Final finals! > MSK > Flashcards

MSK Flashcards

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1
Q

What gene is associated with ankylosing spondylitis

A

HLA B27

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2
Q

Describe the epidemiology of ankylosing spondylitis

A

Males
20-30yrs

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3
Q

Describe the symptoms of ankylosing spondylitis

A

Insidious onset back pain and stiffness
Worse in morning and improves with exercise
May have pain on night, which improves on getting up

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4
Q

What would you see on examination of a patient with ankylosing spondylitis

A

Reduced lateral flexon
Reduced forwards flexion-Schober’s test
Reduced chest expansion

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5
Q

Describe Schober’s test

A

Line drawn 10cm above and 5cm below dimples of Venus
Distance between lines should increase >5cm when patient bends as far forward as possible (>20cm total)

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6
Q

Aside from back pain, what are the other features of ankylosing spondylitis

A

the ‘A’s’:
Apical fibrosis
Anterior uveitis
Aortic regurgitation
AV node block
Amyloidosis
Cauda Equina syndrome
Peripheral arthritis

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7
Q

How is ankylosing spondylitis investigated/diagnosed?

A

ESR/CRP usually raised
Diagnostic: plain X-ray of sacroiliac joints
(MRI if normal but still high suspicion)

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8
Q

What would you see on a plain x-ray of ankylosing spondylitis

A

-May be normal early on
Sacroiliitis: subchondral erosions, sclerosis
Squaring of lumbar vertebrae
‘Bamboo spine’
Syndesmophytes

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9
Q

What investigations might yo use to assess respiratory impact of ankylosing spondylitis

A

CXR: apical fibrosis, kyphosis, ankylosis of costovertebral joints
Spirometry: restrictive defect

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10
Q

Describe the management of ankylosing spondylitis

A

Regular exercise
NSAIDs
Physio
DMARDS only useful if peripheral arthritis
Anti TNF therapy if severe

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11
Q

What is olecranon bursitis

A

Inflammation of fluid filled bursa overlying the olecranon process at the proximal ulna-> reduces friction between the elbow and overlyign tissues

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12
Q

What are the causes of olecranon bursitis

A

Repetitive trauma-writers/students leaning on elbows
Direct trauma
Infection-> S.aureus, mc in diabetes, alcohol, steroids, renal impariment
Gout
RA

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13
Q

What are the symtoms of olecranon bursitis

A

Swelling over olecranon process
Non septic-painless, variable tenderness and mild erythema
Septic-Painful, fever, pronounced erythema

Elbow movement usually preserved but may be painful at extremes of flexion

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14
Q

Describe the examinatin findings in a patient with olecranon bursitis

A

Fluctuant well circumscribed swelling at posterior elbow (golf-ball)
Tenderness/warmth
Fever and skin changes if infection
Tophi or joint effusions if gout or RA

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15
Q

How is olecranon bursitis diagnosed

A

Clinical-if well
If septic bursitis suspected-> aspirate for gram stains, crystals and culture
Consider FBC, CRP and imaging if uncertainty

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16
Q

What colour aspirate suggests infection vs no infection for olecranon bursitis

A

Straw coloured fluid-> non infective cause
Purulent fluid-> infection

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17
Q

Describe the management of olecranon bursitis

A

Non-septic: conservative, RICE, NSAIDS
Septic: aspirate and oral flucloxacillin-> consider admission for IV abx (surgical drainage if persists)
Avoid further trauma

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18
Q

What is compartment syndrome

A

Raised pressure within a closed anatomic space, often a complication from fractures or ischaemia reperfusion injury in ischaemia patients.
Raised pressure-> compromises tissue perfusion-> necrosis

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19
Q

What are the 2 main fractures that can cause compartment syndrome

A

Supracondylar fractures
Tibial shaft injuries

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20
Q

Describe the features of compartment syndrome

A

Pain-especially on movement, even passive (excessive breakthrough analgesia)
Paraesthesia
pallor
Arterial pulsation may still be felt
Paralysis

Pulse presence doesn’t rule out compartment syndrome

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21
Q

How is compartment syndrome diagnosed

A

Measure intracompartmental pressure:
>20mmHg abnormal
>40mmHg: diagnostic

Usually no pathology on x-ray

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22
Q

Describe the treatment of compartment syndrome

A

Prompt and extensive fasciotomies

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23
Q

What is a complications of fasciotomy and how do you manage this

A

Myoglobinuria-> renal failure
Give aggressive IV fluids

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24
Q

What is a complication of compartment syndrome and how would you treat this

A

Death of muscle groups: 4-6 hours
If necrotic muscle groups at fasciotomy-> should be debrieded and consider amputation

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25
What is gout
Form of microcystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium (inflammatory arthritis)
26
What causes gout?
Chronic hyperuricaemia Decreased excretion: -Drugs-> diuretics -CKD -Lead toxicity Increased production: -Myeloproliferative/lymphoproliferative disorder -Cytotoxic drugs 0Severe psoriatsis
27
What is Lesch Nyhan syndrome
X-linked recessive disorder-HGPRTase deficiency Gout, renal failure, neuro deficits, learning difficulties, self-mutilation
28
Describe the clinical presentation of gout
Episodes of flares lasting several days and sx free inbetween -Pain-severe -Swelling -Erythema
29
What joints are typically affected by gout
1st metatarsopharyngeal joint Others: Ankle Wrist Knee
30
What tests are used to diagnose gout?
Uric acid levels Synovial fluid analysis X-ray
31
What uric acid level implies gout
>-360 support dx If <360 during a flare and gout suspected then repeat 2 weeks after flare has settled
32
What would be seen on synovial fluid analysis of a patient with gout
Needle-shaped negatively birefringent monosodium urate crystals under polarised light
33
What are the radiological features of gout
Joint effusion Well defined 'punched out' erosions with sclerotic margins Relative preservation of joint space until late disease Eccentric erosions No periarticular osteopenia (unlike RA) Soft tissue tophi
34
What lifestyle modifications are recommended for patients with gout
Reduce alcohol intake and avoid during flare Lose weight Avoid food high in purines-> liver, kidneys, seafoods, oily fish
35
Describe the acute management of gout
NSAIDs/colchicine 1st line Oral steroids: 15mg pred OD if NSAIDs + colchicine CI Intra-articular steroid injection If already on allopurinol then continue
36
What is the long term management of gout
Urate lowering therapy-> allopurinol 2nd line: febuxostat
37
What are the indications for starting urate lowering therapy
-Now recommended for all patients after 1st attack Particularly recommended if: >=2 attacks in 12 months Tophi Renal disease Uric acid renal stones As prophylaxis if on cytotoxics or diuretics
38
What antihypertensive may be indicated for patients with gout
Losartan
39
What is pseudogout
Microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium
40
Name some risk factos for pseudogout
Increasing age (>60yrs) If under 60yrs: -Haemochromatosis -Hyperparathyroidism -Low Mg, Low phsophate -Acromegaly, Wilson's disease
41
What joints are typically affected by pseudogout
Knee Wrist Shoulder
42
What would be seen on joint aspiration of a patient with pseudogout
Weakly positive birefringent rhomboid-shaped crystals
43
What would be seen on x-ray in a patient with pseudogout
Chondrocalcinosis (Linear calcifications of meniscus and articular cartilage)
44
Describe the management of pseudogout
Aspiration of joint fluid to exclude septic arthritis NSAIDs or steroids
45
What is juvenile idiopathic arthritis
Arthritis occuring in someone <16yrs that lasts >6 weeks
46
What is Still's disease
Systemic onset juvenile idiopathic arthritis
47
Describe the features of Still's disease
Pyrexia Salmon pink rash Lymphadenopathy Arthritis Uveitis Anorexia/weigth loss
48
What investigations are used in juvenile idiopathic arthritis
ANA may be positive-> especially in oligoarticular JIA RF usually negative
49
What is pauarticular JIA
<=4 joints affected
50
What are the features of pauciarticular JIA
Joint pain and swelling-> usually medium-sized joints like knees, ankles, elbows Limo ANA may be positive
51
What rules determine if an x-ray is required for a suspected ankle fracture?
Ottawa rules -Any pain in malleolar zone and 1 of the following: Bony tenderness at lateral malleolar zone bony tenderness at medial malleolar zone Inability to walk 4 weight bearing steps immediately after injury and in ED
52
What group of people are hip fractures most common in
Osteoporotic elderly females
53
What is a risk fo displaced hip fractures and why
Avascular necrosis-> blood supply to femoral head runs up the neck
54
Describe the presentation of a hip fracture
Pain Shortened and externally rotated leg Non-displaced or incomplete neck of femur fractures may be able to weight bear
55
How can hip fractures be classified?
Location Garden system
56
Describe how hip fractures are classified based on location
Intracapsular-from edge of femoral head to insertion of capsule of hip joint Extracapsular: either trochanteric or subtrochanteric
57
Describe the Garden classification system for hip fractures
Type 1: fracture with impaction in valgus Type 2: complete fracture but undisplaced Type 3: Displaced fracture, usually rotate and angulated but still has boney contact Type 4: complete boney disruption
58
What Garden system stages is blood supply disruption most common after
Types 3 and 4
59
How do you manage an undisplaced intracapsular hip fracture
Internal fixation Hemiarthroplasty if unfit
60
How do you manage a displaced intracapsular hip fracture
Replacement arthroplasty (either hemi or total) for everyone
61
What are the indications for a total hip replacement vs hemiarthroplasty in patients with a displaced intracapsular hip fracture
Able to walk independently out of doors with no more than use of stick No cognitive impariment Medically fit for anaesthesia and procedure
62
Describe the management for extracapsular hip fractures
Stable intertrochanteric: dynamic hip screw Reverse oblique, transverse or subtrochanteric: intramedullary device
63
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