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This document was written by students, for students. It is NOT an approved staff-endorsed document. The student volunteers, for whose efforts we are grateful, are listed below.

• Victoria Langton: 2019 AMSS Vice President (Education) • Mahanoor Baig: 2019 Year 6 Education Representative • Malcolm Borg: 2018 AMSS Vice President (Education) • Jarrad Hopkins: 2018 Student Representative on the Board of the Faculty of Health and

Medical Sciences • Thomas Gransbury: 2017 AMSS Vice President (Education) • Simon Cousins: 2016 AMSS Vice President (Education)

Disclaimer: This document was created with good intention from students who have successfully completed the MSK clinical placement. The intention of this document is to guide student learning, not to provide a complete checklist, and to this end, it in no way intends to be an exhaustive list. It may not cover all the required material. However, a student who has good understanding of the clinical diagnosis and background and treatment of the following conditions, we hope should be confident in passing examination questions relating to the MSK course, as well as being a safe, competent junior doctor. While this document is as accurate as we could make it, we are students. Accordingly, there may be errors. The information contained in this document is subject to change. While every effort has been made to provide accurate and up-to-date information, neither the compilers of this document nor the Adelaide Medical Students’ Society accept any liability for the inclusion of incorrect information or the absence of relevant information from this document. The AMSS and authors of this document do not accept any responsibility or liability relating to the use of the information. Furthermore, it is important to note that if any statement in this document contradicts those in official university documents (e.g. Course Outlines, etc.), the latter takes precedence. If there are perceived to be any errors, or inappropriate omissions or inclusions in these objectives, please provide feedback to your year level EdReps or the AMSS Vice President (Education) via vpe@amss.org.au.

MSK Objectives

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Contents

Fundamental Topics.........................................................................................................3Global burden of MSK disease.................................................................................................3Radiology..................................................................................................................................3Rheumatology...........................................................................................................................3

Seropositive Rheumatic Diseases..............................................................................................3Seronegative Rheumatic Disease...............................................................................................4Crystal-induced Arthropathies...................................................................................................4Infectious Conditions..................................................................................................................4Non-articular rheumatism..........................................................................................................4Vasculitides..................................................................................................................................4

MSK Emergencies......................................................................................................................4

Practical Requirements....................................................................................................5Procedural Skills.......................................................................................................................5History and Examination Skills.................................................................................................5Anatomy and Pathophysiology.................................................................................................6

Region Specific................................................................................................................6Spine.........................................................................................................................................6

Spinal Fractures...........................................................................................................................6Spinal Conditions........................................................................................................................6

Upper Limb...............................................................................................................................6Upper Limb Conditions..............................................................................................................6Upper Limb Fractures.................................................................................................................7

Lower limb................................................................................................................................7Lower Limb Conditions...............................................................................................................7Lower Limb Fractures.................................................................................................................8

Specialist Topics..............................................................................................................8Infection....................................................................................................................................8Tumours....................................................................................................................................8Rehabilitation............................................................................................................................8Sports medicine........................................................................................................................9

Innovation........................................................................................................................9Basic Science............................................................................................................................9Biomechanics............................................................................................................................9Biostatistics...............................................................................................................................9Paediatrics.................................................................................................................................9

Document Guide Colour coding These objectives have been colour-coded to guide the depth of understanding recommended for each of the objectives. The coding is broadly as follows:

• Green = key knowledge, know a lot about • Blue = know most about e.g. principles of management but not specifics • Purple = know of, but not the details e.g. classical clinical features but not rare

presentations • Black text is used for titles

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Fundamental Topics

Global burden of MSK disease

- Osteoarthritis o Primary osteoarthritis o Secondary osteoarthritis

- Osteoporosis (covered in Year 4 MHU and Year 5 Geriatrics) o Common osteoporotic fractures (e.g. vertebral fracture, neck of femur fracture,

Colle’s fracture) - Pain

o Acute pain and chronic pain § Detailed acute and chronic pain management is beyond the scope of

Year 4 MSK (covered in Year 5 APIC) o Chronic regional pain syndrome

- General Fracture Principles o Fracture risk factors (e.g. osteoporosis) o Fracture complications

§ Local: acute (e.g. neurovascular injury, infection), intermediate, long term

§ Systemic: acute (e.g. haemorrhagic shock), intermediate (e.g. DVT/PE, fat embolism, sepsis), long term

o Fracture management (closed reduction and casting or open reduction and internal fixation)

Radiology

- Different uses for X-ray, MRI, CT, US - X-ray ordering principles (rule of 2s) - Descriptive fracture terminology (e.g. closed vs. open, comminuted vs. impacted,

transverse vs. spiral etc.) o Specific fracture patterns of the: shoulder, wrist, hip (Garden classification for

fractured neck of femur and Pauwel Classification for fractured neck of femur), ankle (Weber Classification for ankle fractures), and spine

o Specific features identifying bone tumours o Salter-Harris Physeal Fracture Classification system (covered in Year 5

Paediatrics)

Rheumatology

Seropositive Rheumatic Diseases - Rheumatoid arthritis - Systemic lupus erythematosus

o Antiphospholipid antibody syndrome - Systemic sclerosis (scleroderma) - Sjogren’s syndrome - Mixed connective tissue disease - Idiopathic inflammatory myopathy

o Polymyositis o Dermatomyositis

- Aware of outcomes for adults with juvenile idiopathic arthritis (covered in Year 5 Paediatrics)

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Seronegative Rheumatic Disease

- Ankylosing spondylitis - Reactive arthritis (Reiter’s syndrome) - Psoriatic arthritis - Inflammatory bowel disease associated enteropathic arthritis - Aware of outcomes for adults with juvenile ankylosing spondylitis (covered in Year 5

Paediatrics) Crystal-induced Arthropathies

- Gout - Pseudogout - Hydroxyapatite crystal arthritis

Infectious Conditions

- Gonococcal arthritis - Post-streptococcal arthritis - Parvovirus infection - Serum sickness

Non-articular rheumatism

- Polymyalgia rheumatica - Fibromyalgia

Vasculitides

- Large vessels: o Giant cell arteritis/temporal arteritis o ‘Takayasu’s arteritis (pulseless disease) o Behcet’s disease

- Medium vessels: Kawasaki disease (covered in Year 5 Paediatrics) and polyarteritis nodosa

- Small vessels: o Non-ANCA associated: henoch schonlein purpura (covered in Year 5

Paediatrics) and cryoglobulinaemia o ANCA associated: granulomatosis with polyangitis (Wegner’s granulomatosis),

microscopic polyangiitis, eosinophilic granulomatosis with polyangiitis (Churg Strauss Syndrome)

MSK Emergencies

- Early Management of Severe Trauma – EMST principles (Damage Control Orthopaedics) - Cauda Equina Syndrome - Bone infections (e.g. osteomyelitis) - Joint infections

o Native joint infections (septic arthritis) o Infected joint replacements

- Compartment syndrome - Crush syndrome (rhabdomyolysis) - Open fracture - Pelvic fracture

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Practical Requirements

Procedural Skills

- Dislocation relocations: Shoulder, Hip, Knee, Ankle - Closed reduction of fractures - Plastering of fractures - Joint aspirations/injections

History and Examination Skills

- History o Rheumatological History o Orthopaedic History

§ General pain and function history § Joint-specific history (shoulder, elbow, wrist/hand, hip, knee,

foot/ankle) • Back pain history, including red flags/yellow flags, and

identifying common causes of back pain - Examination

o Upper limb § Shoulder exam

• Including specific tests for rotator cuff tear, impingement syndrome, and post-dislocation problems

§ Elbow exam • Including specific tests for tendonitis, ulnar nerve impingement,

and dislocation (radial head/olecranon) § Hand/Wrist exam

• Including specific tests for scaphoid fracture, carpal tunnel syndrome and rheumatological disease

§ Brachial plexus: radial/ulnar/median/musculocutaneous/axillary nerve – examination of each nerve

o Lower limb § Hip exam

• Including specific tests for osteoarthritis § Knee exam

• Including specific tests for osteoarthritis, ligament damage and meniscal damage

§ Foot and ankle exam • Including specific tests for osteoarthritis, ankle fractures

(Ottawa ankle rules) and tibialis posterior damage § Foot exam

• Including specific tests for hallux valgus and morton neuroma o Spine

§ Spine exam • Including specific tests for sciatica/femoralgia and assessment

of the myotomes, dermatomes and peripheral nerve function (both sensory/motor)

§ C-spine clearance § Know principles (not full examination): cervical spine

o Gait Examination § Including specific tests for Trendelenburg gait

o GALS screening examination

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o Know principles (not full examination): ALS/BLS/primary survey/secondary survey (covered in Year 5 APIC)

Anatomy and Pathophysiology

- Lower limb anatomy - Upper limb anatomy - Spinal anatomy - Myotomes and dermatomes - Bone histology (cell types) - Inflammation and infection basic principles - Fracture healing physiology (including bone remodelling)

Region Specific

Spine

Spinal Fractures - Spinal fractures (odontoid fracture, hangman fracture, chance fracture, body fracture) - Bifacet dislocation - Thoracolumbar injury classification and severity (TLICS) score

Spinal Conditions

- Spinal cord injury, including C-spine injuries - Spinal cord syndromes: central cord, anterior cord, brown-sequard, conus medullaris,

cauda equina - Disc herniation (cervical/thoracic/lumbar) - Spondylolythesis, spondylosis, spondylolysis - Spinal stenosis - Myelopathy (spinal cord compression) - Radiculopathy (nerve root compression) - Vertebral osteoarthritis

Upper Limb

Upper Limb Conditions - Shoulder

o Rotator cuff tear o Impingement syndrome o Subacromial bursitis o Adhesive capsulitis (frozen shoulder) o Proximal biceps tendinopathy o SLAP (superior labrum from anterior to posterior tears) lesion o Glenohumeral dislocation o Glenohumeral joint arthritis o Acromioclavicular joint arthritis o Acromioclavicular joint dislocation o Sternoclavicular joint dislocation o Thoracic outlet syndrome

- Upper arm - Elbow

o Epicondylitis: Lateral (Tennis elbow) and Medial (Golfer’s elbow)

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o Olecranon bursitis o Elbow dislocation

- Forearm o Os acromiale o Pronator syndrome o Kienbock’s disease

- Wrist o Ganglion cyst o Osteoarthritis

- Hand o Carpal tunnel syndrome o DeQuervain’s tenosynovitis o Dupuytren’s contracture o Trigger finger o Mallet deformity o Gamekeeper’s thumb o Hand infections: flexor tendon sheath infections and human bite injuries

- Brachial plexus o Upper brachial plexus injury (Erb’s palsy) o Lower brachial plexus injury (Klumpke’s palsy) o Radial/ulnar/median/musculocutaneous/axillary nerve palsies

Upper Limb Fractures - Scapula fracture - Clavicle fracture - Proximal humeral fracture (anatomical neck and surgical neck) - Humeral shaft fracture - Elbow fractures: supracondylar fracture, radial head fracture, and olecranon fracture

(covered in Year 5 Paediatrics) - Forearm fractures: Monteggia fracture, Galeazzi fracture, and Nightstick fracture - Wrist fractures: Colle’s Fracture, Smith’s fracture, Barton’s fracture, scaphoid fracture - Hand fractures: carpal dislocations, perilunate dislocations, lunate dislocations,

metacarpal fractures, Boxer’s/5th metacarpal fracture, Bennet’s thumb fracture, Rolando Fracture, and phalangeal fracture

Lower limb

Lower Limb Conditions - Hip

o Osteoarthritis o Avascular necrosis o Hip dislocation o Snapping hips o Iliotibial band syndrome

- Thigh o Trochanteric bursitis

- Knee o Osteoarthritis o Ligament tears (collateral and cruciate) o Meniscal tears o Patellar dislocation o Knee dislocation o Patellar tendon rupture

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o Patella chondromalacia o Patellofemoral syndrome o Popliteal cysts (e.g. Baker’s cyst) o Pre-patellar bursitis

- Leg - Ankle

o Ankle ligament injuries (acute ankle sprains and syndesmosis injury) o Achilles tendinitis o Achilles rupture o Tarsal tunnel syndrome o Ankle arthritis

- Foot o Plantar fasciitis o Pes planus o Hallux valgus o Morton neuroma o Toe deformity (claw, hammer, mallet) o Charcot foot o Clawed foot (covered in Year 5 Paediatrics) o Clubbed foot (covered in Year 5 Paediatrics)

Lower Limb Fractures

- Neck of femur fractures - Trochanteric fractures - Femoral fractures: shaft fracture, supracondylar (Hoffa) fracture, and condyle fracture - Patellar fractures - Tibial fractures: plateau fracture and shaft fracture - Fibula fractures - Ankle fractures - Foot fracture: tarsometatarsal fracture dislocation (Lisfranc’s), talus fracture, calcaneal

fracture, and metatarsal fracture

Specialist Topics

Infection

- Bone infections (e.g. osteomyelitis) - Joint infections

o Native joint infections (septic arthritis) o Infected joint replacements

Tumours

- Types: benign and malignant bone tumours (primary e.g. osteosarcoma, ewing sarcoma and secondary e.g. prostate, breast)

- Bone cysts, fibrous dysplasia, osteochondroma, enchondroma chrondroblastoma, chondrosarcoma

Rehabilitation

- Physiotherapy principles (strengthening and range of movement exercises) - Assistive devices: walking stick, arm slings, crutches, ankle stabiliser, thumb splints - Occupational therapy principles (regarding devices improving function in the home)

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Sports medicine

- Acute care (RICE principles) - Physiotherapy principles (strengthening and range of movement exercises)

Innovation

Basic Science

- Lower limb anatomy - Upper limb anatomy - Spinal anatomy - Myotomes and dermatomes - Bone histology (cell types) - Inflammation and infection basic principles - Fracture healing physiology (including bone remodelling)

Biomechanics

- Tension band wiring principles - Gait physiological principles

o Trendelenburg gait principles

Biostatistics

- Basic principles of statistical analysis - Patient Reported Outcome Measures - National Joint Registry - National Hip Fracture Registry

Paediatrics

- Salter-Harris Physeal Fractures (covered in Year 5 Paediatrics)