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
16
Q
How is osteomalacia treated?
A
- nutritional osteomalacia - increase dietary intake, increase outdoor time, supplementation of vitamin
- malabsorption osteomalacia - injected/daily oral dosing of vitamin D, easily treated if caught early
- osteomalacia due to other conditions - other conditions need to be treated
17
Q
Case 1 - How is the multidisciplinary approach involved in geriatric patients?
A
- MDT approach to offer holistic, optimal and patient-centred management
- ED doctors, nurses, orthopaedic surgeons, anaesthetist, orthogeriatricians who look after hip fractures in patients >65, physiotherapists, occupational therapists, ward clerk, radiographers, porters, kitchen staff, GP
18
Q
Case 2
A
- 3 years old
- pain and limp in left leg
- had fevers and cold two weeks ago
- on examination, temperature 38.7
- in pain
- crying
- reluctant to move left leg
19
Q
Case 2 - What are the possible causes of a limping child?
A
- inflammation
- infection - may have had UTI and the inflammation has spread to hip joint (transient synovitis = when an infection moves to and settles in hip joint)
- trauma - accidents or non-accidental injury (NAI = abuse)
- others e.g. tumour
20
Q
Case 2 - What causes hip pain in children <4 years old?
A
- transient synovitis
- osteomyelitis / septic arthritis
- juvenile idiopathic arthritis
- NAI
- referred pain from limb
Uncommon:
- leukaemia
- eosinophilic granuloma
- metastases neuroblastoma
21
Q
Case 2 - What causes hip pain in children 4-10 years old?
A
- transient synovitis
- osteomyelitis / septic arthritis
- Perthes disease
Uncommon:
- leukaemia
- Ewing
22
Q
Case 2 - What causes hip pain in children 10-16 years old?
A
- slipped femoral epiphysis
- avulsion fractures
- osteomyelitis / septic arthritis
Uncommon:
- leukaemia
- osteoid osteoma
- Ewing
- osteosarcoma
23
Q
Case 2 - How would we take a history?
A
- did he fall?
- details of cold
- other symptoms e.g. other joints affected, fevers, weight loss
- has he had this before?
- other medical history
- family history of joint problems
24
Q
Case 2 - What is Kocher criteria for septic arthritis?
A
- distinguishes septic arthritis from transient synovitis in a child with an inflamed hip
- need 3 or 4 of the 4 criteria to indicate septic arthritis
- non weight-bearing?
- temperature > 38.5oC / 101.3oF
- ESR > 40mm/hr
- WBC > 12,000 cells/mm3
25
Q
Case 2 - What tests would we do?
A
- bloods - FBS (fasting blood sugar), Esr (erythrocyte sedimentation rate - how long it takes RBCs to fall to bottom of test tube - quicker they fall, the more likely there’s high inflammation), CRP, renal function
- autoantibodies perhaps
- MRI perhaps
- Xray leg or hip
26
Q
Case 2 - Why is it important to detect bacterial infection early?
A
Otherwise, bacteria will eat away at articular cartilage and cause bad damage
27
Q
Case 2 - How is transient synovitis treated?
A
- rest and NSAIDs
- follow fever curve
- close observation for: persistent/worsening limping, fever, signs of systemic illness
28
Q
Case 2 - How is septic arthritis treated?
A
- drainage in all cases - when in doubt, wash out
- multiple aspirations and irrigations - unstable patient, gonococcal infection
- arthroscopic drainage
- open surgical drainage
- IV antibiotics
29
Q
Case 3
A
- 60 year old man
- 3 days red hot swollen knee
- no injury
- feels shivery
- diabetic
30
Q
Case 3 - Describe the knee
A
- left knee which looks swollen, erythematous, warm to touch, painful on palpation
- cardinal signs of inflammation - caused by several things
31
Q
Case 3 - What questions would you ask?
A
- how did the knee swelling start?
- is there any trauma?
- has he had it before?
- what is his past medical history? patient is insulin-dependent diabetic for 20 years, his blood sugars are not tightly controlled
32
Q
Case 3 - What tests would we do?
A
- bloods - FBS, Esr, CRP, renal function
- urate
- glucose
- HbA1c
- autoantibodies perhaps
- Xray knee
- aspirate joint and send fluid for culture
- MRI perhaps
33
Q
Case 3 - How will bacteria change the joint fluid and blood?
A
- clear straw-coloured joint lubricating liquid changes colour and consistency –> turbid/cloudy, perhaps darker, presence of pus, increased viscosity, large volume of effusions from swelling
- inflammatory markers within blood tests include WBC count, ESR and CRP
- joint fluid should be aspirated and sent for MC&S, gram staining and to rule out crystal arthropathy like gout/pseudogout
34
Q
Case 3 - What are different routes of bacteria spread?
A
- inoculation
- blood
- from bone
35
Q
Case 3 - What is the treatment going to be?
A
- aspirate
- then antibiotics (for 6-8 weeks to clear infection, if we give them before they will kill the bacteria so culture cannot be made)
- if confirmed infection: washout with keyhole arthroscopy
- continue antibiotics
