5.5 - Musculoskeletal Emergency Presentations Flashcards
1
Q
Case 1
A
- 78 year old lady
- tripped and fell
- cannot get up
- pain in right groin
- had a fall one year ago and sustained wrist fracture
- she had a right hip fracture which required fixation
2
Q
Case 1 - What is the differential diagnosis for her pain?
A
- high risk of hip fracture, yet it is important to rule out other causes of her right groin pain e.g. infection
- was it painful prior to her fall? (think osteoarthritis, infection, sciatica, hernia)
- can you see a lump? (think hernia)
- can you feel for lumps? (think lymph nodes)
- any change in sensation? (think nerve impingement)
- deformity of the lower limb e.g. short and externally rotated? (think hip fracture)
3
Q
Case 1 - What causes groin pain?
A
- inguinal hernia
- hip labral tear
- hip arthritis
- kidney stone
- groin strain
- lumbar radiculopathy
- early arthritis
4
Q
Case 1 - What factors increase the patient’s risk of osteoporosis?
A
- age - 78 is old
- female - post-menopausal women have lower oestrogen so less bone health
- previous low energy fracture - fragility fracture of wrist = likely wrist was osteoporotic before
5
Q
Case 1 - What are lifestyle risk factors of osteoporosis?
A
- excess alcohol
- smoking
- physical inactivity
- low body weight
6
Q
Case 1 - What drugs increase risk of osteoporosis?
A
- glucocorticoids
- antiepileptic
- anticoagulants e.g. heparin
7
Q
Case 1 - What are endocrine risk factors for osteoporosis?
A
- hypogonadism
- hyperthyroidism
- Cushing’s disease
- growth hormone deficiency
- hyperparathyroidism
8
Q
Case 1 - What medical disorders are risk factors for osteoporosis?
A
- malnutrition/malabsorption
- anorexia nervosa
- inflammatory intestinal disease
- intestinal resection
- chronic inflammatory disease (rheumatoid arthritis)
- transplant patients (solid organs and bone marrow)
- systemic mastocytosis (too many mast cells)
9
Q
What is osteoporosis?
A
- weakening of bones - more likely to fracture and break
- stooped back is one of the first signs
- develops slowly over several years
- caused by reduced bone density
- women have increased risk, particularly after menopause
- oestrogen slows bone loss and improves bodies absorption/retention of calcium
- ratio of inorganic : organic same
10
Q
What is osteomalacia?
A
- inadequate mineralisation of the bone, causing softening of bones
- due to insufficient calcium absorption or dietary intake of vitamin D
- or phosphate deficiency caused by increased renal losses
11
Q
What causes osteoporosis?
A
- long term high dose corticosteroids use
- certain medications for inflammatory, endocrine or malabsorption problems
- family history
- low BMI
- drinking/smoking
12
Q
What causes osteomalacia?
A
- insufficient dietary intake
- faulty vitamin D metabolism
- renal tubular acidosis
- malnutrition during pregnancy
- chronic kidney failure
- bone tumour-induced
- Coeliac disease
13
Q
How is osteoporosis diagnosed?
A
- use risk assessment tools to predict likelihood of a fracture
- DEXA scanning can look at bone density:
Compared to a young and healthy adult:
- score of >-1 = normal
- score of -1 to -2.5 = osteomalacia
- score of <-2.5 = osteoporosis
14
Q
How is osteomalacia diagnosed?
A
- very low vitamin D concentration
- pseudo fractures and protrusion acetabula on radiographic images
15
Q
How is osteoporosis treated?
A
- bisphosphonates - act as anti-bone resorption agents –> increased bone density
- calcium and vitamin D supplements
- PTH - released when calcium levels low, slows down bone thinning in those with low density
- selective oestrogen receptor modulators (SERMs) e.g. raloxifebe - similar effects to oestrogen, maintains bone density and reduces fracture risk
- HRT - replaces loss of oestrogen after menopause, helps maintain bone density, increased risk of breast cancer, stroke and CVD so not commonly used
