Goals & Objectives
Objectives for Musculoskeletal Block
The material provided in this handout is not meant to limit your study and knowledge in the field of the musculoskeletal system. Throughout your training in medicine you will be exposed to a vast amount of material that will complement these learning objectives. Additional material and clinical skills obtained through coursework, PBL, PSD, clinical and research electives should be integrated in your conceptualization of the musculoskeletal system and doctor-patient interaction. Through this integration we believe that you will be able to have a clear conceptualization of the bones and muscles in the human body as well as an overview of common diseases.
Review from Previous Blocks
- Anatomy of the spinal cord and vertebrae (D & H; Respiratory)
- Spinal Cord and Nerves (D & H)
- Neoplasia (Haematology and Neoplasia)
- Anti-nuclear Antibodies (Haematology and Neoplasia)
- Spina Bifida (D & H)
- Osteoporosis (Haematology and Neoplasia)
- Metabolic Bone Disorders (Endocrinology)
- Anatomy and Bone structure of the pelvis and lower abdomen. (Reproduction)
Specific Learning Objectives for Musculoskeletal Block
Week 1: Neck and Back Pain
Lab - Anatomy: Vertebral Column and Back
- Define the following terms: vertebrae, joint, ligament, intervertebral disc, annulus fibrosis, nucleus pulposus.
- Identify the following structures of the vertebral column: neural arch, body, laminae, pedicles, dens/odontoid process, spinous and transverse processes, facet joints.
- Identify and number vertebral sections and vertebrae.
- Identify normal curvature of the spine.
- List normal features of typical vertebrae in cervical, thoracic and lumbar parts of spinal column.
- Identify joints and ligaments of the vertebral column.
- Identify the key anatomical features at C. 1 - C. 2 that are necessary to maintain stability (atlanto-occipital, atlanto-axial joints, transverse ligament, anterior longitudinal ligament).
- Identify the spinal unit in the low lumbar (L. 4 / L. 5 and L. 5 / S. 1) area
- Explain the anatomical relationships between the nerve root and the low lumbar area.
- Explain the relationship between the intervertebral disc and the following structures: intervertebral foramen, facet joints, costovertebral joints, anterior and posterior longitudinal ligaments, ligamentum flavum, interspinous and supraspinous ligaments, lumbosacral and sacroiliac joints, iliolumbar ligament, sacrotuberous and sacrospinous ligaments.
- Name and identify the following structures: spinal nerve, dorsal root ganglion, ventral and dorsal rami.
- Describe the effects of spinal nerve compression in the intervertebral formina (in the cervical and the lumbar regions)
- Explain the relationship between lumbar disc herniation and lower level nerves.
- Identify the vertebral bodies, laminae, pedicles, spinous and transverse processes and facet joints that are typical of each region, in both lateral and posterior X-Rays.
- Identify the dens (odontoid process) and its articulation with atlas on lateral and/or posterior X-Ray.
Back, neck and abdominal wall
- Describe and identify, on the prosected specimen, the key posterior muscle support for the low back.
- Name and identify the major muscle groups which support and move the neck and head.
- Identify the following structures of the abdominal wall on the specimen and X-Ray: ilium, ischium, pubis, symphysis pubis, pubic crest & tubercle, superior and inferior rami of pubis, anterior superior and inferior iliac spines, iliac crest.
- Explain why the muscles in the abdominal wall are a critical support for the low back.
- Identify the following structures on X-Ray: ilium, ischium, pubis, symphysis pubis, pubic crest and tubercle, superior & inferior rami of pubis, anterior superior iliac spine, iliac crest.
Lab - Histology: Bone
- List the components of bone
- Describe the cell types present in bone.
- Describe the term bone matrix.
- List and describe the types of bones.
- Describe the process of bone formation.
- Describe the process of bone repair.
- List the functions of the bone.
Spinal Development and Postural Disorders
- Describe the development of normal curvatures of the spine
- Define scoliosis, kyphosis, lordosis
- Describe the different types of scoliosis
- Describe the clinical presentation of the types of scoliosis
- Describe a classification system for scoliosis
- Outline the basic treatment for scoliosis
Back Pain
- Describe an approach to assessing pediatric back pain
- Provide a differential diagnosis for low back pain in the adult
- Describe the clinical presentation, approach to diagnosis and management of:
- Mechanical lower back pain
- Degenerative disc disease
- Disc herniation (with and without radiculopathy)
- Be able to identify level of lesion
- Cauda equina syndrome
- Spondylolithesis and spondylolysis
- Compression fracture
- Spinal stenosis
- Metastatic lesions
- Infection
- Understand when and what type of imaging is required to assist in the diagnosis and management of back pain
- Understand when the presentation of back pain is an emergency
Neck Pain
- Provide a differential diagnosis for neck pain in the adult
- Describe the clinical presentation, approach to diagnosis and management of:
- Cervical strain
- Degenerative disc disease
- Cervical radiculopathy
- Be able to identify level of lesion
- Cervical stenosis
- Diffuse idiopathic skeletal hyperostosis (DISH)
- Whiplash
- Infection
Week 2: Polyarthritis
Lab - Anatomy: Shoulder joint: scapular & pectoral regions: Axilla
- Identify the bony features of the shoulder girdle including the clavicle, scapula and humerus.
- Explain the inter-relation between the structural features of the shoulder joint including: multiaxial ball and socket joint, head of humerus, glenoid cavity and labrum, extent of synovial membrane, attachment and extent of fibrous capsule, ligamentous thickenings.
- Describe how primary muscles are responsible for the following shoulder motion: adduction, abduction, flexion, extension, rotation.
- Explain the rotation of the scapula and simultaneous movement at acromioclavicular and sterno-clavicular joints during abduction of humerus, resulting in a combination of glenohumeral, sterno-clavicular and scapulo-thoracic motion.
- List the muscles involved in the movements of the scapula and their actions.
- Name and identify the muscles that make up the rotator cuff of the shoulder.
- Explain the role of the muscles that make up the rotator cuff in stabilizing the shoulder joint, as well as their function in the movement of the shoulder joint.
- State the relationship between the rotator cuff, the acromion and the subacromial bursa.
- Identify and describe the cervical root origins of the brachial plexus, and how these roots combine together, divide and rejoin to form the major peripheral nerves of the brachial plexus, each with their mix of root origins.
- Describe the relationship of the axillary artery to the brachial plexus and other structures surrounding it.
- Identify the following structures on X-Ray: clavicle, scapula (acromioclavicular joint, angles, glenoid cavity, spine, acromion, coracoid process), humerus (head, anatomical neck, surgical neck, intertubercular (bicipital) groove, greater and lesser tubercles). Note the rotation of the scapula as the upper limb is brought to an overhead position.
Elbow joint: anterior and posterior arm: anterior and posterior forearm
- Identify the following structures: humerus (medial & lateral epicondyles, lateral condyle (capitulum), medial condyle (trochlea), radius (head, styloid process, tuborosity), ulna (olecranon, coronoid process, styloid process)
- Identify and contrast X-Rays of children and adult for each of the following structures: elbow joint (hinge)
- Describe the movements of flexion and extension of the elbow joint.
- Describe the articulation of the elbow joint with the radius and ulna.
- Explain where you would aspirate a joint effusion.
- Identify and name the muscles of the anterior (flexor) compartment of the arm (coracobrachialis, biceps (2 heads), brachialis) posterior (extensor) compartment (triceps).
- Describe the function of the muscles in the anterior and posterior compartment of the arm.
- Describe the course of neurovascular structures in the arm (brachial artery and vein, nerves - medial, ulnar and radial).
- Name and identify the anatomical region of the cubital fossa (location, boundaries)
- Describe the relationships of the brachial artery, and its radial and ulnar branches, with respect to the major nerves in the cubital fossa and the forearm.
- Name and identify the muscles and neurovascular structures in the anterior (flexor/pronator) and posterior (extensor/supinator) compartments of the forearm, noting their relations.
- Identify the following structures on X-Ray: humerus (medial & lateral epicondyles, lateral condyle, capitulum, medial condyle, trochlea); radius (head, styloid process, tuborosity); ulna (olecranon, coronoid process, styloid process).
Lab - Histology: Cartilage
- List the cells which compose cartilage.
- List the various types of cartilage.
- Explain the concept of cartilage growth and repair.
- List the functions of cartilage.
Bone & Osteoarthritis
- Describe the role of chondrocyte and its enzymes in the biosynthesis, degradation and repair of articular cartilage.
- Describe the role of cartilage, subchondral bone, ligaments, and muscles in the handling of stresses across joints.
- Describe the structure and functions of articular proteoglycans, collagen, and water in normal cartilage, and the alterations that occur in ageing and osteoarthritic cartilage.
- Describe the gross anatomy and histology of normal articular cartilage.
- Contrast the differences between healthy cartilage and diseased cartilage.
- State the prevalence of osteoarthritis.
- Describe the pathogenesis of osteoarthritis.
- List the medical conditions leading to osteoarthritis, and describe how each leads to changes in articular cartilage.
- Describe the cellular interactions in joint that lead to osteoarthritis.
- Describe inflammatory and immune pathways in the affected joints that produce symptoms such as pain and redness of joints.
- Compare the radiological features of osteoarthritis with the pathology of the condition.
- Describe how degenerative disc disease and facet joint degeneration arthritis can cause cervical nerve root and/or vertebral artery impingement.
Avascular Necrosis
- List the common causes and risk factors for avascular necrosis (AVN)
- Define the pathophysiology of AVN
- List the clinical manifestations and common locations of AVN
- Describe the radiological and pathological features of the sequential stages of AVN
Rheumatoid Arthritis
- Define rheumatoid arthritis.
- Explain the pathogenesis of joint destruction in rheumatoid arthritis.
- Identify the radiological features of rheumatoid arthritis on X-Ray.
- Describe approaches to the treatment of rheumatoid arthritis. Describe mechanisms of action and toxicities of ASA and non-steroidal anti-inflammatory drugs (NSAIDs) and cox-2 selective (coxibs) agents. Differentiate treatment goals of these agents from common disease modifying anti-rheumatic drugs (DMARDs.)
- Compare and contrast extra-articular features of rheumatoid arthritis (week 2) and spondylo-arthropathies(week 3).
Week 3: Monoarthritis
Lab - Anatomy: Upper limb - wrist, dorsum & palm of hand
- Name and identify the distal ends of radius and ulna (styloid processes), carpal bones, metacarpals and phalanges.
- Identify the location, type of joint, articular surfaces, synovial membrane, fibrous capsule, ligaments, movements and the muscles acted on for the following: wrist (radio carpal, radio ulnar, triangular cartilage), midcarpal, carpometacarpal, metacarpalphalangeal, proximal and distal interphalangeal.
- Identify the location and structures forming: transverse ligament and carpal bones, structures passing through it, structures passing superficial to the flexor retinaculum.
- Define carpal tunnel syndrome and identify the structures that are involved.
- List the main sensory and motor deficits and tests for carpal tunnel syndrome.
- Explain which anatomical factors would predispose to the development of carpal tunnel syndrome.
- Name and identify the muscular compartments and flexor sheaths of the palm of the hand (thenar - abductor, flexor and opponens of thumb, recurrent median nerve, hypthenar (abductor, flexor and opponens digiti minimi, intermediate - (long flexor tendons of the superficialis and profundus, lumbricals), adductor pollicus, palmar and dorsal interossei).
- Describe and demonstrate the function of the interossei, lumbricals and long finger flexors on the metacarpalphalangeal, proximal and distal interphalangeal joints.
- Explain how you would test for the function of the interossei, lumbricals and long finger flexors on the metacarpalphalangeal, proximal and distal interphalangeal joints.
- List the innervation and blood supply to the palm of the hand (ulnar nerve and its deep branch, median nerve and its recurrent branch, ulnar and radial arteries, superficial and deep palmar arches).
- List and describe the snuffbox (floor, boundaries, relationship to the scaphoid bone and radial artery), extensor expansion (attachments, insertion of lumbricals and interossei, function of the long finger extensors).
- List the innervation of the upper limbs.
- List the dermatomes of the upper limbs.
- List the cutaneous nerve supply from the ulnar, radial and medial nerves.
- Identify the carpal bones on X-Rays.
Soft Tissue Disorders
- Describe the pathology of carpal tunnel syndrome
- List the physical findings associated with carpal tunnel syndrome
- Describe an approach to the assessment and diagnosis of common upper extremity soft tissue disorders and injuries:
- Rotator cuff injuries
- Biceps rupture
- Medial and lateral epicondylitis
- AC joint injuries
- Dequervain’s tenosynovitis
- Describe an approach to the assessment and diagnosis of common lower extremity soft tissue disorders and injuries:
- Ankle sprains
- Plantar fascitis
- Meniscal tears
- ACL tear
- MCL/LCL injuries
- Patellofemoral syndrome
- Trochanteric bursitis
- Iliotibial band syndrome
Spondylo-arthropathies
- Define the following terms: spondyloarthropathy, ankylosing spondylitis, Reiter's syndrome and enthesopathy.
- Describe clinical features of inflammatory back pain and contrast with those of mechanical back pain.
- List the 4 seronegative spondylo-arthropathies.
- Describe the patho physiology of the four spondylo-arthropathies with emphasis on the interaction of environmental (infectious) and genetic (HLA-B27) factors.
- Describe the clinical features of the spondylo-arthropathies. Describe extra-articular features of the spondyloarthropathies and contrast with those of rheumatoid arthritis.
- Explain the possible contributions of the following mechanism to spondyloarthropathy pathogenesis: molecular mimicry, hypersensitivity and persistent organisms.
- Describe the radiological and laboratory features of spondylo-arthropathies.
Tumours and Neoplasia
- Describe the clinical presentation of bone cancer
- Describe the radiographic findings/patterns associated with MSK tumours
- Understand the clinical and radiological presentations that suggest benign rather than malignant tumours
- Describe the imaging used in the identification of bone tumours
- List the neoplasias that commonly metastasize to bone
- Describe a differential diagnosis for lytic or osteoblastic bone lesions
- Describe the clinical presentation and radiologic diagnosis of common benign and soft tissue tumours
- Lipoma
- Osteoid osteoma
- Non-ossifying fibroma
- Describe the clinical presentation and radiologic diagnosis of osteosarcoma
Crystal Induced Disorders
- Explain the patho physiology of crystalline arthropathy.
- Compare and contrast the clinical presentation and pathological features of gout and pseudogout.
- Describe approaches to treatment of gout and hyperuricemia.
Infections of Bones and Joints
- Explain the pathogenesis of bone and joint infections and the common etiologic microorganisms
- Describe the radiologic features of acute and chronic osteomyelitis
- State the importance of early recognition of joint infections
- Describe the common presentation and management of:
- Pediatric joint infection and osteomyelitis
- Adult joint infection and osteomyelitis
NSAIDs (Non-Steroidal Anti-Inflammatory Drugs)
- Describe the metabolism of arachidonic acid.
- Describe the roles of prostaglandins, thromboxane A2 and leukotrienes.
- Describe the absorption and metabolism of salicylate.
- Describe the pharmacological properties, contraindications and complications of aspirin.
- List the contraindications and complications of aspirin.
- Compare and contrast the mechanism of action of aspirin, ibuprofen and selective COX-2 inhibitor.
- List the clinical uses for aspirin, ibuprofen and selective COX-2 inhibitor.
Week 4: Child with a Limp
Lab - Anatomy: Lower Limb - Hip Joint, flexor, extensor, adductor and abductor muscles, femoral triangle and neurovascular relationship
- Identify the bony landmarks of the pelvis and hip on the articulated skeleton and bones. Include: pelvis (ilium, ischium, pubis, iliac crest, iliac fossa, anterior superior iliac spines, pubic tubercle, pubic crest, acetabulum, obturator foramen, greater and lesser sciatic notches, ischial spine, sacroiliac joint, greater and lesser ciatic foramina, ischial tuberosity), femur (head, neck, shaft, greater and lesser trochanters, intertrochanteric line and crest, linea aspera).
- Name and identify the following features of the hip joint: multi-axial ball, articular surfaces of the hip joint (lunate articular surface, acetabular fossa, acetabular labrum), head of femur.
- Contrast the stability and mobility between the hip joint and shoulder joint.
- Name and identify the major muscle groups (flexors, extensors, abductors, adductors, rotators) about the hip.
- Explain how their anatomical position affects their function.
- Explain the relationships of the contents of the femoral triangle to each other and to the surrounding bone and soft tissue landmarks.
- Locate the piriformis muscle and the suprapiriform and the infrapiriform spaces.
- Identify the superior gluteal nerve in the suprapiriform space and the sciatic and inferior gluteal nerves emerging via infrapiriform space.
- Identify the following structures on X-Ray using the bony pelvis and femur as guidelines: pelvis (ilium, ischium, pubis, iliac crest, iliac fossa, anterior superior iliac spines, pubic tubercles, pubic crest and lesser sciatic foramina, ischial tuberosity), femur (head, neck, shaft, greater and lesser trochanters).
Knee joint, anterior and posterior leg
- Name and identify the pertinent bony features of the femur (medial and lateral epicondyles, medial and lateral condyles, patellar surface, popliteal surface, intercondylar notch) tibia (tibial tuberosity, tibial condyles, plateaus, intercondylar eminence) and knee joints (soft tissues of the knee - menisci, cruciate and collateral ligaments, articular surfaces, fibrous capsule and synovial membrane).
- Name and identify the muscles that flex (hamstrings, gracilis, sartorius, gastrocnemius) and extend (quadriceps femoris) the knee joint, and their insertions.
- List the functions of the popliteus and iliotiabial band in the leg.
- Explain the relationship of the neurovascular structures in the popliteal fossa to the major muscles and how the nerves and vessels branch into the leg.
- Identify and name the contents of the fascially enclosed (muscular) compartments of the leg (anterior crural compartment - tibilalis anterior, extensor, digitorum longus, extensor hallucis longus, lateral compartment - peroneus longus and brevis, posterior compartments - superficial soleus, gastrocnemius, plantaris, deep flexor, hallucis longus, flexor digitorum longus, tibilais posterior).
- Explain the functional significance (action) of each muscle group (plantarflexion, dorsiflexion, eversion, inversion, flexion of digits, extension of digits).
- Describe how to test for the proper function each muscle group (plantarflexion, dorsiflexion, eversion, inversion, flexion of digits, extension of digits).
- Identify the neurovasculature behind the knee and in the leg (popliteal artery and vein, tibial nerve, anterior tibial and posterior tibial vessels, common peroneal, superficial peroneal and deep peroneal nerves).
- Identify the following structures on X-Ray: femur (medial and lateral epicondyles, medial and lateral condyles, intercondylar notch), patella, tibia (tibial tuberosity, tibial condyles, plateaus, intercondylar eminence), fibula (head, superior tibia-fibular joint).
Juvenile Arthritis
- State the subtypes of JIA (juvenile idiopathic arthritis).
- Describe the features of JIA.
- State the diagnostic criteria for JIA.
- State the relevance of a positive test for rheumatoid factor and antinuclear antibodies in the setting of juvenile inflammatory arthritis.
- List the differential diagnosis for JIA.
- List the treatment for JIA and JRA (juvenile rheumatoid arthritis)
Pediatric Disorders
- Describe the risk factors, presentation, diagnosis and management of developmental dysplasia of the hip
- Describe the clinical features and management options for clubfoot and metatarsus adductus
- Describe the normal development of pediatric lower extremity alignment
- Describe an approach to pediatric hip and knee pain with a focus on the following:
- Slipped capital femoral epiphysis (SCFE)
- Legg-Calve Perthes Disease
- Transient synovitis of the hip
- Osgood-Schlatter syndrome
- Patellofemoral syndrome
Trauma
- Define
- Fracture, dislocation, subluxation
- Be able to describe the radiographic features of a fracture and dislocation
- Describe how the periosteum is relevant to reduction and stability of a fracture
- Describe the pathogenesis and radiographic findings of fracture healing
- Describe the association between mechanism of injury and fracture pattern
- Describe the diagnosis and approach to a vascular injury of the extremity
- Describe the early management of a closed and open fracture
- Be able to describe the basic management options for a fracture
- Cast
- Percutaneous pinning
- Open reduction internal fixation
- Intramedullary fixation
- External Fixation
Biomechanics of the hip
- Describe why the hip joint has such large forces going through it.
- Describe why a cane should be used in the contra-lateral hand from the hip joint with painful pathology.
- Describe what combinations of muscle imbalance tend to result in hip subluxation.
- Describe the factors that can explain the trendelenberg sign and abductor lurch gait.
Week 5: Multiple Aches and Pains.
Lab - Anatomy
- Lower Limb: Ankle, dorsum and sole of the foot
Name and identify the following structures: tibia (tibial tuberosity, anterior crest, medial malleolus), fibula (head, neck, lateral malleolus), tarsal bones (talus (head trochlea, neck, body), calcaneus (sustentaculum tali, navicular tuberosity) cuboid (tuberosity, groove for tendon of peroneus longus, cuneiforms), metatarsals (tuberosity of the fifth metatarsal, phalanges). - Identify the mortise.
- Explain why the ankle joint is less stable in plantarflexion than in dorsiflexion.
- Explain the muscle groups which act on the ankle joint and their specific action (dorsiflexion vs. plantarflexion).
- Identify the joints where movements of inversion and eversion take place.
- Name and identify the muscle layers in the sole of the foot (1. plantar aponeurosis, 2. abductor hallucis, flexor digitorum brevis, abductor digiti minimi, 3- long flexor tendons - flexor digitorum longus and flexor hallucis longus, quadratus plantae, lumbricals, 4. Flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis, 5. Plantar interossei, dorsal interossei.
- Identify the tibial nerve (dividing into the medial and lateral plantar nerves), posterial tibial artery (dividing into medial and lateral plantar arteries).
- Identify the following structures which support the longitudinal arches: plantar aponeurosis, plantar calcaneonavicular (spring) ligament, long plantar ligament.
- Explain the innervation and dermatomes of the lower limbs by referring to the spinal root levels L4 - S3.
- Identify the following structures on an X-Ray: tibial (medial malleolus), fibula (lateral malleolus), tarsal bones.
Vasculitis
- Define vasculitis.
- Describe how vasculitis is classified
- Describe the laboratory findings of giant cell arteritis.
- Describe the relationship between giant cell arteritis and polymyalgia rheumatica.
- List the importance of prompt management in the case of giant cell arteritis.
- Describe the distribution and pathological features of giant cell arteritis.
- Identify the treatment for giant cell arteritis.
- Describe the potential complications of long-term steroid therapy.
Fibromyalgia
- Describe the clinical presentation of fibromyalgia.
- Describe the diagnostic criteria for fibromyalgia.
- Know the expected laboratory test results in fibromyalgia.
- Outline a management plan for a patient with fibromyalgia.