MSK Flashcards

Question

What is the typical muscle weakness presentation in dermatomyositis?

Answer 1

Proximal muscle weakness +/- tenderness

Answer 2

Around 80%

Answer 3

Around 30%

Answer 4

* Antibodies against histidine-tRNA ligase (Jo-1) * Antibodies to signal recognition particle (SRP) * Anti-Mi-2 antibodies

Answer 5

A localized type III hypersensitivity reaction caused by the deposition of immune complexes in the walls of small blood vessels at the site of antigen exposure. ## Footnote Immune complexes are formed from antigen–IgG antibody complexes.

Answer 6

Deposition of immune complexes in small blood vessels. ## Footnote This occurs particularly in individuals with high circulating antibody levels, usually IgG.

Answer 7

Immune complexes form locally, activating complement, attracting neutrophils, and causing tissue damage. ## Footnote This process leads to vasculitis, edema, and tissue necrosis.

Answer 8

Within 4–12 hours. ## Footnote Symptoms may occur after vaccinations or injections of antigens for which the patient has high antibody levels.

Answer 9

* Localized pain * Swelling * Erythema * Warmth * Induration ## Footnote Severe cases may progress to blistering, ulceration, or tissue necrosis.

Answer 10

* After booster vaccinations (tetanus, diphtheria, pneumococcal) * After therapeutic protein/antitoxin injections (e.g., antivenom, monoclonal antibodies) * In experimental immunology (skin testing with foreign proteins) ## Footnote These examples highlight instances of re-exposure to antigens.

Answer 11

Generally self-limiting with supportive care. ## Footnote Supportive care includes analgesia, cool compresses, and elevation.

Answer 12

False ## Footnote The reaction is generally self-limiting.

Answer 13

Unnecessary repeat antigen exposure. ## Footnote This is to prevent further complications from the hypersensitivity reaction.

Answer 14

An acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss, and thrombocytopenia ## Footnote It may occur as a primary disorder or secondary to conditions like systemic lupus erythematosus (SLE).

Answer 15

Around 30% ## Footnote This indicates a significant association between SLE and antiphospholipid syndrome.

Answer 16

Paradoxical rise in the APTT due to lupus anticoagulant autoantibodies reacting with phospholipids ## Footnote This is an important point for understanding the coagulation cascade in these patients.

Answer 17

* Other autoimmune disorders * Lymphoproliferative disorders * Phenothiazines (rare) ## Footnote These associations highlight the diverse clinical contexts in which antiphospholipid syndrome may occur.

Answer 18

* Venous/arterial thrombosis * Recurrent miscarriages * Livedo reticularis * Other features: pre-eclampsia, pulmonary hypertension ## Footnote Recognition of these features is crucial for diagnosis.

Answer 19

* Anticardiolipin antibodies * Anti-beta2 glycoprotein I (anti-beta2GPI) antibodies * Lupus anticoagulant ## Footnote These laboratory tests are essential for confirming the diagnosis.

Answer 20

* ≥1 clinical episode of arterial, venous, or small-vessel thrombosis * Pregnancy morbidity: three or more consecutive unexplained spontaneous abortions <10 weeks, or ≥1 unexplained fetal loss ≥10 weeks, or ≥1 preterm birth <34 weeks due to placental insufficiency ## Footnote At least one of these criteria must be met.

Answer 21

* Lupus anticoagulant (LA) * Anticardiolipin (aCL) antibodies * Anti-beta2 glycoprotein I (anti-β2GP1) antibodies ## Footnote At least one must be confirmed on ≥2 occasions at least 12 weeks apart.

Answer 22

Low-dose aspirin ## Footnote This is recommended based on EULAR guidelines.

Answer 23

Low-dose aspirin plus LMWH for thromboprophylaxis ## Footnote This is according to RCOG guidance.

Answer 24

Lifelong warfarin with a target INR of 2-3 ## Footnote This is a critical aspect of secondary thromboprophylaxis.

Answer 25

False ## Footnote According to NICE/EULAR guidance, warfarin remains the standard of care for most patients who are not pregnant.

Answer 26

Recurrent miscarriages ## Footnote This highlights the impact of the syndrome on pregnancy outcomes.

Answer 27

Compression of the median nerve in the carpal tunnel ## Footnote It leads to symptoms like pain and numbness in the hand.

Answer 28

Pain and pins and needles in thumb, index, middle finger ## Footnote Symptoms may ascend proximally and are often relieved by shaking the hand.

Answer 29

Weakness of thumb abduction, wasting of thenar eminence, Tinel's sign, Phalen's sign ## Footnote Tinel's sign involves tapping causing paraesthesia, and Phalen's sign involves wrist flexion causing symptoms.

Answer 30

Tapping causes paraesthesia

Answer 31

Flexion of wrist causes symptoms

Answer 32

Idiopathic, pregnancy, oedema, lunate fracture, rheumatoid arthritis ## Footnote Oedema can be due to heart failure.

Answer 33

Prolongation of the action potential

Answer 34

A 6-week trial of conservative treatments

Answer 35

Corticosteroid injection, wrist splints at night, surgical decompression ## Footnote Surgical decompression involves flexor retinaculum division.

Answer 36

median nerve

Answer 37

Giant cell arteritis (GCA) ## Footnote Temporal arteritis is a type of vasculitis affecting medium and large-sized vessels.

Answer 38

> 50 years old, peak in 70s ## Footnote Temporal arteritis primarily occurs in older adults.

Answer 39

To minimize the risk of complications such as permanent loss of vision ## Footnote Prompt treatment is essential to prevent serious complications.

Answer 40

High-dose prednisolone ## Footnote Treatment should start promptly along with referral to a specialist.

Answer 41

Around 50% ## Footnote There is significant overlap between the two conditions.

Answer 42

* Patient typically > 60 years old * Rapid onset (e.g. < 1 month) * Headache (85%) * Jaw claudication (65%) * Tender, palpable temporal artery ## Footnote These features help in the clinical diagnosis of temporal arteritis.

Answer 43

Anterior ischemic optic neuropathy ## Footnote It results from occlusion of the posterior ciliary artery.

Answer 44

Vision testing ## Footnote Essential for assessing potential ocular complications.

Answer 45

Temporal artery biopsy ## Footnote It confirms the presence of granulomatous inflammation with multinucleated giant cells.

Answer 46

GCA cannot be ruled out due to skip lesions; treatment should continue if pre-test probability is high ## Footnote Clinical judgement is important in these cases.

Answer 47

Temporal artery colour Doppler ultrasound ## Footnote It serves as a non-invasive option for diagnosis.

Answer 48

IV methylprednisolone ## Footnote This is given prior to starting high-dose prednisolone.

Answer 49

The diagnosis may be reconsidered if there is no dramatic response ## Footnote This helps confirm the diagnosis of temporal arteritis.

Answer 50

Bisphosphonates ## Footnote Necessary due to the risks associated with long-term glucocorticoid therapy.

Answer 51

Yes, but the evidence base supporting this is weak ## Footnote It may help in some patients, but more research is needed.

Answer 52

Most common causes procainamide hydralazine Less common causes isoniazid minocycline phenytoin

Answer 53

99% ## Footnote This high sensitivity makes ANA a useful rule out test.

Answer 54

Low ## Footnote Despite its high sensitivity, ANA has low specificity.

Answer 55

20% ## Footnote This indicates some overlap with rheumatoid arthritis.

Answer 56

Highly specific (> 99%), sensitivity (70%) ## Footnote Anti-dsDNA is a key marker in systemic lupus erythematosus.

Answer 57

Highly specific (> 99%), sensitivity (30%) ## Footnote Anti-Smith antibodies are another important marker for the disease.

Answer 58

* anti-U1 RNP * SS-A (anti-Ro) * SS-B (anti-La) ## Footnote These antibodies can also be present in systemic lupus erythematosus.

Answer 59

* Anaemia (of chronic disease or haemolytic) * Lymphopenia (common) * Thrombocytopenia due to immune-mediated destruction ## Footnote These findings are often seen in lupus patients.

Answer 60

ESR ## Footnote ESR is a common test for monitoring inflammation.

Answer 61

Underlying infection ## Footnote During active disease, CRP may be normal despite inflammation.

Answer 62

C3, C4 ## Footnote Low complement levels occur due to consumption from complex formation.

Answer 63

Disease monitoring ## Footnote Not all patients will have anti-dsDNA titres present.

Answer 64

The introduction of disease-modifying therapies (DMARDs) ## Footnote DMARDs help modify the disease course and improve patient outcomes.

Answer 65

As soon as possible with a combination of disease-modifying drugs (DMARDs) ## Footnote Early intervention is crucial for better management of RA.

Answer 66

DMARD monotherapy +/- a short-course of bridging prednisolone ## Footnote Previously, dual DMARD therapy was advocated as the initial step.

Answer 67

Methotrexate ## Footnote Methotrexate requires careful monitoring due to potential side effects.

Answer 68

FBC (full blood count) & LFTs (liver function tests) ## Footnote This is due to the risk of myelosuppression and liver cirrhosis.

Answer 69

* Sulfasalazine * Leflunomide ## Footnote Hydroxychloroquine is considered only for mild or palindromic disease.

Answer 70

Using a combination of CRP and disease activity (e.g., DAS28 score) ## Footnote This helps in assessing the efficacy of the treatment.

Answer 71

Corticosteroids - oral or intramuscular ## Footnote Corticosteroids help reduce inflammation during flares.

Answer 72

An inadequate response to at least two DMARDs including methotrexate ## Footnote TNF-inhibitors are used when initial treatments are insufficient.

Answer 73

A recombinant human protein acting as a decoy receptor for TNF-α, administered subcutaneously ## Footnote Risks include demyelination and reactivation of tuberculosis.

Answer 74

A monoclonal antibody that binds to TNF-α, administered intravenously ## Footnote It prevents TNF-α from binding with TNF receptors.

Answer 75

A monoclonal antibody administered subcutaneously ## Footnote It is used for patients who do not respond adequately to DMARDs.

Answer 76

Anti-CD20 monoclonal antibody resulting in B-cell depletion ## Footnote It is given as two 1g intravenous infusions two weeks apart.

Answer 77

Infusion reactions ## Footnote Monitoring during administration is essential due to these reactions.

Answer 78

A fusion protein that modulates a key signal for T lymphocyte activation, decreasing T-cell proliferation and cytokine production ## Footnote It is given as an infusion but is not currently recommended by NICE.

Answer 79

An inflammatory arthritis associated with psoriasis, classed as a seronegative spondyloarthropathy.

Answer 80

It correlates poorly and often precedes the development of skin lesions.

Answer 81

Around 10-20%.

Answer 82

* Symmetric polyarthritis (30-40% of cases) * Asymmetrical oligoarthritis (20-30%) * Sacroiliitis * DIP joint disease (around 10%) * Arthritis mutilans.

Answer 83

Rheumatoid arthritis.

Answer 84

A severe deforming form of psoriatic arthropathy characterized by 'telescoping fingers'.

Answer 85

* Psoriatic skin lesions * Periarticular disease * Enthesitis * Tenosynovitis * Dactylitis * Nail changes (pitting, onycholysis).

Answer 86

Inflammation at the site of tendon and ligament insertion.

Answer 87

* Elevated CRP/ESR * Negative rheumatoid factor (RF) * Negative anti-cyclic citrullinated peptide antibodies (anti-CCP) * HLA-B27 may be positive.

Answer 88

* Erosions * New bone formation * Periostitis * 'Pencil-in-cup' appearance in advanced disease.

Answer 89

A rheumatologist.

Answer 90

NSAIDs alone.

Answer 91

Methotrexate.

Answer 92

* Ustekinumab (targets IL-12 and IL-23) * Secukinumab (targets IL-17) * Ixekizumab (targets IL-17) * Adalimumab (anti-TNF).

Answer 93

An oral phosphodiesterase type-4 (PDE4) inhibitor that modulates inflammatory mediators.

Answer 94

Generally better, though some may develop progressive joint damage and disability.

Answer 95

A form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium. ## Footnote Pseudogout is now more correctly termed acute calcium pyrophosphate crystal deposition disease.

Answer 96

Increasing age ## Footnote Patients who develop pseudogout at a younger age (< 60 years) usually have underlying risk factors.

Answer 97

* Haemochromatosis * Hyperparathyroidism * Low magnesium * Low phosphate * Acromegaly * Wilson's disease

Answer 98

* Knee * Wrist * Shoulders

Answer 99

Weakly-positively birefringent rhomboid-shaped crystals ## Footnote These crystals are indicative of calcium pyrophosphate dihydrate deposition.

Answer 100

Chondrocalcinosis ## Footnote In the knee, this can appear as linear calcifications of the meniscus and articular cartilage.

Answer 101

Aspiration of joint fluid to exclude septic arthritis.

Answer 102

* NSAIDs * Intra-articular steroids * Intra-muscular steroids * Oral steroids ## Footnote These treatments are similar to those used for gout.

Answer 103

A condition of unknown aetiology characterised by hardened, sclerotic skin and other connective tissues. ## Footnote Systemic sclerosis is four times more common in females.

Answer 104

1. Limited cutaneous systemic sclerosis 2. Diffuse cutaneous systemic sclerosis 3. Scleroderma (without internal organ involvement) ## Footnote Each pattern has distinct characteristics and associated antibodies.

Answer 105

Raynaud's phenomenon ## Footnote This may occur before other symptoms.

Answer 106

Face and distal limbs ## Footnote It is associated with anti-centromere antibodies.

Answer 107

A subtype of limited systemic sclerosis characterised by: * Calcinosis * Raynaud's phenomenon * Esophageal dysmotility * Sclerodactyly * Telangiectasia ## Footnote CREST syndrome is associated with limited cutaneous systemic sclerosis.

Answer 108

Trunk and proximal limbs ## Footnote It is associated with anti-scl-70 antibodies.

Answer 109

Respiratory involvement ## Footnote Seen in around 80% of patients, including interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH).

Answer 110

1. Renal disease 2. Hypertension ## Footnote Patients with renal disease should be started on an ACE inhibitor.

Answer 111

Captopril ## Footnote It is chosen for its rapid onset and short half-life, allowing for dose titration.

Answer 112

By reducing efferent arteriolar vasoconstriction and limiting renin-angiotensin system activation. ## Footnote This addresses the underlying mechanism of renal disease.

Answer 113

Poor prognosis ## Footnote Due to severe complications like respiratory involvement.

Answer 114

Tightening and fibrosis of skin ## Footnote It may manifest as plaques (morphoea) or linear.

Answer 115

90% ## Footnote ANA positivity indicates autoimmune activity.

Answer 116

30% ## Footnote RF positivity can indicate other autoimmune conditions.

Answer 117

Anti-scl-70 antibodies ## Footnote They are linked to a higher risk of severe interstitial lung disease.

Answer 118

Anti-centromere antibodies ## Footnote They are a marker for the limited form of the disease.

Answer 119

Chromosome 6 ## Footnote HLA antigens are crucial for immune system function.

Answer 120

HLA A, B, C ## Footnote Class I antigens present peptides to CD8+ T cells.

Answer 121

DP, DQ, DR ## Footnote Class II antigens present peptides to CD4+ T cells.

Answer 122

Haemochromatosis ## Footnote Haemochromatosis is a condition of iron overload.

Answer 123

Behcet's disease ## Footnote Behcet's disease is a systemic vasculitis.

Answer 124

* Ankylosing spondylitis * Reactive arthritis * Acute anterior uveitis * Psoriatic arthritis ## Footnote HLA-B27 is linked to several inflammatory diseases.

Answer 125

Coeliac disease ## Footnote Coeliac disease is an autoimmune disorder triggered by gluten.

Answer 126

* Narcolepsy * Goodpasture's ## Footnote HLA-DR2 is linked to autoimmune conditions.

Answer 127

* Dermatitis herpetiformis * Sjogren's syndrome * Primary biliary cirrhosis ## Footnote HLA-DR3 is associated with several autoimmune disorders.

Answer 128

* Type 1 diabetes mellitus * Rheumatoid arthritis ## Footnote Type 1 diabetes is also associated with HLA-DR3 but more strongly with HLA-DR4.

Answer 129

False ## Footnote Type 1 diabetes mellitus is primarily associated with HLA-DR4.

Answer 130

An arthritis that develops following an infection where the organism cannot be recovered from the joint ## Footnote It is associated with HLA-B27 and includes post-STI and post-dysenteric forms.

Answer 131

A term that described a classic triad of urethritis, conjunctivitis, and arthritis following a dysenteric illness ## Footnote This term has been largely replaced by the concept of reactive arthritis.

Answer 132

Urethritis, conjunctivitis, arthritis ## Footnote This triad was identified in patients following dysenteric illnesses.

Answer 133

Post-STI reactive arthritis (SARA) ## Footnote This form is identified in patients following sexually transmitted infections.

Answer 134

Can't see, pee or climb a tree ## Footnote This phrase summarizes the classic symptoms of reactive arthritis.

Answer 135

Much more common in men, approximately 10:1 ratio ## Footnote The post-dysenteric form has equal sex incidence.

Answer 136

* Shigella flexneri * Salmonella typhimurium * Salmonella enteritidis * Yersinia enterocolitica * Campylobacter ## Footnote These organisms are linked to the post-dysenteric form of reactive arthritis.

Answer 137

Chlamydia trachomatis ## Footnote This organism is linked specifically to sexually transmitted infections.

Answer 138

* Symptomatic treatment * Analgesia * NSAIDs * Intra-articular steroids ## Footnote Sulfasalazine and methotrexate may be used for persistent disease.

Answer 139

Symptoms rarely last more than 12 months ## Footnote This duration varies among individuals but is generally limited.

Answer 140

Frozen shoulder

Answer 141

Middle-aged females

Answer 142

Not fully understood

Answer 143

External rotation

Answer 144

Both active and passive movement

Answer 145

Painful freezing phase, adhesive phase, recovery phase

Answer 146

Between 6 months and 2 years

Answer 147

Clinically

Answer 148

For atypical or persistent symptoms

Answer 149

* NSAIDs * Physiotherapy * Oral corticosteroids * Intra-articular corticosteroids

Answer 150

History of myocardial infarction, lung disease, or neck disease

Answer 151

Females aged 40-60 years

Answer 152

In the non-dominant hand

Answer 153

Prolonged immobilisation of the arm or pain

Answer 154

A rare but serious condition where the lumbosacral nerve roots below the spinal cord are compressed.

Answer 155

Central disc prolapse.

Answer 156

L4/5 or L5/S1.

Answer 157

* Tumours: primary or metastatic * Infection: abscess, discitis * Trauma * Haematoma

Answer 158

Low back pain.

Answer 159

Around 50%.

Answer 160

* Reduced sensation/pins-and-needles in the perianal area * Decreased anal tone * Urinary dysfunction

Answer 161

It may indicate cauda equina syndrome.

Answer 162

It has poor sensitivity and specificity.

Answer 163

* Incontinence * Reduced awareness of bladder filling * Loss of urge to void

Answer 164

Incontinence.

Answer 165

Surgical decompression.

Answer 166

A form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium.

Answer 167

Chronic hyperuricaemia (uric acid > 450 µmol/l).

Answer 168

* NSAIDs * Colchicine

Answer 169

A proton pump inhibitor.

Answer 170

* Inhibits microtubule polymerization by binding to tubulin * Interferes with mitosis * Inhibits neutrophil motility and activity.

Answer 171

Diarrhoea.

Answer 172

15 mg/day.

Answer 173

After their first attack of gout.

Answer 174

* >= 2 attacks in 12 months * Tophi * Renal disease * Uric acid renal stones * Prophylaxis if on cytotoxics or diuretics.

Answer 175

To avoid precipitating a further attack.

Answer 176

Allopurinol.

Answer 177

100 mg od.

Answer 178

< 360 µmol/l.

Answer 179

< 300 µmol/L.

Answer 180

Colchicine cover.

Answer 181

Febuxostat.

Answer 182

An enzyme that catalyzes the conversion of urate to allantoin.

Answer 183

To achieve rapid control of hyperuricemia in refractory cases.

Answer 184

* Reduce alcohol intake * Lose weight if obese * Avoid food high in purines.

Answer 185

* Liver * Kidneys * Seafood * Oily fish (mackerel, sardines) * Yeast products.

Answer 186

Stopping drugs such as thiazides.

Answer 187

It may be particularly suitable for patients with coexistent hypertension.

Answer 188

It may decrease serum uric acid levels.

Answer 189

The correct answer is Aspirin. Sulfasalazine is a sulfonamide drug, and patients with a known allergy to aspirin (a salicylate) may have cross-reactivity with sulfonamides due to their similar chemical structures. As a result, it is generally contraindicated to prescribe sulfasalazine in patients with an existing aspirin allergy.

Answer 190

This patient is suffering from acute gout and therefore normally he would be commenced on a high-dose NSAID such as aspirin or a coxib. However, as he has recently had a peptic ulcer, the two aforementioned are contraindicated. Thus, the next step would be to treat with colchicine.

Answer 191

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

Answer 192

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

Answer 193

A relatively common condition in older people characterised by muscle stiffness and raised inflammatory markers ## Footnote PMR appears to be closely related to temporal arteritis, but the underlying cause is not fully understood and it is not a vasculitic process.

Answer 194

Patients are usually > 60 years old

Answer 195

Usually rapid onset (e.g. < 1 month)

Answer 196

Aching, morning stiffness in proximal limb muscles ## Footnote Weakness is not considered a symptom of polymyalgia rheumatica.

Answer 197

Mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats

Answer 198

Raised inflammatory markers e.g. ESR > 40 mm/hr

Answer 199

Prednisolone e.g. 15mg/od

Answer 200

Patients typically respond dramatically to steroids

Answer 201

Consideration of an alternative diagnosis

Answer 202

Use the mnemonic "SITS" to remember them: Supraspinatus Action: Abduction of the arm (first 15°) Innervation: Suprascapular nerve Infraspinatus Action: External (lateral) rotation of the arm Innervation: Suprascapular nerve Teres minor Action: External rotation and adduction of the arm Innervation: Axillary nerve Subscapularis Action: Internal (medial) rotation of the arm Innervation: Upper and lower subscapular nerves

Answer 203

Collision sports such as rugby, falls onto the shoulder, or FOOSH (falls on outstretched hand) ## Footnote Injuries often occur in high-impact scenarios.

Answer 204

Graded I to VI depending on the degree of separation ## Footnote Each grade reflects the severity and type of injury.

Answer 205

Conservative management including resting the joint and using a sling ## Footnote These grades are common and often heal well with non-surgical treatment.

Answer 206

Grade IV, V, and VI ## Footnote These grades are rare and typically involve more severe injuries.

Answer 207

Debate exists; often depends on individual circumstances ## Footnote Treatment can vary based on specific patient needs and injury characteristics.

Answer 208

age < 20 years or > 50 years history of previous malignancy night pain history of trauma systemically unwell e.g. weight loss, fever thoracic back pain

Answer 209

Bisphosphonate 'holidays' is a recent hot topic, addressed by recent evidence from the National Osteoporosis Guideline Group (NOGG) in January 2016. After a five year period for oral bisphosphonates (three years for IV zoledronate), treatment should be re-assessed for ongoing treatment, with an updated FRAX score and DEXA scan. This guidance separates patients into high and low risk groups. To fall into the high risk group, one of the following must be true: Age >75 Glucocorticoid therapy Previous hip/vertebral fractures Further fractures on treatment High risk on FRAX scoring T score <-2.5 after treatment If any of the high risk criteria apply, treatment should be continued indefinitely, or until the criteria no longer apply. If they are in the low risk group however, treatment may be discontinued and re-assessed after two years, or if a further fracture occurs. In the case of this patient, she has no risk factors which put her into the high risk group, but we do not have a recent DEXA scan. The best option would therefore be to re-scan her now, and consider a two year break if her T score is >-2.5

Answer 210

Basics NSAIDs sun-block Hydroxychloroquine the treatment of choice for SLE If internal organ involvement e.g. renal, neuro, eye then consider prednisolone, cyclophosphamide

Answer 211

Achilles tendon disorders ## Footnote Includes tendinopathy, partial tear, and complete rupture of the Achilles tendon.

Answer 212

Quinolone use (e.g. ciprofloxacin) ## Footnote Quinolones are antibiotics that can increase the risk of tendon problems.

Answer 213

Hypercholesterolaemia ## Footnote High cholesterol levels can lead to the formation of fatty deposits in tendons.

Answer 214

Gradual onset of posterior heel pain, morning pain and stiffness ## Footnote Pain worsens following activity.

Answer 215

Supportive management including: * Simple analgesia * Reduction in precipitating activities * Calf muscle eccentric exercises ## Footnote Exercises may be self-directed or guided by physiotherapy.

Answer 216

Audible 'pop', sudden significant pain in calf or ankle, inability to walk or continue sport ## Footnote These symptoms often occur during sports or running.

Answer 217

To help exclude Achilles tendon rupture ## Footnote Involves examining angle of declination, feeling for a gap in the tendon, and calf muscle squeeze.

Answer 218

Ask the patient to lie prone with feet over the edge of the bed and observe for abnormal angle of declination ## Footnote Also involves feeling for a gap in the tendon.

Answer 219

The injured foot will stay in the neutral position ## Footnote This indicates a lack of function in the Achilles tendon.

Answer 220

Ultrasound ## Footnote Provides an effective assessment of the tendon.

Answer 221

Acute referral to an orthopaedic specialist ## Footnote Timely intervention is crucial for proper management.

Answer 222

Features time course typically develops within 4 weeks of initial infection - symptoms generally last around 4-6 months around 25% of patients have recurrent episodes whilst 10% of patients develop chronic disease arthritis is typically an asymmetrical oligoarthritis of lower limbs dactylitis symptoms of urethritis eye conjunctivitis (seen in 10-30%) anterior uveitis skin circinate balanitis (painless vesicles on the coronal margin of the prepuce) keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)

Answer 223

Hip ## Footnote The hip is particularly vulnerable in osteoporotic patients.

Answer 224

Avascular necrosis ## Footnote This occurs due to disruption of blood supply to the femoral head.

Answer 225

Pain, shortened leg, externally rotated leg ## Footnote These signs help in the clinical diagnosis of hip fractures.

Answer 226

Yes ## Footnote Non-displaced or incomplete fractures may allow for weight bearing.

Answer 227

Intracapsular, Extracapsular ## Footnote Intracapsular fractures are further divided into subcapital, while extracapsular includes trochanteric and subtrochanteric.

Answer 228

Lesser trochanter ## Footnote This anatomical landmark helps classify extracapsular fractures.

Answer 229

Hip fractures ## Footnote It includes types based on stability and displacement.

Answer 230

Stable fracture with impaction in valgus ## Footnote This type indicates stability and a specific angulation.

Answer 231

Complete fracture but undisplaced ## Footnote This type involves a complete break without displacement.

Answer 232

Displaced fracture, rotated and angulated but with boney contact ## Footnote This type indicates some contact between fracture fragments.

Answer 233

Complete boney disruption ## Footnote This type indicates a complete break with no contact between fragments.

Answer 234

Types III and IV ## Footnote These types are associated with increased risk of avascular necrosis.

Answer 235

Internal fixation or hemiarthroplasty if unfit ## Footnote Treatment options depend on the patient's overall health.

Answer 236

Replacement arthroplasty (total hip replacement or hemiarthroplasty) ## Footnote This recommendation is based on the patient's fitness and ability to walk.

Answer 237

If patients can walk independently outdoors, are not cognitively impaired, and are medically fit for anesthesia and the procedure ## Footnote This guideline ensures better outcomes for eligible patients.

Answer 238

Dynamic hip screw ## Footnote This device helps stabilize the fracture effectively.

Answer 239

Intramedullary device ## Footnote This method provides adequate stabilization for complex fracture patterns.

Answer 240

The National Osteoporosis Guideline Group (NOGG) ## Footnote NICE guidelines are also based on the NOGG guidelines.

Answer 241

Asymptomatic

Answer 242

* High risk of fragility fracture based on QFracture or FRAX score * Starting treatment that increases the risk of osteoporosis * Recent fragility fracture

Answer 243

* Healthy, balanced diet * Moderation of alcohol consumption * Avoidance of smoking

Answer 244

Calcium and vitamin D

Answer 245

Bisphosphonates

Answer 246

* Alendronate * Risedronate

Answer 247

IV zoledronate

Answer 248

Second-line treatment

Answer 249

* Strontium ranelate * Raloxifene * Teriparatide * Romosozumab

Answer 250

T-score of -2.5 SD or below

Answer 251

Perform a DEXA scan to assess bone mineral density (BMD)

Answer 252

Bone protective treatment

Answer 253

Straight away

Answer 254

A manifestation of osteoporosis

Answer 255

At least 5 years

Answer 256

At least 3 years

Answer 257

Re-assess fracture risk

Answer 258

Help with weight loss, advice about local muscle strengthening exercises, and general aerobic fitness

Answer 259

Topical NSAIDs

Answer 260

OA of the knee or hand

Answer 261

Oral NSAIDs

Answer 262

A proton pump inhibitor

Answer 263

Only if used infrequently for short-term pain relief and all other pharmacological treatments are contraindicated, not tolerated, or ineffective

Answer 264

Walking aids

Answer 265

Intra-articular steroid injections

Answer 266

2-10 weeks

Answer 267

Joint replacement

Answer 268

Disease modifying anti-rheumatic drug (DMARD) ## Footnote Used in the management of inflammatory arthritis and inflammatory bowel disease.

Answer 269

Management of inflammatory arthritis, especially rheumatoid arthritis ## Footnote Also used in inflammatory bowel disease.

Answer 270

Decreases neutrophil chemotaxis, suppresses proliferation of lymphocytes and pro-inflammatory cytokines ## Footnote It is a prodrug for 5-ASA.

Answer 271

G6PD deficiency ## Footnote Also caution for allergy to aspirin or sulphonamides due to cross-sensitivity.

Answer 272

* Oligospermia * Stevens-Johnson syndrome * Pneumonitis / lung fibrosis * Myelosuppression * Heinz body anaemia * Megaloblastic anaemia * May colour tears, staining contact lenses ## Footnote These effects can vary in severity and frequency.

Answer 273

Yes ## Footnote Considered safe to use in both pregnancy and breastfeeding.

Answer 274

Sulfasalazine is a prodrug for 5-ASA ## Footnote 5-ASA is an active metabolite that contributes to its therapeutic effects.

Answer 275

'Tennis elbow' ## Footnote It typically follows activities such as house painting or playing tennis.

Answer 276

People aged 45-55 years ## Footnote This condition typically affects the dominant arm.

Answer 277

* Pain and tenderness localized to the lateral epicondyle * Pain worse on wrist extension against resistance with the elbow extended * Pain worse with supination of the forearm with the elbow extended * Episodes typically last between 6 months and 2 years * Acute pain for 6-12 weeks

Answer 278

6-12 weeks ## Footnote Episodes of pain can last longer, from 6 months to 2 years.

Answer 279

[unaccustomed]

Answer 280

* Advice on avoiding muscle overload * Simple analgesia * Steroid injection * Physiotherapy

Answer 281

The correct answer is sterile synovial fluid with a high white blood cell count. The patient's presentation is suggestive of reactive arthritis, a seronegative spondyloarthritis classically associated with oligoarthritis of the lower limbs following a gastrointestinal or urogenital infection 1-4 weeks previously. The pathological process is aseptic, does not involve salt crystal formation, but is likely to cause increased white blood cells in the fluid (mostly polymorphonuclear leukocytes).

Answer 282

Lymphopenia is one of the most common haematological manifestations of SLE, occurring in 50-80% of patients. The mechanism is thought to be multifactorial, including increased apoptosis of lymphocytes, anti-lymphocyte antibodies, and bone marrow suppression. Lymphopenia is so characteristic of SLE that it is included in both the American College of Rheumatology (ACR) and the Systemic Lupus International Collaborating Clinics (SLICC) classification criteria for SLE. It is often one of the earliest haematological abnormalities detected and can fluctuate with disease activity. A lymphocyte count below 1.5 × 10^9/L is considered lymphopenia in adults and is a useful diagnostic clue in patients with suspected SLE.

Answer 283

A benign disorder generally seen in younger females

Answer 284

Less than 5%

Answer 285

Erythematous, raised rash; sometimes scaly

Answer 286

Autoimmune

Answer 287

Face, neck, ears, and scalp

Answer 288

Atrophy, scarring, pigmentation

Answer 289

Topical steroid cream; oral antimalarials (e.g., hydroxychloroquine) as second-line

Answer 290

Sun exposure

Answer 291

Follicular

Answer 292

Scarring alopecia

Answer 293

Gram negative diplococci is the correct answer. The most likely organism to cause septic arthritis in young adults who are sexually active is Neisseria gonorrhoeae, subsequent to disseminated infection. This bacterium appears as Gram-negative diplococci. A single hot, swollen, painful knee joint, with accompanying systemic upset (e.g. fever), is likely to be septic arthritis.

Answer 294

tenosynovitis, dermatitis (characterised by pustular skin lesions), and migratory polyarthritis,

Answer 295

Female gender Breech presentation Family history Firstborn Oligohydramnios

Answer 296

It is more common on the left side and is tested for using the Barlow and Ortolani tests which form part of the baby check. For babies who are at risk of congenital hip dislocation an ultrasound examination can be conducted to screen for the condition.

Answer 297

Knee extension, thigh flexion

Answer 298

Anterior and medial aspect of the thigh and lower leg

Answer 299

Hip and pelvic fractures, stab/gunshot wounds

Answer 300

Thigh adduction

Answer 301

Medial thigh

Answer 302

Anterior hip dislocation

Answer 303

Lateral and posterior surfaces of the thigh

Answer 304

Meralgia paraesthetica

Answer 305

Pain, tingling and numbness in the distribution of the lateral cutaneous nerve

Answer 306

Foot plantarflexion and inversion

Answer 307

Sole of foot

Answer 308

Popliteal lacerations, posterior knee dislocation

Answer 309

Foot dorsiflexion and eversion

Answer 310

Extensor hallucis longus

Answer 311

Dorsum of the foot and the lower lateral part of the leg

Answer 312

At the neck of the fibula

Answer 313

Hip abduction

Answer 314

Misplaced intramuscular injection, hip surgery, pelvic fracture, posterior hip dislocation

Answer 315

Positive Trendelenburg sign

Answer 316

Hip extension and lateral rotation

Answer 317

In association with the sciatic nerve

Answer 318

Difficulty rising from seated position, can't jump, can't climb stairs

Answer 319

The introduction of disease-modifying therapies ## Footnote Disease-modifying therapies (DMARDs) are crucial in altering the course of RA.

Answer 320

As soon as possible with a combination of disease-modifying drugs (DMARD) ## Footnote Early intervention is key to managing RA effectively.

Answer 321

DMARD monotherapy +/- a short-course of bridging prednisolone ## Footnote Dual DMARD therapy was previously advocated but is no longer the initial recommendation.

Answer 322

Methotrexate ## Footnote Methotrexate requires monitoring of FBC & LFTs due to potential side effects.

Answer 323

FBC & LFTs ## Footnote Monitoring is critical because of the risks of myelosuppression and liver cirrhosis.

Answer 324

* Sulfasalazine * Leflunomide * Hydroxychloroquine ## Footnote Hydroxychloroquine is only considered for mild or palindromic disease.

Answer 325

Using a combination of CRP and disease activity scores such as DAS28 ## Footnote This helps in evaluating the effectiveness of the treatment.

Answer 326

Corticosteroids - oral or intramuscular ## Footnote Corticosteroids help reduce inflammation during flares.

Answer 327

An inadequate response to at least two DMARDs including methotrexate ## Footnote TNF-inhibitors are used when standard DMARD therapy is insufficient.

Answer 328

Recombinant human protein, acts as a decoy receptor for TNF-α ## Footnote It is administered subcutaneously and has risks including demyelination.

Answer 329

Monoclonal antibody that binds to TNF-α and prevents it from binding with TNF receptors ## Footnote Administered intravenously, it also carries risks like reactivation of tuberculosis.

Answer 330

A monoclonal antibody administered subcutaneously ## Footnote It is used to inhibit TNF-α similar to infliximab.

Answer 331

Anti-CD20 monoclonal antibody resulting in B-cell depletion ## Footnote Rituximab is given as two 1g intravenous infusions two weeks apart.

Answer 332

Common ## Footnote Patients receiving rituximab often experience infusion reactions.

Answer 333

A fusion protein that modulates a key signal for T lymphocyte activation ## Footnote This leads to decreased T-cell proliferation and cytokine production.

Answer 334

No ## Footnote Despite its mechanism, abatacept is not currently recommended for use in RA treatment.

Answer 335

Hip fracture ## Footnote Particularly in those with osteoporosis

Answer 336

Avascular necrosis ## Footnote Due to disruption of blood supply to the femoral head

Answer 337

Pain, shortened leg, externally rotated leg ## Footnote These symptoms are indicative of a hip fracture

Answer 338

Yes ## Footnote They may be able to weight bear despite the fracture

Answer 339

Intracapsular and extracapsular ## Footnote Intracapsular fractures are further divided into subcapital

Answer 340

The lesser trochanter ## Footnote This line differentiates between trochanteric and subtrochanteric fractures

Answer 341

Classifying hip fractures ## Footnote It includes types I to IV based on stability and displacement

Answer 342

Stable fracture with impaction in valgus ## Footnote It is a non-displaced fracture

Answer 343

Complete fracture but undisplaced ## Footnote The bone remains in its normal position

Answer 344

Displaced fracture with boney contact ## Footnote Usually rotated and angulated

Answer 345

Complete boney disruption ## Footnote There is no boney contact

Answer 346

Types III and IV ## Footnote They are associated with higher risk of avascular necrosis

Answer 347

Internal fixation or hemiarthroplasty if unfit ## Footnote Treatment options depend on the patient's fitness

Answer 348

Replacement arthroplasty (total hip replacement or hemiarthroplasty) ## Footnote Total hip replacement is preferred if patients meet certain criteria

Answer 349

* Able to walk independently outdoors with a stick * Not cognitively impaired * Medically fit for anaesthesia ## Footnote Patients should be assessed against these criteria

Answer 350

Dynamic hip screw ## Footnote This is a common surgical intervention

Answer 351

Intramedullary device ## Footnote This is used to stabilize the fracture

Answer 352

Brittle bone disease

Answer 353

Disorders of collagen metabolism

Answer 354

Autosomal dominant

Answer 355

Abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides

Answer 356

Fractures following minor trauma

Answer 357

Blue sclera

Answer 358

Deafness secondary to otosclerosis

Answer 359

Dental imperfections

Answer 360

Usually normal

Answer 361

An exaggerated vasoconstrictive response of the digital arteries and cutaneous arterioles to cold or emotional stress ## Footnote It may be classified as primary (Raynaud's disease) or secondary (Raynaud's phenomenon).

Answer 362

Typically presents in young women around 30 years old

Answer 363

* 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

Answer 364

* Onset after 40 years * Unilateral symptoms * Rashes * Presence of autoantibodies * Features suggesting rheumatoid arthritis or SLE (e.g., arthritis, recurrent miscarriages) * Digital ulcers * Calcinosis * Very rarely: chilblains

Answer 365

All patients should be referred to secondary care

Answer 366

Calcium channel blockers, e.g., nifedipine

Answer 367

Effects may last several weeks to months

Answer 368

most common

Answer 369

Mercaptopurine ## Footnote Mercaptopurine is a purine analogue that inhibits purine synthesis.

Answer 370

Thiopurine methyltransferase (TPMT) test ## Footnote This test helps identify individuals who may experience adverse reactions to azathioprine.

Answer 371

* Bone marrow depression * Nausea/vomiting * Pancreatitis ## Footnote Additional risks include increased risk of non-melanoma skin cancer.

Answer 372

Consider a full blood count ## Footnote This helps monitor for bone marrow depression.

Answer 373

Allopurinol ## Footnote Lower doses of azathioprine should be used if taken with allopurinol.

Answer 374

Yes ## Footnote Data show no increased risk of congenital malformations at standard doses.

Answer 375

Azathioprine is considered safer ## Footnote Mycophenolate, methotrexate, and cyclophosphamide are contraindicated in pregnancy.

Answer 376

Uncontrolled SLE ## Footnote Systemic lupus erythematosus (SLE) can pose significant risks if not managed.

Answer 377

purine analogue

Answer 378

The Gell and Coombs classification ## Footnote This classification helps in understanding the mechanisms and examples of different hypersensitivity reactions.

Answer 379

Antigen reacts with IgE bound to mast cells ## Footnote Type I hypersensitivity is often associated with allergic reactions.

Answer 380

• Anaphylaxis • Atopy (e.g. asthma, eczema, and hayfever) ## Footnote These conditions are characterized by immediate allergic responses.

Answer 381

IgG or IgM binds to antigen on cell surface ## Footnote This type of hypersensitivity involves antibodies reacting with cells.

Answer 382

• Autoimmune haemolytic anaemia • ITP • Goodpasture's syndrome ## Footnote These conditions involve immune responses against the body's own cells.

Answer 383

Free antigen and antibody (IgG, IgA) combine ## Footnote This type is associated with immune complex formation.

Answer 384

• Serum sickness • Systemic lupus erythematosus ## Footnote These conditions result from immune complexes causing tissue damage.

Answer 385

T-cell mediated ## Footnote This type involves delayed immune responses and does not involve antibodies.

Answer 386

• Tuberculosis / tuberculin skin reaction • Graft versus host disease ## Footnote These reactions typically manifest after a delay, unlike Types I-III.

Answer 387

Antibodies that recognise and bind to the cell surface receptors ## Footnote This type can either stimulate or block ligand binding.

Answer 388

• Graves' disease • Myasthenia gravis ## Footnote These conditions involve antibodies affecting receptor function.

Answer 389

Pain exacerbated by exercise and relieved by rest ## Footnote Reduction in internal rotation is often the first sign

Answer 390

Age, obesity and previous joint problems ## Footnote These factors increase the likelihood of developing osteoarthritis

Answer 391

Pain in the morning ## Footnote This type of arthritis is often associated with systemic features and raised inflammatory markers

Answer 392

Femoral nerve compression may cause referred pain in the hip ## Footnote The femoral nerve stretch test may be positive if it is trapped

Answer 393

Lie the patient prone, extend the hip joint with a straight leg, then bend the knee ## Footnote This stretches the femoral nerve and will cause pain if it is trapped

Answer 394

Trochanteric bursitis ## Footnote Caused by repeated movement of the fibroelastic iliotibial band

Answer 395

Pain and tenderness over the lateral side of thigh ## Footnote Most common in women aged 50-70 years

Answer 396

Compression of lateral cutaneous nerve of thigh ## Footnote Typically presents as burning sensation over antero-lateral aspect of thigh

Answer 397

Symptoms may be of gradual or sudden onset ## Footnote May follow high dose steroid therapy or previous hip fracture or dislocation

Answer 398

Pubic symphysis dysfunction ## Footnote Ligament laxity increases in response to hormonal changes of pregnancy

Answer 399

Pain over the pubic symphysis with radiation to the groins and medial aspects of the thighs ## Footnote A waddling gait may be seen

Answer 400

An uncommon condition sometimes seen in the third trimester of pregnancy ## Footnote Associated with groin pain and limited range of movement in the hip

Answer 401

ESR may be elevated ## Footnote Patients may be unable to weight bear

Answer 402

Salter-Harris system ## Footnote The Salter-Harris system categorizes growth plate fractures based on their injury pattern.

Answer 403

Fracture through the physis only (x-ray often normal) ## Footnote Type I fractures may not show any obvious signs on an x-ray.

Answer 404

Fracture through the physis and metaphysis ## Footnote This type of fracture is more common and usually identifiable on x-rays.

Answer 405

Fracture through the physis and epiphysis to include the joint ## Footnote Type III fractures can affect joint function and may require careful management.

Answer 406

Fracture involving the physis, metaphysis and epiphysis ## Footnote These fractures are complex and can have significant implications for growth.

Answer 407

Crush injury involving the physis (x-ray may resemble type I, and appear normal) ## Footnote Type V fractures can be subtle and may require clinical assessment beyond x-rays.

Answer 408

To look for TB prior to starting treatment as biologics can cause reactivation. ## Footnote Reactivation of tuberculosis is a significant risk when using immunosuppressive therapies.

Answer 409

A type of wrist fracture typically arising from a fall onto an outstretched hand (FOOSH)

Answer 410

Falling onto an outstretched hand (FOOSH) and contact sports such as football or rugby

Answer 411

Around 80%

Answer 412

Avascular necrosis of the scaphoid

Answer 413

* Pain along the radial aspect of the wrist, at the base of the thumb * Loss of grip / pinch strength

Answer 414

Over the anatomical snuffbox

Answer 415

Sensitivity around 90-95%, specificity <40%

Answer 416

* Wrist joint effusion * Pain elicited by telescoping of the thumb * Tenderness of the scaphoid tubercle * Pain on ulnar deviation of the wrist

Answer 417

Sensitivity 100%; specificity 74%

Answer 418

Plain film radiographs of the wrist in anterior-posterior and lateral view

Answer 419

* Posterioranterior (PA) * Lateral * Oblique (wrist pronated at 45º) * Ziter view (PA with wrist in ulnar deviation and beam angulated at 20º)

Answer 420

MRI should be considered the first-line imaging following clinical examination

Answer 421

* Immobilisation with a Futuro splint or standard below-elbow backslab * Referral to orthopaedics * Clinical review with further imaging in 7-10 days if initial radiographs are inconclusive

Answer 422

Cast for 6-8 weeks, with union achieved in > 95%

Answer 423

Surgical fixation

Answer 424

Pain and early osteoarthritis

Answer 425

Avascular necrosis

Answer 426

Fixed flexion contracture of the hand where the fingers bend towards the palm and cannot be fully extended. ## Footnote Caused by underlying contractures of the palmar aponeurosis.

Answer 427

The ring finger and little finger. ## Footnote The middle finger may be affected in advanced cases, but the index finger and thumb are nearly always spared.

Answer 428

Males over 40 years of age.

Answer 429

* Liver cirrhosis * Alcoholism * Many cases are idiopathic.

Answer 430

Surgical fasciectomy. ## Footnote The condition may recur, and many surgical therapies are associated with risk of neurovascular damage.

Answer 431

Idiopathic median neuropathy at the carpal tunnel.

Answer 432

The lateral 3 fingers.

Answer 433

Symptoms occur mainly at night in early stages. ## Footnote May include altered sensation and muscle wasting.

Answer 434

Electrophysiological studies.

Answer 435

Surgical decompression of the carpal tunnel by division of the flexor retinaculum.

Answer 436

Painful, red, raised lesions found on the hands and feet due to deposition of immune complexes.

Answer 437

Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints caused by osteoarthritis.

Answer 438

Permanent bony outgrowths at the fingertip resulting from chronic inflammation and pain.

Answer 439

Swelling in association with a tendon sheath, commonly near a joint, usually asymptomatic.

Answer 440

Similar to synovial fluid but slightly more viscous.

Answer 441

They may be excised.

Answer 442

* Fixed flexion * Fusiform swelling * Tenderness * Pain on passive extension ## Footnote These signs are critical for identifying tendon sheath infections.

Answer 443

False ## Footnote The correct sign is pain on passive extension, not active.

Answer 444

Early persistent tachycardia ## Footnote Tachycardia is often one of the first signs presented in fat embolism cases.

Answer 445

Tachypnoea, dyspnoea, hypoxia ## Footnote These symptoms indicate respiratory distress as a result of fat embolism.

Answer 446

Red/brown impalpable petechial rash (usually only in 25-50%) ## Footnote This rash is a common but not universal symptom of fat embolism.

Answer 447

Subconjunctival and oral haemorrhage/petechiae ## Footnote These signs can indicate systemic involvement of fat globules.

Answer 448

Confusion and agitation Retinal haemorrhages and intra-arterial fat globules on fundoscopy ## Footnote CNS symptoms can indicate severe cases of fat embolism.

Answer 449

May be normal ## Footnote Fat emboli often lodge distally, leading to normal imaging results.

Answer 450

Ground glass appearance ## Footnote This appearance can suggest the presence of fat emboli despite no vascular occlusion being visible.

Answer 451

Prompt fixation of long bone fractures ## Footnote Fixing fractures promptly can help reduce the risk of fat embolism.

Answer 452

Benefit vs. risk of increasing fat embolism risk (probably does not) ## Footnote The potential risks associated with medullary reaming are still under discussion.

Answer 453

DVT prophylaxis ## Footnote Deep vein thrombosis prophylaxis is important in managing patients at risk for embolism.

Answer 454

General supportive care ## Footnote Supportive care is crucial to manage symptoms and improve outcomes.

Answer 455

A common cause of lateral knee pain in runners, occurring in around 1 in 10 people who run regularly. ## Footnote Iliotibial band syndrome is often associated with overuse injuries in athletes.

Answer 456

Tenderness 2-3cm above the lateral joint line. ## Footnote This tenderness is a significant indicator of the syndrome.

Answer 457

* Activity modification * Iliotibial band stretches ## Footnote These strategies aim to reduce pain and improve flexibility.

Answer 458

Physiotherapy referral. ## Footnote Physiotherapy can provide tailored exercises and treatments to address the condition.

Answer 459

A complex multisystem disorder associated with presumed autoimmune-mediated inflammation of the arteries and veins.

Answer 460

* Oral ulcers * Genital ulcers * Anterior uveitis

Answer 461

Eastern Mediterranean (e.g. Turkey)

Answer 462

More common in men.

Answer 463

Young adults (e.g. 20 - 40 years old)

Answer 464

Around 30%.

Answer 465

* Thrombophlebitis and deep vein thrombosis * Arthritis * Neurological involvement (e.g. aseptic meningitis) * GI symptoms (abdominal pain, diarrhea, colitis) * Erythema nodosum

Answer 466

No definitive test.

Answer 467

Based on clinical findings.

Answer 468

Suggestive of Behcet's syndrome (puncture site inflames and forms a small pustule).

Answer 469

It is a split antigen of HLA B5.

Answer 470

Advancing age and female sex ## Footnote The prevalence of osteoporosis increases from 2% at 50 years to more than 25% at 80 years in women.

Answer 471

* History of glucocorticoid use * Rheumatoid arthritis * Alcohol excess * History of parental hip fracture * Low body mass index * Current smoking

Answer 472

* Sedentary lifestyle * Premature menopause * Caucasians and Asians * Endocrine disorders * Multiple myeloma, lymphoma * Gastrointestinal disorders * Chronic kidney disease * Osteogenesis imperfecta, homocystinuria

Answer 473

* Hyperthyroidism * Hypogonadism * Growth hormone deficiency * Hyperparathyroidism * Diabetes mellitus

Answer 474

* SSRIs * Antiepileptics * Proton pump inhibitors * Glitazones * Long term heparin therapy * Aromatase inhibitors

Answer 475

* History and physical examination * Blood cell count * Sedimentation rate or C-reactive protein * Serum calcium * Albumin * Creatinine * Phosphate * Alkaline phosphatase * Liver transaminases * Thyroid function tests * Bone densitometry (DXA)

Answer 476

* Exclude diseases that mimic osteoporosis * Identify the cause of osteoporosis and contributory factors * Assess the risk of subsequent fractures * Select the most appropriate form of treatment

Answer 477

full blood count, urea and electrolytes, liver function tests, bone profile, CRP, thyroid function tests

Answer 478

More than 25%

Answer 479

* Inflammatory bowel disease * Malabsorption (e.g. coeliac's) * Gastrectomy * Liver disease

Answer 480

* Lateral radiographs of lumbar and thoracic spine * DXA-based vertebral imaging

Answer 481

* Protein immunoelectrophoresis * Urinary Bence-Jones proteins * 25OHD * PTH * Serum testosterone, SHBG, FSH, LH (in men) * Serum prolactin * 24 hour urinary cortisol/dexamethasone suppression test * Endomysial and/or tissue transglutaminase antibodies (coeliac disease) * Isotope bone scan * Markers of bone turnover * Urinary calcium excretion

Answer 482

The most common cause of heel pain seen in adults.

Answer 483

Around the medial calcaneal tuberosity.

Answer 484

Rest the feet where possible.

Answer 485

Shoes with good arch support and cushioned heels.

Answer 486

A red flag that warrants further intervention

Answer 487

* Degenerative disc disease (a prolapsed disc) * Skeletal disorders * Traumatic or spontaneous vertebral fractures * Vascular malformations * Metastasis

Answer 488

They are associated with small-vessel vasculitides including: * granulomatosis with polyangiitis * eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) * microscopic polyangiitis

Answer 489

ANCA associated vasculitis is more common with increasing age.

Answer 490

Common findings include: * renal impairment * respiratory symptoms * systemic symptoms * vasculitic rash * ear, nose, and throat symptoms

Answer 491

It is caused by immune complex glomerulonephritis, leading to raised creatinine, haematuria, and proteinuria.

Answer 492

Respiratory symptoms include: * dyspnoea * haemoptysis

Answer 493

Systemic symptoms include: * fatigue * weight loss * fever

Answer 494

The vasculitic rash is present only in a minority of patients.

Answer 495

The approach includes: * urinalysis for haematuria and proteinuria * blood tests (urea, creatinine, full blood count, CRP) * ANCA testing * chest x-ray

Answer 496

Urea and creatinine levels are tested for renal impairment.

Answer 497

Normocytic anaemia and thrombocytosis may be seen.

Answer 498

Nodular, fibrotic, or infiltrative lesions may be seen.

Answer 499

The two main types are: * cytoplasmic (cANCA) * perinuclear (pANCA)

Answer 500

Serine proteinase 3 (PR3)

Answer 501

Myeloperoxidase (MPO)

Answer 502

There is some correlation between cANCA levels and disease activity.

Answer 503

No, pANCA levels cannot be used to monitor disease activity.

Answer 504

Immunosuppressive therapy.

Answer 505

Specialist teams such as: * renal * rheumatology * respiratory

Answer 506

Kidney or lung biopsies may be taken.

Answer 507

Chromosome 6 ## Footnote HLA antigens are crucial for the immune response.

Answer 508

HLA A, B, C ## Footnote Class I antigens present to CD8+ T cells.

Answer 509

DP, DQ, DR ## Footnote Class II antigens present to CD4+ T cells.

Answer 510

Haemochromatosis ## Footnote Haemochromatosis involves iron overload in the body.

Answer 511

Behcet's disease ## Footnote Behcet's disease is characterized by recurrent oral ulcers.

Answer 512

* Ankylosing spondylitis * Reactive arthritis * Acute anterior uveitis * Psoriatic arthritis ## Footnote HLA-B27 is linked to several inflammatory diseases.

Answer 513

Coeliac disease ## Footnote Coeliac disease is an autoimmune disorder triggered by gluten.

Answer 514

* Narcolepsy * Goodpasture's ## Footnote Goodpasture's syndrome involves lung and kidney damage.

Answer 515

* Dermatitis herpetiformis * Sjogren's syndrome * Primary biliary cirrhosis ## Footnote HLA-DR3 is linked to autoimmune conditions.

Answer 516

* Type 1 diabetes mellitus * Rheumatoid arthritis ## Footnote HLA-DR4 is particularly associated with the DRB1 gene variants.

Answer 517

False ## Footnote Type 1 diabetes mellitus is associated with both but more strongly with HLA-DR4.

Answer 518

A circulating antibody (usually IgM) that reacts with the Fc portion of the patient's own IgG ## Footnote RF is recommended as the first-line antibody test for patients with suspected rheumatoid arthritis.

Answer 519

* Rose-Waaler test: sheep red cell agglutination * Latex agglutination test (less specific) ## Footnote These tests are used to identify the presence of RF in patients.

Answer 520

70-80% ## Footnote High titre levels of RF are associated with severe progressive disease but are not a marker of disease activity.

Answer 521

* 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 ## Footnote These conditions can show a positive RF test result, complicating the diagnosis of rheumatoid arthritis.

Answer 522

It may be detectable up to 10 years before the development of rheumatoid arthritis and allows for early detection suitable for aggressive anti-TNF therapy ## Footnote Anti-CCP has a sensitivity similar to RF (around 70%) but a higher specificity of 90-95%.

Answer 523

They should be tested for anti-CCP antibodies ## Footnote This recommendation aims to identify patients who may still have rheumatoid arthritis despite a negative RF test.

Answer 524

X-rays of the hands and feet ## Footnote This imaging helps in assessing joint damage or changes associated with rheumatoid arthritis.

Answer 525

Distal tibia, distal fibula, superior aspect of the talus

Answer 526

The configuration of the distal tibia and fibula with the body of the talus

Answer 527

A binding structure that connects the distal tibia and fibula

Answer 528

* Anterior inferior tibiofibular ligament (AITFL) * Posterior inferior tibiofibular ligament (PITFL) * Interosseous ligament (IOL) * Interosseous membrane

Answer 529

* Anterior talofibular ligament (ATFL) * Posterior talofibular ligament (PTFL) * Calcaneofibular ligament

Answer 530

A stretching, partial or complete tear of a ligament

Answer 531

* High ankle sprains (involving syndesmosis) * Low ankle sprains (involving lateral collateral ligaments)

Answer 532

Inversion injury

Answer 533

* Pain * Swelling * Tenderness over affected ligaments * Sometimes bruising

Answer 534

* Grade I (mild): Stretch or micro tear * Grade II (moderate): Partial tear * Grade III (severe): Complete tear

Answer 535

* Bruising and swelling: Minimal * Pain on weight bearing: Normal

Answer 536

* Bruising and swelling: Moderate * Pain on weight bearing: Minimal

Answer 537

* Bruising and swelling: Severe * Pain on weight bearing: Severe

Answer 538

Radiographs should be performed as 15% of sprains are associated with a fracture

Answer 539

* Rest * Ice * Compression * Elevation

Answer 540

MRI and possible surgical intervention

Answer 541

External rotation of the foot causing lateral push of the fibula

Answer 542

About 0.5%

Answer 543

Hopkin's squeeze test

Answer 544

Widening of the tibiofibular joint (diastasis) or ankle mortise

Answer 545

Non-weight-bearing orthosis or cast until pain subsides

Answer 546

Operative fixation

Answer 547

Deltoid ligament

Answer 548

Maisonneuve fracture of the proximal fibula

Answer 549

Treatment can be as per a low ankle sprain

Answer 550

Reduction and fixation may be warranted

Answer 551

Ankylosing spondylitis features - the 'A's Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AV node block Amyloidosis

Answer 552

HLA-B27 associated spondyloarthropathy

Answer 553

Males aged 20-30 years old

Answer 554

Lower back pain and stiffness of insidious onset

Answer 555

In the morning

Answer 556

Pain at night which improves on getting up

Answer 557

Reduced lateral flexion

Answer 558

Schober's test

Answer 559

10 cm above and 5 cm below the back dimples

Answer 560

More than 5 cm

Answer 561

Reduced chest expansion

Answer 562

Clear dermatomal leg pain associated with neurological deficits.

Answer 563

Leg pain usually worse than back pain.

Answer 564

When sitting.

Answer 565

Sensory loss over anterior thigh.

Answer 566

* Weak hip flexion * Weak knee extension * Weak hip adduction

Answer 567

Knee reflex.

Answer 568

Positive femoral stretch test.

Answer 569

Sensory loss anterior aspect of knee and medial malleolus.

Answer 570

* Weak knee extension * Weak hip adduction * Reduced knee reflex

Answer 571

Positive femoral stretch test.

Answer 572

Sensory loss dorsum of foot.

Answer 573

Weakness in foot and big toe dorsiflexion.

Answer 574

Reflexes intact.

Answer 575

Positive sciatic nerve stretch test.

Answer 576

Sensory loss posterolateral aspect of leg and lateral aspect of foot.

Answer 577

Weakness in plantar flexion of foot.

Answer 578

Reduced ankle reflex.

Answer 579

Positive sciatic nerve stretch test.

Answer 580

Management of other musculoskeletal lower back pain.

Answer 581

NSAIDs +/- proton pump inhibitors.

Answer 582

Referral for consideration of MRI.

Answer 583

An inflammatory arthritis associated with psoriasis, classified as one of the seronegative spondyloarthropathies.

Answer 584

It correlates poorly and often precedes the development of skin lesions.

Answer 585

* Symmetric polyarthritis * Asymmetrical oligoarthritis * Sacroiliitis * DIP joint disease * Arthritis mutilans

Answer 586

Symmetric polyarthritis, seen in 30-40% of cases.

Answer 587

Asymmetrical oligoarthritis was historically thought to be the most common type.

Answer 588

* Psoriatic skin lesions * Enthesitis * Tenosynovitis * Dactylitis * Nail changes (pitting, onycholysis)

Answer 589

Inflammation at the site of tendon and ligament insertion.

Answer 590

* Elevated CRP/ESR * Negative rheumatoid factor (RF) and anti-CCP antibodies * Positive HLA-B27 in some cases

Answer 591

* Erosions and new bone formation * Periostitis * 'Pencil-in-cup' appearance in advanced disease

Answer 592

It should be managed by a rheumatologist.

Answer 593

NSAIDs alone.

Answer 594

Methotrexate.

Answer 595

* Ustekinumab (targets IL-12 and IL-23) * Secukinumab and ixekizumab (target IL-17) * Adalimumab (anti-TNF)

Answer 596

An oral phosphodiesterase type-4 (PDE4) inhibitor that modulates inflammatory mediators.

Answer 597

Prognosis is generally better than in RA.

Answer 598

Yes, some may develop progressive joint damage and disability.

Answer 599

A condition of unknown aetiology characterised by hardened, sclerotic skin and other connective tissues. ## Footnote Systemic sclerosis is four times more common in females.

Answer 600

* Limited cutaneous systemic sclerosis * Diffuse cutaneous systemic sclerosis * Scleroderma (without internal organ involvement) ## Footnote Each pattern has distinct characteristics and associated antibodies.

Answer 601

Raynaud's may be the first sign ## Footnote In this type, scleroderma predominantly affects the face and distal limbs.

Answer 602

Anti-centromere antibodies ## Footnote A subtype of this condition is CREST syndrome.

Answer 603

* Calcinosis * Raynaud's phenomenon * Esophageal dysmotility * Sclerodactyly * Telangiectasia ## Footnote CREST syndrome is a subtype of limited systemic sclerosis.

Answer 604

Scleroderma affects trunk and proximal limbs predominantly ## Footnote It is associated with anti-scl-70 antibodies.

Answer 605

Respiratory involvement ## Footnote This is seen in around 80% of cases, including interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH).

Answer 606

* Renal disease * Hypertension ## Footnote Patients with renal disease should be started on an ACE inhibitor.

Answer 607

Captopril ## Footnote It is chosen due to its rapid onset and short half-life, allowing for dose titration.

Answer 608

They target the underlying mechanism by reducing efferent arteriolar vasoconstriction and limiting renin-angiotensin system activation ## Footnote This helps manage renal disease in affected patients.

Answer 609

Tightening and fibrosis of skin ## Footnote It may manifest as plaques (morphoea) or linear.

Answer 610

90% ## Footnote This is a common laboratory finding in this condition.

Answer 611

30% ## Footnote Rheumatoid factor (RF) positivity can occur in systemic sclerosis.

Answer 612

Associated with diffuse cutaneous systemic sclerosis and a higher risk of severe interstitial lung disease ## Footnote This antibody is significant for prognosis.

Answer 613

Associated with limited cutaneous systemic sclerosis ## Footnote This antibody indicates a different disease pattern than anti-scl-70.

Answer 614

A condition where a bone in the lower back (lumbar vertebra) slips forward out of alignment.

Answer 615

Caused by wear and tear, a stress fracture (spondylolysis), or trauma.

Answer 616

Lower back pain, numbness, or weakness that radiates down the legs.

Answer 617

Symptoms can range from mild to severe.

Answer 618

Range from conservative measures like rest and physical therapy to surgical intervention.

Answer 619

[lower back pain, numbness, weakness]

Answer 620

A condition in which the central canal is narrowed by tumour, disk prolapse or other degenerative changes ## Footnote It can lead to various symptoms including back pain and neuropathic pain.

Answer 621

A combination of back pain, neuropathic pain, and symptoms mimicking claudication ## Footnote Symptoms may include difficulty walking, with positional elements affecting pain.

Answer 622

The positional element to the pain; sitting is better than standing ## Footnote Patients may also find it easier to walk uphill rather than downhill.

Answer 623

Degenerative disease ## Footnote This typically begins in the intervertebral disk.

Answer 624

Cell death and loss of proteoglycan and water content ## Footnote These changes lead to progressive disk bulging and collapse.

Answer 625

Increased stress transfer leading to cartilaginous degeneration, hypertrophy, and osteophyte formation ## Footnote This is associated with thickening and distortion of the ligamentum flavum.

Answer 626

Ventral disk bulging, osteophyte formation at the dorsal facet, and ligamentum flavum hypertrophy ## Footnote These factors combine to narrow the space available for neural elements.

Answer 627

Compression of the nerve roots of the cauda equina ## Footnote This compression results in various neurological symptoms.

Answer 628

MRI scanning ## Footnote MRI is effective in demonstrating canal narrowing.

Answer 629

Bicycle test ## Footnote True vascular claudicants were unable to complete this test.

Answer 630

Laminectomy ## Footnote This procedure involves removing the lamina to relieve pressure on the spinal canal.

Answer 631

Marfan's syndrome is an autosomal dominant connective tissue disorder.

Answer 632

The defect is in the FBN1 gene on chromosome 15.

Answer 633

The FBN1 gene codes for the protein fibrillin-1.

Answer 634

It affects around 1 in 3,000 people.

Answer 635

The arm span to height ratio is > 1.05.

Answer 636

* Tall stature * High-arched palate * Arachnodactyly

Answer 637

* Dilation of the aortic sinuses * Aortic aneurysm * Aortic dissection * Aortic regurgitation * Mitral valve prolapse

Answer 638

Repeated pneumothoraces.

Answer 639

Upwards lens dislocation (superotemporal ectopia lentis).

Answer 640

Ballooning of the dural sac at the lumbosacral level.

Answer 641

Around 40-50 years.

Answer 642

Through regular echocardiography monitoring and beta-blocker/ACE-inhibitor therapy.

Answer 643

Aortic dissection and other cardiovascular problems.

Answer 644

Ulcerative colitis ## Footnote ANCA stands for anti-neutrophil cytoplasmic antibodies, and pANCA refers to perinuclear anti-neutrophil cytoplasmic antibodies, which are commonly associated with ulcerative colitis.

Answer 645

Echocardiogram

Answer 646

* pulmonary fibrosis * pleural effusion * pulmonary nodules * bronchiolitis obliterans * methotrexate pneumonitis * pleurisy ## Footnote These complications can affect lung function and overall health in patients with RA.

Answer 647

keratoconjunctivitis sicca ## Footnote This condition is characterized by dry eyes and can lead to discomfort and vision problems.

Answer 648

* keratoconjunctivitis sicca * episcleritis * scleritis * corneal ulceration * keratitis * steroid-induced cataracts * chloroquine retinopathy ## Footnote These conditions can significantly impact vision and eye health.

Answer 649

osteoporosis ## Footnote Osteoporosis increases the risk of fractures in patients with RA.

Answer 650

RA carries a similar risk to type 2 diabetes mellitus ## Footnote This highlights the cardiovascular risks associated with chronic inflammatory conditions like RA.

Answer 651

* infections * depression ## Footnote These complications can worsen overall patient outcomes and quality of life.

Answer 652

RA + splenomegaly + low white cell count ## Footnote This syndrome is a rare complication of RA that can lead to additional health issues.

Answer 653

amyloidosis ## Footnote Amyloidosis can result in organ dysfunction due to the accumulation of amyloid proteins.

Answer 654

Perinuclear anti-neutrophil cytoplasmic antibodies

Answer 655

Ulcerative Colitis (UC)

Answer 656

Crohn's Disease

Answer 657

Ulcerative Colitis

Answer 658

To minimize unnecessary use of x-rays for ankle injuries ## Footnote The rules help determine if x-rays are needed based on specific criteria related to pain and tenderness.

Answer 659

If there is pain in the malleolar zone and: * Inability to weight bear for 4 steps * Tenderness over the distal tibia * Bone tenderness over the distal fibula ## Footnote These criteria help identify significant injuries that require imaging.

Answer 660

Potts, Weber, and AO systems ## Footnote These systems categorize fractures based on different anatomical and clinical criteria.

Answer 661

The level of the fibular fracture ## Footnote This classification helps in understanding the severity and implications of the fracture.

Answer 662

Fractures below the syndesmosis ## Footnote These are typically less severe and may have different management strategies.

Answer 663

Fractures starting at the level of the tibial plafond and may extend proximally to involve the syndesmosis ## Footnote These fractures can be more complex and may require careful evaluation.

Answer 664

Fractures above the syndesmosis which may damage the syndesmosis ## Footnote These fractures are often more serious and may necessitate surgical intervention.

Answer 665

A spiral fibular fracture that leads to disruption of the syndesmosis and widening of the ankle joint ## Footnote This type of fracture often requires surgical repair due to its complexity.

Answer 666

Stability of the ankle joint and patient co-morbidities ## Footnote Different management strategies are applied based on these factors.

Answer 667

Prompt reduction to remove pressure on the overlying skin and prevent necrosis ## Footnote This step is crucial to avoid complications associated with skin integrity.

Answer 668

Usually require surgical repair, often using a compression plate ## Footnote Surgical intervention is more common in younger patients due to better bone quality.

Answer 669

Usually fare better with attempts at conservative management ## Footnote Their thin bone structure does not hold metalwork well, making surgery less favorable.

Answer 670

Frozen shoulder

Answer 671

Middle-aged females

Answer 672

Not fully understood

Answer 673

External rotation

Answer 674

Internal rotation and abduction

Answer 675

Both active and passive movement

Answer 676

* Painful freezing phase * Adhesive phase * Recovery phase

Answer 677

Between 6 months and 2 years

Answer 678

Clinical diagnosis

Answer 679

For atypical or persistent symptoms

Answer 680

No single intervention

Answer 681

* NSAIDs * Physiotherapy * Oral corticosteroids * Intra-articular corticosteroids

Answer 682

Softening of the bones secondary to low vitamin D levels.

Answer 683

* Vitamin D deficiency * Malabsorption * Lack of sunlight * Diet * Chronic kidney disease * Drug induced (e.g. anticonvulsants) * Inherited (e.g. hypophosphatemic rickets) * Liver disease (e.g. cirrhosis) * Coeliac disease

Answer 684

* Bone pain * Bone/muscle tenderness * Fractures (especially femoral neck) * Proximal myopathy (may lead to a waddling gait)

Answer 685

* Low vitamin D levels * Low calcium and phosphate (in around 30%) * Raised alkaline phosphatase (in 95-100% of patients)

Answer 686

Translucent bands (Looser's zones or pseudofractures).

Answer 687

Vitamin D supplementation.

Answer 688

A loading dose of vitamin D.

Answer 689

Calcium supplementation.

Answer 690

Staphylococcus aureus ## Footnote This organism is prevalent in general cases of septic arthritis.

Answer 691

Neisseria gonorrhoeae ## Footnote This is associated with disseminated gonococcal infection.

Answer 692

Hematogenous spread ## Footnote This can occur from distant bacterial infections such as abscesses.

Answer 693

Knee ## Footnote The knee joint is frequently affected in adult cases.

Answer 694

Acute, swollen joint; restricted movement in 80% of patients; warm to touch/fluctuant; fever present in the majority ## Footnote These features assist in the clinical diagnosis of septic arthritis.

Answer 695

Synovial fluid sampling ## Footnote This should be performed prior to antibiotic administration if necessary.

Answer 696

Leucocytosis with neutrophil predominance ## Footnote This indicates an inflammatory response in the joint.

Answer 697

30-50% ## Footnote This highlights the limitations of gram staining in detecting organisms.

Answer 698

Flucloxacillin or clindamycin if penicillin allergic ## Footnote These antibiotics cover Gram-positive cocci.

Answer 699

4-6 weeks ## Footnote This duration is suggested by the BNF.

Answer 700

2 weeks ## Footnote This transition occurs after initial intravenous treatment.

Answer 701

Needle aspiration ## Footnote This helps relieve pressure and may assist in diagnosis.

Answer 702

Arthroscopic lavage ## Footnote This procedure may be necessary for thorough cleaning of the joint.

Answer 703

* Trauma (excessive forces applied to bone) * Stress related (repetitive low velocity injury) * Pathological (abnormal bone which fractures during minimal trauma) ## Footnote These causes highlight the various mechanisms leading to fractures.

Answer 704

* Site and type of injury * Associated injuries * Distal neurovascular deficits ## Footnote Diagnosis may require clinical examination and radiographs of proximal and distal joints.

Answer 705

* Changes in length of the bone * Angulation of the distal bone * Rotational effects * Presence of foreign material (e.g., glass) ## Footnote These evaluations help in understanding the fracture's characteristics.

Answer 706

Fracture lies obliquely to long axis of bone ## Footnote This type of fracture may occur due to twisting forces.

Answer 707

> 2 fragments ## Footnote This indicates a severe fracture with multiple pieces of bone.

Answer 708

More than one fracture along a bone ## Footnote Typically indicates significant trauma.

Answer 709

Perpendicular to long axis of bone ## Footnote This type of fracture is often caused by direct impact.

Answer 710

Severe oblique fracture with rotation along long axis of bone ## Footnote Often seen in twisting injuries.

Answer 711

An open fracture involves a wound that communicates with the fracture ## Footnote Closed fractures do not have an external wound.

Answer 712

Classifying open fractures ## Footnote This system helps in determining the severity and treatment needed.

Answer 713

* Grade 1: Low energy wound <1cm * Grade 2: >1cm wound with moderate soft tissue damage * Grade 3: High energy wound >1cm with extensive soft tissue damage * Grade 3A: Adequate soft tissue coverage * Grade 3B: Inadequate soft tissue coverage * Grade 3C: Associated arterial injury ## Footnote Each grade indicates increasing severity and complexity of treatment.

Answer 714

* Immobilise the fracture including proximal and distal joints * Monitor and document neurovascular status * Manage infection including tetanus prophylaxis * IV broad spectrum antibiotics for open injuries * Thoroughly debride all open fractures * Open fractures should be debrided and lavaged within 6 hours ## Footnote Effective management is crucial to prevent complications.

Answer 715

Anterior dislocation ## Footnote It may follow a fall on arm or shoulder.

Answer 716

Pulses and nerves, particularly AXILLARY ## Footnote The axillary nerve is commonly injured in shoulder dislocations.

Answer 717

Radiograph ## Footnote This is essential for diagnosis.

Answer 718

Reduction, analgesia, and sling ## Footnote Reduction can be achieved by many methods.

Answer 719

Seizure or electrocution ## Footnote This type of dislocation is rare.

Answer 720

Lightbulb sign ## Footnote This sign is indicative of posterior dislocation.

Answer 721

Orthopaedic surgeons ## Footnote Specialized care is often needed for this type of dislocation.

Answer 722

A neuropathic joint

Answer 723

Loss of sensation leading to joint disruption and damage

Answer 724

Neuropathy secondary to syphilis (tabes dorsalis)

Answer 725

They are typically a lot less painful than expected

Answer 726

* Swollen * Red * Warm

Answer 727

The joint becomes unstable, leading to abnormal movements and increased risk of fractures and dislocations

Answer 728

Significant deformities

Answer 729

Collapsed arch, commonly referred to as 'rocker-bottom' foot

Answer 730

* Skin ulceration * Infection due to repeated trauma and poor wound healing

Answer 731

Ulnar nerve palsy ## Footnote It tests the function of the adductor pollicis muscle.

Answer 732

Hold a piece of paper between the thumb and index finger; if unable to hold it, flex the flexor pollicis longus compensates. ## Footnote This indicates ulnar nerve palsy.

Answer 733

Carpal tunnel syndrome ## Footnote It is more sensitive than Tinel's sign.

Answer 734

Hold wrist in maximum flexion; positive if numbness in median nerve distribution occurs.

Answer 735

Carpal tunnel syndrome ## Footnote It evaluates the median nerve.

Answer 736

Tap the median nerve at the wrist; positive if tingling or electric-like sensations occur over median nerve distribution.

Answer 737

A break in the bony segment of any rib, often due to blunt trauma to the chest wall.

Answer 738

Most rib fractures are caused by blunt trauma to the chest wall.

Answer 739

25% of major trauma cases.

Answer 740

Coughing or sneezing, usually in patients with osteoporosis, steroid use, or chronic obstructive pulmonary disease.

Answer 741

Cancer metastases, commonly from prostate cancer in men and breast cancer in women.

Answer 742

Severe, sharp chest wall pain.

Answer 743

Deep breaths or coughing.

Answer 744

Significant chest wall tenderness and possible visible bruising.

Answer 745

Crackles or reduced breath sounds if there is an underlying lung injury.

Answer 746

Pneumothorax.

Answer 747

A serious consequence of multiple rib fractures where two or more ribs are fractured along three or more consecutive ribs.

Answer 748

It moves paradoxically, impairing ventilation of the lung on the side of injury.

Answer 749

Invasive ventilation and surgical fixation.

Answer 750

CT scan of the chest.

Answer 751

They provide suboptimal views and do not show surrounding soft tissue injury.

Answer 752

Consider surgical fixation.

Answer 753

Urgently discuss with cardiothoracic surgery.

Answer 754

Conservative management with good analgesia.

Answer 755

Chest infections.

Answer 756

singly or in multiple places.

Answer 757

A childhood hip condition where the blood supply to the head of the femur is interrupted

Answer 758

The bone softens and becomes deformed

Answer 759

A limp, pain in the groin, thigh, or knee, and limited hip movement

Answer 760

Between ages 4 and 10

Answer 761

More common in boys

Answer 762

The blood supply returns, and the bone regrows and reshapes

Answer 763

A poorly fitting joint and an increased risk of hip arthritis in adulthood

Answer 764

head of the femur

Answer 765

x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening

Answer 766

Osteosarcoma ## Footnote It is primarily seen in children and adolescents.

Answer 767

Metaphyseal region ## Footnote This occurs prior to epiphyseal closure.

Answer 768

40% ## Footnote 20% occur in the tibia and 10% in the humerus.

Answer 769

Codman triangle and 'sunburst' pattern ## Footnote Codman triangle is due to periosteal elevation.

Answer 770

Rb gene mutation ## Footnote There is a notable association with retinoblastoma.

Answer 771

* Paget's disease of the bone * Radiotherapy

Answer 772

Small round blue cell tumour ## Footnote It is also seen mainly in children and adolescents.

Answer 773

Pelvis and long bones ## Footnote It tends to cause severe pain.

Answer 774

t(11;22) translocation ## Footnote This results in an EWS-FLI1 gene product.

Answer 775

'Onion skin' appearance

Answer 776

Malignant tumour of cartilage ## Footnote It most commonly affects the axial skeleton.

Answer 777

Middle-age

Answer 778

Shoulder reduction in patients with a recent anterior dislocation ## Footnote The Kocher technique is one of several methods for reducing shoulder dislocations without analgesia or sedation.

Answer 779

Anterior shoulder dislocation ## Footnote In an anterior dislocation, the humeral head dislodges from the glenoid cavity of the scapula.

Answer 780

The humeral head dislodges from the glenoid cavity of the scapula ## Footnote This dislocation causes significant pain and immobility in the affected shoulder.

Answer 781

The affected arm is bent at the elbow, pressed against the body, and rotated outwards until resistance is felt ## Footnote This technique is effective without the use of medication for pain relief.

Answer 782

Turn the affected arm inwards slowly after lifting it forwards ## Footnote This motion is crucial for successful reduction of the dislocated shoulder.

Answer 783

There is currently no established consensus on which technique is the most effective ## Footnote Different techniques may work better for different patients or circumstances.

Answer 784

outwards ## Footnote This rotation is part of the process to realign the dislocated shoulder.

Answer 785

False ## Footnote The technique can be performed without the use of analgesia or sedation in selected patients.

Answer 786

It can be performed without medication for pain relief ## Footnote This can be beneficial in certain patient populations or settings.

Answer 787

A rare complication of rheumatoid arthritis that can lead to cervical cord compression ## Footnote Atlantoaxial subluxation involves misalignment of the first two cervical vertebrae.

Answer 788

It can lead to cervical cord compression ## Footnote Cervical cord compression can result in neurological deficits.

Answer 789

Anteroposterior and lateral cervical spine radiographs ## Footnote These radiographs help identify any misalignment before surgery.

Answer 790

The patient should go to surgery in a C-spine collar and the neck should not be hyperextended on intubation ## Footnote These precautions help prevent further injury to the cervical spine during the surgical process.

Answer 791

A common type of back or neck pain caused by wear and tear, injury, or overuse of the small facet joints that connect your vertebrae. ## Footnote Facet joints are small stabilizing joints located between and behind adjacent vertebrae.

Answer 792

Localized tenderness, stiffness, muscle spasms, and pain that can spread to other areas such as the buttocks and legs for low back pain. ## Footnote Symptoms may vary in intensity and location depending on the affected area.

Answer 793

Conservative methods such as rest, physical therapy, exercise, medication, and sometimes steroid or anesthetic injections. ## Footnote These treatments aim to reduce pain and inflammation without invasive procedures.

Answer 794

degenerative

Answer 795

Steroid or anesthetic injections. ## Footnote These injections are used to help reduce inflammation and manage pain.

Answer 796

Dull ache localized to the spine.

Answer 797

Bending backward or standing for long periods.

Answer 798

Bending forward.

Answer 799

Sharp pain that can radiate to the limbs.

Answer 800

Sitting, bending forward, or coughing.

Answer 801

Numbness or weakness.

Answer 802

For proper treatment.

Answer 803

A form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium ## Footnote Also known as acute calcium pyrophosphate crystal deposition disease.

Answer 804

Increasing age

Answer 805

* Haemochromatosis * Hyperparathyroidism * Low magnesium * Low phosphate * Acromegaly * Wilson's disease

Answer 806

* Knee * Wrist * Shoulders

Answer 807

Weakly-positively birefringent rhomboid-shaped crystals

Answer 808

Chondrocalcinosis

Answer 809

As linear calcifications of the meniscus and articular cartilage

Answer 810

Aspiration of joint fluid to exclude septic arthritis

Answer 811

* NSAIDs * Intra-articular steroids * Intra-muscular steroids * Oral steroids

Answer 812

Disabling fatigue affecting mental and physical function more than 50% of the time for at least 3 months in the absence of other diseases.

Answer 813

* Sleep problems (insomnia, hypersomnia, unrefreshing sleep) * Muscle and/or joint pains * Headaches * Painful lymph nodes without enlargement * Sore throat * Cognitive dysfunction (difficulty thinking, inability to concentrate, impairment of short-term memory) * Physical or mental exertion worsens symptoms * General malaise or 'flu-like' symptoms * Dizziness * Nausea * Palpitations

Answer 814

A large number of screening blood tests to exclude other pathologies.

Answer 815

* FBC * U&E * LFT * Glucose * TFT * ESR * CRP * Calcium * CK * Ferritin * Coeliac screening * Urinalysis

Answer 816

If symptoms persist for 3 months.

Answer 817

Refer to a specialist CFS service.

Answer 818

A self-management strategy for individuals to manage their activities within their energy limits, with healthcare professional support.

Answer 819

To ensure safety and appropriateness of physical activity.

Answer 820

It is specifically not recommended.

Answer 821

Cognitive behavioural therapy, described as 'supportive' rather than curative.

Answer 822

CFS has a better prognosis in children.

Answer 823

15-25 years and 35-46 years

Answer 824

* Arthralgia * Elevated serum ferritin * Rash: salmon-pink, maculopapular

Answer 825

Rises in the late afternoon/early evening

Answer 826

Both are negative

Answer 827

At least a week

Answer 828

They may control symptoms but won't improve prognosis

Answer 829

* Methotrexate * IL-1 therapy * Anti-TNF therapy

Answer 830

A group of rare cancerous tumors in bones or soft tissues

Answer 831

People age 10 to 20

Answer 832

Bone pain, swollen areas on bones, lumps that feel warm to the touch

Answer 833

Chemotherapy followed by surgery to remove the tumors

Answer 834

A small round blue cell tumour seen mainly in children and adolescents

Answer 835

Pelvis and long bones

Answer 836

Severe pain

Answer 837

t(11;22) translocation

Answer 838

EWS-FLI1 gene product

Answer 839

'Onion skin' appearance

Answer 840

Softening of the bones secondary to low vitamin D levels leading to decreased bone mineral content

Answer 841

* Vitamin D deficiency * Malabsorption * Lack of sunlight * Diet * Chronic kidney disease * Drug induced (e.g. anticonvulsants) * Inherited (e.g. hypophosphatemic rickets) * Liver disease (e.g. cirrhosis) * Coeliac disease

Answer 842

* Bone pain * Bone/muscle tenderness * Fractures (especially femoral neck) * Proximal myopathy (may lead to a waddling gait)

Answer 843

* Low vitamin D levels * Low calcium * Low phosphate (in around 30%) * Raised alkaline phosphatase (in 95-100% of patients)

Answer 844

Translucent bands (Looser's zones or pseudofractures)

Answer 845

Vitamin D supplementation

Answer 846

A loading dose

Answer 847

Calcium supplementation

Answer 848

Discitis is an infection in the intervertebral disc space. ## Footnote It can lead to serious complications such as sepsis or an epidural abscess.

Answer 849

* Back pain * Pyrexia * Rigors * Sepsis * Neurological features (e.g. changing lower limb neurology if an epidural abscess develops) ## Footnote Neurological features may indicate complications such as an epidural abscess.

Answer 850

Staphylococcus aureus ## Footnote Other causes include viral infections and TB.

Answer 851

MRI ## Footnote CT-guided biopsy may be required to guide antimicrobial treatment.

Answer 852

Six to eight weeks of intravenous antibiotic therapy. ## Footnote The choice of antibiotic depends on identifying the organism with a positive culture.

Answer 853

Assess for endocarditis using transthoracic echo or transesophageal echo. ## Footnote Discitis is usually due to haematogenous seeding of the vertebrae.

Answer 854

* Sepsis * Epidural abscess ## Footnote These complications can arise if discitis is not properly treated.

Answer 855

positive culture ## Footnote This can be obtained from blood culture or CT-guided biopsy.

Answer 856

True ## Footnote Neurological changes may include alterations in lower limb function.

Answer 857

They are important when suspecting osteoporosis in a man.

Answer 858

Hypogonadism.

Answer 859

It is classified as either hypergonadotropic or hypogonadotropic.

Answer 860

Primary gonadal failure.

Answer 861

Secondary to a defect in the hypothalamic-pituitary axis.

Answer 862

They stimulate bone formation during puberty and prevent bone resorption during and after puberty.

Answer 863

[Hypogonadism]

Answer 864

A painful stiff shoulder with restriction of active and passive range of motion in abduction, internal and external rotation ## Footnote External rotation shows the most marked restriction and is the first movement to show impairment.

Answer 865

Difficulty dressing and doing up her bra, weakness of external rotation, difficulty sleeping on the affected side ## Footnote These symptoms suggest a globally impaired range of motion.

Answer 866

Coexisting diabetes, female gender, symptoms in the non-dominant hand ## Footnote These are common findings in this condition.

Answer 867

Popping, swelling, clicking, grinding, and a positive scarf test ## Footnote The scarf test was not reported in the stem.

Answer 868

Pain on overhead activities ## Footnote Patients demonstrate a painful arc of abduction, worse between 90 and 120 degrees.

Answer 869

Popping, snapping, or grinding ## Footnote These symptoms are often noted during examination.

Answer 870

Specific trauma or chronic impingement ## Footnote Patients typically describe weakness and pain.

Answer 871

Muscle wasting, tenderness on palpation, painful arc of movement, weakness of the affected muscle ## Footnote These signs help in diagnosing rotator cuff tears.

Answer 872

Tenderness on palpation of the affected area and reluctance to move the arm ## Footnote Symptoms may overlap with impingement syndrome, making it a less likely diagnosis.

Answer 873

82 years old

Answer 874

Tripping on a step

Answer 875

Shoulder pain

Answer 876

90 degrees

Answer 877

Supraspinatus tear

Answer 878

Degeneration

Answer 879

No, it is rare

Answer 880

A Hill-Sachs lesion is when the cartilage surface of the humerus is in contact with the rim of the glenoid. ## Footnote This condition often occurs due to trauma during shoulder dislocation.

Answer 881

About 50% of anterior glenohumeral dislocations are associated with this lesion. ## Footnote This statistic highlights the commonality of this injury in shoulder dislocations.

Answer 882

Direct injury to the superior aspect of the acromion

Answer 883

Loss of shoulder contour and prominent clavicle

Answer 884

In the second decade

Answer 885

Paradoxical movement of the flail segment of the chest when breathing ## Footnote A flail chest requires immediate surgical management and invasive ventilation.

Answer 886

Conservatively with good analgesia ## Footnote Effective analgesia is crucial to prevent complications.

Answer 887

Chest infections and atelectasis ## Footnote Poor breathing due to inadequate pain control can lead to these complications.

Answer 888

Nerve blocks ## Footnote Nerve blocks can provide additional pain relief.

Answer 889

Surgical management and invasive ventilation ## Footnote Flail chest presents a critical condition that needs urgent intervention.

Answer 890

A break in the bony segment of any rib, often caused by blunt trauma to the chest wall ## Footnote Rib fractures can also occur due to underlying diseases that weaken the bone structure.

Answer 891

* Blunt trauma to the chest wall * Spontaneous fractures due to coughing or sneezing * Pathological fractures due to cancer metastases ## Footnote Common cancers that predispose to rib fractures are prostate cancer in men and breast cancer in women.

Answer 892

Severe, sharp chest wall pain ## Footnote Pain worsens with deep breaths or coughing.

Answer 893

* Significant chest wall tenderness * Visible bruising of the skin * Crackles or reduced breath sounds on auscultation ## Footnote These signs may indicate an underlying lung injury.

Answer 894

A serious complication presenting with reduced chest expansion, reduced breath sounds, and hyper-resonant percussion on the affected side ## Footnote Pneumothorax can occur due to a rib fracture.

Answer 895

Two or more rib fractures along three or more consecutive ribs, leading to paradoxical movement during respiration ## Footnote Flail chest can impair ventilation and cause serious lung injury.

Answer 896

CT scan of the chest ## Footnote CT scans show fractures in 3D and associated soft tissue injuries.

Answer 897

They may demonstrate fractures but provide suboptimal views and no information about surrounding soft tissue injuries.

Answer 898

Conservative management with good analgesia ## Footnote This ensures breathing is not affected by pain.

Answer 899

If pain is not controlled by normal analgesia and fractures have failed to heal after 12 weeks ## Footnote Flail chest segments should be urgently discussed with cardiothoracic surgery.

Answer 900

* Pneumothorax * Haemothorax ## Footnote These lung complications should be addressed as necessary.

Answer 901

Knee extension, thigh flexion ## Footnote The femoral nerve innervates the anterior compartment of the thigh.

Answer 902

Anterior and medial aspect of the thigh and lower leg ## Footnote This includes the skin over these regions.

Answer 903

Hip and pelvic fractures, stab/gunshot wounds ## Footnote These injuries can lead to damage of the femoral nerve.

Answer 904

Thigh adduction ## Footnote The obturator nerve innervates the adductor muscles of the thigh.

Answer 905

Medial thigh ## Footnote This includes the skin covering the medial aspect of the thigh.

Answer 906

Anterior hip dislocation ## Footnote This can lead to damage of the obturator nerve.

Answer 907

None ## Footnote This nerve does not have motor functions.

Answer 908

Lateral and posterior surfaces of the thigh ## Footnote This nerve supplies sensation to the skin in these areas.

Answer 909

Meralgia paraesthetica ## Footnote Characterized by pain, tingling, and numbness in the distribution of the nerve.

Answer 910

Foot plantarflexion and inversion ## Footnote It innervates muscles in the posterior compartment of the leg.

Answer 911

Sole of foot ## Footnote This includes the skin on the plantar aspect of the foot.

Answer 912

Popliteal lacerations, posterior knee dislocation ## Footnote These injuries can damage the tibial nerve.

Answer 913

Foot dorsiflexion and eversion ## Footnote It innervates muscles in the anterior and lateral compartments of the leg.

Answer 914

Dorsum of the foot and the lower lateral part of the leg ## Footnote This includes the skin over these regions.

Answer 915

At the neck of the fibula ## Footnote This is a common site for nerve injury.

Answer 916

Injury to the common peroneal nerve leading to foot drop ## Footnote Foot drop is characterized by inability to dorsiflex the foot.

Answer 917

Hip abduction ## Footnote It innervates the gluteus medius and minimus muscles.

Answer 918

Misplaced intramuscular injection, hip surgery, pelvic fracture, posterior hip dislocation ## Footnote These can lead to damage of the superior gluteal nerve.

Answer 919

Positive Trendelenburg sign ## Footnote This sign indicates weakness in hip abduction.

Answer 920

Hip extension and lateral rotation ## Footnote It innervates the gluteus maximus muscle.

Answer 921

Generally injured in association with the sciatic nerve ## Footnote This can occur in various traumatic situations.

Answer 922

Difficulty rising from seated position, can't jump, can't climb stairs ## Footnote These symptoms are due to weakness in hip extension.

Answer 923

Atherosclerotic occlusive disease involving the abdominal aorta and/or both iliac arteries.

Answer 924

A triad of symptoms: * Claudication of the buttocks and thighs * Atrophy of the musculature of the legs * Impotence (due to paralysis of the L1 nerve)

Answer 925

Compromised blood flow to the pelvic viscera.

Answer 926

Correcting underlying risk factors such as hypercholesterolaemia and stopping smoking.

Answer 927

Angiography.

Answer 928

Endovascular angioplasty and stent insertion.

Answer 929

[a triad of symptoms including claudication, atrophy, and impotence]

MSK Flashcards

(1022 cards)