1
Q
What are the clinical findings of ankylosing spondylitis?
A
reduced chest expansion, reduced lateral flexion and reduced forward flexion (Schober’s test)
2
Q
Sulfasalazine can cause what?
A
Reduced sperm count -> usually returns to normal upon stopping the medication
3
Q
What would joint aspiration of rheumatoid arthritis show?
A
- High WBC
- Polymorph neutrophils
- Cloudy/Yellow appearance
4
Q
What is previous chemo a big risk factor for?
A
Avascular necrosis
5
Q
Methotrexate plus trimethoprim can cause what?
A
Bone marrow suppression and panycytopenia
6
Q
DIP swelling and dactylitis with arthritis suggests what?
A
Psoriatic arthritis
7
Q
Which antibody is specific for anti-phospholipid syndrome?
A
Anticardiolipin antibody
8
Q
What are the smoking cessation drugs?
A
- Nicotine replacement (causes N+V, headaches, flu symptoms)
- Varenicline (causes nausea and C/I in pregnancy/BF)
- Bupropion (reduces seizure threshold)
9
Q
What type of shock does tension pneumothorax cause?
A
Obstructive
10
Q
Which lung cancer is gynaecomastia associated with?
A
Adenocarcinoma of the lung
11
Q
What does an isolated rise in ALP suggest?
A
Pagets disease of the bones
12
Q
What is Paget’s disease of the bone?
A
Increased but uncontrolled bone turnover- XS osteoclast resorption and increased osteoblastic activity
13
Q
What is most commonly affected in Paget’s
A
Skull, spine/pelvis, long bones of lower extremities
14
Q
Paget’s predisposing factors?
A
Age, male, northern latitude, FHx
15
Q
Paget’s CP
A
- 5% symptomatic
- older male with bone pain and raised ALP
- bone pain: pelvis, lumbar, femur
- bowing of tibia, bossing of skull
16
Q
Paget’s Ix
A
- bloods
- other markers of bone turnover
- x-ray= osteolysis in early disease; mixed lytic/sclerotic lesions later. Skull= thickened vault, osteoporosis circumscripta
- Bone scintigraphy (increased uptake at sites of active bone lesions)
17
Q
Bloods in Paget’s?
A
- Raised ALP
- Ca and phosphate normal (sometimes hypercalcaemia with prolonged immobilisation)
18
Q
Other markers of bone turnover in Paget’s?
A
- procollagen type I N-terminal propeptide (PINP)
- serum C-telopeptide (CTx)
- urinary N-telopeptide (NTx)
- urinary hydroxyproline
19
Q
Paget’s Mx?
A
- Bisphosphonate (oral risedronate or IV zoledronate)
- calcitonin less common
20
Q
Paget’s indications for Mx
A
Bone pain, skull or long bone deformity, fracture, periarticular Paget’s
21
Q
Paget’s Cx
A
Deafness, bone sarcoma, fractures, skull thickening, high-output cardiac failure
22
Q
subchondral erosions, sclerosis
and squaring of lumbar vertebrae
A
Anklyosing spondylitis
23
Q
What is the most common site of metatarsal stress fractures?
A
2nd metatarsal
24
Q
hyperpigmentation of the palmar creases indicates what?
A
Addisons
25
How should proximal scaphoid pole fracture be managed?
Refer to orthopaedics for surgical fixation
26
Features of a acetabular labral tear?
- Following trauma
- Hip/groin pain
- Snapping sensation
27
Features of a femoroacetabular impingement?
- More chronic history
28
Long term steroid use/chemo therapy + someone with hip pain suggests?
Avascular necrosis of the hip
29
Pain following tibial surgery?
Compartment syndrome
30
What is the management of AVN?
If displaced: total hip replacement for anyone who is mobile, no co-morbidities etc otherwise hemiarthroplasty
If not displaced: internal fixation
31
Rheumatic vs psoriatic arthritis?
Psoriatic will be asymmetrical
32
When should uric acid levels be measured again with gout?
2 weeks after the flare has settled
33
X-ray findings for rheumatoid arthritis
L – loss of joint space
E – erosions
S – soft tissue swelling
S – soft bones (periarticular osteopenia)
+ juxta-articular osteoporosis
subluxation
34
Extra-articular manifestations of RA?
Nodules, scleritis, episcleritis, pleural effusion, Felty, anaemia, Raynaud's, carpal tunnel
35
RA, Splenomegaly and neutropenia?
Felty
36
Antibody of choice for RA
Anti-ccp
37
Hand signs for RA
- Ulnar deviation
- Swan neck deformity
- Z neck thumb
- Muscle wasting
- Wrist subluxation
38
What organism can cause septic arthritis with metal joint?
Early stages after surgery - staph aureus
Later onset - staph epidermidis
39
What are risk factors for septic arthritis?
RA, DM, Immunosuppression, Penetrating injury, infection elsewhere
40
What are the rotator cuff muscles?
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
41
What muscles are responsible for shoulder abduction?
0-15 degrees: supraspinatus
15 - 90 degrees: deltoid
90 degrees+: Trapezius and serratus anterior
42
Which muscles does the accessory nerve innervate?
Deltoid and teres minor
43
Investigations to assess for supraspinatus impingement?
US and MRI
44
Proximal muscle weakness + raised CK + no rash
Polymyositis
45
Dermatomyositis vs polymyositis
Dermatomyositis would have a rash
46
What would be seen on X-ray to support a diagnosis of ankylosing spondylitis?
Sacro-ilitis
47
What should be given to women >75 with a fragility fracture?
Bisphosphonates
48
When should a referral for sciatica be considered?
4-6 weeks after analgesia + physio treatment
49
What are the features of ankylosing spondylitis?
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
and cauda equina syndrome
50
Pain worse on walking on tip toes?
Plantar fasciitis
51
Fever + back pain + IVDU
Iliopsoas abscess
52
What is the treatment for psoas abscess?
Abx + percutaneous drainage
53
muscle wasting of the hands, numbness and tingling and possibly autonomic symptoms
Neurogenic thoracic outlet syndrome
54
What is osteomalacia?
Softening of the bones secondary to vit D deficiency
55
How does osteomalacia present?
- Bone pain/tenderness
- Fractures e.g NOF
- Proximal myopathy: waddling gait
56
How would osteomalavcia present on investigations?
- Low Vit D
- Low calcium and phosphate
- Raised ALP
- Translucent bands over the X-ray
57
Management of NOF fractures
Non-displaced + intracapsular: cannulated screw fixation
Stable + extra capsular: dynamic hip screw
Displaced + Intacapsular if not very mobile older patient: Hemiarthroplaty
Displaced + intracapsular if young/mobile older patient: Total hip arthroplasty
58
flexion deformities of his 4th and 5th digit which cannot be passively corrected
Duputrynes contracture
59
What is often the earliest sign of Dupuytrens?
Firm, thickened palmar nodule over the metacarpal head
60
What are risk factors for Dupuytrens?
- Diabetes
- Alcohol
- FH
- AIDS
61
Limited vs diffuse cutaneous systemic sclerosis
Diffuse will have widespread skin and organ involvement (lungs and kidneys)
62
What is fat embolism?
A syndrome secondary to trauma/fractures/orthopaedic surgery
63
How does fat embolism present?
Pulmonary: PE like symptoms
Neuro: altered mental status, seizures, coma
Derm: petechial rash on upper body
Managed with supportive treatment/prophylaxis
64
What are common precipitants of gout?
- Surgery
- Dehydration
- Alcohol
- Trauma
- Infection
- Foods rich in purines
65
What are x-ray findings of gout?
- Normal joint space
- Soft tissue swelling
- Periarticular erosions
66
What can be some examination findings of osteoarthritis?
- Antalgic gait
- Joint swelling
- Joint tenderness
- Pain on movement
- Crepitus
- Reduced ROM
67
purple discolouration of eyelids in dermatomyositis?
Heliotrope
68
What are Gottron's papules?
Rough, red papules over the knuckles -> dermatomyositis
69
What antibodies are associated with dermatomyositis?
Anti-Jo, Anti-MI, RF, ANA
70
What is Raynauds phenomenon?
Peripheral digital ischaemic caused by vasospasm which is precipitated by cold/emotion
71
What are some causes of Raynauds phenomenon?
- SLE
- Raynaud's disease
- RA
- Ehler-Danlos
- Beta blockers
- Atherosclerosis
72
What are the features of CREST?
Calcinosis
Raynaud's
Oesophageal dysmotility
Sclerodactyly
Telangiectasia
73
What respiratory condition is associated with AS?
Pulmonary fibrosis
74
What is mononeuritis multiplex?
Damage to 2+ peripheral nerves
75
What are causes of mononeuritis multiplex?
- HIV/AIDS
- Diabetes
- RA
- Sarcoidosis
76
What is the definitive investigation for Sjogrens?
Salivary gland biopsy
77
What is the most common cause of cauda equina syndrome?
Lumbar disc herniation at L4/L5/ or L5/S1
78
Pseudogout is strongly associated with what?
Haemochromatosis
79
What are the most specific markers for SLE?
anti-dsDNA and anti-SM
ANA - most sensitive
80
Erb's palsy has injury to which myotomes?
C5 and C6 (11 erbs and spices)
81
How does Erb's palsy present?
Imparied wrist extension and elbow flexion - waiters tip
82
Carbamazepine increases risk of what?
Osteoporosis
83
Back pain red flags?
- Thoracic or cervical spine pain
- Progressive pain not relieved by rest
- Fevers, chills, weight loss
- Early morning stiffness > 30 mins
- Bowel/bladder/neuro dysfunction
84
What should be given for cord compression secondary to bone metastases?
Dexamethasone
85
Osteoporosis risk factors?
Steroids
Hyperthyroidism/Hyperparathyroidism
Alcohol/Smoking
Thin
Testosterone deficiency
Early menopause
Renal failure
Erosive bone disease
Diabetes
86
What is a Colles fracture?
Fracture of the distal radium with dorsal angulation of the distal fracture fragments
87
Septic Arthritis in a prosthetic joint?
Admit patient and arrange ortho review
88
pain and swelling at the base of the thumb and along the radial aspect of the wrist, often worsened by thumb movement or grasping in a YOUNG person
De Quervain;s tenosynovitis
89
What should take place before starting anyone on biologics?
Quantiferon test - assess for TB as biologics can reactivate latent TB
90
Abx regiment for septic arthritis?
2 weeks of IV plus 4 weeks of orals
91
Which antibodies are specific for anti phospholipid
Anti-beta-2-glycoprotein I antibody
92
What is a common early finding in professional players who have had trauma?
Osteoarthritis
93
What cover should be given to those receiving allopurinol?
NSAIDs cover for 3 months as allopurinol can acutely raise urate levels
94
'rain-drop skull'
Myeloma
95
'pepper pot skull'
Hyperparathyroidism
96
What are the most common side effects of colchicine?
Diarrhoea, nausea + vomiting
97
What scoring system can be for RA and what does it indicate?
Disease-activity score
<2.6 - remission
>5.1 - high disease activity
98
What is the dose for steroids in GCA?
60mg of prednisolone
99
How would lumbar spondylosis present?
- Arthritis like pain which gets worse throughout the day in older patients
100
What is recommended in patients with GCA with CVD risk factors/IHD?
Aspirin 75mg as prophylaxis
101
What is the inheritance of Marfans?
Autosomal dominant
102
How should methotrexate be monitored?
FBC, Renal function and LFTs weekly until established then every 2-3 months
103
What can patients with limited systemic sclerosis develop as a late manifestation?
Interstitial lung disease
104
What investigation should be done for women with polymyalgia due to steroid use?
DEXA
105
What are the 4 features of antiphospholipid syndrome?
Clots - VTE/PE
Livedo reticularis
Obstetric loss
Thrombocytopenia
106
c-ANCA positive?
Granulomatosis with polyangiitis
107
What are features of granulomatosis with polyangiitis?
- Resp involvement
- Kidney involvement: glomerulonephritis
- Systemic symptoms
- Ocular manifestations e.g. scleritis
108
How is granulomatosis with polyangiitis managed?
- Cyclophosphamide/rituximab in acute
- Azathioprine/Methotrexate during remission
109
asthma, nasal polyps and a mononeuritis multiplex
Eosinophilic granulomatosis with polyangiitis
110
Recurrent oral and genital ulcers with uveitis and erythema nodosum?
Behcet's disease- HLA B51
111
Common sites where osteoporotic fragility fractures occur?
- Pubic ramus
- Hip
- Distal radium
- Proximal humerus
112
What are side effects of bisphosphonates?
- Abdominal pain
- Dyspepsia
- Nausea
- Abdominal distension
- Oesophageal ulceration
113
What is the first line imaging in myeloma?
MRI
114
Acute back pain in a patient with osteoporosis?
Think osteoporotic verterbral fracture -> X-ray needed
115
What is the Z score adjusted for in patients with DEXA scans?
Age, gender and ethnic factors
116
What antibodies are found in CREST syndrome?
Anti-centromere
117
What is Behcet's syndrome?
- Common in young Turkish men
- Oral ulcers, genital ulcers and anterior uveitis
- Erythema nodosum also present
118
Which DMARD is associated with retinopathy?
Hydroxychloroquine
119
What is Caplan syndrome?
Massive fibrosis in patients with RA and pneumoconiosis
120
What is polyarteritis nodosa?
Medium vessel vasculitis common in middle aged men with Hep B
Can cause testicular pain, weight loss, HTN, renal failure
PANCA positive
121
Ejection systolic murmur with SLE?
Libman-Sacks endocarditis
122
What are some skin changes with dermatomyositis?
- Heliotrope rash of eyelids
- Periorbital oedema
- Dilated capillary loops under the fingernails
123
What are some symptoms of dermatomyositis?
- Muscle swelling
- Muscle tenderness
- Arthralgia
- Fatigue
- Weakness
124
What are some symptoms of fibromyalgia?
- Pain
- Sleep disturbance
- Paraesthesia
- Memory disturbance
- Headaches
- Dizziness
125
What are some skin changes with Reiters?
- Mouth ulcers
- Erythema nodosum
- Keratoderma blennorrhagica (yellow/brown papules on soles of feet)
126
What are some cardiac complications of Reiters?
- Pericarditis
- Aortic regurg
- Aortitis
127
What is there not in someone with polymyalgia?
True weakness of muscles -> normal power
128
Management of a prolapsed disc?
Analgesia + Physio
129
Painful click on McMurrays test?
Think twisted knee injury - meniscal tear
130
What is a Galeazzi fracture?
Dislocation of the distal radioulnar joint with an associated fracture of the radius
131
tenderness in the anatomic snuffbox dorsally
Scaphoid fracture
132
What should be corrected before giving bisphosphonates?
Calcium level / Vit D deficiency
133
Pain on the radial side of the wrist/tenderness over the radial styloid process in a young women?
De Quervain's tenosynovitis
134
What does co-trimoxazole contain?
Trimethoprim -> think about methotrexate
135
Most likely places for bone mets?
Women - breast
Men - prostate
136
What are major risk factors for osteoporosis?
- Steroid use
- RA
- Alcohol excess
- Low BMI
- Smoking
137
What will the blood test values be with osteoporosis?
Everything normal
138
Imaging of choice for osteomyelitis?
MRI
139
lead pipe appearance of the colon
Ulcerative colitis
140
popping sensation, immediate swelling and immediate unable to weight-bear
ACL injury - Lachmans test
141
Knee locking and giving-way
Meniscal lesions
142
What is the management of newly diagnosed RA?
Methotrexate and oral steroids
143
Z score is helpful for what?
Diagnosing secondary osteoporosis
144
Compartment syndrome produces what?
Pain on passive stretch
145
What is the management of flares of rheumatoid arthritis?
Steroids oral or IM
146
When can reactive arthritis present and how long do symptoms last?
- Can develop upto 4 weeks after initial infection
- Symptoms last around 4-6 months
147
dull shoulder pain, that often disturbs sleep, followed by
stiffness and loss of shoulder mobility
Frozen shoulder - Adhesive capsulitis
148
Management of undisplaced scaphoid fractures?
Cast for 6-8 weeks
149
What are some hand signs of psoriatic arthritis?
- Dactylitis
- Nail pitting
- Onchylosis
- Nail discolouration
150
What are some X-ray findings of psoriatic arthritis?
- Soft tissue swelling
- Bony erosions
- Pencil in cup deformity
- Loss of joint space
151
What is the most severe form of psoriatic arthritis?
Arthritis mutilans
152
What is the treatment of psoriatic arthritis?
- NSAIDs if mild
- Methotrexate
- anti-TNF biologics
153
Chalky nodules in someone with gout?
Gouty tophi
154
What HLA type is rheumatoid?
HLA-DR4 / HLA-DR1
155
Risk factors for pseudogout?
- Steroid use
- Hyperparathyroidism
- Haemochromatosis
- Wilson's
- Acromegaly
156
What is the prognosis of pseudogout?
Resolves within 10 days
157
What are some complications of eosinophilic granulomatosis with polyangiitis?
- HF
- Myocarditis
- HTN
- Stroke
- Bowel ischaemia
- Pancreatitis
158
Prophylactic bisphosphonates should be offered to who?
Those with T score <1.5 if they are on steroids for more than 3 months
159
What should alendronate be changed to if patients are experiencing bad GI side effects?
Risedronate
160
SGLT-2 inhibitors can increase the risk of what?
Ulcers or infection -> increased risk of amputation
161
Which organism causes osteomyelitis in sickle cell?
Salmonella
162
anti-histone antibodies can be a sign of what?
Drug induced lupus - common causes include isoniazid, phenytoin
163
Lace like rash on shins is a sign of what?
Livedo reticularis -> associated with anti-phospholipid syndrome
164
raised CRP in a patient with known SLE
Can suggest underlying infection
165
What is an early x ray finding of rheumatoid arthritis?
Juxta-articular osteopenia
166
What is a fragility fracture?
A fracture from a fall from standing height or less
167
What are examples of fragility fracture?
- Vertebral compression fractures
- Hip
- Distal radium
- Proximal humerus fracture
168
Nerve and which fracture they are associated with?
Radial - fracture of shaft of humerus (wrist drop)
Ulnar - supracondylar fracture of humerus
Axillary - fracture of proximal humerus
169
Bilateral carpal tunnel?
Rheumatoid
170
Lateral knee pain in a runner?
Iliotibial band syndrome -> treat with stretches
171
Lateral epicondylitis causes what?
- Pain worse on supination of the wrist
- Pain worse on wrist extension against resistance
172
What is the main structure which is damaged in scaphoid fractures?
dorsal carpal branch of the radial artery
173
dislocation of the proximal radioulnar joint in association with an ulnar fracture
Monteggia fracture
174
Most common sites of osteomyelitis in children and adults?
Children - Metaphysis
Adults - Epiphysis
175
What are different management options for carpal tunnel?
- Night splints
- Intraarticular steroid injections
- Carpal tunnel decompression
176
Bruised, swollen, deformed and painful elbow?
Think supracondylar fracture
177
What would Perthes disease x-ray show?
- Widening of joint space
- Decreased femoral head size
- Flattening
178
What are surgical management options for osteoarthritis?
- Osteotomies
- Arthroplasty
179
What is duputryens?
Thickening of the palmar fascia which eventually causes a fixed flexion deformity
180
What is the most common type of shoulder dislocation?
Anterior dislocation
181
What is the weight bearing status after NOF surgeries?
Cannulated screws - less than full initially
Everything else - full weight bearing
182
Radiculopathy vs myelopathy
Radiculopathy - compression of a single nerve root which has exited the spinal cord
Myelopathy - pain due to compression of the spinal cord
183
Which nerve roots correspond to reflexes?
Ankle - S1/2
Knee - L3/L4
Bicep - C5/C6
Tricep - C7/C8
184
Simmonds test - calf squeeze
Achilles tendon rupture
185
Which knee compartment is most commonly affected in osteoarthritis?
Medial
186
Open tibial fractures should be covered with what?
Sterile saline gauze
187
Which muscle is responsible for the weakness in thumb abduction in carpal tunnel?
Abductor pollicis brevis
188
Haematogenous vs direct contamination?
Haematogenous - infection reaches bone through bloodstream
Direct contamination - infection spreads directly from adjacent tissues/structures to the bone
189
Bakers cysts occur secondary to what?
Degeneration
190
Imaging for achilles tendon rupture?
US
191
What is the test of choice for Duputryen's?
Table top test
192
Which arteries are at risk in NOF?
Circumflex arteries
193
Soft, non-tender swelling near joints or tendons, containing clear,
viscous fluid
Ganglionic cyst
194
Sciatic nerve originates from?
L4-S3
195
What is RICE mnemonic for soft tissue injuries?
Rest, ice, compression, elevation
196
Synovial fluid aspiration in someone with reactive arthritis?
No organisms will be recovered + cloudy/yellow colour
197
What is the most common mechanism of ankle sprains?
Inversion
198
Any MSK pain/Osteoarthritis first line treatment?
Topical NSAIDs/Oral NSAIDs
199
What is spondylolisthesis?
One vertebra slips out of line with one above it, usually in the lumbar spine
200
Pain on painful arc with normal X ray?
Painful arc syndrome / subacromial bursitis / impingement syndrome
201
Trigger finger management?
1. Rest and splint
2. NSAIDs
3. Steroid injections
202
What are examination findings of NOF?
Affected side shortened
Externally rotated
Abducted
203
S/E of bisphosphonates
- Oesophageal erosions
- Osteonecrosis of jaw
- Atypical fractures
204
CREST antibodies?
- Anti-centromere
- Anti-Scl70
205
What are pulmonary complications of CREST?
- Pulmonary fibrosis
- Pulmonary HTN
206
What are causes of sciatica?
- Spinal stenosis
- Disc herniation
- Pelvic tumours
207
Greenstick fractures are unique to who?
Children - usually under 10s
208
3rd line management for acute gout in renal disease?
Steroids
209
What is the investigation of choice for Takayasu's arteritis?
CT angio
210
What is Caplan syndrome?
RA plus pulmonary nodules
211
What is the diagnostic test for Behcet's disease?
Pathergy test
212
Diabetics are susceptible to what infections?
Staphylococcal
213
diffuse thickening of the pancreatic body and tail
Sausage pancreas sign -> autoimmune pancreatitis
214
Antiphospholipid causes prolonged what?
APTT
215
What drug makes Raynaud's worse?
Propranolol
216
RA spares which joint?
DIP
217
Progressive shoulder pain with reduced ROM in middle aged?
Frozen shoulder
218
Management of achilles tendonitis?
Rest, NSAIDs and physio if symptoms persistent beyond 7 days
219
What is Simmonds triad?
- palpation
- examining the angle of declination at rest
- squeeze test
220
Investigation for suspected hip fracture if X-ray is normal?
MRI
221
What can be done for NOF fractures?
Iliofascial nerve block
222
What is the most common reason for revising a total hip replacement?
Asceptic loosening of the implant
223
Joint aspirate with high WBC count, mainly neutrophils with well patient?
Rheumatoid
224
Gold standard diagnostic investigation for Ankylosing spondyliitis?
MRI of sacroiliac joints
225
Methotrexate can cause what when not given folate alongside?
Macrocytic anaemia due to folate deficiency
226
What is the treatment for reactive arthritis?
NSAIDs
227
Management of patients who do not respond to steroids in poly myalgia?
Refer to specialist
228
Compartment syndrome can cause what?
Rhabdomyolysis
229
Management of undisplaced patella fracture with intact extensors?
Conservative with knee immobilisation
230
Management of renal hypertensive crises in systemic sclerosis?
ACE inhibitors
231
What are S/E of leflunomide?
Raised BP and peripheral neuropathy
232
What is the anticoagulant of choice in antiphospholipid?
Warfarin
233
Kids born to mums with SLE/Sjogrens can get what?
Congenital heart block -> neonatal lupus syndrome
234
Axial spondyloarthritis?
group of clinically heteriogeneous chronic inflam rheumatologic conditions that may cause MSK and extra MSK manifestations
features of axial (saroiliac joints and spine) and peripheral spondyloarthritis can overlap and coexist
eg. alkylosing spondylitits
235
Radiographic axial spondyloarthritis is characterised by?
signs of sacroilitis and structural changes on x-ray (aka ankylosing spondylitis)
236
Non-radiographic axial spondyloarthritis?
no x-ray changes but possible sarcoilitis on MRI
237
Extra-MSK manifestations of axial spondyloarthritis?
acute anterior uveitis, IBD, psoriasis
238
Ankylosing spondylitis?
HLA-B27 associated sponyloarthropathy
239
When does ankylosing spondylitis typically present?
20-30yrs
men>women
240
Spondyloarthropathy?
group of chronic inflam diseases that affects the joints
241
Features of ankylosing spondylitis?
- typically young man with lower back pain and stiffness of insidious onset
- stiffness worse in morning and improves with exercise
- may be pain at night which improves on getting up
- extra-MSK manifestations
242
Stiffness in ankylosing spondylitis?
worse in morning and improves with exercise
243
Clinical exam in ankylosing spondylitis?
- reduced lateral flexion
- reduced forward flexion (Schober's test)
- reduced chest expansion
244
What test is used in ankylosing spondylitis?
Schober's= reduced forward flexion
line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible
245
Extra-MSK features of ankylosing spondylitis?
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
cauda equina syndrome
peripheral arthritis (25%, more common if female)
246
When to suspect and refer for ankylosing spondylitis?
- low back pain, spinal stiffness, <45yrs and >3m with:
- 4+ of: started before 35yrs, waking at night with pain, buttock pain, improves with movement and within 48hrs of NSAIDs, FHx, current/past arthritis or/+ psoriasis
or
- with 3 criteria and +ve HLA-B27 blood test
or
- suspected dactylitis
247
Ix for ankylosing spondylitis?
- Bloods= inflam markers raised; HLA-B27 +ve (positive in 90%)
- Plain x-ray of sacroiliac joints= diagnosis (may be normal in early disease)
- If X-ray -ve then MRI
- spirometry= restrictive defect
248
Later changes of ankylosing spondylitis on plain x-ray of sacroiliac joints?
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
'bamboo spine' (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis
249
What would MRI in ankylosing spondylitis show?
signs of early inflam invl. sacroiliac joints (bone marrow oedema)
250
Why in ankylosing spondylitis does spirometry show a restrictive defect?
combination of pulmonary fibrosis, kyphosis and ankylosis of costoverebral joints
251
Mx of ankylosing spondylitis?
- regular exercise eg. swimming
- 1st= NSAIDs
- physio
- if peripheral joint invl. may consider DMARDs eg. sulphasalazine
- Anti-TNF therapy if persistent high disease despite other Tx eg. entanercept and adalimumab
252
Follow up for pt with ankylosing spondylitis?
- risk of osteoporosis and screening every 2yrs
- same day referral to opthal if acute anterior uveitis suspected
253
Compartment sydrome?
raised pressure within a closed anatomical space; will eventually compromise tissue perfusion resulting in necrosis
254
Compartment syndrome is a Cx that may occur following what?
fractures
or ischaemia reperfusion injury in vascular pts
255
2 fractures that may cause compartment syndrome?
supracondylar fractures and tibial shaft injuries
256
Sacroiliac joints?
joints that connect the sacrum (the base of the spine) to the ilium (the pelvis)
257
Features of compartment syndrome?
- Pain= esp on movement (even passive), XS use of breakthrough analgesia
- paraesthesia
- pallor
- paralysis of muscle group may occur
- arterial pulse may still be felt
258
Why may arterial pulsation still be felt in compartment syndrome?
as the necrosis occurs as a result of microvascular compromise
259
What does NOT rule out compartment syndrome?
presence of a pulse
260
Pt has fracture, has pain on movement (even passive) and is using excessive use of breakthrough analgesia?
think compartment syndrome
261
Diagnosis of compartment syndrome?
- measure intracompartmental pressure; >20mmHg pressure is abnormal and >40 is diagnostic
- typically no pathology on x-ray
262
fasciotomy?
surgical procedure that involves cutting the fascia, or connective tissue, around a muscle to relieve pressure and increase blood flow
limb saving procedure
263
Mx of compartment syndrome?
- prompt and extensive fasciotomies
- aggressive IV fluids
264
Compartment syndrome: why do pts require aggressive IV fluids?
Myoglobinuria may occur following fasciotomy and result in renal failure.
265
What may happen in fasciotomy for compartment syndrome?
if operator is inexperienced, smaller incisions may be performed and in the lower limb the deep muscles may be inadequately be decompressed
266
Compartment syndrome: what if muscle groups are frankly necrotic at fasiotomy?
should be debrided and amputation may be considered
267
How quick does death of muscle groups occur in compartment syndrome?
within 4-6hrs
268
Gout?
type of arthritis caused by monosodium urate crystals forming inside and around joints, causing sudden flares of severe pain, heat and swelling
269
Joints affected in gout?
any joint but most commonly= distal joints eg. toes, knees, ankles, finger joints
270
Most important RF for the development of gout?
hyperuricaemia
271
RFs for gout?
- hyperuricaemia
- increasing age
- FHx
- genetics
- obesity
- male
- diet
- postmenopausal
- medications
- CKD, HTN, DM
272
What type of diet is a RF for gout?
XS alcohol, sugary drinks, red meat, seafood
273
What drugs are RFs for gout?
diuretics (thiazides, furosemide), low-dose aspirin, ciclosporin, alcohol, cytotoxic agents, pyrazinamide
274
Cx of gout?
- CVD
- chronic arthritis
- CKD
- joint damage
- reduced QOL
- renal stones
- tophi
275
Tophi?
hard, stone-like deposits of monosodium urate crystals that form in the soft tissues, cartilage, tendons, or bones near joints
usually painless
eg. in gout
276
Presentation of gout?
rapid onset severe pain, redness and swelling in one or both first metatarsophalangeal joints. May be midfoot, ankle, knee, hand, wrist or elbow.
tophi
277
Ix for gout?
- clinical exam
- serum urate 6mg/dL (360micromol/L) or more confirms diagnosis
278
Mx for gout?
acute= NSAIDs or colchicine (until 1-2d after flare resolved) or short course oral corticosteroid (pred 30-35mg od 3-5d)
long term= urate-lowering therapy eg. allopurinol or febuxostat
279
Who should urate-lowering therapy eg. allopurinol be offered to pts with gout?
multiple/troublesome flares
CKD stage 3-5
on diuretic therapy
have tophi
or have chronic gout
280
Where can tophi in gout appear?
extensor surfaces of affected joints, Achilles tendons, dorsal aspect of hands and feet and in the helix of the ears. They suggest longstanding, untreated gout.
281
Most common joint affected in gout?
1st metatarsophalangeal joint (big toe)
282
Is gout monoarticular?
usually bit can be oligoarticular or rarely polyarticular
283
When does flare severity reach max intensity in gout?
within 24hrs
284
When to measure serum urate level for gout diagnosis?
diagnosis= 360micromol/L or more
- if lower but suspect gout repeat serum urate in 2-4w after flare settled
285
Diagnosis of gout?
- serum urate level 2-4w after flare has settled
if uncertain then:
- joint aspiration and microscopy of synovial fluid
- still uncertain the x-ray
286
Gout differential diagnosis?
- bursitis, tenosynovititis, cellulitis
- haemochromatosis
- psuedogout
- osteoarthritis
- psoriatic arthritis
- reactive arthritis
- RA
- septic arthritis
- trauma
287
What must be considered in any person who is systemically unwell (with or without a temperature) and an acutely painful, hot, swollen joint?
septic arthritis
288
Self-care advice for gout?
- rest and elevate limb
- keep joint exposed and in cool environment
- consider ice pack
289
Follow up following acute flare of gout?
4-6w after settled:
- serum urate
- review meds
290
form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium
gout
291
What causes gout?
chronic hyperuricaemia (uric acid >0.45mmol/l)
292
Gout episodes?
typically flares that can last several days then often symptom free episodes in between
293
Name 4 commonly affected joints in gout?
1st MTP joint= big toe
knee
ankle
wrist
294
Synovial fluid analysis in gout?
needle shaped negatively bifringent monosodium urate crystals under polarised light
295
X-ray findings in gout?
- joint effusion (early sign)
- well-defined 'punched-out' erosions with sclerotic margins in a juxta-articular distribution, often with overhanging edges
- relative preservation of joint space until late disease
- eccentric erosions
- no periarticular osteopenia (in contrast to rheumatoid arthritis)
- soft tissue tophi may be seen
296
MOA of colchicine used for acute flares of gout?
inhibits microtubule polymerization by binding to tubulin, interfering with mitosis. Also inhibits neutrophil motility and activity
Slow onset of action
297
Main side effect of colchicine?
diarrhoea
298
When should colchicine for acute gout be used with caution?
in renal impairment: reduce dose if GFR 10-50 and avoid if <10ml/min
299
Acute flare of gout, if pt is on allopurinol should this be continued alongside other drugs for acute flares?
yes continue allopurinol
if havent started it before, start once acute flare settled
300
Urate lowering therapy is particularly recommended for pts with gout when?
Now offer to all pts after 1st attack.
Esp:
- >= 2 attacks in 12 months
- tophi
- renal disease
- uric acid renal stones
- prophylaxis if on cytotoxics or diuretics
301
Allopurinol dose for gout?
initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 360 µmol/l
a lower target uric acid level below 300 µmol/L may be considered for patients who have tophi, chronic gouty arthritis or continue to have ongoing frequent flares despite having a uric acid below 360 µmol/L
a lower initial dose if pt has a reduced eGFR
colchicine cover should be considered when starting allopurinol. NSAIDs can be used if colchicine cannot be tolerated.
302
Avoid what foods in gout?
food high in purines eg. liver, kidneys, seafood, oily fish (mackerel, sardines), red meat, yeast products
303
Other considerations in the Mx of gout?
- high vit C may lower serum uric acid
- maybe stop precipitating drugs eg. thiazides
304
Lesch-Nyhan syndrome?
hypoxanthine-guanine phosphoribosyl transferase (HGPRTase) deficiency
x-linked recessive therefore only seen in boys
features: gout, renal failure, neurological deficits, learning difficulties, self-mutilation
305
What may cause hyperuricaemia (increased levels of uric acid)?
secondary to increased cell turnover or reduced renal excretion of uric acid
may be associated with hyperlipidaemia and HTN and metabolic syndrome
306
Hyperuricaemia caused by increased synthesis examples?
Lesch-Nyhan disease
myeloproliferative disorders
diet rich in purines
exercise
psoriasis
cytotoxics
307
Hyperuricaemia caused by decreased excretion examples?
drugs: low-dose aspirin, diuretics, pyrazinamide
pre-eclampsia
alcohol
renal failure
lead
308
Pseudogout?
form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium.
aka acute calcium pyrophosphate crystal deposition disease
309
Pseudogout RFs?
- increasing age
- haemochromatosis
- hyperparathyroidism
- low magnesium, low phosphate
- acromegaly
- Wilsons
310
Features of pseudogout?
knee, wrist and shoulders most commonly affected like gout just different cause
311
Gout vs pseudogout?
Gout is caused by monosodium urate monohydrate crystals; pseudogout is caused by calcium pyrophosphate (CPP) crystals
312
Joint aspiration findings in psuedogout?
weakly-positively birefringent rhomboid-shaped crystals
313
X-ray findings in pseudogout?
chondrocalcinosis
- in the knee this can be seen as linear calcifications of the meniscus and articular cartilage
314
Mx of psuedogout?
aspiration of joint fluid, to exclude septic arthritis
NSAIDs or colchicine intra-articular, intra-muscular or oral steroids as for gout
can use long term low dose colchicine in chronic to reduce flares
TUC eg. magnesium supplement if hypomagnesaemia
315
Ix for pseudogout?
- joint aspiration for microscopy diagnostic
- x-ray affected joints
can screen for RFs= ferritin (haemochromatosis), magnesium, thyroid function (hypothyroidism), inflam markers +ve, Ca and PTH (hyperparathyroidism)
316
Correct name now used instead of pseudogout?
calcium pyrophosphate deposition disease
317
Greater trochanteric pain syndrome?
regional pain syndrome where chronic intermittent pain is felt around the greater trochanter
318
What is the greater trochanter?
bony prominence on lateral aspect of the hip
319
tronchanteric bursitis?
inflam of a bursa adjacent to greater trochanter
320
Greater trochanteric pain syndrome is caused by what?
inflam or physical trauma in muscles, tendons, fascia or bursae
321
Common population affected by greater trochanteric pain syndrome?
women>men
40-60yrs
322
What other conditions is greater trochanteric pain syndrome typically seen with?
low back pain, osteoarthritis of knee, RA and fibromyalgia
323
Mx of greater trochanteric pain syndrome?
>90% recover fully with conservative Tx eg. rest, pain relief, physio or corticosteroid injection
324
RFs for a poorer outcome of greater trochanteric pain syndrome?
higher initial pain intensity, longer duration of pain, greater movement restriction, higher functional impairment, older age
325
Diagnosis of greater trochanteric pain syndrome?
clinical
326
CP of greater trochanteric pain syndrome?
- lateral hip pain, worse with exercise
- point tenderness adjacent to greater trochanter
- when tendons & muscles attached to greater trochanter are put under tension on exam= point tenderness and pain
327
What should be excluded when diagnosing greater trochanteric pain syndrome?
sports hernia, osteoarthritis, lumbar nerve root compression, infection of bursa
328
Advice for greater trochanteric pain syndrome?
- usually self-limiting
- avoid activity that may worsen pain
- ice pack applied 10-20mins several times a day
- analgesia= paracetamol, NSAIDs
- weight loss
if initial Mx doesnt help then= peri-trochanteric corticosteroid injection and physio
329
Emergency referral in greater trochanteric pain syndrome?
- hip pain with systemic symptoms
- infection s&s
- known primary malignancy
- suspicion of pathological fracture
- sudden inability to bear weight
- Hx of fall
330
Urgent referral to ortho in greater trochanteric pain syndrome?
severe pain unresponsive to analgesia and persistent loss of function
331
Referral to ortho for greater trochanteric pain syndrome?
<40, persistent, affects ADLs, not responded to 3m physio
painful irritable and stiff hip affecting ADLs
332
Features of greater trochanteric pain syndrome?
- chronic lateral hip/thigh/buttock pain
- intermittent or persistent
- gradual
- worsen over time
- may radiate down lateral aspect of thigh but rarely below knee
- aggravated by physical activity eg. walking and with pressure on that side of body eg. lying down
- pain on palpation of greater trochanter
333
Tests to examine for greater trochanteric pain syndrome?
- Trendelenburg's
- Single leg stance
- Hip flexion, abduction, external rotation (FABER)
- Hip flexion, adduction, external rotation (FADER)
- resisted active abduction
- resisted internal rotation
- resisted external rotation
334
Gait in greater trochanteric pain syndrome?
Antalgic gait — there is a shortened stance on the affected leg, and when walking, less time is spent bearing weight on the affected side than on the other.
Trendelenburg gait — there is a lateral trunk lean towards the supported limb during the stance phase.
335
On palpation of the greater trochanter in greater trochanteric pain syndrome, where is tenderness elicited?
at a point over the gluteus medius tendon or its insertion into the greater trochanter.
336
Pain on greater trochanter palpation?
greater trochanteric pain syndrome
337
Trendelenburgs test
With the person standing, they are observed from behind while lifting each foot off the ground in turn.
A positive test is the pelvis dipping (rather than staying horizontal or rising slightly) on lifting the unaffected leg.
338
Single leg stance test?
The person is asked to remain standing on their affected leg with their contralateral knee flexed to 90 degrees for 30 seconds using a finger on the unaffected side on a wall for balance.
The test is positive if there is lateral hip pain within the 30 seconds.
339
Hip flexion, abduction, external rotation (FABER test)
The lateral malleolus of the test leg is placed above the patella of the contralateral leg, the pelvis stabilized via the opposite anterior superior iliac spine and the knee passively lowered so the hip moves into abduction and external rotation. If there is lateral hip pain, the test is positive.
340
Hip flexion, adduction, external rotation (FADER test)
With the person lying supine, the hip is passively flexed to 90°, adducted, and externally rotated to end of range. If there is lateral hip pain, the test is positive.
341
Resisted active abduction
With the person lying supine their hip joints are placed in the neutral position (legs together and straight out). The affected hip joint is abducted by 45 degrees while the person resists the movement. If there is lateral hip pain, the test is positive.
342
Resisted internal rotation
With the person lying supine, the affected hip joint is positioned at 45 degrees flexion and maximal external rotation. The hip joint is internally rotated while the person resists the movement. If there is lateral hip pain, the test is positive.
343
Resisted external rotation
With the person lying supine, the affected hip joint is positioned at 45 degrees flexion and maximal internal rotation. The hip joint is externally rotated while the person resists the movement. If there is lateral hip pain, the test is positive.
344
What may greater trochanteric pain syndrome be referred to as?
trochanteric bursitis
345
What is greater trochanteric pain syndrome due to?
repeated movement of the fibroelastic iliotibial band and is most common in women aged 50-70 years.
346
2 features of greater trochanteric pain syndrome?
1) pain over the lateral side of hip/thigh
2) tenderness on palpation of the greater trochanter
347
Juvenile idiopathic arthritis (JIA)?
arthritis occurring in pt <16yrs and lasts for >6m
348
3 types of Juvenile idiopathic arthritis (JIA)?
- systemic onset= aka Still's disease
- polyarticular= more than 4 joints
- pauciarticular= 4 or less joints
349
Pauciarticular JIA?
4 or less joints are affected
60% of cases of JIA
350
Features of pauciarticular JIA?
joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows
limp
ANA may be positive in JIA - associated with anterior uveitis
351
Another name for systemic onset JIA?
Still's disease
352
Features of systemic onset JIA?
pyrexia
salmon-pink rash
lymphadenopathy
arthritis
uveitis
anorexia and weight loss
353
Ix for systemic onset JIA?
ANA may be positive, especially in oligoarticular JIA
rheumatoid factor is usually negative
354
What is used to rule out clinically significant foot and ankle fractures to reduce the use of x-ray imaging?
Ottawa Ankle Rule:
1) location of pain= malleolar or midfoot
2) bone tenderness location
2) inability to weight bear both immediately after injury AND in ED
355
When is an ankle x-ray only required in ?ankle fracture?
if any pain in malleolar zone and any one of:
- bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
- bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
- inability to walk four weight bearing steps immediately after the injury and in the emergency department
356
In what pts is the hip a common site of fracture?
esp in osteoporotic elderly females
357
What is a risk in displaced hip fractures?
avascular necrosis as the blood supply to the femoral head runs up the neck
358
Features of hip fracture?
- shortened and externally rotated leg
- pain
- may be able to weight bear if non-displaced or incomplete neck of femur fracture
359
Pts with non-displaced or incomplete neck of femur fractures may be able to do what?
weight bear
360
Classification of hip fractures based on location?
intracapsular (subcapital) or extracapsular
361
Intracepsular (subcapital) hip fractures?
from the edge of the femoral head to the insertion of the capsule of the hip joint
362
Extracapsular hip fracture?
can either be trochanteric or subtrochanteric (lesser trochanter is the dividing line)
363
Classification of hip fractures?
Garden system
364
Garden system classification for hip fractures?
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
365
What type of hip fracture according to the Garden system classification is blood supply disruption most common?
types III and IV
366
2 types of intracapsular hip fracture?
- undisplaced fracture
- displaced fracture
367
Mx of intracapsular undisplaced hip fracture?
internal fixation
or hemiarthroplasty if unfit
368
Mx of intracapsular displaced hip fracture?
replacement arthroplasty (total hip replacement or hemiarthroplasty) to all pts
total hip replacement favoured over hemiarthoplasty if pt= able to walk idependently outdoors with no more than use of a stick; not cognitively impaired and med fit for anaesthesia and the procedure
369
Mx of extracapsular hip fracture?
if stable intertrochantic fractures= dynamic hip screw
if reverse oblique, transverse or subtrochanteric fractures= intramedullary device
370
Most common site of stress fracture?
metatarsals
371
Stress fracture?
when fracture occurs due to repeated mechanical stress
372
Metatarsal fractures>
quite common; can be limited to 1 metatarsal or multiple eg. by direct trauma or crush injuries
373
Most common metatarsal affected in fracture?
proximal 5th (also most common site of midfoot fractures)
1st is least commonly fractured
374
5th metatarsal fractures?
Proximal avulsion fractures (pseudo-Jones fractures)= most common type. Occurs at the proximal tuberosity. Usually associated with a lateral ankle sprain and often follow inversion injuries of the ankle.
Jones fractures= much less common. This is a transverse fracture at the metaphyseal-diaphyseal junction.
375
Metatarsal stress fractures?
occurs in otherwise healthy athletes eg. runners
most common site of met stress fractures is 2nd metatarsal shaft
376
5th metatarsal fractures usually associated with what?
lateral ankle sprain and often follow inversion injuries of the ankle
377
Features of metatarsal fracture?
pain and bony tenderness
swelling
antalgic gait
378
Ix for metatarsal fractures?
- x-rays
- isotope scan or MRI= in case of stress fractures as x-ray often normal.
379
When may isotope scan or MRI be preferred to x-ray in metatarsal fractures?
help establish stress fractures, may appear normal on x-ray
380
x-ray for metatarsal fractures?
distinguish between displaced and non-displaced fractures to help guide Mx
stress fractures normally appear normal but sometimes there is a periosteal reaction seen 2-3w later
381
Patella
sesamoid bone that develops within the the quadriceps tendon (dividing it into the quadriceps tendon superiorly and the patella ligament inferiorly).
Protects the knee from physical trauma and plays important role in the extensor mechanism of the knee.
382
How does the patella increase efficieny of quadriceps movement (extensor mechanism of knee)?
The quadriceps apply force around a centre of rotation (the knee joint). The patella increases the distance of the quadriceps tendon from this centre of rotation thereby increasing its efficiency (if you imagine it is easier to open a door by pushing or pulling near the handle as opposed to near the door hinge).
383
Patella anatomy?
roughly triangular in coronal and axial planes. The anterior surface is flat and the posterior surface is composed of a medial and lateral facet and articulates with the femur at the patellofemoral joint.
384
How can the patella be injured?
- direct or indirect means
- consider in the context of the entire extensor mechanism of the knee
- consider posterior surface of the patella as any disruption of the patellofemoral joint may lead to secondary osteoarthritis down the line.
385
On the posterior surface of the patella, any disruption of the patellofemoral joint may lead to what?
secondary osteoarthritis down the line
386
Direct injury causing patella fracture?
direct blow or trauma to front of knee eg. fall or dashboard injury
usually an undisplaced crack or comminuted fracture, but with an intact extensor mechanism
387
Indirect injury causing patella fracture?
when quads forcefully contract against a block to knee extension
eg. when someone catches their foot against a solid obstacle and in order to prevent themselves from falling the quads contract forcefully
results in transverse patella fracture with possible disruption of the extensor mechanism
388
Direct injury to patella may result in what?
undisplaced crack or comminuted fracture, but with an intact extensor mechanism
389
indirect injury to patella may result in what?
transverse patella fracture with possible disruption of the extensor mechanism.
390
Clinical features of patella fracture?
- swelling and bruising
- open wound= ? open fracture (more urgent Mx)
- pain and tenderness around knee, localised to patella and palpable gap may be appreciable
- if able to straight leg raise= extensor mechanism is grossly intact; may be difficult due to pain so have pt lie on side to eliminate gravity
391
Ix for patella fractures?
plain films, min of 2 views required (AP and lateral)
if diagnosis still in doubt, skyline views can be taken but is uncomfortable and difficult to obtain
392
Mx of undisplaced patella fractures, particularly vertical fractures with an intact extensor mechanism?
can be managed non-operatively in a hinged knee brace for 6w and pt allowed to fully weight bear
393
Mx of displaced patella fractures and those with loss of extensor mechanisms?
consider operative Mx with either tension band wire, inter-fragmentary screws or cerclage wires
then pt placed in hinged knee brace for 4-6w and allowed to fully weight bear
394
Tendinopathy?
term describing pain, swelling and impaired function of the tendon
395
Achilles tendon?
thickest and strongest tendon in the body; made up of fibres from the gastrocneumius and soleus muscles
396
Achilles tendon pathology is common in who?
active people
397
Cx of achilles tendon injury?
tendon rupture, negative impact on a pts ability to work and carry out ADLs, limitation in sports activity
398
Signs and symptoms of Achilles tendinopathy?
- aching (or sharp) pain in heel, aggravated by activity or pressure to the area
- stiffness in the tendon, may occur in morning or after period of prolonged sitting
- tenderness, swelling, crepitus along the tendon
399
Suspected achilles tendon rupture?
same day assessment by ortho specialist
400
Mx of achilles tendinopathy?
- Mx of underlying cause
- cold packs/ice after acute injury
- analgesia for pain relief eg. paracetamol
- rest, exercise when pain allows
401
What if symptoms of Achilles tendinopathy fails to improve within 7-10d?
refer to physio
402
Chronic achilles tendinopathy or fails to respond to Mx?
refer to sports physician or ortho
403
Pain in achilles tendinopathy?
ache or sharp pain in heel
- worse with activity or pressure to area
- Gradual onset of pain 2–6 cm proximal to the Achilles tendon insertion that limits activity suggests mid-portion Achilles tendinopathy.
- Pain and swelling at the insertion to the posterior calcaneus with impairment of function suggests insertional tendinopathy.
- some symptoms at both the insertion and mid-portion.
404
Stiffness in achilles tendinopathy?
may occur in morning or after period of prolonged sitting
405
What can be used to assess pain and severity with activity win people with achilles tendinopathy?
Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire
406
RFs for achilles tendinopathy?
DM, dyslipidaemia, fluoroquinolone use
407
Diagnosis of achilles tendinopathy?
- clinical: examine if no rupture
- imaging not usually recommended
- Ix for ULC= lipid profile, HbA1c, ?fluoroquinolone use
408
Examination findings for achilles tendinopathy (do not examine if achilles tendon rupture)?
redness, swelling, and asymmetry
Palpate along the length of the tendon for tenderness, heat, crepitus, thickening, and nodularity.
Tenderness on palpation of the mid-portion of the tendon is indicative of mid-portion Achilles tendinopathy.
Tenderness on palpation around the distal 2 cm of the tendon is usually found in insertional Achilles tendinopathy.
Evaluate the range of motion of the ankle. Pain worsens with passive dorsiflexion of the ankle.
Hop and heel-raise endurance tests, as appropriate.
409
CP of achilles tendinopathy?
- sudden pain back of leg, may be audible snap
- may occur with running or exercise, may be like being kicked or hit by a racket
- 1/3 with complete rupture say no pain
- aching of calf, swelling, mild bruising, weakness when pushing off with affected foot
- difficulty weight bearing
410
In some cases, why may pt with achilles tendinopathy be able to walk?
other plantar flexors may mask the tendon injury
411
How to exclude achilles tendon rupture?
Simmonds triad (angle of declination, palpation, and the calf squeeze test)
412
Simmonds triad examination to exclude achilles tendon rupture?
(angle of declination, palpation, and the calf squeeze test)
- abnormal angle of declination= rupture may lead to greater dorsiflexion of the injured ankle and foot compared with the uninjured limb.
- Feel for a gap in the tendon. No gap may be felt because of local swelling or bleeding. Bruising may be seen.
- Gently and sequentially squeeze the calf muscles= in acute rupture of the Achilles tendon the injured foot will typically remain in the neutral position when the calf is squeezed.
413
Why may the diagnosis of chronic achilles tendon rupture be difficult?
- pain and swelling often subsided and the gap may have filled with fibrous tissue.
- Calf muscles may be wasted.
- Other muscles may facilitate plantar flexion.
414
Differential diagnosis for achilles tendoninopathy?
True tendon pain (from rupture or tendinopathy) is usually confined to the tendon itself.
Retrocalcaneal bursitis.
Plantaris tendinopathy.
Dislocation of the peroneal or other plantar flexor tendons.
Posterior ankle impingement.
Haglund's deformity.
Os trigonum syndrome.
Fascial tears.
Calcaneal fracture.
Irritation or neuroma of the sural nerve.
Fat pad irritation.
Systemic inflammatory disease.
415
Tx for achilles tendinopathy in secondary care (if conservative measures fail)?
non-surgical= Eccentric exercise, or a heavy-load, slow-speed (concentric/eccentric) exercise programme (if not already tried); Extracorporeal shock-wave therapy (ESWT) — acoustic shockwaves are passed through the skin to the affected tissue.
Surgery= if chronic or not responsive to Tx; debridement and removal of diseased areas of tendon
416
Most common cause of posterior heel pain?
achilles tendon disorders
417
Examples of achilles tendon disorders?
tendinopathy (tendinitis), partial tear, complete rupture
418
What are associated with achilles tendon disorders?
floroquinolone use eg. ciprofloxacin
hypercholesterolaemia (predisposes to tendon xanthomata)
DM
419
Gradual onset of posterior heel pain that is worse following activity; morning pain and stiffness common?
achilles tendinopathy (tendiniti)
420
3 supportive Mx for achilles tendinopathy?
- simple analgesia
- reduction in activities
- calf muscle eccentric exercies
421
playing a sport or running; an audible 'pop' in the ankle, sudden onset significant pain in the calf or ankle or the inability to walk or continue the sport
achilles tendon rupture
422
How is Simmond's triad examination be conducted to exclude achilles tendon rupture?
ask pt to lie prone with their feet over the edge of the bed. Look for an abnormal angle of declination; Achilles tendon rupture may lead to greater dorsiflexion of the injured foot compared to the uninjured limb.
Feel for a gap in the tendon and gently squeeze the calf muscles if there is an acute rupture of the Achilles tendon the injured foot will stay in the neutral position when the calf is squeezed.
423
Imaging of choice for suspected achilles tendon rupture?
USS
424
Suspected achilles tendon rupture?
acute referral to ortho and USS
425
Bony components of ankle joint include what
distal tibia and fibula and the superior aspect of the talus
- form a mortise with the body of the talus acting as the tendon
- arrangement is secured by ligamentous structures
426
Ligaments in the ankle?
1) syndesmosis binds the distal tibia and fibula together (another example of a syndesmosis is the distal radio-ulnar joint). It is composed of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), interosseous ligament (IOL) and the interosseous membrane.
2) Distal fibular= secured to the to the talus by the anterior and posterior talofibular ligaments (ATFL and PTFL) and to the calcaneus by the calcaneofibular ligament.
Sometimes referred to collectively as the lateral collateral ligaments.
3) Distal tibia= secured to the talus by the deltoid ligament, in view of its triangular shape.
427
Sprain?
stretching, partial or complete tear of a ligament
428
Types of ankle sprains?
- high ankle sprain= invl syndesmosis
- low ankle sprain= invl lateral collateral ligaments
429
Presentation of low ankle sprain?
- injury to ATFL most common
- inversion injury common mechanism
- pain, swelling, tenderness over affected ligaments and sometimes bruising
- able to weight bear unless severe
430
Most common type of ankle sprain?
low sprain
431
Inversion injury to the ankle can cause what?
low ankle sprain
432
Grades of low ankle sprain?
Grade I (mild)= stretch or micro tear to ligament; minimal bruising/swelling; weight bearing normal
Grade II= partial tear; moderate bruising/swelling; minimal pain on weight bearing
Grade III (severe)= complete tear; severe swelling and bruising; severe pain on weight bearing
433
Ix for low ankle sprain?
- 15% associated with fracture so x-ray according to Ottawa ankle rules
- MRI if persistent pain= can evaluate perineal tendons
434
Tx for low ankle sprain?
- RICE= rest, ice, compression, elevation
- occasionally= removable orthosis, cast and/or crutches may be needed short term
- fails or signif joint instability= MRI and surgery but rare
435
Presentation of high ankle sprain?
- injury to syndesmosis
- rare and severe
- caused by external rotation of food causing talus to push fibula laterally
- weight bearing painful
- pain when tibia and fibula squeezed together at mid calf (Hopkin's squeeze test)
436
Hopkin's squeeze test?
high ankle sprain
Pain when the tibia and fibula are squeezed together at the level of the mid-calf
437
Injury to ankle caused by external rotation of foot causing talus to push fibula laterally?
high ankle sprain
438
Ix for high ankle sprain?
- x-ray= may show widening of tibiofibular joint (diastasis) or ankle mortise
- MRI= if high suspicion but normally just plain films
439
Tx of high ankle sprain?
- if no diastasis= non weight bearing orthosis or cast until pain stops
- diastasis or failed non-op Mx= operative fixation
440
What are isolated injuries to the deltoid ligament in ankle associated with?
they are rare
fracture so look for Maisonneuve fracture of the proximal fibula.
Ankle mortise anatomically reduced= same Tx as low ankle sprain
- if not then reduction and fixation
441
Common cause of lateral knee pain in runners?
iliotibial band syndrome
442
iliotibial band syndrome?
common cause of lateral knee pain in runners (1 in 10 regular runners)
tenderness 2-3cm above lateral joint line
443
Mx of iliotibial band syndrome?
- activity modification and iliotibial band stretches
- no improvement then physio
444
Causes of knee pain?
osteoarthritis, injuries (muscle strain, ligament damage, fractures); inflam conditions; infection; tumours; referred pain from hip or lumbosacral spine; bursitis
445
RFs for knee pain?
- increasing age
- obesity
- knee-straining work
- participation in sport
446
Red flags for knee pain?
- infection (septic arthritis or osteomyelitis)
- tumours
- inflam polyarthritis
- signif bony or soft tissue injury eg. fractures, dislocation and tendon/ligament rupture
447
When is admission or referral for immediate hospital assessment indicated in knee pain?
septic arthritis, slipped capital femoral epiphysis, fracture, neurovascular damage, quadriceps or patellar tendon rupture, severe soft tissue injury with gross instability, first-time traumatic patellar dislocation, or a recurrent dislocation associated with moderate or severe swelling.
448
When is admission or referral for immediate hospital assessment indicated in knee pain in a child?
limp or suspected Henoch-Schönlein purpura.
infection (such as fever, erythema, swelling) or severe pain, swelling, instability or inability to weight bear in association with an acute injury.
449
What if signif soft tissue injury is suspected in pt with acute knee pain following trauma?
acute knee clinic (admission or immediate assessment)
450
Ottawa knee rule?
determine whether an X-ray is needed in people over 2 years with a suspected knee fracture.
Only required after a knee injury for people with any of these findings:
1) Inability to weight bear both immediately and during the consultation for four steps (inability to transfer weight twice onto each lower limb regardless of limping).
2) Inability to flex the knee to 90 degrees.
3) Tenderness of the head of the fibula.
4) Isolated tenderness of the patella (no bone tenderness of the knee other than the patella).
5) Age 55 years or older.
451
Direct blow to the knee can cause what?
anterior knee= patellar fracture or if knee in flexion can cause PCL injury; hyperextended knee can cause ACL injury
lateral knee= medial collateral ligament injury or patellar dislocation
medial knee= lateral collateral ligament injury (uncommon) or patellar dislocation
452
Knee injury: what can sudden decleration or stopping cause?
ACL injury
453
Twisting or pivoting can injury the knee how?
can injure the menisci or cause ACL injury. If twisted when the knee is extended, patellar subluxation or dislocation can occur.
454
Hyperextension of the knee can cause what?
ACL and PCL injury
455
Anterior knee pain may be caused by what?
Patellar subluxation or dislocation.
Osgood-Schlatter disease.
Patellar tendonitis.
Patellofemoral pain syndrome.
Patellar or quadriceps tendon rupture.
Patellofemoral joint arthritis.
456
Medial knee pain may be caused by what?
Medial collateral ligament sprain.
Medial meniscal tear.
Pes anserine bursitis.
Medial plica syndrome.
Medial compartment arthritis.
457
Lateral knee pain may be caused by what?
Lateral collateral ligament sprain.
Lateral meniscal tear.
Iliotibial band tendonitis.
Lateral compartment arthritis.
458
Posterior knee pain may be caused by what?
Baker's cyst.
Posterior cruciate ligament injury.
Posterior horn meniscal tears.
459
What does Lachman's test test for?
ACL tear
460
What does the anterior drawer/draw test test for?
ACL tear
461
What does the pivot shift test test for?
ACL tear
462
What does the posterior drawer/draw test test for?
PCL tear
463
What does the posterior sag test test for?
PCL tear
464
What does the valgus stress test test for?
Medial collateral ligament injury
(Joint line tenderness may also indicate meniscal tear)
465
What does the varus stress test test for?
Lateral collateral ligament injury
(Joint line tenderness may also indicate meniscal tear)
466
What does the patellar apprehension test test for?
Subluxing or dislocating patella
467
What does the McMurray test test for?
meniscal tear
468
What does the Thessaly test test for?
meniscal tear
469
Testing for effusion in knee?
- patellar tap test
- stroke test
- cross fluctuance test for larger effusions
470
Most commonly injured knee ligament?
ACL
471
Common mechanisms of injury to the ACL?
- lateral blow to knee
- skiing
- non-contact= sudden twisting or awkward landing (most common) eg. hyperextension
472
Features of ACL injury?
- sudden popping sound
- knee swelling
- instability
- feeling that knee will give way
473
2 tests to test for ACL injury?
anterior draw test and Lachman's test
474
Anterior draw test to test for ACL injury?
the patient lies supine with the knee at 90 degrees
the examiner should place one hand behind the tibia and the other grasping the patient's thigh. It is important that the examiner's thumb be on the tibial tuberosity
the tibia is pulled forward to assess the amount of anterior motion of the tibia in comparison to the femur
an intact ACL should prevent forward translational movement
475
Lachman's test to test for ACL injury?
variant of anterior draw test, but the knee is at 20-30 degrees
evaluate the anterior translation of the tibia in relation to the femur and is considered a variant
more reliable than anterior draw test
476
Knee pain= meniscal tear typically results from what?
twisting injuries
477
Knee pain= meniscal tear features?
pain worse on straightening the knee
knee may 'give way'
displaced meniscal tears may cause knee locking
tenderness along the joint line
478
Test to test for meniscal tear (knee pain)?
Thessaly's test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee
479
Thessaly's test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee
Condition?
meniscal tear
480
Common knee problems in children and young adults?
- Chondromalacia patellae
- Osgood-Schlatter disease
(tibial apophysitis)
- Osteochondritis dissecans
- Patellar subluxation
- Patellar tendonitis
481
Referred knee pain may come from where?
hip problems such as slipped upper femoral epiphysis
482
Key features of chondromalacia patellae?
Softening of the cartilage of the patella
Common in teenage girls
Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
Usually responds to physiotherapy
483
Key features of Osgood-Schlatter disease
(tibial apophysitis)?
seen in sporty teens
pain, tenderness and swelling over tibial tubercle
484
Key features of osteochondritis dissecans?
Knee pain after exercise
Intermittent swelling and locking
In children and young adults
485
Key features of Patellar subluxation?
Medial knee pain due to lateral subluxation of the patella
Knee may give way
in children and young adults
486
Key features of Patellar tendonitis?
More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination
487
Osgood-Schlatter disease?
apophysitis of the tibial tuberosity that causes anterior knee pain during adolescence and is usually self-limiting
488
Osgood-Schlatter disease is thought to occur as a result of what?
repetitive strain from the patella tendon at its insertion on the ossification centre (apophysis) of the tibial tuberosity
489
Apophysis?
a normal developmental outgrowth of a bone which arises from a separate ossification centre, and fuses to the bone later in development; usually where muscle, tendon or ligament inserts
apophysitis= inflam of this
ossification= process of making new bone
ossification centre= area this happens
490
RFs for Osgood-Schlatter disease?
age= during growth spurts in adolescence
sports eg. running, jumping, repetitive bending of knee
biomechanical factors= quad muscle tightness, reduced flexibility of hamstrings
491
Type of knee pain in Osgood-Schlatter disease?
- unilateral (70%)
- during growth spurts (8-12yrs girls, 12-15yrs boys)
- develops slowly, mild and intermittent but can progress to continuous and severe
- fluctuates
- exacerbated by activity eg. running, jumping, kneeling
- improves with rest and skeletal maturity
- settles over w to m but can take 1-2yrs to resolve
- 10% persist into adulthood= chronic pain, decreased lower body strength
492
Exam findings in Osgood-Schlatter disease?
tenderness over tibial tuberosity that is provoked by knee extension against resistance, swelling or bony enlargement of the tibial tuberosity
normal passive ROM and absence of effusion
493
tenderness over tibial tuberosity that is provoked by knee extension against resistance, swelling or bony enlargement of the tibial tuberosity
Osgood-Schlatter disease
494
Ix for Osgood-Schlatter disease?
- clinical unless features of other causes of knee pain eg. persists at night or after rest, systemic symptoms, sudden after trauma, bone/joint pain at other sites
- routine x-ray not recommended to confirm diagnosis
495
Mx of Osgood-Schlatter disease?
- paracetamol +/or NSAIDs
- protective knee pads when kneeling
- intermittent ice packs over tibial tuberosity (10-15mins up to 3x d)
- exercise modification & muscle stretching exercises= swimming, cycling, straight leg raises
496
Osgood-Schlatter disease: what if pain does not improve or it worsens despite Mx?
- reassess cause: refer to paeds or ortho surgon
- physio referral
- persist into adulthood= ortho surgeon is symptoms affecting functioning
497
Differential diagnosis for Osgood-Schlatter disease (knee pain)?
- tumour
- juvenile idiopathic arthritis
- referred pain from hip= SUFE, transient synovitis; perthes
- trauma
- infection= septic arthritis or osteomyelitis
- osteochondritis dissecans, patellofemoral pain syndrome, chondromalacia patellae, and patellar dislocation or subluxation.
498
Preventative strategies for Osgood-Schlatter disease?
regular quadriceps and hamstring stretching and cross-training (swimming, cycling)
499
Most common cause of heel pain seen in adults?
plantar fasciitis
500
Pain in plantar fasciitis?
heel pain usually worse around the medial calcaneal tuberosity
501
Mx of plantar fasciitis?
rest feet where possible
wear shoes with good arch support and cushioned heels
insoles and heel pads may help
- analgesia and ice pack; consider short term USS guided corticosteroid injections
- if no better= refer to ortho or podiatrist or physio
502
Plantar fasciitis?
persistent pain associated with degeneration of plantar fascia as result of repetitive microtears in the contracted fascia
common 40-60yrs
503
Characteristic symptoms of plantar fasciitis?
- insidious onset
- intense pain during 1st steps after waking or period of inactivity
- pain reduces with moderate activity but worsens later during day or after long periods of standing/walking
504
Signs of plantar fasciitis?
Tenderness on palpation of the plantar heel area (esp localized around the medial calcaneal tuberosity).
Limited ankle dorsiflexion range (with the knee in extension).
Positive 'Windlass test' (reproduction of pain by extension of the first metatarsophalangeal joint).
Tightness of the Achilles tendon.
An antalgic gait (abnormal walking to avoid pain) or limping.
505
Differential diagnosis of plantar fasciitis?
Achilles tendonitis.
Calcaneal stress fractures.
Fat pad atrophy.
Sub-calcaneal bursitis.
Other less common neuro and MSK causes, such as nerve entrapment, peripheral neuropathy, plantar fibromatosis, and plantar fascia rupture.
Neoplasm and vascular insufficiency (very rare).
506
Diagnosis of plantar fasciitis?
clinical
507
Most people with plantar fasciitis will make full recovery within how long?
1yr
508
Osteoarthritis (OA)?
long term disorder of synovial joints which occurs when damage triggers repair processes leading to structural changes within a joint, with features of localised cartilage loss, remodelling of adjacent bone and formation of osteophytes, and mild synovitis
509
3 symptoms of osteoarthritis?
pain, stiffness and loss of function
510
What joints can be involved in osteoarthritis?
any synovial joint= knees, hips, small joints of hand most common
511
Flare of osteoarthritis?
sudden, sustained increase in symptoms for at least 24hrs, worse than usual patterns and lasts 3-8d
512
Causes of osteoarthritis?
multifactorial: genetics, biological (age, obesity), biomechanical (joint injury and damage)
513
Flares of osteoarthritis?
acute-on-chronic flares
may fluctuate
514
Cx of osteoarthritis?
joint deformity and chronic pain
515
Features of osteoarthritis?
- activity related joint pain= 1 or few joints at any one time; develops over m-yrs
- no morning stiffness or for <30mins
- functional limitation
Signs:
- bony swelling
- joint deformity
- restricted and painful ROM
- mild synovitis/joint effusion
- crepitus
- joint instability
516
Diagnosis of osteoarthritis?
- clinical= typical features, posture, gait, BMI, atypical features, other sources of pain
- if uncertain= joint x-ray
517
Mx of osteoarthritis?
- self care
- simple analgesia= topical NSAIDs (ibuprofen 5% gel 3x d); or oral 2nd line
- refer to MSK MDT= intra-articular corticosteroid injections (work for 2-10w); assistive aids; therapeutic exercise with education ('structured Tx package')
- ineffective after 3m= ortho surgeon (?joint replacement)
518
Hand OA?
typically affects 1st carpometacarpal joint (CMC) at base of thumb, distal interphalangeal (DIP) joint and the proximal interpahalngeal (PIP) joint
- wasting of thenar muscles at base of thumb
- CMC= fixed flexion deformity with hyperextension of distal joints
- advanced= squaring at joint; ulnar or radial deviation
- mucoid cysts
- Heberden's and Bouchard's nodes
519
Why in advaced hand OA may you get 'squaring' at the joint?
caused by subluxation (partial dislocation), formation of osteophytes and remodelling of bone
520
Mucoid cysts in OA of hand?
(painful mucus-filled cysts) adjacent to the joint on the dorsum of the finger, which may cause longitudinal ridging of the nail.
521
Nodes in OA of the hand?
Heberden's= bony nodules on the dorsum of the finger next to the DIP joints
Bouchard's nodes= next to the PIP joints
522
Hip OA may present with what?
deep pain in anterior groin on walking or climbing stairs
possible referred pain to lateral thigh, buttock, anterior thigh, knee and ankle
painful restriction of internal rotation with hip flexed
523
painful restriction of internal rotation with hip flexed
OA of the hip
524
What may be present in hip OA when the disease is advanced?
Trendelenburg gait
A fixed flexion external rotation deformity, with compensatory increased lumbar lordosis and pelvic tilt. The lower limb can be significantly shortened.
525
Trendelenburg gait?
in advanced hip OA
a lurch towards the affected hip with less time spent weight-bearing on that side and the pelvis tilting down on the unaffected side, caused by wasting and weakness of the gluteal and anterior thigh muscles
526
Knee OA?
typically bilateral and symmetrical
medial tibiofemoral (causes anteromedial pain on walking), lateral tibiofemoral (anterolateral pain on walking) or patellofemoral compartments (anterior knee pain worsened on incline or going down stairs; aching on prolonged sitting relieved my standing)
pain localsied to affected compartment
527
Associated features in knee OA?
Giving way — due to altered patella tracking, weak quadriceps muscles, severe patellofemoral involvement, and altered load-bearing mechanics.
Locking (inability to straighten the knee) — suggests loose meniscal cartilage in the joint.
Crepitus and tenderness along the joint line or with pressure on the patella.
Restricted flexion and extension.
528
weakness of the quadriceps is suggested if...
passive extension of the knee joint is greater than active extension
529
What may be present in advanced knee OA?
Bony swelling of the femoral condyles and lateral tibial plateau.
Varus (bow-legged), or less commonly valgus (knock-knee), deformity.
An antalgic gait.
530
X-ray findings in OA (done if uncertain or atypical features)?
subchondral bone thickening and/or cysts
osteophyte formation (new bone formation at joint margins)
loss or narrowing of the joint space (provides an estimate of the severity of cartilage damage).
531
Self care advice for pt with OA?
- self-care= info, weight loss, good footwear
- exercise= aerobic and muscle strengthening
- physiological support
532
Common joints affected in osteoarthritis?
DIPs
CMC joint (base of thumb)
Knees
Hips
L spine
C spine (c spondylosis)
533
DIPS or PIPS in osteoarthritis?
DIPS
534
Mneumonic for X-ray changes in osteoarthritis?
L.oss of joint space
O.steophytes
S.ubarticular scleorsis
S.ubchondral cysts
535
Signs in the hands in osteoarthritis?
- Heberden's nodes (DIPs)
- Bouchard's nodes (PIPs)
- Squaring at base of thumb (CMC joint)
- weak grip and reduced ROM
536
When can osteoarthritis be diagnosed clinically?
>45yrs, typical pain and no morning stiffness (or <30mins)
537
What should be co-prescribed alongside oral NSAIDs (eg. in osteoarthritis when topical NSAIDs don't work)?
PPI for gastroprotection
538
NSAIDs should be used in caution with pts with high BP, why?
they cause HTN by blocking prostaglandins (prostaglandins cause vasodilation)
539
Why should NSAIDs (ibuprofen and naproxen) be used cautiously in older pts and those on anticoags (aspirin, DOAC) eg. for osteoarthritis?
use short term for flares as:
- GI Cx= peptic ulcers, gastritis
- Renal= AKI (eg. acute tubular necrosis) and CKD
- CVD= HTN, HF, MI, stroke
- exacerbate asthma
540
Most common presentation of OA (joint)?
knee
then hip
541
RFs for OA of the hip?
- increasing age
- female
- obesity
- developmental dysplasia of hip
542
chronic history of groin ache following exercise and relieved by rest
osteoarthritis of hip
543
Red flags that may suggest an alternative cause in OA of the hip?
rest pain
night pain
morning stiffness >2hrs
544
What can be used to assess severity of OA of the hip?
Oxford Hip Score
545
Ix for OA of hip?
clinical
if atypical features= plain x-rays
546
Definitive Tx for OA of the hip?
total hip replacement
547
Cx of total hip replacement?
perioperative= VTE,
intraoperative fracture, nerve injury, surgical site infection
leg length discrepancy
posterior dislocation= may occur during extremes of hip flexion; typically presents acutely with a 'clunk', pain and inability to weight bear
on examination there is internal rotation and shortening of the affected leg
548
Most common reason for revision of total hip replacement?
aseptic loosening
- prosthetic joint infection
549
Summary of osteoarthritis Mx?
1) weight loss; local muscle strenthening exercises & aerobic fitness
1) topical NSAIDs
2) oral NSAIDs + PPI
3rd line) intra-articular steroid injections (2-10w relief)
4) fail= joint replacement
+ walking aids
can use paracetamol short term for flares (only if infrequent) but DO NOT use opioids
550
Osteomalacia?
softening of bones secondary to low vit D that in turn lead to decreased bone mineral density
551
Osteomalacia in children vs adults?
children= called rickets
adults= osteomalacia
552
Causes of osteomalacia?
- vit D def= malabsorption, lack of sunlight, diet
- CKD
- drug induced eg. anticonvulsants
- liver disease eg. cirrhosis
- coeliac
- inherited
553
inherited cause of osteomalacia?
hypophosphatemic rickets (aka vit D-resistant rickets)
554
Features of osteomalacia?
- bone pain
- bone/muscle tenderness
- fractures: esp femoral neck
- proximal myopathy= waddling gait
555
What fracture is common in osteomalacia?
femoral neck
556
Ix for osteomalacia?
- bloods= low vit D; low Ca and phosphate (30%) and raised ALP
- x-ray= translucent bands (Looser's zones or pseudofractures)
557
Tx for osteomalacia?
- vit D supplementation= loading dose initially needed
- Ca supplementation if dietary inadequate
558
Osteomyeleitis?
infection of the bone
559
Osteomyelitis may be classified into what?
Haematogenous osteomyelitis and non-haematogenous osteomyelitis
560
Haematogenous osteomyelitis?
results from bacteraemia
is usually monomicrobial
most common form in children
vertebral osteomyelitis is the most common form of haematogenous osteomyelitis in adults
561
Most common form of osteomyelitis in children?
Haematogenous osteomyelitis
562
Haematogenous osteomyelitis RFs?
sickle cell anaemia, intravenous drug user, immunosuppression due to either medication or HIV, infective endocarditis
563
Non-haematogenous osteomyelitis?
results from the contiguous spread of infection from adjacent soft tissues to the bone or from direct
injury/trauma to bone
is often polymicrobial
most common form in adults
564
Most common form osteomyelitis in adults?
Non-haematogenous osteomyelitis
565
Non-haematogenous osteomyelitis RFs?
diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease
566
Most common cause of osteomyelitis (microbio)?
staph.aureus
(except if pt has sickle cell anaemia)
567
Most common cause of osteomyelitis in sickle cell anaemia pts?
Salmonella species
568
Ix for osteomyelitis?
MRI
569
Mx for osteomyelitis?
flucloxacillin for 6 weeks
clindamycin if penicillin-allergic
570
Mneumonic for ankylosing spondylitis?
S.ausage digitis
P.soriasis
I.nflam back pain
N.SAID responsive
E.nethesis (heel pain)
A.rthritis
C.rohns/UC
H.LA-B27
E.yes (uveitis)
571
Osteoporosis?
disease characterised by low bone mass and structural deterioration of bone tissue, causing increase in bone fragility and susceptibility to fracture
572
Does pt know they have osteoporosis?
it is asymptomatic so remains undiagnosed normally until a fragility fracture occurs
573
Osteoporotic fracture occurs as a consequence of...
increased bone fragility
574
Characteristic fractures occur where in pt with osteoporosis?
wrist, spine, hip
575
Fragility fracture?
fracture following a fall from standing height or less
576
Vertebral fractures in pt with osteoporosis?
may occur spontaneously or as a result of routine activities
577
RFs for osteoporosis?
Female sex.
Increasing age.
Menopause.
Oral corticosteroids.
Smoking.
Alcohol.
Previous fragility fracture.
Rheumatological conditions, eg. RA and other inflammatory arthropathies.
Parental history of hip fracture.
BMI less than 18.5 kg/m2.
578
What should be done in pt with fragility fracture prior to calculating fracture risk (osteoporosis)?
Ix to check for non-osteoporotic causes eg. metastatic bone ca and undiagnosed secondary causes eg. hyperthyroidism
579
Pt presents with fragility fracture, what Ix do you do?
1) rule out non-osteop causes and undiagnosed 2 causes eg. hyperthroidism
2) 10yr fragility fracture risk score PRIOR to arranging DXA scan to measure BMD or starting bisphosphonate except in certain pts (if 'high risk eg. due to age or RFs then just straight to DXA)
580
What pts with suspected osteoporosis do you not bother calculating 10-yr fragility fracture risk score for ('high risk')? In these pts you just do DXA scan straight away without calculating risk.
>50yrs with Hx of fragility fracture= offer DXA scan
<40yrs with major RF for fragility fracture= DXA scan then refer to specialist in Tx of osteop depending on BMD T-score
581
What is the BMD T-score?
the number of standard deviations below the mean BMD of young adults at their peak bone mass.
582
How to calculate 10 yr fragility fracture risk in pt with suspected osteoporosis? What do you do with the results?
- QFracture or FRAX
High risk= DXA scan to confirm osteop
Intermediate risk= close to threshold and have RFs (eg. taking high dose oral corticosteroids)= DXA scan
Low risk= lifestyle advice and NO scan
583
What RF for osteoporosis may not be included in FRAX?
pt taking high dose oral corticosteroids
584
Who should be offered bisphosphonates in suspected osteoporosis?
with BMD T-score of -2.5 or lower
585
Mx of osteoporosis?
1) 10yr fragility fracture risk score unless 'high risk'
2) DXA scan for BMD if high risk score/intermediate
3) BMD T-score -2.5 or lower= bisphosphonates
- consider HRT in younger postmen women to reduce risk of fracture
4) manage RFs= smoking, alcohol, Ca & vit D def; falls risk
586
Why is follow up needed following starting Tx for osteoporosis?
- adverse effects of bone-sparing Tx
- adherence
- need for continuing bisphosphonate after 5yrs
587
Consider assessing fragility fracture risk in who?
- all women 65yrs+ and all men 75yrs+
- < them ages if RF= previous frag fracture; Hx of falls; current/freq use of oral corticosteroids; FHx hip fracture; BMI <18.5; smoking; alcohol >14units; have secondary causes for osteoporosis
- Do not assess if <50yrs or <40yrs unless major RF
588
Do not routinely assess fracture risk in pt <50yrs unless they have what major RFs?
Current or frequent use of oral corticosteroids.
Untreated premature menopause.
A previous fragility fracture.
589
Do not routinely assess fracture risk in pt <40yrs unless they have what major RFs?
Current or recent use of high-dose oral corticosteroids equivalent to, or more than, 7.5 mg prednisolone daily for 3 months or more.
A previous major osteoporotic fracture.
History of multiple fragility fractures.
590
Consider assessing fracture risk in pt taking what meds, esp in presence of other RFs?
- SSRI
- anti-epileptic= carbamazepine
- aromatase inhib eg. exemastane, anastrozole
- gonadotropin-releasing hormone agonists eg. goserelin
- PPI
- thiazolidinediones eg. pioglitazone
- glitazones
591
Non-osteoporotic causes for fragility fracture?
- met bone ca
- multiple myeloma
- osteomalacia
- Pagets
592
Secondary causes of osteoporosis (eg. pt with fragility fracture despite being low risk)?
- endocrine= untreated premature menopause; DM; hyperthyroidism; hypogonadism in men
- RA
- GI that cause malabsorption= crohns; UC; coeliac; chronic pancreatitis
- chronic liver disease= hep B, hep C, NAFLD
- COPD
593
Osteoporosis: offer a dual-energy X-ray absorptiometry (DXA) scan to measure bone mineral density (BMD) without calculating the fragility fracture risk in people....
Over 50 years of age with a history of fragility fracture.
Younger than 40 years of age who have a major risk factor for fragility fracture — depending on the BMD T-score, refer to a specialist experienced in the treatment of osteoporosis.
594
Osteoporosis: when can drug Tx without a DXA scan be considered?
in pts with vertebral fracture
595
Osteoporosis: offer oral bisphosphonates to pt taking corticosteroid therapy without waiting for BMD assessment (should follow later) if they have what RFs?
A prior fragility fracture.
Women age 70 years or over.
Postmenopausal women, and men age 50 years or over taking high dose glucocorticoids (7.5 mg or more of prednisolone daily or equivalent over 3 months).
Postmenopausal women, and men age 50 years or over with a FRAX probability of major osteoporotic fracture or of hip fracture exceeding the intervention threshold.
596
What pts are at risk of Vit D def?
>65yrs
not exposed to much sunlight (indoors or wear clothes that cover whole body)
597
Recommended calcium intake for pt at increased risk of fragility fracture (osteoporosis)?
1000mg/day at least
598
What are the QFracture and FRAX risk assessment toold for osteoporosis?
predict the absolute risk of hip fracture, and major osteoporotic fractures (spine, wrist, or shoulder) over 10 years.
599
What score is considered high, intermediate and low risk according to the QFracture and FRAX score for a fragility fracture (osteoporosis)?
QFracture:
- High= 10% or more
- I= below 10% but close
to
- Low= below 10%
FRAX:
- high= red zone of risk chart
- i= amber
- low= green
600
What factors foes the FRAX score underestimate (when calculating fragility fracture risk)?
Regular use of corticosteroids equivalent to or less than 5 mg prednisolone daily.
Use of corticosteroids more than or equivalent to 7.5 mg prednisolone daily for more than 3 months.
A history of multiple fragility fractures.
High alcohol intake.
Heavy smoking.
601
Osteoporosis: fracture risk above the recommended threshold eg. 10%?
offer DXA scan
602
DXA scan stands for?
dual-energy x-ray absorptiometry scan
603
DXA scan in osteoporosis= T score -2.5 or less?
offer bisphosphonates (bone-sparing drug Tx)
604
DXA scan in osteoporosis= T score greater than -2.5?
modify RFs, treat underlying conditions and repeat DXA at appropriate interval eg. 2yrs
605
Fragility fracture risk intermediate eg. close to 10% but below, and they have RFs that may be underestimated by FRAX?
DXA scan to measure BMD and offer Tx if T-score -2.5 or less
606
Drug Tx for osteoporosis?
alendronate 70 mg once weekly, or risedronate 35 mg once weekly first-line
- 2nd line= ibandronate 150mg once monthly
- still not tolerated= specialist referral for eg. zoledronic acid or denosumab
?vit D and Ca supplements depending on current intake
607
Calcium management in osteoporosis?
If the person's calcium intake is adequate (700 mg/day)= 10 micrograms (400 international units) of vitamin D (without calcium) for people not exposed to much sunlight.
Inadequate=
- 10 micrograms (400 international units) of vitamin D with at least 1000 mg of calcium daily.
- Prescribe 20 micrograms (800 international units) of vitamin D with at least 1000 mg of calcium daily for elderly people who are housebound or living in a nursing home
608
Lifestyle advice for pt with osteoporosis?
- regular exercise to improve muscle strenth
- balanced diet
- stop smoking
- cut down alcohol
609
After starting bone-sparing Tx for osteoporosis, what should you do?
- follow up: check tolerance after 12-16w
- then at 12m
- then at 5yrs
610
Atypical fracture in osteoporosis?
new onset hip, groin or thigh pain= stop osteop Tx and arrange x-ray of femur
611
What if pt has osteoporosis but requires oral corticosteoirds?
maintain bone protection
612
What when pt has been on bisphosphonates for osteoporosis for 5yrs?
follow up
- if still high risk (started Tx at 70yrs+; previous hip/vertebral fracture or 1+ fracture after starting Tx)= continue for at least 10yrs
- in others= DXA scan: continue for another 5yrs if T score -2.5 or less; if greater then pause treatment for 1.5-3yrs then reasssess
613
When to reassess fracture risk at anytime in pt with osteoporosis?
if re-fracture occurs or clinical RFs change
614
Pt sustained osteoporotic fracture whilst on bisphosphonates?
check adherence and exclude secondary causes for oestop; refer to specialist for drug Tx advice
615
Osteoporosis: If bisphosphonate treatment is discontinued and no new fracture occurs?
reassess fracture risk after 18 months for risedronate and ibandronate, 2 years for alendronate, and 3 years for zoledronate to inform whether treatment should be restarted.
616
Bisphosphonates MOA?
Analogues of pyrophosphate, a molecule that decreases demineralisation in bone. They inhibit osteoclasts by reducing recruitment and promoting apoptosis
617
Clinical uses for bisphosphonates?
- prevention and Tx of osteoporosis
- hypercalcaemia
- Paget's disease
- pain from bone mets
618
Adverse effects of bisphosphonates?
- oesophagitis and oesophageal ulcers
- osteonecrosis of the jaw
- increased risk of atypical stress fractures of proximal femoral shaft
- acute phase response
- hypocalcaemia
619
Osteonecrosis of the jaw with bisphosphonates?
greater risk for pts having IV in Tx of ca rather than for osteoporosis or Pagets
poor dental hygiene/prior dental procedure also RF
620
All pts with cancer before bisphosphonate treatment should have what?
if poor dental status then they should have dental check up as it is a RF for osteonecrosis of the jaw
621
Acute phase response when taking bisphosphonates eg. for osteoporosis?
fever, myalgia and arthralgia may occur following administration
622
Why is hypocalcaemia an adverse effect of bisphosphonates?
due to reduced calcium efflux from bone; usually clinically unimportant
623
How should pt take bisphosphonates for osteoporosis?
'Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking tablet'
624
What should be done before starting a pt on bisphosphonates for osteoporosis?
hypocalcaemia/vit D def should be corrected
but for osteoporosis, calcium should only be prescribed if dietary intake is inadequate; Vit D supplements are normally given
625
Sometimes bisphosphonates are recommended to be stopped at 5yrs in who?
patient is < 75-years-old
femoral neck T-score of > -2.5
low risk according to FRAX/NOGG
626
Patients who've had a fragility fracture and are >= 75 years of age are presumed to have....
underlying osteoporosis and should be started on first-line therapy (an oral bisphosphonate), without the need for a DEXA scan
If a patient is under the age of 75 years a DEXA scan should be arranged. These results can then be entered into a FRAX assessment (along with the fact that they've had a fracture) to determine the patients ongoing fracture risk.
627
79-year-old woman falls over on to an outstretched hand and sustains a Colles' fracture (fracture of the distal radius).
Given her age she is presumed to have osteoporosis and therefore started on oral alendronate 70mg once weekly. No DEXA scan is arranged.
628
Osteoporosis: A DEXA scan should be offered without calculating the fragilty risk score in the following situations?
> 50 years of age with a history of fragility fracture
< 40 years of age who have a major risk factor for fragility fracture - these patients should be referred to a specialist depending on the T-score
before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer)
629
QFracture
if the 10-year fracture risk is ≥ 10% then
a DEXA scan should be arranged
630
FRAX
patients in the orange zone should have...
red zone...
patients in the orange zone should have a DEXA scan if not already done to further refine their 10-year risk
patients in the red zone should also have a DEXA scan if not already done to act as a baseline and guide drug treatment
631
Osteoporosis: NICE recommend that we recalculate a patient's risk (i.e. repeat the FRAX/QFracture)?
if the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of 2 years, or
when there has been a change in the person's risk factors
632
Osteoporosis: risk factors that are used by major risk assessment tools such as FRAX...
history of glucocorticoid use
rheumatoid arthritis
alcohol excess
history of parental hip fracture
low body mass index
current smoking
633
RFs for osteoporosis other than those including in FRAX?
- sedentary lifestyle
- premature menopause
- Caucasians and Asians
- hyperthyroid, hypogonadism (eg. Turners, testosterone def), growth hormone def, hyperparathyroidism, DM
- multiple myeloma, lymphoma
- IBD, malabsorption (coeliac), gastrectomy, liver disease
- CKD
- osteogenesis imperfecta, homocystinuria
634
What bloods should be done as a minimum in suspected osteoporosis following a fragility fracture (eg. to rule out other causes)?
FBC
U&Es
LFTs
Bone profile
CRP
TFTs
635
DEXA scan: T score?
based on bone mass of young reference population
T score of -1.0 means bone mass of one standard deviation below that of young reference population
636
DEXA scan: Z score?
adjusted for age, gender and ethnic factors
637
DEXA scan: T score values?
> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis
638
DEXA scan: osteoporosis?
< -2.5
639
DEXA scan: osteopaenia?
-1.0 to -2.5
640
DEXA scan: normal?
> -1.0
641
Most important RF for osteoporosis?
use of corticosteroids
risk rises significantly once a patient is taking the equivalent of prednisolone 7.5mg a day for 3 or more months.
642
if it likely that the patient will have to take steroids for at least 3 months then we should start what
bone protection straight away rather than waiting until 3m has elapsed
643
patient with newly diagnosed polymyalgia rheumatica. As it is very likely they will be on a significant dose of prednisolone for greater than 3 months what should be started immediately
bone protection
644
Management of patients at risk of corticosteroid-induced osteoporosis: patients can be divided into what 2 groups?
1. Patients over the age of 65 years or those who've previously had a fragility fracture should be offered bone protection.
2. Patients under the age of 65 years should be offered a bone density scan, with further management dependent
645
Management of patients at risk of corticosteroid-induced osteoporosis= ? for pts under 65yrs who had bone density scan and now need Mx?
T >0= reassure
T 0- -1.5= repeat scan in 1-3yrs
T <-1.5= offer bone protection
646
First line for bone protection eg. corticosteroid-induced osteoporosis?
alendronate
may need Ca and Vit D too
647
1st line bone protection following hip fracture?
IV zoledronate
648
Postmenopausal women, and men age ≥50, who are treated with oral glucocorticoids: what should you do?
if starting ≥7.5 mg/day prednisolone or equivalent for the next 3 months, start bone protective treatment at the same time (alendronate or risedronate)
don't wait for DEXA scan before starting Tx
+ general osteoporosis Mx
649
How long should you plan to prescribe oral vs IV bisphosphonates?
oral= at least 5yrs
IV= at least 3yrs
650
How do bisphosphonates work?
bind to hydroxyapatite in bone, inhibiting osteoclast-mediated bone resorption
651
Denosumab MOA eg. for osteoporosis?
human monoclonal antibody that inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts
also used for cancer patients with bone metastases to reduce skeletal-related events.
given as a single subcutaneous injection every 6 months
652
Raloxifene eg. for osteoporosis MOA?
selective oestrogen receptor modulator (SERM)
has been shown to prevent bone loss and to reduce the risk of vertebral fractures, but has not yet been shown to reduce the risk of non-vertebral fractures
has been shown to increase bone density in the spine and proximal femur
may worsen menopausal symptoms
increased risk of thromboembolic events
may decrease the risk of breast cancer
653
Strontium ranelate eg. for osteoporosis MOA?
'dual action bone agent' - increases deposition of new bone by osteoblasts (promotes differentiation of pre-osteoblast to osteoblast) and reduces the resorption of bone by inhibiting osteoclasts
concerns regarding the safety profile of strontium have been raised recently. It should only be prescribed by a specialist in secondary care
should only be used by people for whom there are no other treatments for osteoporosis
increased risk of cardiovascular events: any history of cardiovascular disease or significant risk of cardiovascular disease is a contraindication
not used in patients with a history of venous thromboembolism
may cause serious skin reactions such as Stevens Johnson syndrome
654
Teriparatide MOA eg. for osteoporosis?
recombinant form of parathyroid hormone
very effective at increasing bone mineral density but role in the management of osteoporosis yet to be clearly defined
655
Romosozumab MOA eg. for osteoporosis?
a monoclonal antibody that inhibits sclerostin, thereby increasing bone formation and decreasing bone resorption
this dual action significantly improves bone density and reduces fracture risk.
656
Definition of osteoporosis?
presence of bone mineral density (BMD) of less than 2.5 standard deviations (SD) below the young adult mean density.
657
Around ?% of post-menopausal women will suffer an osteoporotic fracture at some point.
50%
658
What does the DEXA scan look at?
hip and lumbar spine
659
Polymyalgia rheumatica (PMR)?
relatively common condition seen in older pts characterised by muscle stiffness and raised inflam markers
660
Cause of polymyalgia rheumatica?
condition is closely related to temporal arteritis but underlying cause not understood, does not appear to be vasculitic process
661
Features of polymyalgia rheumatica?
- typically >60yrs
- rapid onset eg. <1m
- aching, morning stiffness in proximal limb muscles
- WEAKNESS NOT CONSIDERED A SYMPTOM
- mild polyarthralgia, lethargy, depression, low grade fever, anorexia, night sweats
662
Pt with new temporal arteritis with a history of aching and morning stiffness in proximal limb muscles eg. neck and shoulders and pelvic girdle- what is the background condition?
polymyalgia rheumatica
663
Ix for polymyalgia rheumatica?
raised inflam markers eg. ESR >40
creatine kinase and EMG normal
664
Tx for polymyalgia rheumatica?
prednisolone eg. 15mg/od
typically respond dramatically, if they don't then consider alternative diagnosis
665
Definition of polymyalgia rheumatica?
chronic, systemic, rheumatic inflam disease characterised by pain and morning stiffness in neck, shoulder and pelvic girdle
666
RFs for polymyalgia rheumatica?
- older age
- female
- northern european
- infection eg. mycoplasma, chlamydia, pneumonia and parovirus B19
667
One of most common indications for long term corticosteroid Tx?
polymyalgia rheumatica
668
Cx of polymyalgia rheumatica?
GCA (may be abrupt in early course of PMR)
Cx of long term corticosteroids
669
Prognosis of polymyalgia rheumatica?
usually resolves after few days of steroid Tx; treatment is often needed for 1-2yrs and some need low dose for several yrs
relapse is common but responds to restarting/increasing steroid dose
670
Key features of polymyalgia rheumatica?
Bilateral shoulder and/or pelvic girdle pain lasting more than 2 weeks.
Morning stiffness (for more than 45 minutes).
Evidence of an acute phase response.
Other more general symptoms, such as low-grade fever, fatigue, anorexia, weight loss, or depression.
671
Diagnosis of PMR?
working diagnosis in the combination of:
- core features
- exclusion of differentials
- +ve response to oral corticosteroids within 1w
- normal inflam markers within 4w
672
Mx of person with working diagnosis of PMR involves what?
Gradually reducing the dose of corticosteroids when symptoms are fully controlled, adjusting the magnitude of each dose reduction and the duration at each dose to avoid relapses.
Assessing for, and managing, symptoms of relapse, GCA, and steroid-related adverse effects.
Assessing and managing the risk of osteoporosis.
673
Referral to rheumtology in pts with PMR if?
- not possible to reduce steroids at reasonable intervals without causing relapse
- steroids needed for >2yrs
674
Type of pain in PMR?
unilateral then quickly is bilateral
worsens with movement
interferes with sleep
shoulder pain may radiate to elbows
hip and neck pain; hip pain may radiate to knees
675
Stiffness in PMR?
at least 45mins after waking or periods of rest
may be difficult to turn over in bed, rise from chair or raise arms above shoulders
676
Morning stiffness >45mins and difficulty rising from a chair?
?polymyalgia rheumatica
muscle strength not impaired but pain may restrict movement
677
What additional symptoms may be present in polymyalgia rhuematica?
peripheral MSK signs:
- carpal tunnel
- peripheral arthritis (knees and wrists): asymmetric and self limiting
- swelling with pitting oedema of hands, wrists, feet and ankles
678
PMR follow up?
after 1w of pred
then 3-4w of Tx: consider reducing dose, recheck ESR/plasma viscosity and/or CRP to assess Tx response
679
Pt with core symptoms of PMR and is >50yrs what should you do?
- request ESR/plasma viscosity and/or CRP= raised supports diagnosis but can be normal
- Exclude GCA immediately (as may cause vision loss)
- arrange tests in all pts to rule out other conditions before starting steroids= FBC, U&E, LFT, Ca, ALP, protein electrophoresis, TSH, creatine kinase, RF, urine dip; consider= urine sample for Bence Jones protein, ANA and anti-CCP, CXR
- if PMR most likely= trial prednisolone
680
When can you make a working diagnosis of PMR?
if pt reports improvement of 70%+ within 1w of steroids and normalisation of inflam markers within 4w
if lesser response, consider uping dose to 20mg
681
Typical course of Tx for PMR?
Typically, treatment is required for between 1–2 years.
Continue prednisolone 15 mg each day until symptoms are fully controlled (usually 3 weeks), then
Reduce the dose to 12.5 mg each day for 3 weeks, then
Reduce the dose to 10 mg each day for 4–6 weeks, then
Reduce the dose by 1 mg every 4–8 weeks until treatment is stopped.
682
What must pt with PMR be provided with when started on prednisolone?
blue steroid card= don't stop abruptly; avoid close contacts who have chickenpox, shingles or measles if no immunity
683
What to measure at 3 monthly reviews for PMR?
FBC, ESR/CRP, U&E, BP and glucose
684
Differential diagnosis for PMR?
- degenerative disorders= cervical and L spondylosis, osteoarthritis, bilateral adhesive capsulitis (frozen shoulder) and rotator cuff disorders
- thyroid disease and hyperparathyroidsm
- viral illness
- chronic osteomyelitis
- TB
- infective endocarditis
- RA
- spondyloarthropathy
- SLE
- Ca
- myositis or myalgia due to statins
- PMR like syndrome due to quinidine
- osteomalacia
- fibromyalgia
- chronic fatigue syndrome
685
Reactive arthritis is part of what group of conditions?
HLA-B27 seronegative spondyloarthropathies
686
What was reactive arthritis previously called?
Reiter's triad
687
(Reiter's) Triad in reactive arthritis?
urethritis, conjunctivitis and arthritis
'can't see, pee or climb a tree'
688
Reactive arthritis?
arthritis that develops following an infection where the organism cannot be recovered from the joint
eg. post-STI or post-dysenteric (GI disease)
689
Cant see, pee or climb a tree....
Conjunctivitis, urethritis and arthritis
reactive arthritis
690
Organisms most commonly associated with reactive arthritis?
Post-STI (m>f)= chlamydia trachomatis
Post-dysenteric form (m&f same)= shigella flexneri; salmonella typhimurium; salmonella enteritidis; yersina enterocolitica; campylobacter
691
Mx of reactive arthritis?
- analgesia, NSAIDs, intra-articular steroids
- persistent= sulfasalazine and methotrexate
- rarely lasts more than 12m
692
Features of reactive arthritis?
- arthritis= asymmetrical oligoarthritis of lower limbs
- urethritis symptoms
- eye= conjunctivitis (10-30%); anterior uveitis
- dactylitis
- skin= circinate balanitis and keratoderma blenorrhagica
"cant see, wee or climb a tree"
693
Circinate balanitis in reactive arthritis?
painless vesicles on the coronal margin of the prepuce (foreskin/skin surrounding clitoris)
694
Keratoderma blenorrhagica in reactive arthritis?
waxy yellow/brown papules on palms and soles
695
Methotrexate MOA?
antimetabolite that inhibits dihydrofolate reductase, an enzyme essential for synthesis of purines and pyrimidines
696
Why is careful prescribing and close monitoring of methotrexate important?
very effective in controlling disease but the side-effects can be life threatening
697
Indications for methotrexate?
- inflam arthritis, esp RA
- psoriasis
- some chemo ALL
698
Adverse effects of methotrexate?
- mucositis
- myelosuppression
- pneumonitis
- pulmonary fibrosis
- liver fibrosis
699
Most common pulmonary adverse effect of methotrexate?
pneumonitis
- similar disease pattern to hypersensitivity pneumonitis secondary to inhaled organic antigens
- typically develops within a year of starting treatment, either acutely or subacutely
- presents with non-productive cough, dyspnoea, malaise, fever
700
Methotrexate in pregnancy?
avoid pregnancy for at least 6m after stopping methotrexate
men using methotrexate need to use effective contraception for at least 6m after Tx
701
How is methotrexate taken?
7.5mg weekly starting dose (not daily)
- only one strength of methotrexate tablet should be prescribed (2.5mg)
- co-prescribed with 5mg folic acid
702
What needs to be co-prescribed with methotrextae?
5mg folic acid once weekly, take >24hrs after methotrexate dose
703
What needs to be monitored in pts taking methotrexate?
FBC, U&E (renal function) and LFTs before starting, then repeated weekly until therapy stabilised and then monitor every 2-3m
704
Methotrexate interactions?
trimethorpim and
co-trimoxazole = avoid as increases risk of marrow aplasia
high dose aspirin
705
What increases the risk of methotrexate toxicity?
high dose aspirin increases risk of methotrexate toxicity secondary to reduced excretion
706
Tx for methotrexate toxicity?
folinic acid
707
Rheumatoid arthritis (RA)?
chronic systemic inflam disease
708
How does RA present?
inflam arthritis affecting small joints of hands and feed symmetrically and equally; any synovial joint can be involved
as it progresses, any system can be affected so increased risk of premature death
709
Cx and cormorbidities of RA?
CVD, osteoporosis, anaemia, infection
710
What population does RA typically affect?
women > men
peak onset 30-50yrs
711
Clinical features of synovitis in RA?
pain, swelling heat and stiffness in affected joints
712
synovitis vs arthritis?
Synovitis is swelling in the synovial membrane that lines some of your joints that leads to arthritis (acute or chronic joint inflammation in the joint)
713
Ix for RA?
- clinical= if suspected refer urgently within 3d for specialist assessment to confirm within 3w
to speed up diagnosis:
- bloods= rheumatoid factor +ve in 60-70%
- if -ve in RF= test for anti-CCP (80%)
- x-rays of hands and feet= severity
714
When should you suspect RA and so refer the pt for assessment?
1 or more of...
- small joints of the hands or feet affected
- more than 1 joint affected
- present for 3m+
715
Mx for RA?
1) NSAIDs + PPI whilst waiting specialist assessment
2) specialist MX:
cDMARD monotherapy eg. oral methotrexate, leflunomide or sulfasalazine. Dose increased depending on tolerance.
2) may give short-term oral/intramuscular/intra-articular corticosteroids whilst waiting for DMARD to start working
3) not responded= combination of DMARDs
4) severe and still not responded= methotrexate + biological DMARDs
716
Mx of RA flare?
- exclude septic arthritis
- specialist advice
- short term corticosteroids intra-articular= methylprednisolone acetate ; if can't then intramuscular; if can't then oral
717
When to refer pt with RA for surgical opinion?
- no response to Mx
- persistant pain: joint damage or soft tissue cause
- worsening joint function
- progressive deformity
- persistent localised synovitis
- if Cx= imminent or actual tendon rupture, nerve compression, stress fracture
718
CP of RA?
symmetrical synovitis= pain, swelling, heat and stiffness in affected joints
most common in small joints of small hands and feet, but any synovial joint can be affected
pain worse at rest
swelling= around joint 'boggy' on palpation not boney
siffness= early morning >1hr
- may have rheumatoid nodules; systemic features (fever, fatigue, sweats, weight loss); FHx and extra-articular features
719
Rheumatoid nodules in RA?
hard firm swellings over extensor surfaces
720
Extra-articular features in RA?
vasculitis or invl of other body systems eg. eye, lungs and heart
721
Type of presentation in RA?
normally insidious but can be rapid or relapsing and remitting (palindromic presentation)
722
In RA, persistent synovitis and poor prognosis is more likey when...
- greater number of joints affected
- swelling and tenderness
- PIPs and MCP joints affected and there is symmetry
- +ve MCP squeeze test
723
What presentation is associated with ability to diagnose RA from other diagnoses?
inability to make a fist or flex fingers in RA
724
What Ix can be done in RA to speed up diagnosis and act as baseline measure prior to Tx?
- FBC, renal (U&E) and LFTs
- CRP or ESR (normal in 40%)
725
Clinically suspect RA (have 1 of: small joints of hand or feet affected, more than one joint, been >3m) but normal acute phase response, negative anti-CCP and RF?
still refer urgently within 3d for specialist assessment within 3w as clinically suspect
726
Can you prescribe glucocorticoids in primary care for RA whilst awaiting for specialist assessment?
no they may mask the clinical features and delay diagnosis, wait until assessment carried out
727
Target of Tx in RA?
achieve a target of remission of low disease activity if remission cannot be achieved
728
What does cDMARD stand for?
conventional disease-modifying anti-rheumatic drug
729
What can be alternative to a DMARD eg. methotrexate in RA if pt has mild or palindromic disease?
hydroxychloroquine
730
How long until DMARD takes affect in RA?
can take 2-3m
731
Other causes of worsening joint symptoms in RA other than a flare?
- avascular necrosis= sudden pain in pt taking steroids in absence of synovitis
- nerve root compression
- anaemia, infection
- failure of meds to control symptoms
- failure to take meds regularly
- osteoporotic fracture
- secondary osteoarthritis
- psychological/social problems
732
Differential diagnosis for RA?
- connective tissue disorders eg. SLE
- fibromyalgia
- infectious arthritis
- osteoarthritis
- polyarticular gout
- PMR
- psoriatic arthritis
- reactive arthritis
- sarcoidosis
- septic arthritis
- seronegative spondyloarthritis= ?psoriais, back pain or bowel problenms
733
Symmetrical distal polyarthritis
RA
734
Most common gene associated with RA?
HLA DR4
735
Rheumatoid factor (RF)?
autoantibody present in around 70% of RA patients. It targets the Fc portion of the immunoglobulin G (IgG). All antibodies (immunoglobulins) have an Fc portion that interacts with other parts of the immune system. Rheumatoid factor causes immune system activation against the patient’s own IgG, resulting in systemic inflammation. Rheumatoid factor is most often IgM but can be other types of immunoglobulin.
736
what does anti-CCP antibodies stand for (in RA)?
Anti-cyclic citrullinated peptide antibodies
737
Anti-CCP antibodies?
More sensitive and specific than rheumatoid factor in RA. They are positive in around 80% of patients with rheumatoid arthritis. They often pre-date the development of rheumatoid arthritis and indicate that a patient will develop the condition at some point.
738
most common joints affected in RA?
MCP joints
PIP joints
wrist
MTP joints in foot
739
MCP joints
Metacarpophalangeal joints (knuckle)
740
PIP joints
Proximal interphalangeal
741
MTP joints
Metatarsophalangeal joints (in foot- between metatarsal bones and proximal phalanges)
742
Enlarged and painful distal interphalangeal joints
? Heberden’s nodes due to osteoarthritis.
743
What large joints may be affected in RA?
ankle, knee, hips, shoulders, C spine (not L)
744
Arthritis worse with rest, improve with activity. Worse in morning.
RA
745
Morning stiffness >30mins
RA
746
Arthritis worse with activity and improve with rest
OA
747
Morning stiffness <30mins
OA
748
Palindromic rheumatism?
self-limiting episodes of inflammatory arthritis, with pain, stiffness and swelling typically affecting only a few joints.
symptoms last days, then completely resolve
Joints appear normal between episodes.
RF or anti-CCP antibodies may indicate that it will progress to rheumatoid arthritis.
749
Same 4 hand signs in RA?
Z-shaped deformity
Swan neck deformity
Boutonniere deformity
Ulnar deviation
750
RA hand signs: Z-shaped deformity?
to the thumb
751
RA hand signs: swan neck derformity?
hyperextended PIP and flexed DIP
752
RA hand signs: boutonniere deformity?
hyperextended DIP and flexed PIP
753
RA hand signs: ulnar deviation?
ulnar deviation of the fingers at the MCP joints
754
What causes Boutonniere deformity in RA?
Tear in the central slip of the extensor components at the PIP joint. The central slip connects to the middle phalanx at the PIP, and the lateral bands go around the PIP and connect to the distal phalanx. When the patient tries to straighten their finger, the lateral bands pull on the distal phalanx, causing the distal interphalangeal (DIP) joint to hyperextend and the PIP joint to flex.
755
What causes swan neck deformity in RA?
opposite of Boutonnieres deformity. It is caused by an extensor mechanism imbalance, causing flexion of the DIP joint and extension of the PIP joint.
756
Atlantoaxial Subluxation in RA?
Occurs in the C spine.
Synovitis and damage to the ligaments around the odontoid peg of the axis (C2) allow it to shift within the atlas (C1). Subluxation can cause spinal cord compression and is an emergency.
Needs to be considered when a patient is having a general anaesthetic and requires intubation.
MRI can be used to visualise changes in these areas as part of a pre-operative assessment.
757
Name some extra-articular manifestations of RA?
- eye manifestations
- Pulmonary fibrosis
- Felty's syndrome
- Sjögren’s syndrome (with dry eyes and dry mouth)
- Anaemia of chronic disease
- CVD
- Rheumatoid nodules
- Lymphadenopathy
- Carpel tunnel syndrome
- Amyloidosis
- Bronchiolitis obliterans
- Caplan syndrome
758
Felty's syndrome?
extra-articular manifestation of RA
triad= RA, neutropenia and splenomegaly
759
RA, neutropenia and splenomegaly
Felty's syndrome
760
Bronchiolitis obliterans in RA?
small airway destruction and airflow obstruction in the lungs
761
Caplan syndrome?
pulmonary nodules in patients with rheumatoid arthritis exposed to coal, silica or asbestos dust
762
Eye manifestations in RA?
Dry eye syndrome (keratoconjunctivitis sicca)
Episcleritis
Scleritis
Keratitis
Cataracts (secondary to steroids)
Retinopathy (secondary to hydroxychloroquine)
763
X-ray changes in RA?
Periarticular osteopenia
Joint destruction & deformity (advanced)
L.oss of joint space
E.rosions (boney)
S.oft tissue swelling
S.ubluxation
764
Scoring systems in RA?
Health Assessment Questionnaire (HAQ) measures functional ability= response to Tx
Disease Activity Score 28 Joints (DAS28) score is used in monitoring disease activity and response to treatment. It involves assessing 28 joints and assigning points for=
Swollen joints
Tender joints
The ESR or CRP result
765
What is considered the safest cDMARD in RA in pregnancy?
Hydroxychloroquine and sulfasalazine
766
Examples of biological therapies that can be used in RA (interact with immune system to reduce inflam)?
Tumour necrosis factor (TNF) inhibitors (e.g., adalimumab, infliximab, etanercept, golimumab and certolizumab)
Anti-CD20 on B cells (e.g., rituximab)
Anti-interleukin-6 inhibitors (e.g., sarilumab and tocilizumab)
JAK inhibitors (e.g., upadacitinib, tofacitinib and baricitinib)
T-cell co-stimulation inhibitors (e.g., abatacept)
767
How do TNF inhibitors work in RA?
Tumour necrosis factor is a cytokine involved in stimulating inflammation. Blocking TNF reduces inflammation.
768
Main biologics to remember for RA?
- TNF inhibitors= adalimumab, infliximab, entanercept
- Rituximab ( monoclonal antibody that targets the CD20 proteins on the surface of B cells)
769
Adverse effects of biologics in RA?
cause immunosuppression, increasing the risk of infection, certain cancers (e.g., skin) and reactivation of latent TB.
770
Why does folic acid need to be co-prescribed with methotrexate?
methotrexate interferes with folate metabolism and suppresses the immune system
771
RA drug side effects= methotrexate?
Bone marrow suppression and leukopenia, and highly teratogenic
772
RA drug side effects= leflunomide?
Hypertension and peripheral neuropathy
773
RA drug side effects= sulfasalazine?
Orange urine and male infertility (reduces sperm count)
774
RA drug side effects= hydroxychloroquine?
Retinal toxicity, blue-grey skin pigmentation and hair bleaching
775
RA drug side effects= anti-TNF medications?
Reactivation of tuberculosis
775
RA drug side effects= rituximab?
Night sweats and thrombocytopenia
776
American College of Rheymatology criteria for RA?
need 6/10 to diagnose
A) joint involvement= 2-10 large joints (1 point); 1-3 small (2); 4-10 small (3); 10 joints (5)
B) serology= negative RF and ACPP (0); low positive RF or ACPP (2); high positive (3)
C) acute phase reactants= abnormal CRP or ESR (1)
D) duration= >6 w (1)
777
Acute phase reactants in RA?
CRP/ESR
778
How can RF be detected?
Rose-Waaler test: sheep red cell agglutination
Latex agglutination test (less specific)
779
Conditions associated with RF other than RA?
Felty's syndrome (around 100%)
Sjogren's syndrome (around 50%)
infective endocarditis (around 50%)
SLE (= 20-30%)
systemic sclerosis (= 30%)
general population (= 5%)
rarely: TB, HBV, EBV, leprosy
780
What pts with suspected RA should be tested for anti-CCP antibodies?
if RF negative
781
How long can anti-CPP antibodies be detected for in RA?
may be detectable up to 10 years before the development of rheumatoid arthritis
allows early detection of patients suitable for aggressive anti-TNF therapy
782
What is RF (in RA for example)?
circulating antibody (usually IgM) that reacts with the Fc portion of the patients own IgG.
1st line antibody test in suspected RA
783
TNF-inhibitors in RA?
indication= inadequate response to at least two DMARDs including methotrexate
etanercept: recombinant human protein, acts as a decoy receptor for TNF-α, subcutaneous administration, can cause demyelination, risks include reactivation of tuberculosis
infliximab: monoclonal antibody, binds to TNF-α and prevents it from binding with TNF receptors, intravenous administration, risks include reactivation of tuberculosis
adalimumab: monoclonal antibody, subcutaneous administration
784
Rituximab for RA?
anti-CD20 monoclonal antibody, results in B-cell depletion
two 1g intravenous infusions are given two weeks apart
infusion reactions are common
785
Iatrogenic ocular manifestations in RA?
steroid-induced cataracts
chloroquine retinopathy
786
Most common ocular manifestations in RA?
keratoconjunctivitis sicca (most common)
episcleritis (erythema)
scleritis (erythema and pain)
corneal ulceration
keratitis
787
Mx of RA in pregnancy?
sulfasalazine and hydroxychloroquine
low-dose corticosteroids may be used in pregnancy to control symptoms
NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus
patients should be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation
788
When do pts with RA typically get flares if they are pregnant?
after delivery
789
positive 'squeeze test' - discomfort on squeezing across the metacarpal or metatarsal joints
RA
790
Are hand joint deformities an early or late sign in RA?
late
791
Poor prognostic features in RA?
rheumatoid factor positive
anti-CCP antibodies
poor functional status at presentation
X-ray: early erosions (e.g. after < 2 years)
extra articular features e.g. nodules
HLA DR4
insidious onset
792
Periarticular?
area surrounding the joint
793
Most common cause of septic arthritis in adults?
staph aureus overall
young adults who are sexually active= N.gonorrhoeae (disseminated gonococcal infection)
794
Most common cause of septic arthritis in adults (how is it spread)?
hematogenous spread,
may be from distant bacterial infections eg. abscesses
795
Most common location of septic arthritis in adults?
knee
796
Features of septic arthritis in adults?
- acute swollen joint= restricted movement, warm to touch
- fever in majority
797
Ix for septic arthritis?
- synovial fluid sampling under radiographic guidance
- blood cultures
- joint imaging
798
What does synovial fluid sampling show in septic arthritis?
- leucocytosis with neutrophil predominance
- gram staining is negative in around 30-50% of cases
- fluid culture is positive in patients with non-gonococcal septic arthritis
799
When is fluid culture positive in septic arthritis (from synovial joint sampling)?
pts with non-gonococcal septic arthritis
800
Mx of septic arthritis?
IV Abx that cover gram +ve cocci= flucloxacillin or clindamycin if penicillin allergic
- give 4-6w, switched from IV to oral after 2w
- needle aspiration to decompress joint
- may need arthroscopic lavage
801
Most common joints affected in septic arthritis in children?
hip, knee, ankle
m>f
802
Symptoms and signs of septic arthritis in children?
symptoms= joint pain, limp, fever, systemically unwell (lethargy)
signs= swollen red joint, typically only able to minimally move affected joint
803
Ix for septic arthritis in children?
joint aspiration: for culture. Will show a raised WBC
raised inflammatory markers
blood cultures
804
Criteria to diagnose septic arthritis in children?
Kocher criteria:
1) fever >38.5 degrees C
2) non-weight bearing
3) raised ESR
4) raised WCC
805
How to pts with osteoporotic vertebral fractures typically present?
- asymptomatic= my be incidental finding on x-ray
- acute back pain
- breathing difficulties= change in shape may compress organs eg. lungs, heart, intestine
- GI problems= compression abdo organs
- minority will have Hx of fall/trauma
806
Signs of osteoporotic vertebral fracture?
- loss of height= compress spinal vertebrae so reduction in length of spine
- kyphosis (curved spine)
- localised tenderness on palpation of spinous processess at fracture site
807
Ix for osteoporotic vertebral fracture?
x-ray spine= wedging of vertebrae due to compression of bone, may show old fractures (sclerotic appearance)
2nd line= CT spine (extent of fracture) or MRI (differentiate from those caused by another pathology like tumour)
808
Epidemiology of SLE?
F:M (9:1)
Afro-Caribbeans and Asian
onset 20-40yrs
809
What does SLE stand for?
systemic lupus erythematosus
810
What type of disease is SLE?
autoimmune disease= a type 3 hypersensitivity reaction
811
What genes is SLE associated with?
HLA B8, DR2, DR3
812
What is SLE thought to be caused by?
immune system dysregulation leading to immune complex formation; immune complex deposition can affect any organ eg, skin, joints, kidneys and brain
813
Immune complex deposition (formed by immune system dysregulation) in SLE can affect where?
any organ icl. skin, joints, kidney and brain
814
Systemic lupus erythematosus (SLE)?
multisystem autoimmune disorder; typically presents in early adulthood and more common in women & Afro-Caribeean
815
General features of SLE?
- fatigue
- fever
- mouth ulcers
- lymphadenopathy
- skin features= malar rash
- MSK= arthralgia
- CVD= pericarditis
- Resp= pleurisy, fibrosing alveolitis
- Renal= proteinuria, glomerulonephritis
- Neuropsychiatric= anxiety, depression, seizures
816
Skin features in SLE (6)?
malar (butterfly) rash: spares nasolabial folds
discoid rash
photosensitivity
Raynaud's phenomenon
livedo reticularis
non-scarring alopecia
817
2 types of rash in SLE?
malar (butterfly) rash= spares nasolabial folds
discoid rash= scaly, erythematous, well demarcated rash in sun-exposed areas. Lesions may progress to become pigmented and hyperkeratotic before becoming atrophic
818
MSK features in SLE?
arthralgia
non-erosive arthritis
819
Cardiovascular features in SLE?
pericarditis (most common)
myocarditis
820
Resp features in SLE?
pleurisy
fibrosing aleovlitis
821
Renal features in SLE?
proteinuria
glomerulonephritis (diffuse proliferative glomerulonephritis is the most common type)
822
Neuropsychiatric features in SLE?
anxiety & depression
psychosis
seizures
823
Ix in SLE?
- ANA positive (90%)
- RF +ve (20%)
- anti-dsDNA
- anti-Smith
- anti-RO (SS-A), anti-La (SS-B) and anti-U1 RNP
824
Antibodies in SLE?
- ANA positive (90%), high sensitivity so useful rule out test, low specificity
- RF +ve (20%)
- anti-dsDNA: very specific but low sensitive
- anti-Smith: high specific, low sensitive
- anti-RO (SS-A), anti-La (SS-B) and anti-U1 RNP
825
Monitoring in SLE?
1) ESR used; during active disease CRP may be normal, if it is raised may mean infection
2) complement levels (C3,C4) low during active disease
3) anti-dsDNA titres can be used but not present in all pts
826
Why in SLE are complement levels (C3 and C4) low during active disease?
formation of immune complexes leads to consumption of complement
827
Mx for SLE?
Hydroxychloroquine
+ NSAIDs and sun-block
internal organ involvement (eg. renal, neuro, eye)= consider prednisolone or cyclophosamide
828
Lupus nephritis?
severe manifestation of SLE that can result in end-stage renal disease
829
SLE pts should be monitored how to look for renal Cx (eg. lupus nephritis)?
urinalysis to rule out proteinuria
830
WHO classification of renal Cx (SLE)?
class I: normal kidney
class II: mesangial glomerulonephritis
class III: focal (and segmental) proliferative glomerulonephritis
class IV: diffuse proliferative glomerulonephritis
class V: diffuse membranous glomerulonephritis
class VI: sclerosing glomerulonephritis
831
Most common form of renal Cx in SLE?
Class IV (diffuse proliferative glomerulonephritis)
832
What does renal biopsy show in pt with SLE with renal Cx: Class IV (diffuse proliferative glomerulonephritis) ?
glomeruli shows endothelial and mesangial proliferation, 'wire-loop' appearance
if severe, the capillary wall may be thickened secondary to immune complex deposition
electron microscopy shows subendothelial immune complex deposits
granular appearance on immunofluorescence
833
Mx of renal Cx in SLE?
treat HTN
initial therapy for focal (class III) or diffuse (class IV) lupus nephritis=
glucocorticoids with either mycophenolate or cyclophosphamide
subsequent therapy=
mycophenolate is generally preferred to azathioprine to decrease the risk of developing end-stage renal disease
834
Boxer fracture?
a minimally displaced fracture of the 5th metacarpal (little finger)
typically following pt punching a hard surface eg. wall
835
Pt punches wall, what fracture?
boxer (5th metacarpal)
836
Fall onto outstretched hand- what fracture?
Colles' fracture
Scaphoid fracture
837
When does a Colles' fracture occur?
fall onto outstretched hand (known as a FOOSH)
838
Colles' fracture?
distal radius fracture with dorsal displacement of fragments
described as a dinner fork type deformity
839
3 features of Colles' fracture?
Transverse fracture of the radius
1 inch proximal to the radio-carpal joint
Dorsal displacement and angulation
840
How to remember Colles' fracture?
Dorsally Displaced Distal radius → Dinner fork Deformity
841
Early Cx of Colles' fracture?
median nerve injury: acute carpal tunnel syndrome presenting with weakness or loss of thumb or index finger flexion
compartment syndrome
vascular compromise
malunion
rupture of the extensor
pollicis longus tendon
842
acute carpal tunnel syndrome presenting with weakness or loss of thumb or index finger flexion following fall onto outstretched hand
median nerve injury due to colles' fracture
843
What nerve injury does Colles' fracture cause?
median nerve injury: acute carpal tunnel syndrome presenting with weakness or loss of thumb or index finger flexion
844
Late Cx of Colles' fracture?
osteoarthritis
complex regional pain syndrome
845
Smith's fracture (reverse colles' fracture)?
Volar angulation of distal radius fragment (Garden spade deformity)
Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed
846
falling backwards onto the palm of an outstretched hand or falling with wrists flexed- what fracture?
Smith's
847
Bennetts' fracture?
Intra-articular fracture of the first carpometacarpal joint
Impact on flexed metacarpal, caused by fist fights
X-ray: triangular fragment at ulnar base of metacarpal
848
Impact on flexed metacarpal, caused by fist fights- what fracture?
Bennetts
849
Monteggia's fracture?
Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
Needs prompt diagnosis to avoid disability
850
Fall on outstretched hand with forced pronation- what fracture?
Monteggia's fracture
851
Galeazzi fracture?
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow
852
What fracture can be associated with a direct blow?
Galeazzi fracture
853
Pott's fracture?
Bimalleolar ankle fracture
Forced foot eversion
854
Forced foot eversion- what fracture?
Pott's
855
Barton's fracture?
Distal radius fracture (Colles'/Smith's) with associated radiocarpal dislocation
Fall onto extended and pronated wrist
856
Fall onto extended and pronated wrist- what fracture?
Barton's fracture
857
Fractures of the humerus can be divided into what?
proximal humeral fractures
humeral shaft fractures
distal humeral fractures
858
proximal humeral fractures?
typically seen in elderly
859
distal humeral fractures?
typically seen in children
includes supracondylar fractures
860
Examples of Eponymous fractures?
Colles'
Smith's
Bennett's
Monteggia's
Galeazzi
Pott's
Barton's
861
Supracondylar fractures?
fractures of the distal humerus just above elbow joint
typically seen in children and most common type of elbow fracture in children
862
Features of Supracondylar fractures (fractures of the distal humerus just above elbow joint)?
typically result from a fall onto an outstretched hand
pain
swelling over the elbow immediately
the elbow will typically be in a semi-flexed position
complications due to neurovascular involvement:
median nerve
radial nerve
brachial artery
ulnar nerve
863
child falls onto outstretched hand and the elbow is now in semi-flexed postition?
Supracondylar fracture (fractures of the distal humerus just above elbow joint)
864
Mx of Supracondylar fractures (fractures of the distal humerus just above elbow joint)?
non-displaced fractures=
collar and cuff
displaced fractures=
manipulation under anaesthesia with fixation
865
Types of paediatric fractures?
- complete fracture
- toddlers fracture
- plastic deformity
- Greenstick fracture
- Buckle ('torus') fracture
- Growth plate fractures
- Pathological fractures
866
Paediatric fractures: injury pattern in a complete fracture?
both sides of cortex are breached
867
Paediatric fractures: injury pattern in a toddlers fracture?
oblique tibial fracture in infants
868
Paediatric fractures: injury pattern in a plastic deformity?
stress on bone resulting in deformity without cortical disruption
869
Paediatric fractures: injury pattern in a Greenstick fracture?
unilateral cortical breach only
870
Paediatric fractures: injury pattern in a buckle ('torus') fracture?
incomplete cortical disruption resulting in periosteal haematoma only
871
Paediatric fractures: injury pattern in a growth plate fracture?
fractures that involve growth plates
872
How are growth plate fractures in paeds classified?
Salter-Harris system:
I= Fracture through the physis only (x-ray often normal)
II= Fracture through the physis and metaphysis
III= Fracture through the physis and epiphysis to include the joint
IV= Fracture involving the physis, metaphysis and epiphysis
V= Crush injury involving the physis (x-ray may resemble type I, and appear normal)
873
What indicates a growth plate fracture in children?
growth plate tenderness even if x-ray is normal
874
Mx of growth plate fractures in children?
Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.
875
Signs of non-accidental injury in children?
Delayed presentation
Delay in attaining milestones
Lack of concordance between proposed and actual mechanism of injury
Multiple injuries
Injuries at sites not commonly exposed to trauma
Children on the at risk register
Bruising of different ages
876
What conditions may cause pathological fractures in children?
genetic:
- osteogenesis imperfecta
- osteopetrosis
877
Pathological fractures in children: osteogenesis imperfecta?
Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.
Failure of maturation of collagen in all the connective tissues.
Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.
878
Pathological fractures in children: subtypes of osteogenesis imperfecta?
Type I - The collagen is normal quality but insufficient quantity.
Type II - Poor collagen quantity and quality.
Type III - Collagen poorly formed. Normal quantity.
Type IV - Sufficient collagen quantity but poor quality.
879
Pathological fractures in children: osteopetrosis?
Bones become harder and more dense.
Autosomal recessive condition.
It is commonest in young adults.
Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone.
880
Scaphoid fracture?
type of wrist fracture
typically arises as a result of a fall onto an outstretched hand (FOOSH); contact sports (rugby, football) or road traffic accident when pt holding wheel
881
Result of a scaphoid fracture?
axial compression of the scaphoid, with the wrist hyperextended, and radially deviated
882
axial compression of the scaphoid, with the wrist hyperextended, and radially deviated
scaphoid fracture
883
What is it important to examine for in anyone presenting with acutely painful wrist for medico-legal reasons?
scaphoid fracture
884
Blood supply to scaphoid bone?
Around 80% of the blood supply is derived from the dorsal carpal branch (branch of the radial artery), in a retrograde manner.
885
Why is it so important to recognise scaphoid fractures?
given the unusual blood supply of the scaphoid bone; Interruption of the blood supply risks avascular necrosis of the scaphoid, with this most commonly complicating proximal injuries.
886
What do pts with scaphoid fracture present with?
Pain along the radial aspect of the wrist, at the base of the thumb
Loss of grip / pinch strength
887
Name 5 signs of a scaphoid fracture?
1. Point of maximal tenderness over the anatomical snuffbox
2. Wrist joint effusion`;
Hyperacute injuries (<4hrs old), and delayed presentations (>4days old) may not present with joint effusions.
3. Pain elicited by telescoping of the thumb (pain on longitudinal compression)
4. Tenderness of the scaphoid tubercle (on the volar aspect of the wrist)
5. Pain on ulnar deviation of the wrist
888
Ix for scaphoid fractures?
- clinical: look for signs, esp 1,3 and 4
- Plain film radiographs of the wrist in the anterior-posterior view, and lateral view
- CT if uncertain or planning operative Mx
- MRI definitive to confirm (use 2nd line when x-ray inconclusive)
889
X-ray in scaphoid fracture?
'Scaphoid views': posterioranterior (PA), lateral, oblique (with wrist pronated at 45º) and Ziter view (PA view with the wrist in ulnar deviation and beam angulated at 20º)
The sensitivity in the first week of injury is only 80%
890
Mx of scaphoid fracture?
- initial= immobilisation with a Futuro splint or standard below-elbow backslab
- referral to orthopaedics
clinical review with further imaging should be arranged for 7-10 days later when initial radiographs are inconclusive
- may need ortho Mx
891
Ortho Mx of scaphoid fracture?
dependent on the patient and type of fracture
undisplaced fractures of the scaphoid waist=
cast for 6-8 weeks;
union is achieved in > 95%;
certain groups e.g. professional sports people may benefit from early surgical intervention
displaced scaphoid waist fractures=
requires surgical fixation
proximal scaphoid pole fractures=
require surgical fixation
892
Cx of scaphoid fractures?
non-union → pain and early osteoarthritis
avascular necrosis
893
Commonest carpal fractures?
scaphoid
894
Why does fracture of scaphoid risk blood supply?
Surface of scaphoid is covered by articular cartilage with small area available for blood vessels
895
What forms floor of anatomical snuffbox?
scaphoid
896
Summarise features of scaphoid fracture?
The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb.
Ulnar deviation AP needed for visualization of scaphoid
Immobilization of scaphoid fractures difficult
897
Radial head fracture?
Fracture of the radial head is common in young adults.
It is usually caused by a fall on the outstretched hand.
marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).
898
marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination)
radial head fracture
899
De Quervain's tenosynovitis?
common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed
900
De Quervain's tenosynovitis typically affects who?
females 30-50yrs
901
Features of De Quervain's tenosynovitis?
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Finkelstein's test
902
Finekelstein's test in De Quervain's tenosynovitis?
examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus
903
Mx for De Quervain's tenosynovitis?
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required
904
Lateral epicodylitits aka
tennis elbow
905
Lateral epicodylitits (tennis elbow) features?
pain and tenderness localised to the lateral epicondyle
pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks
906
Medial epicondylitis aka
golfer's elbow
907
Medial epicondylitis (golfer's elbow) features?
pain and tenderness localised to the medial epicondyle
pain is aggravated by wrist flexion and pronation
symptoms may be
accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
908
pain is aggravated by wrist flexion and pronation
symptoms may be
accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
Medial epicondylitis (golfer's elbow)
909
pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
Lateral epicondylitis (tennis elbow)
910
Radial tunnel syndrome most commonly due to what?
compression of the posterior interosseous branch of the radial nerve. It is thought to be a result of overuse.
911
Radial tunnel syndrome features?
symptoms are similar to lateral epicondylitis making it difficult to diagnose
however, the pain tends to be around 4-5 cm distal to the lateral epicondyle
symptoms may be worsened by extending the elbow and pronating the forearm
912
symptoms are similar to lateral epicondylitis making it difficult to diagnose
however, the pain tends to be around 4-5 cm distal to the lateral epicondyle
symptoms may be worsened by extending the elbow and pronating the forearm
radial tunnel syndrome (compression of the posterior interosseous branch of the radial nerve/overuse)
913
Cubital tunnel syndrome due to?
compression of ulnar nerve
914
Cubital tunnel syndrome features?
initially intermittent tingling in the 4th and 5th finger
may be worse when the elbow is resting on a firm surface or flexed for extended periods
later numbness in the 4th and 5th finger with associated weakness
915
initially intermittent tingling in the 4th and 5th finger
may be worse when the elbow is resting on a firm surface or flexed for extended periods
later numbness in the 4th and 5th finger with associated weakness
cubital tunnel syndrome (ulnar nerve compression)
916
Olecranon bursitis summary?
Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.
917
Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.
Olecranon bursitis
918
Olecranon bursa?
verlying the olecranon process of the elbow beneath the skin. It reduces friction on movement between the skin, tendons, ligaments, and bone, and allows them to glide smoothly over one another.
919
When does bursitis occur?
when the bursa is irritated and inflamed and is generally classified as:
Non-septic (most common) — sterile inflammation resulting from various causes including trauma or overuse.
Septic — infection resulting from seeding of the bursal sac with micro-organisms, usually bacteria.
920
Who is olecranon bursitis more common in?
Young or middle-aged men.
People in jobs which involve risk of regular elbow trauma or pressure on the bursa.
For example gardeners and mechanics.
Athletes who play sports which involve repetitive overhead throwing or elbow flexion and extension.
921
Mx of olecranon bursitis?
conservative measures (such as rest, compression bandaging, avoidance of trauma to the elbows, and analgesia) until symptoms improve.
most resolve without complications; however, recurrent episodes may occur especially after recurrent minor trauma.
922
CP of olecranon bursitis?
- swelling over the elbow that appears over several hours to several days, may be tender or warm (but may be painless), and is fluctuant.
- Movement at the elbow joint is painless except at full flexion when the swollen bursa is compressed.
- Hx of preceding trauma or bursal disease.
- local skin abrasion.
923
Non-septic bursitis Mx?
reassurance that most people will respond to conservative treatment.
Considering aspiration, particularly if the effusion is large.
Considering corticosteroid injection into the bursa.
Referral if there is no response to available treatments in primary care after 2 months.
924
Septic bursitis Mx?
Aspiration and Tx empirically with Abx until culture results are known.
Urgent referral or specialist advice sought if there is no response, or an inadequate response to an antibiotic in septic bursitis, or complications are suspected.
Considering repeated aspiration if swelling, tenderness, and erythema recur.
Mx any associated conditions, such as gout, rheumatoid arthritis, or cellulitis.
925
Admission to hospital with bursitis?
if...
suspected septic joint (which presents with a limited range of movement of the elbow joint, unlike septic bursitis).
Septic bursitis and severe infection or systemic toxicity.
A pointing abscess requiring incision and drainage, if the expertise to perform this procedure is not available.
Extensive cellulitis.
926
Recurrent septic bursitis?
urgent referral
or consider referral in non-septic bursitis (in whom septic bursitis has been excluded) does not respond after 2 months of conservative measures
927
Lateral epicondylitis (tennis elbow)?
typically follows unaccustomed activity such as house painting or playing tennis ('tennis elbow'). It is most common in people aged 45-55 years and typically affects the dominant arm.
928
Pain in Lateral epicondylitis (tennis elbow)?
pain and tenderness localised to the lateral epicondyle
pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended
929
Lateral epicondylitis (tennis elbow) episodes?
episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks
930
Mx options for Lateral epicondylitis (tennis elbow)?
advice on avoiding muscle overload for 6w but maintain activity
heat and ice
simple analgesia
consider orthosis eg. forearm strap
steroid injection if severe but only short term relief
physiotherapy
if uncertain, refractory pain, severe impairment or persist 6-12m then refer to ortho surgeon
931
Definition of Lateral epicondylitis (tennis elbow)?
tendinosis (chronic symptomatic degeneration of the tendon) that affects the common attachment of the tendons of the extensor muscles of the forearm to the lateral epicondyle of the humerus.
932
Pt with Lateral epicondylitis (tennis elbow) may describe what?
pain around lateral epicondyle with radiation down extensor aspect of forearm
difficulty with common activities= raising cup, shaking hands, shaving, lifting bags
exacerbated by XS and repetitive use of extensor muscles of forearm eg. gripping and repetitive wrist movements; occupational activities eg. vibrating tools, typing, playing piano, tennis, construction work
933
What is Lateral epicondylitis (tennis elbow) also known as?
lateral elbow pain, 'rowing elbow', tendonitis of the common extensor origin, and peri-tendinitis of the elbow.
934
Lateral epicondylitis (tennis elbow) pathophysiology?
Occurs after minor or unrecognized trauma of the forearm extensor muscles.
Repetitive overuse causes micro-tears near the origin of the common extensor tendon at the lateral epicondyle of the humerus, which initiates a degenerative process.
935
Examination findings in Lateral epicondylitis (tennis elbow)?
Localized point tenderness on palpation over and/or distal to the lateral epicondyle and along the common extensor tendon.
Pain on resisted middle finger extension.
Pain on resisted wrist extension.
Reduced grip strength due to pain.
Preserved full range of active and passive movement at the elbow and wrist joints.
936
Ottawa ankle rules state that x-rays are only needed to assess for ankle fracture if...
pain in the malleolar zone and:
1. Inability to weight bear for 4 steps
2. Tenderness over the distal tibia
3. Bone tenderness over the distal fibula
937
Weber classification for ankle fracture?
Related to the level of the fibular fracture.
Type A is below the syndesmosis
Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis
Type C is above the syndesmosis which may itself be damaged
938
Weber classification for ankle fracture- subtype?
Maisonneuve fracture may occur with spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint, surgery is required.
939
Mx of ankle injuries?
All ankle fractures should be promptly reduced to remove pressure on the overlying skin and subsequent necrosis
Young patients, with unstable, high velocity or proximal injuries will usually require surgical repair. Often using a compression plate.
Elderly patients, even with potentially unstable injuries usually fare better with attempts at conservative management as their thin bone does not hold metalwork well.
940
Discitis?
infection of the intervertebral disc space; can lead to serious Cx eg. sepsis or epidural abscess
941
Features of discitis?
- back pain
- general= pyrexia, rigors, sepsis
- neuro= eg. changes in lower limb neurology, if epidural abscess develops
942
Causes of discitis?
- bacterial= staph aureus most common cause of discitis
- viral
- TB
- aseptic
943
Diagnosis of discitis?
MRI
- CT guided biopsy may be needed to guide antimicrobial Tx
944
Tx for discitis?
6-8w IV Abx
Choice of antibiotic is dependent on a variety of factors. The most important factor is to identify the organism with a positive culture (e.g. blood culture, or CT-guided biopsy)
the patient should be assessed for endocarditis e.g. with transthoracic echo or transesophageal echo. Discitis is usually due to haematogenous seeding of the vertebrae implying that the patient has had a bacteraemia and seeding could have occurred elsewhere
945
Cx of discitis?
sepsis
epidural abscess
946
Red flags for lower back pain?
age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever
947
name 4 specific causes of lower back pain?
- facet joint
- spinal stenosis
- ankylosing spondylitis
- PAD
948
Causes of lower back pain (LBP): facet joint?
May be acute or chronic
Pain worse in the morning and on standing
On examination there may be pain over the facets. The pain is typically worse on extension of the back
949
Causes of lower back pain (LBP): spinal stenosis?
Usually gradual onset
Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as 'aching', 'crawling'.
Relieved by sitting down, leaning forwards and crouching down
Clinical examination is often normal
Requires MRI to confirm diagnosis
950
Causes of lower back pain (LBP): ankylosing spondylitis?
Typically a young man who presents with lower back pain and stiffness
Stiffness is usually worse in morning and improves with activity
Peripheral arthritis (25%, more common if female)
951
Causes of lower back pain (LBP): peripheral arterial disease?
Pain on walking, relieved by rest
Absent or weak foot pulses and other signs of limb ischaemia
Past history may include smoking and other vascular diseases
952
What does low back pain refer to?
pain in the lumbosacral area, from the 12th ribs to the iliac crest, and sometimes the buttocks and gluteal folds.
953
Non-specific low back pain?
pain not attributable to an underlying cause. It is also referred to as 'mechanical', 'musculoskeletal', or 'simple' low back pain
90-95% cases in primary care
954
Acute vs chronic low back pain?
A= <3m
C= 3m+
955
RFs for low back pain?
obesity, physical inactivity, heavy lifting, and stress or depression.
956
prognosis of low back pain?
self-limiting normally and usually resolves within few w
957
Cx of low back pain?
impact on daily activities including work, study, leisures, and sleep; depression and anxiety; increased risk of falls and chronic pain.
958
Assessment for pt with low back pain?
onset, type, site, and pattern of pain; any pain radiation; duration of symptoms; associated symptoms and red flags; impact on daily functioning; drug treatments.
Examine: gait, posture, spine for localized tenderness and range of movement; red flags; and neuro examination.
Using a risk stratification screening tool to assess risk factors for a prolonged or complex recovery if non-specific low back pain is suspected.
959
Mx of non-specific low back pain?
keep active, normal activities when able, local heat for symptom relief
NSAIDs; 2nd line- short term codeine +/- para
exercise programmes
occy health assessment
review if persist or worsen after 3-4w
?refer to chronic pain
960
Lumbar spinal stenosis?
central canal is narrowed by tumour, disc prolapse or other similar degenrative changes
961
Lumbar spinal stenosis presentation?
combination of back pain, neuropathic pain and symptoms mimicking claudication
Sitting is better than standing and patients may find it easier to walk uphill
962
How to differentiate lumbar spinal stenosis from true claudication?
Sitting is better than standing and patients may find it easier to walk uphill rather than downhill. Makes lumbar spinal stenosis a likely underlying diagnosis, the absence of such symptoms makes it far less likely.
963
Pathophysiology of lumbar spinal stenosis?
degenerative disease commonest cause
Degeneration begins in intervertebral disk where biochemical changes (cell death and loss of proteoglycan and water content) lead to progressive disk bulging and collapse.
Leads to increased stress transfer to the posterior facet joints, which accelerates cartilaginous degeneration, hypertrophy, and osteophyte formation; this is associated with thickening and distortion of the ligamentum flavum.
The combination of the ventral disk bulging, osteophyte formation at the dorsal facet, and ligamentum flavum hyptertrophy combine to circumferentially narrow the spinal canal and the space available for the neural elements.
The compression of the nerve roots of the cauda equina leads to the characteristic clinical signs and symptoms of lumbar spinal stenosis.
964
Diagnosis of lumbar spinal stenosis?
MRI= canal narrowing
Historically a bicycle test was used as true vascular claudicants could not complete the test.
965
Tx for lumbar spinal stenosis?
laminectomy
966
Paget's disease of the bone?
disease of increased but uncontrolled bone turnover. It is thought to be primarily a disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity.
967
How common is Paget's?
5% UK but only 1 in 20 have symptoms
968
What is most commonly affected in Paget's?
skull, spine/pelvis, and long bones of the lower extremities
969
Paget's predisposing factors?
increasing age
male sex
northern latitude
family history
970
Clinical features of Paget's?
- only 5% symptomatic
- bone pain (e.g. pelvis, lumbar spine, femur)
-classical, untreated features: bowing of tibia, bossing of skull
- typically: older male with bone pain and an isolated raised ALP
971
older male with bone pain and an isolated raised ALP
?Paget's
972
Bowing of tibia and bossing of the skull?
classic untreated features of Paget's
973
Ix for Paget's?
- Bloods= raised ALP, normal Ca and phosphate; hypercalcaemia may occur with prolonged immobilisation
- other markers of bone turnover= PINP, CTx, NTx, urinary hydroxyproline
- x-rays
- bone scintigraphy
974
Markers of bone turnover results in Pagets?
raised alkaline phosphatase (ALP)
calcium and phosphate are typically normal.
Hypercalcaemia may occasionally occur with prolonged immobilisation
other markers of bone turnover includeL
procollagen type I N-terminal propeptide (PINP)
serum C-telopeptide (CTx)
urinary N-telopeptide (NTx)
urinary hydroxyproline
975
X-ray findings in Paget's?
osteolysis in early disease → mixed lytic/sclerotic lesions later
skull x-ray: thickened vault, osteoporosis circumscripta
976
Bone scintigraphy in Paget's?
increased uptake is seen focally at the sites of active bone lesions
977
Indications for Tx in Paget's?
bone pain
skull or long bone deformity
fracture
periarticular Paget's
978
Mx of Paget's?
if indicated= bisphosphonate (oral risedronate or IV zoledronate)
979
Cx of Paget's?
deafness (cranial nerve entrapment)
bone sarcoma (1% if affected for > 10 years)
fractures
skull thickening
high-output cardiac failure
980
Polyarthritis?
inflammation of 5+joints simultaneously, within the first 6 weeks of symptom onset.
981
Features of polyarthritis?
pain, swelling, and stiffness in multiple joints
the pattern of joint involvement may be symmetrical, as seen in rheumatoid arthritis, or asymmetrical, as noted in psoriatic arthritis
systemic symptoms= fever, weight loss, and fatigue may also be present, reflecting the underlying systemic inflammatory process.
982
Differential diagnosis of polyarthritis?
inflammatory arthritis= RA,
psoriatic arthritis, SLE, seronegative spondyloarthropathies
infective= viral : EBV, HIV, hepatitis, mumps, rubella; TB; disseminated gonococcal infection
pseudogout
Henoch-Schonlein purpura
sarcoidosis
983
Psoriatic arthropathy (arthritis)?
inflammatory arthritis associated with psoriasis and is classed as one of the seronegative spondyloarthropathies
984
Link between psoriasis and arthritis in psoriatic arthritis?
often precedes the development of skin lesions
Around 10-20% of patients with skin lesions develop an arthropathy with males and females being equally affected.
985
Presentation patterns in psoriatic arthritis?
symmetric polyarthritis= very similar to rheumatoid arthritis; most common type
asymmetrical oligoarthritis: typically affects hands and feet (20-30%)
sacroiliitis
DIP joint disease (10%)
arthritis mutilans (severe deformity fingers/hand, 'telescoping fingers')
986
Signs in psoriatic arthritis other than the disease patterns?
psoriatic skin lesions
periarticular disease - tenosynovitis and soft tissue inflammation resulting in:
- enthesitis: inflammation at the site of tendon and ligament insertion e.g. Achilles tendonitis, plantar fascitis
- tenosynovitis: typically of the flexor tendons of the hands
- dactylitis: diffuse swelling of a finger or toe
Nail changes
987
Nail changes in psoriatic arthritis?
pitting and onycholysis
988
Ix in psoriatic arthritis?
x-ray= 'penicl-in-cup' appearance; periostitis; often unusual combination of coexistence of erosive changes and new bone formation
989
Mx of psoriatic arthritis?
- Mx by rheumatology
Tx similar to RA but:
- mild= NSAID not DMARD
- moderate/severe= methotrexate
- use of monoclonal antibodies such as ustekinumab (targets both IL-12 and IL-23) and secukinumab (targets IL-17)
- apremilast: phosphodiesterase type-4 (PDE4) inhibitor
better prognosis than RA
990
apremilast: phosphodiesterase type-4 (PDE4) inhibitor MOA in psoriatic arthritis?
→ suppression of pro-inflammatory mediator synthesis
991
Causes of limping child?
1) transient synovitis
2) septic arthritis/osteomyelitis
3) Juvenile idiopathic arthritis
4) trauma
5) developmental dysplasia of hip
6) perthes disease
7) slipped upper femoral epiphysis
992
Cervical spondylosis?
degenerative condition affecting the cervical spine, essentially osteoarthritis of the cervical vertebral bodies.
993
If spinal canal is narrowed due to cervical sponylosis then that can happen?
C vertebral bodies can press on spinal cord resulting in neuro dysfunction
994
Link between cervical spondylosis and cervical spondylitic myelopathy?
myelopathy occurs in 5-10% pts with C spondylosis
995
Features of cervical spondylitic myelopathy?
a variety of motor weakness, sensory loss and
bladder/bowel dysfunction may be seen
neck pain
wide-based, ataxic or spastic gait
UMN weakness in the lower legs - increased reflexes, increased tone and upgoing plantars
bladder dysfunction e.g. urgency, retention
996
Definition of cervical spondylosis?
degenerative condition affecting the cervical spine, particularly the intervertebral discs, vertebral bodies, and facet joints.
997
Causes of cervical spondylosis?
primarily an age-related process, often referred to as 'cervical osteoarthritis,' and is characterised by the progressive deterioration of the spinal structures in the neck region.
998
Is cervical spondylosis common?
common, esp in >50yrs
by 60yrs radiographic evidence is present in >85% of individuals, although many remain asymptomatic.
999
4 stages of the pathogenesis of cervical spondylosis (sequence of degenerative changes)?
1) intervertebral disc degeneration
2) osteophyte formation
3) facet joint arthropathy
4) ligamentous hypertrophy
1000
4 stages of the pathogenesis of cervical spondylosis (sequence of degenerative changes): 1) intervertebral disc degeneration?
process begins with the dehydration and shrinkage of the nucleus pulposus within the intervertebral discs, leading to reduced disc height and loss of elasticity.
1001
4 stages of the pathogenesis of cervical spondylosis (sequence of degenerative changes): 2) osteophyte formation?
In response to disc degeneration, the body attempts to stabilise the spine by forming osteophytes, or bone spurs, at the margins of the vertebral bodies and facet joints. These osteophytes can encroach upon the spinal canal and intervertebral foramina.
1002
4 stages of the pathogenesis of cervical spondylosis (sequence of degenerative changes): 3) facet joint arthropathy?
Degenerative changes in the facet joints contribute to instability, inflammation, and further osteophyte formation. This can result in nerve root compression (radiculopathy) or, less commonly, spinal cord compression (myelopathy).
1003
4 stages of the pathogenesis of cervical spondylosis (sequence of degenerative changes): 4) ligamentous hypertrophy?
The ligamentum flavum and other supporting ligaments may thicken and lose elasticity, contributing to spinal canal stenosis and potential neurological complications.
1004
Clinical features of cervical spondylosis?
- neck pain= chronic, stiffness, limited ROM, may radiate to shoulder & upper back
- radiculopathy= compression C nerve roots- radicular pain, paraesthesia, weakness in upper limbs (follows dermatomal pattern)
- myelopathy= severe manifestation due to spinal cord compression; clumisness in hands, gait disturbance, limb weakness, bowel or bladder dysfunction in advanced
- headaches= occipital due to irritation of C nerve roots or muscles in upper C region
1005
Examination findings in cervical spondylosis?
reduced range of motion in the neck, tenderness over the cervical spine, and signs of radiculopathy or myelopathy (e.g., positive Spurling's test, hyperreflexia, or gait instability).
1006
Ix (imaging) for cervical spondylosis?
- plain x-rays of C spine= disc space narrowing, osteophytes and facet joint arthropathy
- MRI= GOLD; images soft tissue eg. spinal cord, nerve roots and intervertebral discs
- electrophyisological studies= nerve conduction and electromyography to differentiate C radiculopaty from peripheral neuropathy & other conditions
1007
Mx for cervical spondylosis can be what?
conservative or interventional procedures
1008
Mx for cervical spondylosis: conservative?
- NSAIDs
- physio= improve neck strength, postural training
- cervical collar= temp in acute flares but long term use discouraged due to risk of muscle weakness
1009
Mx for cervical spondylosis: interventional procedures?
- cervical epidural steroid injections= if radicular symptoms, temp relief by reducing inflam around affected nerve root
- facet joint injections or radiofrequency ablation= pts with chronic facet-mediated pain
1010
Radiculopathy
neurological state in which conduction is limited or blocked along a spinal nerve or its roots — it is differentiated from radicular pain, although they commonly occur together.
1011
Radicular pain?
usually caused by compression of the nerve root due to cervical disc herniation or degenerative spondylotic changes, but radicular symptoms can also occur without evident compression (for example, due to inflammation of the nerve).
1012
Cervical radiculopathy?
pain and weakness and/or numbness in one or both of the upper extremities, which corresponds to the dermatome of the involved cervical nerve root.
- neck pain secondary to compression or irritation of nerve roots in C spine
- pain may radiate to shoulders, upper back and chest
1013
The most common causes of cervical radiculopathy are
degenerative changes, including cervical disc herniation and spondylosis.
1014
Prognosis of cervical radiculopathy?
most will improve regardless of Tx
88% of people improve within four weeks with non-operative management.
1015
Tests to identify cervical radiculopathy?
The Spurling test.
Arm squeeze test.
Axial traction — a combination of a positive Spurling’s test, axial traction test, and arm squeeze test increases the likelihood of cervical radiculopathy.
Upper limb neurodynamic tests — a combination of four neurodynamic tests and an arm squeeze test can rule out cervical radiculopathy.
1016
Ix for cervical radiculopathy?
not normally needed, usually clinical
1017
For people who have neck pain for less than 4–6 weeks and no objective neurological signs, management should include:
Providing reassurance, information, and advice.
Offering oral analgesia to relieve symptoms.
Considering offering amitriptyline, duloxetine, pregabalin, or gabapentin.
Considering a referral for physiotherapy.
1018
People with cervical radiculopathy that has been present for 4–6 weeks or more, or objective neurological signs?
refer for MRI and for invasive procedures to be considered. These may include interlaminar cervical epidural injections, transforaminal injections, or spinal surgery.
1019
Cervical radiculopathy: Spurling test?
flex the neck laterally, rotate and then press on top of the person's head. The test is positive if this pressure causes the typical radicular arm pain.
Note: This test should not be performed in people with rheumatoid arthritis, cancer, infection, or possible neck injury.
1020
Cervical radiculopathy: arm squeeze test?
squeeze the middle third of the upper arm with simultaneous thumb and fingers compression (the thumb from posterior on the triceps muscle and the fingers from anterior on the biceps muscle). The test is positive when the pain score (on a 0-10 visual analogue scale) is 3 points or higher during pressure on the middle third of the upper arm compared with two other areas.
1021
How are fractures classified?
based on...
1) bone alignment
2) fracture line
3) cause
4) bone location
5) stability
6) special types
7) pt age
8) special patterns
1022
Types of fracture: based on bone alignment?
- closed (simple) fracture
- open (compound fracture)
1023
Types of fracture: based on bone alignment= closed (simple) fracture?
bone breaks but does not pierce skin
1024
Types of fracture: based on bone alignment= open (compound) fracture?
bone breaks and pierces skin, increases risk of infection
1025
Types of fracture: based on fracture line?
- transverse fracture
- oblique
- spiral
- longitudinal
- comminuted
- segmental
- greenstick
1026
Types of fracture: based on fracture line= transverse fracture?
straight horizontal break across the bone
1027
Types of fracture: based on fracture line= oblique fracture?
angled break across bone
1028
Types of fracture: based on fracture line= spiral fracture?
twisting break resembling a spiral, often caused by rotational force
1029
Types of fracture: based on fracture line= longitudinal fracture?
break that runs along the bone's length
1030
Types of fracture: based on fracture line= comminuted fracture?
bone shatters into 3 of more fragments
1031
Types of fracture: based on fracture line= segmental fracture?
2 fractures create an isolated segment of bone
1032
Types of fracture: based on fracture line= greenstick fracture?
incomplete break in which one side of the bone bends, common in children
1033
Types of fracture: based on cause?
- traumatic
- pathologic
- stress
1034
Types of fracture: based on cause= traumatic fracture?
caused by direct trauma or force
1035
Types of fracture: based on cause= pathologic fracture?
occurs in weakend bone due to disease eg. tumours or osteoporosis
1036
Types of fracture: based on cause= stress fracture?
small hairline crack caused by repetitive stress or overuse
1037
Types of fracture: based on bone location?
intra-articular
extra-articular
epiphyseal
diaphyseal
metaphyseal
1038
Types of fracture: based on bone location= intra-articular fracture?
break extends into a joint surface
1039
Types of fracture: based on bone location= extra-articular fracture?
break does not involve a joint surface
1040
Types of fracture: based on bone location= epiphyseal fracture?
break at the growth plate in children
1041
Types of fracture: based on bone location= diaphyseal fracture?
break in shaft of a long bone
1042
Types of fracture: based on bone location= metaphyseal fracture?
break in widened part of the bone near the joint
1043
Types of fracture: based on stability?
stable
unstable
1044
Types of fracture: based on stability= stable fracture?
broken ends of the bone are aligned and minimally displaced
1045
Types of fracture: based on stability= unstable fracture?
broken ends are misaligned or move easily
1046
Types of fracture: special types?
- impacted
- compression
- avulsion
- hairline
- buckle (torus)
1047
Types of fracture: special types= impacted fracture?
broken ends of the bone are driven into eachother
1048
Types of fracture: special types= compression fracture?
bone collapses, often seen in vertebrae
1049
Types of fracture: special types= avulsion fracture?
a fragment of bone is pulled away by a tendon or ligament
1050
Types of fracture: special types= hairline fracture?
very thin crack in bone
1051
Types of fracture: special types= buckle (torus) fracture?
an incomplete fracture where one side of the bone buckles under pressure, common in children
1052
Types of fracture: based on pt age?
paediatric
adult
1053
Types of fracture: based on pt age= paediatric fractures?
greenstick, buckle and epiphyseal fractures more common in children due to softer bones
1054
Types of fracture: based on pt age= adult fractures?
complete and comminuted fractures are more typical in adults due to denser brittle bones
1055
Types of fracture: special types?
Colles'
Smiths'
Pott's
Le Fort
1056
Types of fracture: special types= Colles' fracture?
distal radius fracture, typically from falling on outstretched hand
1057
Types of fracture: special types= Smith's fracture?
distal radius fracture with the broken segment displaced toward the palm
1058
Types of fracture: special types= Pott's fracture?
fracture affecting one or both malleoli (ankle)
1059
Types of fracture: special types= Le Fort fractures?
fractures of the maxilla (face), classified into 3 types based on severity
1060
Mx of stable vs unstable/open fractures?
stable= may only need immobilisation
unstable or open= often need surgery
1061
epiphyseal vs diaphyseal vs metaphyseal
The epiphysis is the rounded end of a long bone that includes the growth plate (in children) and contributes to joint formation; fractures here can affect growth.
The diaphysis is the long, tubular shaft made of dense compact bone and houses the marrow, commonly fractured by trauma.
The metaphysis is the flared region between the diaphysis and epiphysis, consisting of spongy bone and absorbing stress; fractures here are common in children and adults.
1062
Acetabular labral tear?
may occur following trauma (most commonly in younger adults) or as a result of degenerative change (typically in older adults).
1063
Acetabular labral tear features?
hip/groin pain
snapping sensation around hip
there may occasionally be the sensation of locking
1064
Acromioclavicular joint injury?
Injury to the AC joint is relatively common and typically occurs during collision sports such as rugby following a fall on to the shoulder or a FOOSH (falls on outstretched hand).
1065
How are Acromioclavicular joint injuries graded?
graded I to VI depending on the degree of separation.
Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling.
Grade IV, V and VI are rare and require surgical intervention.
Mx of grade III injuries is a matter of debate and often depends on individual circumstances.
1066
Avascular necrosis?
death of bone tissue secondary to loss of the blood supply. This leads to bone destruction and loss of joint function.
1067
Avascular necrosis most commonly affects what?
the epiphysis of long bones such as the femur
1068
Causes of avascular necrosis of the hip?
long term steroid use
chemo
alcohol XS
trauma
1069
Features of avascular necrosis of the hip?
initially asymptomatic
pain in affected joint
1070
Ix for avascular necrosis of the hip?
MRI Ix of choice
plain x-ray may be normal initially:
- osteopenia and microfractures may be seen early on
- collapse of the articular surface may result in the crescent sign
1071
Mx for avascular necrosis of the hip?
May need joint replacement
1072
Baker's cysts (a popliteal cyst)?
not true cysts but rather a distension of the gastrocnemius-semimembranosus bursa. They may be primary or secondary
1073
Primary vs secondary Baker's cysts (a popliteal cyst)?
Primary: no underlying pathology, typically seen in children
Secondary: underlying condition such as osteoarthritis, typically seen in adults
1074
CP of Baker's cysts (a popliteal cyst)?
swellings in the popliteal fossa behind the knee
1075
Rupture of Baker's cysts (a popliteal cyst)?
may occur resulting in similar symptoms to a deep vein thrombosis, i.e. pain, redness and swelling in the calf. However, the majority of ruptures are asymptomatic.
1076
Mx of Baker's cysts (a popliteal cyst)?
children= usually resolve and don't require Tx
adults= treat underlying cause
1077
Biceps muscle tendons?
has 2 tendons:
- long tendon attaches to glenoid
- short attaches to coracoid proceps
It inserts distally via another tendon onto the radial tuberosity.
1078
Biceps rupture?
biceps tendon rupture is when one of the tendons (long or short) separates from its attachment site or is torn across it's full width. This most frequently occurs at the long tendon (90%), but rarely can occur in the distal tendon (10%).
1079
Epidemiology of biceps tendon rupture?
M>F
Proximal tendon rupture= >60yrs, long tendon, most common (90%)
distal= less common, mean age is 40; mainly men
1080
RFs for biceps rupture?
Heavy overhead activities
Shoulder overuse or underlying shoulder injuries which may stress the biceps tendon
Smoking
Corticosteroids; these weaken tendons
1081
Biceps rupture: mechanism of injury?
Proximal biceps long tendon ruptures: typically occurs when the biceps are lengthened and contracted and a load is applied. e.g. the descent phase of a pull-up.
Distal biceps tendon ruptures: Usually when a flexed elbow is suddenly and forcefully extended whilst the biceps muscle is contracted. already
1082
CP of biceps rupture?
sudden pop or tear at shoulder (long tendon) or anticubital fossa (distal tendon) followed by pain, bruising, swelling
Popeye deformity= buscle bulk results in bulge in middle upper arm
distal tendon rupture= reverse popeye deformity
weakness in shoulder & elbow follows eg. difficulty supination
may have chronic shoulder pain prior to rupture then notice improvement in pain
1083
Popeye deformity
rupture of proximal tendon of biceps muscle
1084
Ix for biceps rupture?
- palpate
- biceps squeeze test= if intact then squeeze will cause supination
- 1st Ix= MSK USS
- long head biceps rupture= conservative Mx
- distal biceps= then do urgent MRI as requires surgical intervention
1085
Blood results in Pagets?
ALP high
others normal
1086
Blood results in osteoporosis?
ALP normal
Ca ect all normal
1087
Blood results in secondary bone tumours?
high Ca
high ALP
1088
Buckle (torus) fractures?
incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex. They typically occur in children aged 5-10 years.
1089
Mx of Buckle (torus) fractures?
typically self-limiting they do not usually require operative intervention and can sometimes be managed with splinting and immobilisation rather than a cast.
1090
Cauda equina syndrome (CES)?
rare
lumbosacral nerve roots that extend below the spinal cord are compressed
1091
What to always consider in pts who present with new/worsening lower back pain and why?
cauda equina
late diagnosis may lead to permanent nerve damage resulting in long term leg weakness and urinary/bowel incontinence
1092
Causes of cauda equina syndrome?
most common= central disc prolapse
this typically occurs at L4/5 or L5/S1
- tumours: primary or metastatic
- infection: abscess, discitis
- trauma
- haematoma
1093
Central disc prolapse causing cauda equina typically occurs at what spinal level?
L4/5 or L5/S1
1094
Possible features of cauda equina (variety of presentations and not one symptom or sign that can diagnose or exclude CES)?
- low back pain
- bilateral sciatica
- reduced sensation/paraesthesia in perianal area
- decreased anal tone (check in pts with new onset back pain)
- uriniary dysfunction eg. reduced awareness of bladder filling, loss of urge to void; incontinence is late sign
1095
Incontinence in cauda equina?
late sign and may indicate irreversible damage
1096
Bilateral sciatica
think cauda equina as 50% present with this
1097
Ix for cauda equina?
urgent MRI
1098
Mx of cauda equina?
surgical decompression
1099
Charcot joint?
(neuropathic joint)
a joint which has become badly disrupted and damaged secondary to a loss of sensation.
most commonly seen in diabetics or caused by neuropathy secondary to syphilis (tabes dorsalis)
1100
Features of charcot joints?
- lot less painful than would be expected given the degree of joint disruption due to the sensory neuropathy
- swollen red and warm joint
- as progresses= affected joint becomes unstable -> abnormal movements and increased risk of fractures & dislocations
- progressive joint destruction can cause significant deformities
common deformities include a collapsed arch in the foot (commonly referred to as 'rocker-bottom' foot) or severe joint misalignment
- secondary Cx such as skin ulceration and infection can occur due to repeated trauma and poor wound healing
1101
Dupuytren's contracture?
an abnormal thickening of the skin in the palm of the hand. The skin may develop into a hard lump. Over time, it can cause one or more fingers to curl (contract) or pull in toward the palm.
the ring finger and little finger are the fingers most commonly affected
1102
Epidemiology of Dupuytren's contacture?
5% prevalence
older male pts
60-70% FHx
1103
Specific causes of Dupuytren's contracture?
manual labour
phenytoin Tx
DM
alcoholic liver disease
trauma to hand
1104
Mx of Dupuytren's contracture?
consider surgical treatment of Dupuytren's contracture when the metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table
1105
Features of fat embolism?
Resp= early persistent tachycardia; tachypnoea, dyspnoea, hypoxia 72hrs following injury; pyrexia
Derm= red/browm impalpable petechial rash (25-50%); subconjunctival and oral haemorrhage/petechiae
CNS= confusion, agitation; Retinal haemorrhages and intra-arterial fat globules on fundoscopy
1106
Fat embolism?
when one or more droplet-like particles of fat enter your bloodstream and block circulation through some of your blood vessels.
caused following trauma eg. long bone and pelvic fractures
1107
Ix for fat embolism?
imaging may be normal
fat emboli tend to lodge distally so CTPA may not show vascular occlusion; may see ground glass appearance at the periphery
1108
Fat embolism Mx?
Prompt fixation of long bone fractures
Some debate regarding benefit Vs. risk of medullary reaming in femoral shaft/ tibial fractures in terms of increasing risk (probably does not).
DVT prophylaxis
General supportive care
1109
Fracture diagnosis?
clinical + x-rays of proximal and distal joints= assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass
1110
Oblique fracture?
fracture lies obliquely to long axis of bone
1111
Comminuted fracture?
>2 fragments
1112
Segmental fracture?
more than 1 fracture along a bone
1113
Transverse fracture?
perpendicular to long axis of bone
1114
Spiral fracture?
severe oblique fracture with rotation along long axis of bone
1115
Gustilo and Anderson classification system for open fractures?
1 Low energy wound <1cm
2 Greater than 1cm wound with moderate soft tissue damage
3 High energy wound > 1cm with extensive soft tissue damage
3 A (sub group of 3) Adequate soft tissue coverage
3 B (sub group of 3) Inadequate soft tissue coverage
3 C (sub group of 3) Associated arterial injury
1116
Key points in the Mx of fractures?
Immobilise the fracture including the proximal and distal joints
Carefully monitor and document neurovascular status, particularly following reduction and immobilisation
Manage infection including tetanus prophylaxis
IV broad spectrum antibiotics for open injuries
All open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution)
Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury
1117
Ganglion?
'cyst' arising from a joint or tendon sheath. They are most commonly seen around the dorsal aspect of the wrist
W>M
1118
a firm and well-circumscribed mass that transilluminates
ganglion
1119
Mx of ganglion?
often disappear spontaneously after several months
surgical excision is indicated for cysts associated with severe symptoms or neurovascular manifestations
1120
Osler's nodes?
Osler's nodes are painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes.
1121
Bouchard's nodes?
Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage.
1122
Herberden's nodes?
Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways.
1123
Summary of ganglion?
Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise. They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the cysts are troublesome they may be excised.
1124
name 4 types of hand lumps?
- osler's nodes
- bouchard's nodea
- heberden's nodes
- ganglion
1125
Hip dislocation?
extremely painful
mostly caused by direct trauma eg. fall from height or RTA
may be associated with other fractures and life-threatening injuries due to the large force required to cause
1126
What is it important to do if ?hip dislocation?
prompt diagnosis and Mx to reduce morbidity
1127
Types of hip dislocation?
Posterior dislocation: (90%) The affected leg is shortened, adducted, and internally rotated.
Anterior dislocation: The affected leg is usually abducted and externally
rotated. No leg shortening.
Central dislocation
1128
Mx of hip dislocation?
ABCDE approach.
Analgesia
A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.
Long-term management: Physiotherapy to strengthen the surrounding muscles.
1129
Cx of hip dislocation?
Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients.
Recurrent dislocation: due to damage of supporting ligaments
1130
Prognosis of hip dislocation?
It takes about 2 to 3 months for the hip to heal after a traumatic dislocation
the prognosis is best when the hip is reduced less than 12 hours post-injury and when there is less damage to the joint.
1131
iliopsoas abscess?
collection of pus in iliopsoas compartment (iliopsoas and iliacus).
1132
Causes of primary iliopsoas abscess?
Haematogenous spread of bacteria
Staphylococcus aureus: most common
1133
Causes of secondary iliopsoas abscess?
Crohn's (commonest cause in this category)
Diverticulitis, colorectal cancer
UTI, GU cancers
Vertebral osteomyelitis
Femoral catheter, lithotripsy
Endocarditis
intravenous drug use
1134
Mortality rate in primary iliopsoas abscess vs secondary?
secondary 20%
primary 2.4%
1135
Features of iliopsoas abscess?
fever
back/flank pain
limp
weight loss
1136
Clinical exam of iliopsoas abscess?
Patient in the supine position with the knee flexed and the hip mildly externally rotated
Specific tests to diagnose iliopsoas inflammation:
- Place hand proximal to the patient's ipsilateral knee and ask patient to lift thigh against your hand. This will cause pain due to contraction of the psoas muscle.
- Lie the patient on the normal side and hyperextend the affected hip. This should elicit pain as the psoas muscle is stretched.
1137
Ix for iliopsoas abscess?
CT abdo
1138
Mx of iliopsoas abscess?
Antibiotics
Percutaneous drainage is the initial approach and successful in around 90% of cases
Surgery is indicated if:
1. Failure of percutaneous drainage
2. Presence of an another intra-abdominal pathology which requires surgery
1139
What is commonly seen following a lateral blow to the knee?
Unhappy triad (damage to):
1) anterior cruciate ligament
2) medial collateral ligament
3) meniscus (lateral meniscus is more commonly injured)
1140
What knee injury may result from twisting injuries and
Anterior drawer test and Lachman test may be positive if damaged
ACL
1141
What knee injury may occur following dashboard injuries?
posterior cruciate ligament
1142
What knee injury may commonly result from skiing and following valgus stress;
damage typically causes abnormal passive abduction of the knee
medial collateral ligament
1143
Isolated injury to what structure in the knee is uncommon?
lateral collateral ligament
1144
What knee injury may result from twisting injuries;
Locking and giving way are common symptoms?
menisci
1145
Ruptured ACL?
Sport injury
Mechanism: high twisting force applied to a bent knee
Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis)
Poor healing
Management: intense physiotherapy or surgery
1146
Ruptured PCL?
Mechanism: hyperextension injuries
Tibia lies back on the femur
Paradoxical anterior draw test
1147
Rupture of medial collateral ligament?
Mechanism: leg forced into valgus via force outside the leg
Knee unstable when put into valgus position
1148
Menisceal tear?
Rotational sporting injuries
Delayed knee swelling
Joint locking (Patient may develop skills to 'unlock' the knee
Recurrent episodes of pain and effusions are common, often following minor trauma
1149
Chondromalacia patellae?
Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting
1150
Dislocation of the patella?
Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation
Genu valgum, tibial torsion and high riding patella are risk factors
Skyline x-ray views of patella are required, although displaced patella may be clinically obvious
An osteochondral fracture is present in 5%
The condition has a 20% recurrence rate
1151
Fractured patella?
2 types:
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture
1152
Tibial plateau fracture?
Occur in the elderly (or following significant trauma in young)
Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture
Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs
Classified using the Schatzker system (see below)
1153
Schatzker Classification system for tibial plateau fractures?
1) Vertical split of lateral condyle
2) Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle
3) Depression of the articular surface with intact condylar rim
4) Fragment of the medial tibial condyle
5) Fracture of both condyles
6) Combined condylar and subcondylar fractures
1154
Schatzker Classification system for tibial plateau fractures: 1) Vertical split of lateral condyle?
Fracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted
1155
Schatzker Classification system for tibial plateau fractures: 2) Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle?
The wedge fragment (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop
1156
Schatzker Classification system for tibial plateau fractures: 3) Depression of the articular surface with intact condylar rim?
The split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable
1157
Schatzker Classification system for tibial plateau fractures: 4) Fragment of the medial tibial condyle?
Two injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe
1158
Schatzker Classification system for tibial plateau fractures: 5) Fracture of both condyles?
Both condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft.
1159
Schatzker Classification system for tibial plateau fractures: 6) Combined condylar and subcondylar fractures?
High energy fracture with marked comminution.
1160
Features of meniscal tear?
pain worse on straightening the knee
knee may 'give way'
displaced meniscal tears may cause knee locking
tenderness along the joint line
Thessaly's test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee
1161
Anterior draw test (test for ACL injury)?
the patient lies supine with the knee at 90 degrees
the examiner should place one hand behind the tibia and the other grasping the patient's thigh. It is important that the examiner's thumb be on the tibial tuberosity
the tibia is pulled forward to assess the amount of anterior motion of the tibia in comparison to the femur
an intact ACL should prevent forward translational movement
1162
Lachman's test (test for ACL injury)?
variant of anterior draw test, but the knee is at 20-30 degrees
evaluate the anterior translation of the tibia in relation to the femur and is considered a variant
more reliable than anterior draw test
1163
Knee injurys in older pts: Infrapatellar bursitis
(Clergyman's knee) vs Prepatellar bursitis
(Housemaid's knee)?
Infrapatellar bursitis
(Clergyman's knee)= associated with kneeling
Prepatellar bursitis
(Housemaid's knee)= Associated with more upright kneeling
1164
Leriche syndrome?
Atheromatous disease involving the iliac vessels. Blood flow to the pelvic viscera is compromised. Patients may present with buttock claudication and impotence (in this particular syndrome). Diagnostic work up will include angiography, where feasible, iliac occlusions are usually treated with endovascular angioplasty and stent insertion.
1165
Femoral nerve= motor?
knee extension, thigh flexion
1166
Femoral nerve= sensory?
anterior & medial aspect of thigh and lower leg
1167
Femoral nerve= typical mechanism of injury?
hip and pelvic fractures
stab/gunshot wounds
1168
Obturator nerve= motor?
thigh adduction
1169
Obturator nerve= sensory?
medial thigh
1170
Obturator nerve= typical mechanism of injury?
anterior hip dislocation
1171
Lateral cutaneous nerve of thigh= motor?
none
1172
Lateral cutaneous nerve of thigh= sensory?
lateral and posterior surfaces of thigh
1173
Lateral cutaneous nerve of thigh= typical mechanism of injury?
Compression of the nerve near the ASIS → meralgia paraesthetica, a condition characterised by pain, tingling and numbness in the distribution of the lateral cutaneous nerve
1174
Tibial nerve= motor?
foot plantarflexion and inversion
1175
Tibial nerve= sensory?
sole of foot
1176
Tibial nerve= mechanism of injury?
Not commonly injured as deep and well protected.
Popliteral lacerations, posterior knee dislocation
1177
Common peroneal nerve= motor?
foot dorsiflexion and eversion
extensor hallucis longus
1178
Common peroneal nerve= sensory?
Dorsum of the foot and the lower lateral part of the leg
1179
Common peroneal nerve= mechanism of injury?
often occurs at neck of fibula
tightly applied lower limb plaster cast
injury causes foot drop
1180
Injury to what nerve causes foot drop?
common peroneal nerve
1181
Superior gluteal nerve= motor?
hip abduction
1182
Superior gluteal nerve= sensory?
none
1183
Superior gluteal nerve= mechanism of injury?
Misplaced intramuscular injection
Hip surgery
Pelvic fracture
Posterior hip dislocation
Injury results in a positive Trendelenburg sign
1184
Injury to what nerve results in +ve Trendelenburg sign?
Superior gluteal nerve
1185
Inferior gluteal nerve= motor?
hip extension and lateral rotation
1186
Inferior gluteal nerve= sensory?
none
1187
Inferior gluteal nerve= mechanism of injury?
Generally injured in association with the sciatic nerve
Injury results in difficulty rising from seated position. Can't jump, can't climb stairs
1188
Injury to what nerve causes difficulty rising from seated position; can't jump and can't climb stairs?
inferior gluteal nerve
1189
What muscles are in the anterior compartment of the lower limb?
tibialis anterior
extensor digitorum longus
peroneus tertius
extensor hallucis longus
1190
What nerve is in the anterior compartment of the lower limb?
deep peroneal (aka fibular) nerve
1191
Muscular compartments of the lower limb? (4)
- anterior
- peroneal
- superficial posterior
- deep posterior
1192
Anterior compartment of lower limb muscles= Tibialis anterior:
- action?
- nerve?
dorsiflexes ankle joint, inverts foot
deep peroneal (aka fibular) nerve
1193
Anterior compartment of lower limb muscles= extensor digitorum longus:
- action?
- nerve?
extends lateral four toes, dorsiflexes ankle joint
deep peroneal (aka fibular) nerve
1194
Anterior compartment of lower limb muscles= peroneus tertius:
- action?
- nerve?
dorsiflexes ankle, everts foot
deep peroneal (aka fibular) nerve
1195
Anterior compartment of lower limb muscles= extensor hallucis longus:
- action?
- nerve?
dorsiflexes ankle joint, extends big toe
deep peroneal (aka fibular) nerve
1196
Muscles in the peroneal compartment of the lower limb?
peroneus longus
peroneus brevis
1197
Nerve in the peroneal compartment of the lower limb?
superficial peroneal (aka fibular) nerve
1198
Peroneal compartment of lower limb muscles= Peroneus longus:
- action?
- nerve?
everts foot, assists in plantar flexion
superficial peroneal (aka fibular) nerve
1199
Peroneal compartment of lower limb muscles= Peroneus brevis:
- action?
- nerve?
plantar flexes the ankle joint
superficial peroneal (fibular) nerve
1200
Muscles in the superficial posterior compartment of the lower limb?
Gastrocnemius
Soleus
1201
Nerve in the superficial posterior compartment of the lower limb?
tibial nerve
1202
2 main terminal branches of the sciatic nerve?
tibial nerve
fibular (peroneal) nerve
1203
Superficial posterior compartment of lower limb muscles= Gastrocnemius:
- action?
- nerve?
plantar flexes the foot, may also flex the knee
tibial nerve
1204
Superficial posterior compartment of lower limb muscles= Soleus:
- action?
- nerve?
plantar flexor
tibial nerve
1205
Muscles in the deep posterior compartment of the lower limb?
flexor digitorum longus
flexor hallucis longus
tibialis posterior
1206
Nerve in the deep posterior compartment in the lower limb?
tibial nerve
1207
Deep posterior compartment of lower limb muscles= Flexor digitorum longus:
- action?
- nerve?
flexes the lateral 4 toes
tibial
1208
Deep posterior compartment of lower limb muscles= Flexor hallucis longus:
- action?
- nerve?
flexes the great toe
tibial
1209
Deep posterior compartment of lower limb muscles= Tibialis posterior:
- action?
- nerve?
plantar flexor, inverts the foot
tibial
1210
Meralgia paraesthetica?
syndrome of paraesthesia or anaesthesia in distribution of lateral femoral cutaneous nerve (LFCN)
meros=high
algos=pain
1211
Cause of Meralgia paraesthetica?
entrapment mononeuropathy of the LFCN, but can also be iatrogenic after a surgical procedure, or result from a neuroma. Although uncommon, meralgia paraesthetica is not rare and is hence probably underdiagnosed.
1212
Anatomy in Meralgia paraesthetica syndrome?
The LFCN is primarily a sensory nerve, carrying no motor fibres.
It most commonly originates from the L2/3 segments.
After passing behind the psoas muscle, it runs beneath the iliac fascia as it crosses the surface of the iliac muscle and eventually exits through or under the lateral aspect of the inguinal ligament.
As the nerve curves medially and inferiorly around the anterior superior iliac spine (ASIS), it may be subject to repetitive trauma or pressure.
Compression of this nerve anywhere along its course can lead to the development of meralgia paraesthetica.
1213
Epidemiology of meralgia paraesthetica?
30-40yrs
In some, both legs may be affected.
It is more common in men than women.
Occurs more commonly in those with diabetes than in the general population.
1214
RFs for meralgia paraesthetica?
Obesity
Pregnancy
Tense ascites
Trauma
Iatrogenic, such as pelvic osteotomy, spinal surgeries, laparoscopic hernia repair and bariatric surgery. In some cases, may result from abduction splints used in the management of Perthe's disease.
Various sports have been implicated, including gymnastics, football, bodybuilding and strenuous exercise.
Some cases are idiopathic.
1215
Symptoms in meralgia paraesthetica?
Burning, tingling, coldness, or shooting pain
Numbness
Deep muscle ache
Symptoms are usually aggravated by standing, and relieved by sitting
They can be mild and resolve spontaneously or may severely restrict the patient for many years.
1216
Signs in meralgia paraesthetica?
Symptoms may be reproduced by deep palpation just below the ASIS (pelvic compression) and also by extension of the hip.
There is altered sensation over the upper lateral aspect of the thigh.
There is no motor weakness.
1217
Ix for meralgia paraesthetica?
pelvic compression test is highly sensitive, and often, can be diagnosed based on this test alone
Injection of the nerve with local anaesthetic will abolish the pain. Using ultrasound is effective both for diagnosis and guiding injection therapy in meralgia paraesthetica
Nerve conduction studies may be useful.
1218
Mx of meralgia paraesthetica?
Physical therapy to strengthen the muscles of the legs and buttocks, and reduce injury to the hips.
Wearing less restrictive clothing.
Weight loss management.
Corticosteroid injection to reduce swelling.
1219
Froment's sign?
Assess for ulnar nerve palsy
Adductor pollicis muscle function tested
Hold a piece of paper between their thumb and index finger. The object is then pulled away. If ulnar nerve palsy, unable to hold the paper and will flex the flexor pollicis longus to compensate (flexion of thumb at interphalangeal joint).
1220
Phalen's test?
Assess carpal tunnel syndrome
More sensitive than Tinel's sign
Hold wrist in maximum flexion and the test is positive if there is numbness in the median nerve distribution.
1221
Tinel's sign (test)?
Assess for carpal tunnel syndrome
Tap the median nerve at the wrist and the test is positive if there is tingling/electric-like sensations over the distribution of the median nerve.
1222
open fracture
disruption of the bony cortex associated with a breach in the overlying skin. Any wound that is present in the same limb as a fracture should be suspected as being representative of an open fracture
1223
One of the main problems with open fractures is
associated injuries to the surrounding soft tissues. Whilst the skin is usually relatively resistant to trauma, underlying muscle can be damaged or devitalised, nerves, blood vessels and periosteum may all be disrupted the degree to which this occurs correlates with the severity of the injury and the outcome. These can be graded using the Gustilo and Anderson system
1224
Open fractures: Gustilo and Anderson system?
1 Low energy wound <1cm
2 Greater than 1cm wound with moderate soft tissue damage
3 High energy wound > 1cm with extensive soft tissue damage
3 A (sub group of 3) Adequate soft tissue coverage
3 B (sub group of 3) Inadequate soft tissue coverage
3 C (sub group of 3) Associated arterial injury
1225
Open fractures: In Type IIIc injuries, the mangled extremity scoring system (MESS) can help to predict the need for?
primary amputation
1226
Mx for open fractures?
- check for associated injuries, control haemorrhage and extent of injury
- area should be carefully imaged, distal neurovascular status established the wound covered with a dressing and antibiotics administered.
- Early debridement. The aim of the debridement is to remove foreign material and devitalised tissue. In most cases the wound is left open. The wound should be irrigated, generally, 6 litres of saline is used.
- The fracture should be stabilised and an external fixator is often used in the first instance
1227
Most effective Tx for osteoarthritis in pts who experience signif pain?
joint replacement (arthroplasty)
1228
Selection criteria for Osteoarthritis joint replacement?
25% <60yrs
whilst obesity is often thought to be a barrier to joint replacement there is only a slight increase in short-term complications. There is no difference in long-term joint replacement survival
1229
Surgical techniques for joint replacement in osteoarthritis?
hips= cemented hip replacement: metal femoral component is cemented into the femoral shaft. This is accompanied by a cemented acetabular polyethylene cup
uncementened hip replacements more popular in active and younger pts but more expensive
hip resurfacing sometimes used where a metal cap is attached over the femoral head. Younger pts; femoral neck is preserved which may be useful if conventional arthroplasty is needed later in life
1230
Joint replacement in osteoarthritis: post-op recovery?
physio and home exercises
walking sticks or crutches are usually used for up to 6 weeks after hip or knee replacement surgery
1231
Patients who have had a hip replacement operation (eg. due to osteoarthritis) should receive basic advice to minimise the risk of dislocation:
avoiding flexing the hip > 90 degrees
avoid low chairs
do not cross your legs
sleep on your back for the first 6 weeks
1232
Cx of joint replacement in osteoarthritis?
wound and joint infection
VTE so LMWH for 4w after
dislocation
1233
Osteochondritis dissecans (OCD)?
pathological process affecting the subchondral bone (most often in the knee joint) with secondary effects on the joint cartilage, including pain, oedema, free bodies and mechanical dysfunctions.
children and young adults
OCD may progress to degenerative changes if untreated.
1234
Presentation of Osteochondritis dissecans (OCD)?
subacute onset
Knee pain and swelling, typically after exercise
Knee catching, locking and/or giving way: more constant and severe symptoms are associated with the presence of loose bodies
Feeling a painful 'clunk' when flexing or extending the knee - indicating the involvement of the lateral femoral condyle
1235
Signs of Osteochondritis dissecans (OCD)?
Joint effusion
Tenderness on palpation of the articular cartilage of the medial femoral condyle, when the knee is flexed
Wilson's sign for detecting medial condyle lesion
1236
Wilson's sign in Osteochondritis dissecans (OCD)?
for detecting medial condyle lesion - with the knee at 90° flexion and tibia internally rotated, the gradual extension of the joint leads to pain at about 30°, external rotation of the tibia at this point relieves the pain
1237
Ix for Osteochondritis dissecans (OCD)?
x-ray (AP, lateral and tunnel views)= subchondral cresent sign or loose bodies
MRI= to evaluate cartilage, visualise loose bodies, stage and assess stability of the lesion
1238
Mx of Osteochondritis dissecans (OCD)?
Early diagnosis is important
Clinical signs may be subtle in the early stages hence there should be a low threshold for imaging and/or orthopaedic opinion.
rest, NSAIDs, avoid intense activity 2-4m, physio, may need brace or crutches
1239
Rib fracture?
break in the bony segment of any rib and is most often the consequence of blunt trauma to the chest wall but can be due to underlying diseases which weaken the bone structure of the ribs.
They can occur singly or in multiple places along the length of a rib and may be associated with soft tissue injuries to the surrounding muscles or the underlying lung.
1240
RFs for rib fractures?
- blunt trauma to chest wall
- polytrauma (chest injuries present in 25% major trauma)
- spontaneous= coughing, sneezing eg. if PMH osteoporosis, steroid use, COPD
- pathological= ca mets eg. prostate in men and breast in women
1241
Features of rib fracture?
- severe, sharp chest wall pain worse with deep breaths or coughing
- chest wall tenderness over site of fracture & bruising
- crackles or reduced breath sounds if lung injury
- reduction in ventilation & so drop in O2 sats due to pain/underlying lung injury
- pneumothorax
1242
Serious Cx of rib fractures?
Pneumothorax= reduced chest expansion, reduced breath sounds and hyper-resonant percussion on the affected side
1243
Serious Cx of multiple rib fractures eg. following trauma?
Flail chest- caused by two or more rib fractures along three or more consecutive ribs, usually anteriorly
1244
Flail chest (follows multiple rib fractures)?
caused by two or more rib fractures along three or more consecutive ribs, usually anteriorly
the flail segment moves paradoxically during respiration and impairs ventilation of the lung on the side of injury
the segment can cause serious contusional injury to the underlying lung if left untreated
often requires treatment with invasive ventilation and surgical fixation to prevent complications
1245
Ix of rib fractures?
CT scan GOLD
CXR= A or P fracrures but suboptimal views and non info on soft tissue injury
1246
Mx of rib fractures?
- most cases= conservative + analgesia to ensure breathing not affected by pain. Pain not controlled= can consider nerve blocks
- Surgical fixation if pain still not managed and fractures failed to heal after 12w
- flail chest segments= urgent consideration for cardiothoracic surgery as they can impair ventilation and result in signif lung trauma
1247
Lung Cx of rib fractures?
pneumothorax or haemothorax
1248
What type of rib fractures need to be discussed urgently with cardiothoracic surgery as they can impair ventilation?
flail chest
1249
Most common cause of shoulder pain?
rotator cuff injuries
1250
Rotator cuff injuries include what?
spectrum of:
1. Subacromial impingement (also known as impingement syndrome, painful arc syndrome)
2. Calcific tendonitis
3. Rotator cuff tears
4. Rotator cuff arthropathy
1251
Shoulder pain worse on abduction?
rotator cuff injuries
1252
Signs of rotator cuff injuries?
painful arc of abduction. With subacromial impingement, this is typically between 60 and 120 degrees. With rotator cuff tears the pain may be in the first 60 degrees.
tenderness over anterior acromion
1253
Scaphoid bone?
concave articular surface for the head of the capitate and at the edge of this is a crescentic surface for the corresponding area on the lunate.
Proximally= wide convex articular surface with the radius. It has a distally sited tubercle that can be palpated. The remaining articular surface is to the lateral side of the tubercle. It faces laterally and is associated with the trapezium and trapezoid bones.
The narrow strip between the radial and trapezial surfaces and the tubercle gives rise to the radial collateral carpal ligament. The tubercle receives part of the flexor retinaculum. This area is the only part of the scaphoid that is available for the entry of blood vessels. It is commonly fractured and avascular necrosis may result.
1254
Shoulder dislocation?
occurs when the humeral head dislodges from the glenoid cavity of the scapula.
The shoulder is the most common joint in the body to dislocate, accounting for approximately 50% of all major joint dislocations.
1255
Most common type of shoulder dislocations?
Anterior shoulder dislocations account for > 95% of cases.
1256
Mx for shoulder dislocation?
reduction
If the dislocation is recent then reduction may be attempted without any analgesia/sedation. However, other patients may require analgesia +/- sedation to ensure the rotator cuff muscles are relaxed.
1257
Common shoulder problems?
Adhesive capsulitis
(frozen shoulder)
Supraspinatus tendonitis
(Subacromial impingement,
painful arc)
1258
Shoulder problems: Adhesive capsulitis
(frozen shoulder)?
Common in middle-age and diabetics
Characterised by painful, stiff movement
Limited movement in all directions, with loss of external rotation and abduction in about 50% of patients
1259
Shoulder problems:
Supraspinatus tendonitis
(Subacromial impingement,
painful arc)?
Rotator cuff injury
Painful arc of abduction between 60 and 120 degrees
Tenderness over anterior acromion
1260
Dorsal column lesion
loss of vibration and proprioception
tabes dorsalis, SACD
1261
Spinothalamic tract lesion?
loss of pain, sensation and temp
1262
Central cord lesion?
flaccid paralysis of the upper limbs
1263
Osteomyelitis of the spine?
Normally progressive
Staph aureus in IVDU, normally cervical region affected
Fungal infections in immunocompromised
Thoracic region affected in TB
1264
Infarction to spinal cord?
dorsal column signs (loss of proprioception and fine discrimination)
1265
Cord compression?
UMN signs
malignancy
haematoma
fracture
1266
Brown-sequard syndrome?
Hemisection of the spinal cord
Ipsilateral paralysis
Ipsilateral loss of proprioception and fine discrimination
Contralateral loss of pain and temperature
1267
Signs/symptoms of Brown-sequard syndrome?
Ipsilateral paralysis
Ipsilateral loss of proprioception and fine discrimination
Contralateral loss of pain and temperature
1268
Ipsilateral paralysis
Ipsilateral loss of proprioception and fine discrimination
Contralateral loss of pain and temperature
Brown-sequard syndrome
1269
Dermatomes C2-C4
C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle. C4 covers the area just below the clavicle.
1270
Dermatomes C5 to T1?
Situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the medial aspect of the hand, and T1 covers the medial side of the forearm.
1271
Dermatomes T2-T12?
The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.
1272
Dermatomes L1 to L5?
The cutaneous dermatome representing the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.
1273
Dermatomes S1 to S5?
S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.
1274
Upper limb myotomes?
C5-T1
1275
Lower limb myotomes?
L1 to S1
1276
Anal sphincter myotomes?
S2-S4
1277
What myotome= elbow flexors/biceps?
C5
1278
What myotome= wrist extensors?
C6
1279
What myotome= elbow extensors/triceps?
C7
1280
What myotome= long finger flexors?
C8
1281
What myotome= small finger abductors?
T1
1282
What myotome= hip flexors (psoas)?
L1 and L2
1283
What myotome= knee extensors (quads)?
L3
1284
What myotome= ankle dorsiflexors (tibialis anterior)?
L4 and L5
1285
What myotome= toe extensors (hallucis longus)?
L5
1286
What myotome= ankle plantar flexors (gastrocnemius)?
S1
1287
What myotome= anal sphinceter?
S2,3,4
1288
Stress fractures?
Repetitive activity and loading of normal bone may result in small hairline fractures. Whilst these may be painful they are seldom displaced. Surrounding soft tissue injury is unusual.
1289
Stress fractures- presentation/magament?
may present late following the injury, in which case callus formation may be identified on radiographs. Such cases may not require formal immobilisation, injuries associated with severe pain and presenting at an earlier stage may benefit from immobilisation tailored to the site of injury.
1290
Most common upper limb injury in children <6yrs?
subluxation of the radial head (pulled elbow)
due to the fact that the distal attachment of the annular ligament covering the radial head is weaker in children at this age group.
1291
Signs of subluxation of the radial head (pulled elbow)?
elbow pain and limited supination and extension of the elbow. The child usually refuses examination on the affected elbow due to the pain
1292
Mx of subluxation of the radial head (pulled elbow)?
analgesia and passively supination of the elbow joint whilst the elbow is flexed to 90 degrees
1293
Subluxation?
partial dislocation
1294
Talipes equinovarus (club foot)?
describes an inverted (inward turning) and plantar flexed foot. It is usually diagnosed on the newborn exam.
M>F
50% bilateral
1295
Talipes equinovarus (club foot) assocaitions?
idiopathic
spina bifida
cerebral palsy
Edward's syndrome (trisomy 18)
oligohydramnios
arthrogryposis
1296
Diagnosis of talipes equinovarus (club foot)?
clinical (the deformity is not passively correctable) and imaging is not normally needed.
1297
Mx of talipes equinovarus (club foot)?
Ponseti method= manipulation and progressive casting which starts soon after birth. The deformity is usually corrected after 6-10 weeks.
An Achilles tenotomy is required in around 85% of cases but this can usually be done under local anaesthetic
night-time braces should be applied until the child is aged 4 years. The relapse rate is 15%
1298
Trigger finger?
common condition associated with abnormal flexion of the digits. It is thought to be caused by a disparity between the size of the tendon and pulleys through which they pass. In simple terms the tendon becomes 'stuck' and cannot pass smoothly through the pulley.
1299
Trigger finger associations?
idiopathic
F>M
RA
DM
1300
Features of trigger finger?
more common in the thumb, middle, or ring finger
initially stiffness and snapping ('trigger') when extending a flexed digit
a nodule may be felt at the base of the affected finger
1301
Mx of trigger finger?
- steroid injections + finger splint after
- surgery if not responded
1302
Musculocutaneous nerve (C5-C7)= motor?
elbow flexion (supplies biceps brachii) and supination
1303
Musculocutaneous nerve (C5-C7)= sensory?
lateral part of forearm
1304
Musculocutaneous nerve (C5-C7)= typical mechanism of injury?
Isolated injury rare - usually injured as part of brachial plexus injury
1305
Axillary nerve (C5,C6)= motor?
shoulder abduction (deltoid muscle)
1306
Axillary nerve (C5,C6)= sensory?
inferior region of the deltoid muscle
1307
Axillary nerve (C5,C6)= mechanism of injury?
humeral neck fracture/dislocation
results in flattened deltoid
1308
Humeral neck fracture/dislocation resulting in flattened deltoid- injury to what nerve?
Axillary nerve (C5,C6)
1309
Radial nerve (C5-C8)= motor?
extension (forearm, wrist, fingers, thumb)
1310
Radial nerve (C5-C8)= sensory?
small area between the dorsal aspect of the 1st and 2nd metacarpals
1311
Radial nerve (C5-C8)= mechanism of injury?
humeral midshaft fracture
palsy results in wrist drop
1312
Humeral midshaft fracture resulting in wrist drop- injury to what nerve?
Radial nerve (C5-C8)
1313
Median nerve (C6, C8, T1)= motor?
LOAF muscles
Features depend on the site of the lesion:
wrist: paralysis of thenar muscles, opponens pollicis
elbow: loss of pronation of forearm and weak wrist flexion
1314
Median nerve (C6, C8, T1)= sensory?
Palmar aspect of lateral 3½ fingers
1315
Median nerve (C6, C8, T1)= mechanism of injury?
wrist lesion -> carpal tunnel syndrome
1316
wrist lesion causing carpal tunnel syndrome- injury to what nerve?
Median nerve (C6, C8, T1)
1317
Ulnar nerve (C8, T1)= motor?
intrinsic hand muscles except LOAF
wrist flexion
1318
Ulnar nerve (C8, T1)= sensory?
Medial 1½ fingers
1319
Ulnar nerve (C8, T1)= mechanism of injury?
Medial epicondyle fracture
Damage may result in a 'claw hand'
1320
Medial epicondyle fracture resulting in 'claw hand'- injury to what nerve?
Ulnar nerve (C8, T1)
1321
Long thoracic nerve (C5-C7)= motor?
serratus anterior
1322
Long thoracic nerve (C5-C7)= sensory?
N/A
1323
Long thoracic nerve (C5-C7)= mechanism of injury?
Often during sport e.g. following a blow to the ribs. Also possible complication of mastectomy
Damage results in a winged scapula
1324
Often during sport e.g. following a blow to the ribs. Also possible complication of mastectomy
Damage results in a winged scapula
Injury to what nerve?
Long thoracic nerve (C5-C7)
1325
Erb-Duchenne palsy ('waiter's tip')?
due to damage of the upper trunk of the brachial plexus (C5,C6)
may be secondary to shoulder dystocia during birth
the arm hangs by the side and is internally rotated, elbow extended
1326
Klumpke injury?
due to damage of the lower trunk of the brachial plexus (C8, T1)
as above, may be secondary to shoulder dystocia during birth. Also may be caused by a sudden upward jerk of the hand
associated with Horner's syndrome
1327
LOAF muscles (in hand)?
Lateral two lumbricals
Opponens pollis
Abductor pollis brevis
Flexor pollis brevis
1328
ANCA antibodies stands for what?
Anti-neutrophil cytoplasmic antibodies
1329
ANCA (antibodies) are associated with what?
number of small-vessel vasculitides, including:
granulomatosis with polyangiitis
eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
microscopic polyangiitis
1330
ANCA associated vasculitis more common with....
increasing age
1331
ANCA associated vasculitis: whilst each condition has its own distinct features, there are a number of common findings...
renal impairment
caused by immune complex glomerulonephritis → raised creatinine, haematuria and proteinuria
respiratory symptoms:
dyspnoea, haemoptysiis
systemic symptoms: fatigue,
weight loss, fever
vasculitic rash: present only in a minority of patients
ENT symptoms: sinusitis
1332
ANCA associated vasculitis: first line Ix?
urinalysis for haematuria and proteinuria
bloods:
- urea and creatinine for renal impairment
- full blood count: normocytic anaemia and thrombocytosis may be seen
- CRP: raised
- ANCA testing (see below)
chest x-ray: nodular, fibrotic or infiltrative lesions may be seen
1333
ANCA types?
cytoplasmic (cANCA) and perinuclear (pANCA)
1334
ANCA types- cANCA and pANCA= There is considerable overlap between which antibodies are found in which condition, but as a rule of thumb...
cANCA - granulomatosis with polyangiitis
pANCA - eosinophilic granulomatosis with polyangiitis + others
1335
cANCA?
- serine proteinase 3 (PR3)
- Granulomatosis with polyangiitis= 90%
- Eosinophilic granulomatosis with polyangiitis= Low
- Microscopic polyangiitis= 40%
- other associated conditions= N/A
- Use for monitoring= Some correlation between cANCA levels and disease activity
1336
pANCA?
- myeloperoxidase (MPO)
- Granulomatosis with polyangiitis= 25%
- Eosinophilic granulomatosis with polyangiitis= 50%
- Microscopic polyangiitis= 75%
- other associated conditions= Ulcerative colitis (70%); Primary sclerosing cholangitis (70%); Anti-GBM disease (25%); Crohn's disease (20%)
- Use for monitoring= Cannot use level of pANCA to monitor disease activity
1337
ANCA associated vasculitis: general approach to Mx?
once suspected, should be managed by specialist teams (e.g. renal, rheumatology, respiratory) to allow an exact diagnosis to be made. Kidney or lung biopsies may be taken to aid the diagnosis.
The mainstay of management is immunosuppressive therapy.
1338
Antisynthetase syndrome?
autoimmune condition caused by the presence of autoantibodies against aminoacyl-tRNA synthetase enzymes.
These autoantibodies play a critical role in the pathogenesis of the disease by targeting and interfering with these essential enzymes, which are responsible for protein synthesis in cells.
1339
Antisynthetase syndrome most common autoantibody associated with this condition?
anti-Jo-1
1340
Clinical features of Antisynthetase syndrome?
- myositis= muscle weakness, primarily affecting the proximal muscles so difficulties in performing everyday activities, such as climbing stairs or lifting objects. Elevated muscle enzymes, such as creatine kinase (CK), are often observed.
- interstitial lung disease= chronic dry cough, SOB, reduced exercise tolerance. High-resolution CT for diagnosis
- mechanic's hands
- Raynaud's phenomenon= episodic vasospasm of the small blood vessels, usually in response to cold or stress, leading to pallor, cyanosis, and erythema of the fingers and toes
1341
Antisynthetase syndrome= mechanic's hands?
hyperkeratotic, thickened, and cracked skin on the sides of their fingers and palms, resembling the hands of a manual labourer. This distinctive feature, known as 'mechanic's hands,' is a key clinical sign of the syndrome.
1342
Additional features of Antisynthetase syndrome?
- inflam arthritis
- fever
- fatigue, weight loss, malaise
1343
Diagnosis of Antisynthetase syndrome?
based on clinical features, serological tests for specific autoantibodies (like anti-Jo-1), and imaging studies to assess lung involvement. Muscle biopsies and electromyography (EMG) may be used to confirm myositis.
1344
Mx of Antisynthetase syndrome?
immunosuppressive therapy, such as corticosteroids and other immunomodulatory drugs, to control inflammation and prevent disease progression. Patients with significant lung involvement may require additional treatments, including antifibrotic agents and supplemental oxygen.
1345
Behcet's syndrome?
complex multisystem disorder associated with presumed autoimmune-mediated inflammation of the arteries and veins.
Cause uncertain.
1346
Behcet's syndrome triad?
oral ulcers, genital ulcers and anterior uveitis
1347
oral ulcers, genital ulcers and anterior uveitis
Behcet's syndrome
1348
Epidemiology of Behcet's syndrome?
M>F (more common & more severe)
more common in eastern Mediterranean eg. Turkey
20-40yrs
associated with HLA B51
30% have +ve FHx
1349
Features of Behcet's syndrome?
1) oral ulcers 2) genital ulcers 3) anterior uveitis
thrombophlebitis and deep vein thrombosis
arthritis
neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis
erythema nodosum
1350
Diagnosis of Behcet's syndrome?
no definitive test
diagnosis based
on clinical findings
positive pathergy test is suggestive (puncture site following needle prick becomes inflamed with small pustule forming)
1351
Ca, Phosphate, ALP and PTH in osteoporosis?
Ca= normal
Phosphate= normal
ALP= normal
PTH= normal
1352
Ca, Phosphate, ALP and PTH in osteomalacia?
Ca= decreased
Phosphate= decreased
ALP= increased
PTH= increased
1353
Ca, Phosphate, ALP and PTH in primary hyperparathyroidism (-> osteitis fibrosa cystica)?
Ca= increased
Phosphate= decreased
ALP= increased
PTH= increased
1354
Ca, Phosphate, ALP and PTH in CKD (-> secondary hyperparathyroidism)?
Ca= decreased
Phosphate= increased
ALP= increased
PTH= increased
1355
Ca, Phosphate, ALP and PTH in Paget's disease?
Ca= normal
Phosphate= normal
ALP= increased
PTH= normal
1356
Ca, Phosphate, ALP and PTH in osteopetrosis?
Ca= normal
Phosphate= normal
ALP= normal
PTH= normal
1357
Osteopetrosis?
group of a rare disorders that cause bones to grow abnormally and become overly dense
1358
Benign bone tumours?
osteoma
osteochondroma (exotosis)
giant cell tumour
1359
Benign bone tumours: osteoma?
benign 'overgrowth' of bone, most typically occuring on the skull
associated with Gardner's syndrome (a variant of familial adenomatous polyposis, FAP)
1360
Benign bone tumours: osteochondroma (exotosis)?
most common benign bone tumour
more in males, usually diagnosed in patients aged < 20 years
cartilage-capped bony projection on the external surface of a bone
1361
Benign bone tumours: giant cell tumour?
tumour of multinucleated giant cells within a fibrous stroma
peak incidence: 20-40 years
occurs most frequently in the epiphyses of long bones
X-ray shows a 'double bubble' or 'soap bubble' appearance
1362
Malignant bone tumours?
osteosarcoma
Ewing's sarcoma
chondrosarcoma
1363
Malignant bone tumours: osteosarcoma?
most common primary malignant bone tumour
seen mainly in children and adolescents
occurs most frequently in the metaphyseal region of long bones prior to epiphyseal closure, with 40% occuring in the femur, 20% in the tibia, and 10% in the humerus
x-ray= Codman triangle (from periosteal elevation) and 'sunburst' pattern
mutation of the Rb gene increases risk (hence association with retinoblastoma)
other predisposing factors include Paget's disease of the bone and radiotherapy
1364
Malignant bone tumours: Ewing's sarcoma?
small round blue cell tumour
seen mainly in children and adolescents
occurs most frequently in the pelvis and long bones. Tends to cause severe pain
associated with t(11;22) translocation which results in an EWS-FLI1 gene product
x-ray shows 'onion skin' appearance
1365
Malignant bone tumours: chondrosarcoma?
malignant tumour of cartilage
most commonly affects the axial skeleton
more common in middle-age
1366
Dactylitis?
inflammation of a digit (finger or toe)
1367
Causes of dactylitis?
spondyloarthritis: e.g. Psoriatic and reactive arthritis
sickle-cell disease
other rare causes include tuberculosis, sarcoidosis and syphilis
1368
Discoid lupus erythematosus?
benign disorder generally seen in younger females. It very rarely progresses to systemic lupus erythematosus (in less than 5% of cases). Discoid lupus erythematosus is characterised by follicular keratin plugs and is thought to be autoimmune in aetiology
1369
Features of Discoid lupus erythematosus?
erythematous, raised rash, sometimes scaly
may be photosensitive
more common on face, neck, ears and scalp
lesions heal with atrophy, scarring (may cause scarring alopecia), and pigmentation
1370
Mx of of Discoid lupus erythematosus?
topical steroid cream
oral antimalarials may be used second-line e.g. hydroxychloroquine
avoid sun exposure
1371
Drug-induced lupus?
not all the typical features of systemic lupus erythematosus are seen, with renal and nervous system involvement being unusual. It usually resolves on stopping the drug.
1372
Features of drug-induced lupus?
arthralgia
myalgia
skin (e.g. malar rash) and pulmonary involvement (e.g. pleurisy) are common
ANA positive in 100%, dsDNA negative
anti-histone antibodies are found in 80-90%
anti-Ro, anti-Smith positive in around 5%
1373
Causes of drug-induced lupus?
Most common causes:
procainamide
hydralazine
Less common causes:
isoniazid
minocycline
phenytoin
1374
Ehler-Danlos syndrome?
autosomal dominant connective tissue disorder that mostly affects type III collagen. This results in the tissue being more elastic than normal leading to joint hypermobility and increased elasticity of the skin.
1375
Features and Cx of Ehler-Danlos syndrome?
elastic, fragile skin
joint hypermobility: recurrent joint dislocation
easy bruising
aortic regurgitation, mitral valve prolapse and aortic dissection
subarachnoid haemorrhage
angioid retinal streaks
1376
Referred lumbar spine pain?
Femoral nerve compression may cause referred pain in the hip
Femoral nerve stretch test may be positive - lie the patient prone. Extend the hip joint with a straight leg then bend the knee. This stretches the femoral nerve and will cause pain if it is trapped
1377
Summary of Meralgia paraesthetica?
Caused by compression of lateral cutaneous nerve of thigh
Typically burning sensation over antero-lateral aspect of thigh
1378
Pubic symphysis dysfunction?
Common in pregnancy
Ligament laxity increases in response to hormonal changes of pregnancy
Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen
1379
Pregnant pt with pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen
pubic symphysis dysfunction
1380
Transient idiopathic osteoporosis
An uncommon condition sometimes seen in the third trimester of pregnancy
Groin pain associated with a limited range of movement in the hip
Patients may be unable to weight bear
ESR may be elevated
1381
1382
An uncommon condition sometimes seen in the third trimester of pregnancy
Groin pain associated with a limited range of movement in the hip
Patients may be unable to weight bear
ESR may be elevated
transient idiopathic osteoporosis
1383
Causes of hip pain in adults?
OA
inflam arthritis
referred L spine pain
Greater trochanteric pain syndrome
Meralgia paraesthetica
Avascular necrosis
Pubic symphysis dysfunction
Transient idiopathic osteoarthritis
1384
HLA antigens are encoded for by genes on chromosome
6
1385
HLA A, B and C are what? DP, DQ and DR?
class I antigens
class II antigens
1386
HLA associations- what one for:
- haemochromatosis?
HLA-A3
1387
HLA associations- what one for:
- Behcet's disease?
HLA-B51
1388
HLA associations- what one for:
- ankylosing spondylitis
- reactive arthritis
- acute anterior uveitis
- psoriatic arthritis
HLA-B27
1389
HLA associations- what one for:
- coeliac disease?
HLA-DQ2/DQ8
1390
HLA associations- what one for:
- narcolepsy
- Goodpasture's
HLA-DR2
1391
HLA associations- what one for:
- dermatitis herpetiformis
- Sjogren's syndrome
- primary biliary cirrhosis
(sometimes DM but not strongly)
HLA-DR3
1392
HLA associations- what one for:
- DMT1
- RA
HLA-DR4
RA= in particular the DRB1 gene (DRB1*04:01 and DRB1*04:04 hence the association with DR4)
1393
Hydroxychloroquine
used in Mx of RA and systemic/discoid lupus erythematosus
pharmacologically similar to chloroquine used to treat malaria
1394
Can hydroxychloroquine be used in pregnancy?
yes
1395
Monitoring of hydroxychloroquine?
'Ask patient about visual symptoms and monitor visual acuity annually using the standard reading chart'
1396
Adverse effects of hydroxychloroquine?
bull's eye retinopathy - may result in severe and permanent visual loss
baseline ophthalmological examination and annual screening is generally recommened
colour retinal photography and spectral domain optical coherence tomography scanning of the macula
1397
Langerhans cell histiocytosis?
are disorder characterised by the proliferation of Langerhans cells, which are specialised dendritic cells that normally function to present antigen to T lymphocytes. The disease can affect multiple organs, including the bones, skin, lungs, and endocrine system. It is notable for its variable clinical presentation, ranging from isolated bone lesions to multisystem disease.
1398
Features of Langerhans cell histiocytosis?
bone pain, typically in the skull or proximal femur
cutaneous nodules
pituitary involvement: leads to diabetes insipidus due to pituitary stalk involvement
pulmonary involvement: More common in adults, presenting with dyspnoea, cough, and chest pain
recurrent otitis media/mastoiditis
tennis racket-shaped Birbeck granules on electromicroscopy
1399
Diagnosis of Langerhans cell histiocytosis?
biopsy: confirmation is through biopsy showing Langerhans cells with characteristic grooved nuclei and positive staining for CD1a and S100 protein
imaging: radiographs and MRI for bone lesions; CT may be used for chest and abdominal involvement
1400
Tx of Langerhans cell histiocytosis?
localized disease: surgical resection or limited radiotherapy for isolated lesions.
multisystem disease: systemic therapy including steroids, chemotherapy (e.g., vinblastine, cytarabine), and targeted therapies for refractory cases.
supportive care: management of diabetes insipidus, pain control, and treatment of secondary infections.
1401
Young girl with multiple well defined 'punched out' osteolytic lesions with scalloped edges (geographic skull) are seen in the bilateral parietal regions. The lesions have a characteristic bevelled edge.
Langerhans cell histiocytosis
1402
Marfan's syndrome?
autosomal dominant connective tissue disorder
1403
Cause of Marfan's syndrome?
defect in the FBN1 gene on chromosome 15 that codes for the protein fibrillin-1.
1404
Features of Marfan's syndrome?
tall stature with arm span to height ratio > 1.05
high-arched palate
arachnodactyly (long curved slender fingers)
pectus excavatum (caved chest)
pes planus (flat foot)
scoliosis of > 20 degrees
dural ectasia (ballooning of the dural sac at the lumbosacral level)
heart, lung and eye symptoms
1405
tall stature with arm span to height ratio > 1.05
high-arched palate
arachnodactyly (long curved slender fingers)
pectus excavatum (caved chest)
pes planus (flat foot)
scoliosis of > 20 degrees
blue sclera
Marfan's syndrome
1406
Marfan's syndrome: heart features?
dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation
mitral valve prolapse (75%),
1407
Marfan's syndrome: lung features?
repeated pneumothoraces
1408
Marfan's syndrome: eye features?
upwards lens dislocation (superotemporal ectopia lentis)
blue sclera
myopia
1409
Life expectancy of Marfan's syndrome/Mx?
used to be around 40-50 years.
But with regular echocardiography monitoring and beta-blocker/ACE-inhibitor therapy this has improved significantly over recent years.
Aortic dissection and other cardiovascular problems remain the leading cause of death however.
1410
McArdle's disease?
autosomal recessive type V glycogen storage disease
caused by myophosphorylase deficiency
this causes decreased muscle glycogenolysis
1411
Features of McArdle's disease?
muscle pain and stiffness following exercise
muscle cramps
second wind phenomenon
rhabdomyolysis & myoglobinuria
low lactate levels during exercise
1412
Second wind phenomenon in McArdle's disease?
occurs when patients experience an improvement in exercise tolerance after a brief rest or reduction in intensity
due to the body's switch from glycogen-dependent energy metabolism to increased reliance on circulating glucose and fatty acids
this adaptation allows for better energy utilisation during prolonged activity despite the underlying myophosphorylase deficiency.
1413
Myopathies: features?
symmetrical muscle weakness (proximal > distal)
common problems are rising from chair or getting out of bath
sensation normal, reflexes normal, no fasciculation
1414
Myopathies: causes?
inflammatory: polymyositis
inherited: Duchenne/Becker muscular dystrophy, myotonic dystrophy
endocrine: Cushing's, thyrotoxicosis
alcohol
1415
OA vs RA: aetiology?
OA=
Mechanical - wear & tear
- localised loss of cartilage
- remodelling of adjacent bone
- associated inflammation
RA=
Autoimmune
1416
OA vs RA: gender?
OA= slightly more in W
RA= signif more in W
1417
OA vs RA: age?
OA= elderly
RA= adults of all ages
1418
OA vs RA: typical joints affected?
OA= Large weight-bearing joints (hip, knee); Carpometacarpal joint; DIP, PIP joints
RA= MCP, PIP joints
1419
OA vs RA: typical symptoms?
OA= Pain following use, no morning stiffness or <30mins; improves with rest; Unilateral symptoms; No systemic upset
RA= Morning stiffness, improves with use; Bilateral symptoms; Systemic upset
1420
OA vs RA: x-ray findings?
OA=
Loss of joint space
Subchondral sclerosis
Subchondral cysts
Osteophytes forming at joint margins
RA=
Loss of joint space
Juxta-articular osteoporosis
Periarticular erosions
Subluxation
1421
Osteogenesis imperfecta (brittle bone disease)?
group of disorders of collagen metabolism resulting in bone fragility and fractures.
The most common, and milder, form of osteogenesis imperfecta is type 1
1422
Osteogenesis imperfecta overview?
autosomal dominant
abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides
1423
Osteogenesis imperfecta features?
presents in childhood
fractures following minor trauma
blue sclera
deafness secondary to otosclerosis
dental imperfections are common
1424
presents in childhood
fractures following minor trauma
blue sclera
deafness secondary to otosclerosis
dental imperfections are common
Osteogenesis imperfecta
1425
Osteogenesis imperfecta Ix?
adjusted calcium, phosphate, parathyroid hormone and ALP results are
1426
Polymyositis?
inflammatory disorder causing symmetrical, proximal muscle weakness
thought to be a T-cell mediated cytotoxic process directed against muscle fibres
may be idiopathic or associated with connective tissue disorders
associated with malignancy
dermatomyositis is a variant of the disease where skin manifestations are prominent, for example a purple (heliotrope) rash on the cheeks and eyelids
typically affects middle-aged, female:male 3:1
1427
Features of Polymyositis?
proximal muscle weakness +/- tenderness
Raynaud's
respiratory muscle weakness
interstitial lung disease
e.g. fibrosing alveolitis or organising pneumonia
seen in around 20% of patients and indicates a poor prognosis
dysphagia, dysphonia
1428
Ix for polymyositis?
elevated creatine kinase
other muscle enzymes (lactate dehydrogenase (LDH), aldolase, AST and ALT) are also elevated in 85-95% of patients
EMG
muscle biopsy
anti-synthetase antibodies: anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud's and fever
1429
Mx for polymyositis?
high-dose corticosteroids tapered as symptoms improve
azathioprine may be used as a steroid-sparing agent
1430
Raynaud's phenomenon?
an exaggerated vasoconstrictive response of the digital arteries and cutaneous arteriole to the cold or emotional stress. It may be primary (Raynaud's disease) or secondary (Raynaud's phenomenon).
1431
How does raynaud's disease typically present?
young women (e.g. 30 years old) with bilateral symptoms.
1432
Secondary causes of Raynaud's phenomenon?
connective tissue disorders:
- scleroderma (most common)
- rheumatoid arthritis
- systemic lupus erythematosus
leukaemia
type I cryoglobulinaemia, cold agglutinins
use of vibrating tools
drugs: oral contraceptive pill, ergot
cervical rib
1433
Factors suggesting underlying connective tissue disease in Raynaud's phenomenon?
onset after 40 years
unilateral symptoms
rashes
presence of autoantibodies
features which may suggest rheumatoid arthritis or SLE, for example arthritis or recurrent miscarriages
digital ulcers, calcinosis
very rarely: chilblains
1434
Mx for Raynaud's phenomenon?
all patients with suspected secondary Raynaud's phenomenon should be referred to secondary care
first-line: calcium channel blockers e.g. nifedipine
IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months
1435
Rotator cuff muscles?
SItS
Supraspinatus
Infraspinatus
teres minor
Subscapularis
1436
Rotator cuff muscles: Supraspinatus?
aBDucts arm before deltoid
Most commonly injured
1437
Rotator cuff muscles: Infraspinatus?
Rotates arm laterally
1438
Rotator cuff muscles: teres minor?
aDDucts & rotates arm laterally
1439
Rotator cuff muscles: Suprascapularis?
aDDuct & rotates arm medially
1440
Common features of Seronegative spondyloarthropathies?
associated with HLA-B27
rheumatoid factor negative - hence 'seronegative'
peripheral arthritis, usually asymmetrical
sacroiliitis
enthesopathy: e.g. Achilles tendonitis, plantar fasciitis
extra-articular
manifestations: uveitis, pulmonary fibrosis (upper zone), amyloidosis, aortic regurgitation
1441
Spondyloarthropathies?
ankylosing spondylitis
psoriatic arthritis
reactive arthritis
enteropathic arthritis (associated with IBD)
1442
Sjogren's syndrome?
autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces.
1443
Sjogren's syndrome can be...
primary (PSS) or secondary to rheumatoid arthritis or other connective tissue disorders, where it usually develops around 10 years after the initial onset.
1444
Sjogren's syndrome more common in who?
females (9:1)
1445
There is a marked increased risk of what in Sjogren's syndrome?
lymphoid malignancy (40-60 fold).
1446
Sjogren's syndrome features?
dry eyes: keratoconjunctivitis sicca
dry mouth
vaginal dryness
arthralgia
Raynaud's, myalgia
sensory polyneuropathy
recurrent episodes of parotitis
renal tubular acidosis (usually subclinical)
Raynaud's, myalgia
sensory polyneuropathy
recurrent episodes of parotitis
renal tubular acidosis (usually subclinical)
1447
dry eyes: keratoconjunctivitis sicca
dry mouth
vaginal dryness
arthralgia
Raynaud's, myalgia
sensory polyneuropathy
recurrent episodes of parotitis
renal tubular acidosis (usually subclinical)
Raynaud's, myalgia
sensory polyneuropathy
recurrent episodes of parotitis
renal tubular acidosis (usually subclinical)
Sjogren's syndrome
1448
Sjogren's syndrome Ix?
rheumatoid factor (RF) positive in nearly 50% of patients
ANA positive in 70%
anti-Ro (SSA) antibodies in 70% of patients with PSS
anti-La (SSB) antibodies in 30% of patients with PSS
Schirmer's test: filter paper near conjunctival sac to measure tear formation
histology: focal lymphocytic infiltration
also: hypergammaglobulinaemia, low C4
1449
Sjogren's syndrome histology?
focal lymphocytic infiltration
1450
Clinical test for Sjogren's syndrome?
Schirmer's test: filter paper near conjunctival sac to measure tear formation
1451
Mx of Sjogren's syndrome?
artificial saliva and tears
pilocarpine may be helpful to stimulate saliva production
1452
Still's disease in adults?
rare type of inflam arthritis
1453
Still's disease in adults epidemiology?
bimodal age distribution - 15-25 yrs and 35-46 yrs
1454
Still's disease in adults features?
arthralgia
elevated serum ferritin
rash: salmon-pink, maculopapular
pyrexia= typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash
lymphadenopathy
rheumatoid factor (RF) and anti-nuclear antibody (ANA) negative
1455
arthralgia
elevated serum ferritin
rash: salmon-pink, maculopapular
pyrexia= typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash
Still's disease in adults
1456
Diagnosis of Still's disease in adults?
challenging
The Yamaguchi criteria is the most widely used criteria and has a sensitivity of 93.5%.
1457
Mx of Still's disease in adults?
NSAIDs= should be used first-line to manage fever, joint pain and serositis; they should be trialled for at least a week before steroids are added.
steroids= may control symptoms but won't improve prognosis
if symptoms persist, the use of methotrexate, IL-1 or anti-TNF therapy can be considered
1458
Systemic sclerosis?
condition of unknown aetiology characterised by hardened, sclerotic skin and other connective tissues. It is four times more common in females
1459
Systemic sclerosis: 3 patterns of disease?
Limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis
Scleroderma (without internal organ involvement)
1460
Systemic sclerosis: 3 patterns of disease= Limited cutaneous systemic sclerosis?
Raynaud's may be the first sign
scleroderma affects face and distal limbs predominately
associated with anti-centromere antibodies
a subtype of limited systemic sclerosis is CREST syndrome: Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
1461
Systemic sclerosis: 3 patterns of disease= Diffuse cutaneous systemic sclerosis?
scleroderma affects trunk and proximal limbs predominately
associated with anti scl-70 antibodies
the most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)
other complications include renal disease and hypertension= patients with renal disease should be started on an ACE inhibitor
poor prognosis
1462
Systemic sclerosis: 3 patterns of disease= Scleroderma (without internal organ involvement)?
tightening and fibrosis of skin
may be manifest as plaques (morphoea) or linear
1463
Systemic sclerosis antibodies?
ANA positive in 90%
RF positive in 30%
anti-scl-70 antibodies associated with diffuse cutaneous systemic sclerosis
- associated with a higher risk of severe interstitial lung disease
anti-centromere antibodies associated with limited cutaneous systemic sclerosis
1464
The following groups should be advised to take vitamin D supplementation:
all pregnant and breastfeeding women should take a daily supplement containing 10µg of vitamin D
all children aged 6 months - 5 years. Babies fed with formula milk do not need to take a supplement if they are taking more than 500ml of milk a day, as formula milk is fortified with vitamin D
adults > 65 years
'people who are not exposed to much sun should also take a daily supplement' e.g. housebound patients
(People who are at higher risk of vitamin D deficiency (see above) should be treated anyway so again testing is not necessary)
1465
When to test for vit D def?
patients with bone diseases that may be improved with vitamin D treatment e.g. known osteomalacia or Paget's disease
patients with bone diseases, prior to specific treatment where correcting vitamin deficiency is appropriate e,g, prior to intravenous zolendronate or denosumab
patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency e.g. bone pain ?osteomalacia
1466
Why is vit D not tested in pt with osteoporosis?
Patients with osteoporosis should always be given calcium/vitamin D supplements so testing is not considered necessary.
1467
FINALS
flashcards
Decks in class (37)
# Cards
-
Cardiology975
-
Respiratory1042
-
GI and Liver1174
-
Renal Medicine366
-
Urology292
-
Endocrinology543
-
Haematology852
-
Neuro1661
-
MSK1468
-
ENT244
-
Dermatology720
-
Opthalmology346
-
Palliative Care49
-
Cancer943
-
Sexual health373
-
Gynae925
-
Paeds1695
-
Obstetrics863
-
Psych764
-
Geriatrics176
-
Infection1099
-
Surgery147
-
Anaesthetics/Pre-Op281
-
Vascular Surgery52
-
Random128
-
Electrolyte Imbalances85
-
Public Health48
-
My common mistakes531
-
Microbio5
-
Drugs283
-
ECG160
-
X-rays21
-
DVLA51
-
Differential diagnosis0
-
Scoring systems0
-
Acute and Emergency271
-
GP76
