will be able to explain key concepts in Juvenile Idiopathic Arthritis (JIA).
• Describe the embryological derivation of the musculoskeletal system.
• Explain the difference between congenital and developmental problems in limb deformities.
• Discuss the importance of prenatal and postnatal counselling.
• Describe neonatal physical exam focused on the musculoskeletal system.
• Describe the assessment and management of congenital foot abnormalities.
• Describe the anatomy of the lower limb, including bones, joints, and main ligaments.
• Describe the structure and blood supply of a long bone.
• Identify the compartments of the lower limb, including major muscles, and their function.
• Describe the innervation of compartments, and motor function of the main nerves of the lower limb: femoral, obturator, and sciatic (branches to tibial and common peroneal) nerves.
• Describe the anatomy of the upper limb, including bones, joints, and main ligaments.
• Identify the compartments of the upper limb, including major muscles, and their function.
• Describe the innervation of compartments, and motor function of the main nerves of the upper limb: median, ulnar and radial
• Define the common fracture terms of angulation, translation, shortening, and rotation as well as the other descriptors of fracture characteristics: comminuted, oblique, butterfly fragment, segmental, compound (open).
• Identify the different types of fractures in children including physeal and non-physeal fractures.
• Describe the anatomy and physiology of the physis.
• Explain how acceptable alignment for fractures of the upper and lower extremities varies with fracture location and age of the patient.
• Describe growth arrest and the possible sequelae of this.
• Discuss the differences between fractures in children versus adults.
• Identify what is meant by a compound fracture and discuss the management of such a fracture.
• Describe compartment syndrome pathophysiology, diagnosis and management.
• Explain how to examine the peripheral nerve supply to the upper and lower extremity.
• Identify the anatomy and biomechanics of menisci, cruciate ligaments, and collateral ligaments of knee.
• Summarize the pathogenesis of lesions affecting these structures (menisci, cruciate ligaments, and collateral ligaments of knee).
• Identify features of clinical tests to detect lesions in these structures.
• Discuss the management of meniscal and ligament lesions of the knee.
• Identify the epidemiology of rotator cuff disease and how certain principles can be generalized to other degenerative tendon disorders.
• Describe the anatomy of the rotator cuff.
• Describe the pathophysiology of impingement syndrome.
• Explain the relevance of imaging studies (X-Ray and ultrasound).
• Explain how to formulate an individual treatment plan, understanding that some components of care (such as physiotherapy) are not funded.
• Interpret key clinical findings in a patient who presents with this scenario.
• Explain how to investigate such a patient.
• Describe an approach to management.
• Describe the effects and potential side effects of the planned therapies.
• Explain how to counsel the patient regarding probable outcomes, both short-term and long-term.
• Recognize that the course of chronic osteoarthritis can be punctuated by acute exacerbations that require adjustments to treatment.
• Identify the identifying features of osteonecrosis.
• Recognize the usual presentation of osteoarthritis can be complicated/confounded by other conditions (such as spontaneous osteonecrosis, especially in older adults).
• Describe normal bone physiology, including the cells involved.
• Identify the relevant clinical consequences of osteoporosis.
• Discuss the spectrum of diseases that may lead to bone loss.
• Explain how bone density is measured.
• Explain the consequences of a low bone mineral density.
• Discuss the risk factors for fracturing.
• Discuss the treatment of osteoporosis.
• Compare and contrast osteomalacia with osteoporosis.
• Describe the physiology of vitamin D.
• Identify the spectrum of diseases that may lead to vitamin D deficiency.
• Discuss the pathophysiology of vitamin D deficiency and osteomalacia.
• Identify that vitamin D deficiency presents in children as rickets and in adults as osteomalacia.
• Discuss the treatment of vitamin D deficiency.
• Describe the metabolism of uric acid pathways.
• Explain the concept of overproduction vs underexcretion and renal handling of uric acid.
• Review factors predisposing to hyperuricemia and gout, including diet and medication.
• Describe treatment of acute gout.
• Describe treatment of chronic (tophaceous) gout.
• Summarize the epidemiology and pathophysiology of rheumatoid arthritis.
• Explain the role autoantibodies and cytokines play in mediating rheumatoid arthritis.
• Identify the effectiveness of laboratory and diagnostic tests in evaluating rheumatoid arthritis.
• Identify management options for rheumatoid arthritis.
• Review the classification criteria for rheumatoid arthritis (strengths and weaknesses).
• Develop a differential for arthritis in children.
• Review the ILAR classification of JIA (Juvenile Idiopathic Arthritis), and the clinical presentation of the subtypes.
• Review the complications of JIA: uveitis, macrophage activation syndrome, effects on growth.
• Discuss the general approach to treatment (for Juvenile Idiopathic Arthritis (JIA)).
• Summarize the epidemiology of systemic lupus erythematosus (incidence and prevalence, and ethnic variation).
• Describe the clinical presentation of systemic lupus erythematosus and its diagnosis.
• Become aware of presentations in lupus which require urgent care.
• Describe the pathophysiology of lupus with a specific focus on autoantibodies which make up lupus and the diagnostic tests used in its diagnosis and management.
• Identify the strengths and weaknesses of the classification criteria.
• Explain the role of a kidney biopsy in the management of lupus nephritis.
• Identify other features of lupus particularly neuropsychiatric lupus in particular mood disturbances and psychosis.
• Summarize the epidemiology of reactive arthritis.
• Describe the pathophysiology of reactive arthritis, including molecular mimicry and other concepts.
• Differentiate reactive arthritis from rheumatoid arthritis clinically and be able to contrast the two diseases processes.
• Describe the approach to management of reactive arthritis, including the role of antibiotics (if any).
• Explain the mechanisms of bone and joint infection.
• Provide an overview of septic arthritis including common organisms.
• Compare and contrast acute versus chronic bone infection.
• Discuss the significance of an acute monoarthritis and proper emergent management.
• Briefly review the classification of vasculitis into large, medium and small-vessel vasculitis.
• Discuss the distribution of blood vessels that can be affected by GCA, including the temporal arteries, carotids, subclavian and vertebral arteries.
• Discuss the presentation, diagnosis and emergent management of GCA.
• Identify the critical complications of giant cell arteritis (GCA) that warrant urgency of treatment.
• Identify the various types of spinal deformities in children.
• Discuss the effect of spinal deformity on the cardiorespiratory system.
• Describe the various etiologies of scoliosis, recognizing that a genetic predisposition may be present in some patients.
• Identify the issues surrounding the management of idiopathic scoliosis.
• Describe spinal anatomy, spinal nerves, bowel and bladder innervations.
• Review the common causes of back pain.
• Identify the 'Red Flags' for back pain.
• Develop a basic approach to the acute pain patient.
• Interpret the significance of physical findings.
• Discuss the rational approach to investigations x-ray, CT scan, MRI for back pain.
• Compare and contrast Inflammatory back pain with mechanical back pain.
• Discuss the pathophysology of ankylosing spondylitis.
• Discuss the presentation, diagnosis and management of ankylosing spondylitis.
• Discuss the structure of skeletal muscle.
• Recognise that weakness can arise at various points (CNS, peripheral nerves, neuromuscular junction, muscles).
• Briefly review the classification of inflammatory muscle disorders, with a focus on dermatomyositis and polymyositis.
• Develop an approach to evaluating muscle disease
• Describe the initial management of fractures including pain management.
• Explain how guarding, and immobilisation can lead to loss of function and myofascial pain (including Frozen Shoulder Syndrome).
• Discuss the mechanism of action, efficacy and toxicity of acetaminophen.
• Discuss the mechanism of action, indications for use and adverse effects of Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) particularly with respect to their role in managing osteoarthritis.
• Describe the mechanism of action of bisphosphonates, denosumab, and teriparatide.
• Describe how spinal fractures can lead to different types of pain, including neuropathic pain.
• Describe the mechanism of action of colchicine, allopurinol, and febuxostat.
• Describe the mechanism of action of action of methotrexate.
• Explain how biologic therapies work in inflammatory arthritis through targeting specific cytokines or Lymphocytic cells.
• Discuss the acute and chronic adverse effects that are associated with high dose glucocorticoid therapy.
• Compare and contrast back pain, spine pain, and radicular pain.
• Formulate an approach to managing uncomplicated low back pain.
• Recognize that non-medical treatment modalities may be an important aspect of management management (while understanding that many of these modalities are not part of public ally funded health care).