Block 12 Week 2 Flashcards

Question

SALTER HARRIS CLASSIFICATION

Answer 1

- Used to describe physeal (epiphyseal) fractures

Answer 2

Greenstick fracture is a mild bone fracture commonly seen in young children. This kind of fracture is characterized by a crack or break on one side of a long bone in the arm or leg that does not extend all the way through the bone. The bone fracture occurs the same way you would bend a green branch of tree.

Answer 3

TYPE 1: injuries involve only a slip of the zone of provisional classification TYPE 2: injuries are similar to type one injuries with a fracture extending into the metaphysis TYPE 3: are composed of a slip of a growth plate plus a fracture through the epiphyses involving the articular surface TYPE 4: are similar to type 3 fractures with additional involvement of a metaphysical fracture TYPE 5: fractures are crushing injuries of the epiphyseal plate usually produced by a compressive force

Answer 4

- The most common way to diagnose (confirm or exclude) fractures is to use X-rays. Other pathological conditions can be identified e.g. penetrating trauma, foreign bodies, air and gas may also be detected. - Atleast two views perpendicular to each other are mandatory in examining long bones and an oblique view is also usually obtained. If doubt still exists the clinician should ask for more views in various degrees of obliquity to the other films - A fracture line is most visible when it is parallel to the X Ray beam, and is invisible when it is exactly 90o to the beam. The clinician should never accept a study that examines the bone in only one plane - When a long bone is found to be fractured, it is imperative that the bone be viewed radiographically in its entire length. - In unstable patients in whom the risk of moving the patient does not outweigh the benefit of the more detailed study, a portable film is acceptable. -Even with good techniques some fractures are not visible initially and do not appear until the margins of the fracture absorb. Absorption widens the radiolucent line and a defect appears in 7 to 10 days . If a fracture is suggested but not visible at the initial visit, the injury should be treated as a fracture and re-examined clinically and radiographically in 7 to 10 days

Answer 5

- Radionucleotide bone scanning is helpful to detect stress fractures, occult fractures and certain other bone lesions - A radionuclide scan is an imaging technique that uses a small dose of a radioactive chemical (isotope) called a tracer that can detect cancer, trauma, infection or other disorders.

Answer 6

- CT is used to confirm possible fractures or to define better displacements, alignment, fragmentation or fracture

Answer 7

- MRI is the most advanced non-invasive examination of orthopedic structures

Answer 8

- Infection such as OSTEOMYELITIS (inflammation of bone marrow), SEPTIC ARTHRITIS. The risk is associated more with open fractures. You can reduce the risk of infection using vigorous irrigation and debridement of the wound and the use of antibiotics if needed. What causes osteomyelitis? Osteomyelitis occurs when bacteria from nearby infected tissue or an open wound circulate in your blood and settle in bone, where they multiply. Staphylococcus aureus bacteria (staph infection) typically cause osteomyelitis. - Hemorrhage: the skeleton has a rich blood supply so you can lose a large amount of blood, shock, and death from exsanguination. The risk is greater in certain pelvic fractures or fractures of the shaft of the femur. - Vascular Injuries: for example popliteal artery injury in knee injuries. - Nerve Injuries: nerves can be injured by blunt or penetrating trauma

Answer 9

Septic arthritis is an infection in the joint (synovial) fluid and joint tissues. It occurs more often in children than in adults. The infection usually reaches the joints through the bloodstream SYMPOTMS: -Fever -Joint pain -Joint swelling

Answer 10

Neuropraxia (bruised nerve): is a contusion of a nerve with disruption of the ability to transmit impulses; normal function usually returns in weeks to months. The most mild injury to a peripheral nerve Axonotmesis: is a more severe crush injury to a nerve. The injury to nerve fibres occurs within their sheets. Spontaneous healing is possible but slow. Anatomical interruption of the axon with no or only partial interruption of the connective tissue framework. T Neurotmesis: is the severing of a nerve usually requiring a surgical repair. When the nerve is completely severed, all functions are absent including superficial sensation to touch, pain, and temperature; deep sensation to muscle and joint movements, position, deep pressure ,and vibration; motor supply and deep tendon reflexes ;and response to electrical stimulation - For less severe injuries any subjective changes in sensation should be noted. Light touch is a good screening test. Two point discrimination is a more sensitive examinations and should be used routinely in evaluating digital nerves.

Answer 11

- Compartment syndrome is a serious acute emergency complication that should be considered whenever pain and paraesthesia occur in an extremity after a fracture within an enclosed osseofascial space. - The immediate threat is to the viability of nerve and muscle tissue within the involved compartment but infection, gangrene, myoglobinuria and renal failure also may ensue. - Compartment syndrome can occur with soft tissue trauma alone and even with open fractures. Presentation: - In a conscious patients, pain that is disproportionate to the injury or physical findings is a hallmark finding in the compartment syndrome. - Pain often is characterised as deep burning and unrelenting and is difficult to localise. -Pain on passive stretching of the muscle groups in their suggestive compartment is an important finding. -Pallor and loss of pulses are late and ominous signs. Complete fasciotomy is the only treatment that can reliably normalise elevated compartment pressure and this should be carried out as quickly as possible

Answer 12

- You can get compartment syndrome in any muscle, but it most often affects the muscles in the lower legs and forearms. Symptoms: - pain in a muscle – this may feel like a burning pain or a deep ache (moving the body part can make the pain even worse) - swelling or bulging of the muscle -numbness, weakness or pins and needles - tightness or difficulty moving the affected body part Two types: - Sudden (acute) compartment syndrome. This is when compartment syndrome happens suddenly you'll need surgery as soon as possible to relieve the pressure in the muscle. This type of surgery is called FASCIOTOMY. During a fasciotomy, the surgeon makes cuts around the muscle to relieve the pressure. Gradual (chronic) compartment syndrome: - develops gradually, surgery is not required. You can avoid the activity that causes the symptoms to reduce symptoms eg switch from running to low impact exercises.

Answer 13

- Compartment refers to separate sections of the body that contain muscles, nerves, and blood vessels surrounded by a layer of fibrous connective tissue, called fascia. - When the pressure within these compartments rises, normal blood flow can be cut off, leading to tissue damage due to hypoxia, or the lack of oxygen. - The first ones to feel the effect of compression are the veins, because the pressure inside their lumen is normally low. - As the pressure increases, the arteries will become compressed next and this obstructs the normal blood flow. -This cuts off the oxygen supply and hypoxia develops, which causes cells to start releasing substances like histamine and nitric oxide. - These substances cause capillaries to become leaky so fluid leaks out, causing extracellular edema that further increase intra-compartment pressure Muscles: - Hypoxia prevent their mitochondria from producing adenosine triphosphate, or ATP, which is the cell’s main source of energy. - So without ATP, there’s an increase of intracellular sodium levels which cause water to move into the cells causing intracellular edema.

Answer 14

- most common cause is bleeding after injury -This typically occurs with long bone fracture, like the tibia or the forearm bones, and penetrating wounds or surgical procedures that injure blood vessels. - Other causes are swelling of the tissue after severe burns, intravenous drug injection, repetitive use of the injured muscles, or a vigorous muscle contractions like in a tetany or seizures. - Any limb compression, like from a crush injury or from an inappropriately placed cast can also lead to compartment syndrome.

Answer 15

- pain - paresthesia - which is an abnormal sensation like feeling of pins and needles or numbness that can even progress to anesthesia, or loss of sensation. - pulselessness - pallor - poikilothermia - which is the inability to regulate body temperature and usually presents as cold extremities. - paralysis

Answer 16

Avascular Necrosis - disease that results from the temporary or permanent loss of blood supply to the bone - When blood supply is cut off, the bone tissue dies and the bone collapses. - Often happens at the end of long bones. Causes: fracture, injury, damage to blood vessels, long term use of corticosteroids Symptoms: - minimal early joint pain - Increased joint pain as bone and joint begin to collapse - Limited range of motion due to pain talus (in pic)

Answer 17

Complex Regional Pain Syndrome: - symptoms normally start a few weeks after fracture, surgery and injury but can also develop without known cause. - The most common and prominent symptoms is Dissproportionate PAIN ( constant or intermittent, burning, stinging sensation) - Tends to afect your lower extremities more: legs, feet, arms and hands. Most common cause is bone fracture - wrist fracture. Fat Embolism Syndrome: - Most common cause orthopedic trauma, which somehow opens venuous sinusiods which fat gets through. - The embolized fat obstructs capillary beds. Often the embolisms form within pulmonary capillaries. - Embolized fat droplets can travel to microvasculature throughout the body. FES is, therefore, a multiorgan disease and can damage any microcirculatory system within the body. Common symptom's of FES: - respiratory distress -altered mental status - rash

Answer 18

Subluxation: Subluxation occurs when a bone is partially pulled or pushed out of place (out of its normal relationship to the other bones that make up a joint). This can happen in joints such as the kneecap, hip, finger, elbow, or shoulder. A subluxation may be caused by a direct blow to the joint, a fall, or a sudden twisting movement. Everyday activities may cause this injury if a person has unstable joints. The treatment for subluxations may include resetting the joint, pain relief, rehabilitation therapy, and, in severe cases, surgery.

Answer 19

- Fracture and dislocation occur at the same time.

Answer 20

- Ligamentous injury resulting from abnormal motion of a joint - Pts may say they hear a 'snap' or 'pop' at the time of injury MANAGAMENT: - Intially apply ice, elevation and analgesia (NSAIDs) - Immobilisation is used to provide protection and comfort in the intial management of most injuries using splints, braces and casts - Ultrasound is a reliable and readily available imaging modality for sprains.

Answer 21

Common sites: - rotator cuff of the shoulder - Achilles tendon - Radial aspect of the wrist and elbow joint Management: - Ice - rest - NSAIDs - rehabilitation and training and control of force loads to prevent reoccurence

Answer 22

Common sites of bursitis: - Olecranon - Subacromial - Greater trochanter of the femur - Prepatellar bursa

Answer 23

MANAGEMENT OF ORTHAPEDIC INJURIES: - Primary: ABCDE assessment - SECONDARY: Assessment of orthapedic injuries is part of the secondary survey unless there is profuse bleeding or ischaemia of the limb - FOCUSED ASSESSMENT: Inspection, Palpatation, Neurovascular status, range of movements - PAIN CONTROL - IMAGING

Answer 24

- Airway - Breathing - Circulation - Disability - Exposure

Answer 25

MANAGEMENT OF ORTHAPEDIC INJURIES: - Reduction of fracture or dislocation - Wound management in open fractures - Splinting and Bandaging - Casts - Surgery - Rehabilitation

Answer 26

Is the area of transition between the anatomical arm and forearm. Triangular space: Superior border: transverse line between the medial and lateral epicondyles of the humerus. Medial border: Pronator Teres Lateral border: Brachioradialis

Answer 27

- Radial nerve - Median nerve - Brachial artery - Biceps Tendon - The roof of the cubital fossa contains several superficial veins. Notably the MEDIAN CUBITAL VEIN, which connect the basilic and cephalic vein and can be accessed easily - common site for venepuncture

Answer 28

- Median Nerve - Ulnar nerve - Radial artery - Ulnar artery

Answer 29

- Carpal tunnel syndrome is caused by compression of the medial nerve as it travels through the carpal tunnel in the wrist, causing pain and numbness in the median nerve distribution on the hand. zero to finals

Answer 30

https://www.youtube.com/shorts/61fE1TV_-Qk?feature=share FDP tendon - bend the fingertip joint of index, middle, ringer and small finger (for cadaver this is the bottom tendon) FDS tendon- bends the middle finger joint of index, middle, ring and small finger (cadaver this is the top tendon)

Answer 31

Radial Nerve innervates all of the posterior compartment muscles

Answer 32

- Triangular depression on lateral aspect of hand. - It is located at the level of the carpal bones and is best seen when the thumb is extended. Borders: -Ulnar (medial) border: Tendon of the extensor pollicis longus. -Radial (lateral) border: Tendons of the extensor pollicis brevis and abductor pollicis longus. -Proximal border: Styloid process of the radius. -Floor: Carpal bones; scaphoid and trapezium. -Roof: Skin Note: The terms medial and lateral are used in the context of the anatomical position, where the forearm is supinated. Take care when describing these borders, as when observing a patient’s anatomical snuffbox, the forearm is usually pronated).

Answer 33

- Radial Artery - - Superficial Branch of the Radial nerve - Cephalic vein

Answer 34

Phalanges - The 14 bones that are found in the fingers of each hand and also in the toes of each foot. Metacrpal bones - The 5 bones that compose the middle part of the hand Carpal bones - The 8 bones that create the wrist. The 2 rows of carpal bones are connected to 2 bones of the arm--the ulna bone and the radius bone 'some lovers try positions that they can't handle'

Answer 35

Numerous muscles, ligaments, tendons, and sheaths can be found within the hand. Muscles: muscles are the structures that can contract, allowing movement of the bones in the hand. Ligaments: The ligaments are fibrous tissues that help bind together the joints in the hand. Sheaths: are tubular structures that surround part of the fingers. Tendons: connect muscles in the arm or hand to the bone to allow movement

Answer 36

Extrinsic muscles: located in the anterior and posterior compartments of the forearm. They control crude movements and produce a forceful grip. Intrinsic muscles: located within the hand itself. They are responsible for the fine motor functions of the hand.

Answer 37

The thenar muscles are three short muscles located at the base of the thumb: - Opponens Pollicis - Abductor Pollicis brevis - Flexor Pollicis Brevis The muscle bellies produce a bulge, known as the thenar eminence. They are responsible for the fine movements of the thumb. The median nerve innervates all the thenar muscles. Opponens Pollicis: Attachments: Originates from the tubercle of the trapezium and the associated flexor retinaculum. It inserts onto the lateral margin of the first metacarpal. Action: opposition of the thumb, by medially rotating and flexing the metacarpal on the trapezium. ABDUCTOR POLLICIS BREVIS: Attachments: Originates from the tubercles of the scaphoid and trapezium, and from the associated flexor retinaculum. Attaches to lateral side of proximal phalanx of the thumb. Actions: Abducts the thumb. FLEXOR POLLICS BREVIS: Attachments: Originates from the tubercle of the trapezium and from the associated flexor retinaculum. Attaches to the base of the proximal phalanx of the thumb. Actions: Flexes the metacarpophalangeal joint of the thumb. Innervation: Median nerve (recurrent branch). The deep head is innervated by the d branch of the ulnar nerve.

Answer 38

The hypothenar muscles form the hypothenar eminence – a muscular protrusion on the medial side of the palm, at the base of the little finger: - Opponens Digiti Minimi -Abductor Digiti Minimi -Flexor Digiti Minimi Brevis The ulnar nerve innervates the muscles of the hypothenar eminence. OPPONENS DIGIT MINIMI: Attachments: Originates from the hook of hamate and associated flexor retinaculum, inserts into the medial margin of metacarpal V. Actions: It rotates the metacarpal of the little finger towards the palm, producing opposition. ABDUCTOR DIGIT MINIMI: Attachments: Originates from the pisiform and the tendon of the flexor carpi ulnaris. It attaches to the base of the proximal phalanx of the little finger. Actions: Abducts the little finger. FLEXOR DIGIT MINIMI BREVIS: Attachments: Originates from the hook of hamate and adjacent flexor retinaculum, and inserts into the base of the proximal phalanx of the little finger. Actions: Flexes the metacarpophalangeal joint of the little finger.

Answer 39

There are four lumbricals in the hand, each associated with a finger. They are very crucial to finger movement, linking the extensor tendons to the flexor tendons. Denervation of these muscles is the basis for the ulnar claw and hand of benediction. Attachments: Each lumbrical originates from a tendon of the flexor digitorum profundus. They pass dorsally and laterally around each finger, and inserts into the extensor hood. Actions: Flexion at the MCP joint and extension at the interphalangeal (IP) joints of each digit. Innervation: The lateral two lumbricals (of the index and middle fingers) are innervated by the median nerve. The medial two lumbricals (of the little and ring fingers) are innervated by the ulnar nerve.

Answer 40

FDS: MCP + PIP FDP: MCP + PIP + DIP

Answer 41

- When making a fist patient is unable to flex there thumb, index or middle finger - Flexor Digitorium Profundus and FLexor Digitorium Superficialis allows you to flex the fingers. They are all supplied by the median nerve aswell as the thenar muscles - The Flexor Digitorium profundus is supplied by the median and ulnar nerve. So when the median is nerve is damaged you cant flex the other three fingers but you can flex the last 2 because there supplied by the ulnar nerve.

Answer 42

- Ulnar claw is present all the time when the hand is rest, whereas the hand of benediction only happens when you ask the patient to flex the fingers - How it looks: Distal and proximal interphalangeal joints are flexed but the MCP joint is extended - Cause: damage to the ulnar nerve which supplies the last two lumbricals

Answer 43

The interossei muscles are located between the metacarpal bones of the hand. They can be divided into two groups – dorsal and palmar. In addition to their actions of abduction (dorsal interossei) and adduction (palmar interossei) of the fingers, the interossei also assist the lumbricals in flexion at the MCP joints and extension at the IP joints. Dorsal Interossei: Attachments: Each interossei originates from the lateral and medial surfaces of the metacarpals. They attach into the extensor hood and proximal phalanx of each finger. Actions: Abduction of the digits. Assists in flexion at the metacarpophalangeal joints and extension at the interphalangeal joints. Innervation: Ulnar nerve. Palmar Interossei These are located anteriorly on the hand. There are three palmar interossei muscles (although some texts describe a fourth muscle at the base of the proximal phalanx of the thumb). Attachments: Each interossei originates from a medial or lateral surface of a metacarpal, and attaches into the extensor hood and proximal phalanx of same finger. Actions: Adduction of the digits. Assists in flexion at the metacarpophalangeal joints and extension at the interphalangeal joints. Innervation: Ulnar nerve.

Answer 44

There are two other muscles in the palm that are not lumbricals or interossei and do not fit in the hypothenar or thenar compartments: - PALMARIS BREVIS - ADDUCTOR POLLICIS PALMARIS BREVIS: Attachments: Originates from the palmar aponeurosis and flexor retinaculum, attaches to the dermis of the skin on the medial margin of the hand. Actions: Wrinkles the skin of the hypothenar eminence and deepens the curvature of the hand, improving grip. Innervation: Ulnar nerve. ADDUCTOR POLLICIS: Attachments: One head originates from metacarpal III. The other head originates from the capitate and adjacent areas of metacarpals II and III. Both attach into the base of the proximal phalanx of the thumb. Actions: Adductor of the thumb.

Answer 45

Adductor Pollicis

Answer 46

Caused because of 'wear and tear' in the joints from: - overuse - genetics - injury - It occurs in the SYNOVIAL JOINTS

Answer 47

- Obesity - Increased age - Occupation - Trauma - Female - Family History

Answer 48

Osteoarthritis is thought to result from an imbalance between cartilage damage and the chondrocyte response, leading to structural issues in the joint

Answer 49

The changes in osteoarthritis can be seen on a x-ray. The memonic for what to look out for is 'LOSS' L: Loss of joint space (bones comes closer to each other' O: Osteophytes (little bits of bone which come out of either end of the bone) S: Subarticular Sclerosis (increased density of the bone, along the joint line where the bones come in contact with each other) S: Subchondral Cysts (small fluid filled holes in the bone along the joint line ) - X ray may not necessarily correlate with symptoms. So you may have someone with significant bone changes and no symptoms - Equally someone with severe symptoms of osteoarthritis may only have mild x-ray changes

Answer 50

- Joint Pain - Stiffness - The joint pain and stiffness doesn't with activity in comparison to rheumatoid arthritis which improves with activity - Deformity of joints - Instability of joints - Reduced function of joints

Answer 51

- knees - hips - sacroiliac joints - distal interphalangeal joints of the hand (DIP) - carpometacarpal joint at the base of the thumb (CMC) - wrist - cervical spine - ( osteoarthritis of cervical spine is called cervical spondylosis)

Answer 52

Signs: - HABERDENS NODES ( occur in the DIP joint) - BOUCHARDS NODES (occur in the PIP) - Squaring of the base of the thumb (CMC joint) - Weak/ reduced grip - Reduced range of motion

Answer 53

- Saddle joint - CMC joint key joint where osteoarthritis occurs in people who use there hands a lot

Answer 54

The NICE guidelines (2022) suggest that a diagnosis can be made without any investigations if the patient is: - over 45 - has typical pain associated with activity - has no morning stiffness (or stiffness lasting under 30 minutes). ( if over 30 mins probs inflammatory cause) X- rays are useful to: - Checking severity - Confirming diagnosis - Not always necessary

Answer 55

* Blood tests would show raised CRP and ESR levels (but neither as high as in RA), and negative CCP and RF levels (unlike RA)

Answer 56

Non-pharmacological management involves patient education and lifestyle changes, such as: -Therapeutic exercise to improve strength and function and reduce pain -Weight loss if overweight, to reduce the load on the joint -Occupational therapy to support activities and function (e.g., walking aids and adaptations to the home) Pharmacological management recommended by the NICE guidelines (2022) are: -Topical NSAIDs first-line for knee osteoarthritis -Oral NSAIDs where required and suitable (co-prescribed with a proton pump inhibitor for gastroprotection) Weak opiates and paracetamol are only recommended for short-term, infrequent use. NICE (2022) recommend against using any strong opiates for osteoarthritis. Intra-articular steroid injections may temporarily improve symptoms (NICE say up to 10 weeks). Joint replacement may be used in severe cases. The hips and knees are the most commonly replaced joints.

Answer 57

NSAIDs (e.g., ibuprofen or naproxen) are very effective for musculoskeletal pain. However, they must be used cautiously, particularly in older patients and those on anticoagulants, such as aspirin or DOACs. They are best used intermittently, only for a short time during flares. They have several potential adverse effects, including: Gastrointestinal side effects, such as gastritis and peptic ulcers (leading to upper gastrointestinal bleeding) Renal side effects, such as acute kidney injury (e.g., acute tubular necrosis) and chronic kidney disease Cardiovascular side effects, such as hypertension, heart failure, myocardial infarction and stroke Exacerbating asthma There is little evidence that opiates help with chronic pain. They are associated with side effects, risks, tolerance, dependence and withdrawal. They often result in dependence without any objective benefits.

Answer 58

Is an autoimmune condition that causes chronic inflammation in the synovial lining of the joints, tendon sheaths and bursa. Symmetrical Polyarthritis: Rheumatoid arthritis tends to affect multiple small joints symmetrically across both sides of the body.

Answer 59

- 2-3 times more likely to affect women than men - Often develops in middle age - but can present in any age - Smoking - Obesity - Family History - The most common gene associated with rheumatoid arthritis is HLA DR4. - The disease course varies between patients, from mild and remitting to severe and progressive - Disease activity, positive antibodies and erosions on an x-ray predict worse disease.

Answer 60

Rheumatoid factor (RF) is an autoantibody present in around 70% of RA patients. It targets the Fc portion of the immunoglobulin G (IgG). All antibodies (immunoglobulins) have an Fc portion that interacts with other parts of the immune system. Rheumatoid factor causes immune system activation against the patient’s own IgG, resulting in systemic inflammation. Rheumatoid factor is most often IgM but can be other types of immunoglobulin. Anti-cyclic citrullinated peptide antibodies (anti-CCP antibodies) are more sensitive and specific than rheumatoid factor. They are positive in around 80% of patients with rheumatoid arthritis. They often pre-date the development of rheumatoid arthritis and indicate that a patient will develop the condition at some point.

Answer 61

- The speed of onset can vary from rapid (e.g., overnight) to gradual (e.g., over months) The three joint symptoms are: -Pain -Stiffness -Swelling Associated symptoms: -Fatigue -Weight loss -Flu-like illness -Muscles aches and weakness Rheumatoid arthritis typically causes symmetrical distal polyarthritis affecting the small joints of the hands and feet. The most commonly affected joints are: -Metacarpophalangeal (MCP) joints -Proximal interphalangeal (PIP) joints -Wrist -Metatarsophalangeal (MTP) joints (in the foot) On palpation of the joints, there will be tenderness and synovial thickening, giving them a “boggy” feeling. Other joints affected: - ankle -knee -hips -shoulders -It can affect the cervical spine (but not the lumbar spine).

Answer 62

Rheumatoid arthritis very rarely affects the distal interphalangeal joints. Enlarged and painful distal interphalangeal joints are more likely to represent Heberden’s nodes due to osteoarthritis. : Inflammatory arthritis symptoms are worse with rest and improve with activity. They are worst in the morning. Symptoms of mechanical problems (e.g., osteoarthritis) are worse with activity and improve with rest.

Answer 63

Palindromic rheumatism involves self-limiting episodes of inflammatory arthritis, with pain, stiffness and swelling typically affecting only a few joints. The symptoms last days, then completely resolve. Joints appear normal between episodes. Rheumatoid factor or anti-CCP antibodies may indicate that it will progress to rheumatoid arthritis.

Answer 64

-Z-shaped deformity to the thumb -Swan neck deformity (hyperextended PIP and flexed DIP)(flat pip) -Boutonniere deformity (hyperextended DIP and flexed PIP) (first pic) (bumpy pip) -Ulnar deviation of the fingers at the MCP joints

Answer 65

Boutonniere deformity is caused by a tear in the central slip of the extensor components at the proximal interphalangeal (PIP) joint. The central slip connects to the middle phalanx at the PIP, and the lateral bands go around the PIP and connect to the distal phalanx. When the patient tries to straighten their finger, the lateral bands pull on the distal phalanx, causing the distal interphalangeal (DIP) joint to hyperextend and the PIP joint to flex. Swan neck deformity is the opposite of Boutonnieres deformity. It is caused by an extensor mechanism imbalance, causing flexion of the DIP joint and extension of the PIP joint.

Answer 66

Atlantoaxial subluxation occurs in the cervical spine. Synovitis and damage to the ligaments around the odontoid peg of the axis (C2) allow it to shift within the atlas (C1). Subluxation can cause spinal cord compression and is an emergency. This needs to be considered when a patient is having a general anaesthetic and requires intubation. MRI can be used to visualise changes in these areas as part of a pre-operative assessment.

Answer 67

The NICE clinical knowledge summaries (updated 2020) recommend an urgent rheumatology referral for patients with persistent synovitis (to be seen within three weeks). They suggest considering an NSAID and arranging baseline bloods while waiting for the specialist assessment. The investigations that help in the initial assessment are: -Rheumatoid factor -Anti-CCP antibodies -Inflammatory markers, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) -X-rays of the hands and feet for bone changes Ultrasound or MRI can be used to detect synovitis (useful when clinical findings are unclear)

Answer 68

X-ray Changes: -Periarticular osteopenia -Boney erosions -Soft tissue swelling -Joint destruction and deformity (in more advanced disease)

Answer 69

Treatment involves the multidisciplinary team: -rheumatologists - specialist nurses -GPs - physiotherapists - occupational therapists -psychologists and podiatrists. Starting treatment early improves outcomes. The aim is to induce remission or get as close to remission as possible. C-reactive protein and DAS28 are used to monitor the success of treatment. -Short-term steroids (oral or intramuscular) may be used at initial presentation, when initiating a new treatment and during flares to settle the inflammation and control symptoms quickly. Treatment is with conventional disease-modifying anti-rheumatic drugs (cDMARDs) and biologic DMARDs: -Monotherapy with methotrexate, leflunomide or sulfasalazine -Combination treatment with multiple cDMARDs -Biologic therapies (usually alongside methotrexate)

Answer 70

Hydroxychloroquine may be used in mild disease and palindromic rheumatism. It is the “mildest” DMARD.

Answer 71

-azathioprine - ciclosporin - cyclophosphamide - mycophenolate.

Answer 72

- Initiation phase = non-specific inflammation - Amplification phase = T-cell activation - Chronic inflammatory phase = tissue injury due to cytokines IL-1, TNF-alpha, and IL-6

Answer 73

1) A trigger (smoking, infection etc) in genetically predisposed individuals stimulates T cells, which activate macrophages, fibroblasts and B cells, as well as a range of cytokines (e.g. TNF-alpha (main cytokine involved, IL-1, IL-6) 2) Cytokines initiate an inflammatory cascade, which leads to cell activation and enzyme activation. These products ultimately lead to tissue damage, joint destruction and cartilage damage 3) B cells produce rheumatoid factor (RF) and antibodies like anti-CCP antibody, which are things involved in the pathophysiology of RA and inflammatory response that can be detected on blood tests

Answer 74

-excessive uric acid levels, which causes crystallized uric acid (monosodium urate crystals ) to be deposited into tissues -Gout is caused by the precipitation and deposition of monosodium urate crystals into the joint spaces and tissues, resulting in inflammatory arthritis. -Precipitation of monosodium urate is due to increased uric acid production or decreased uric acid excretion. Purine-rich foods include red meats, liver, shellfish, and alcohol increase risk of gout

Answer 75

Gout is a type of crystal arthritis, along with diseases like calcium phosphate disease. Gout forms uric acid crystals, and calcium phosphate disease forms calcium pyrophosphate dehydrate (CPPD) crystals Crystals in all types of crystal arthritis are very irritative. They form on articular cartilage or tendons and cause inflammatory reactions around joints * Urate is the end product of purine metabolism. It is soluble in the blood, and we all have it, but when urate levels are high (i.e. overproduction of urate, or underexcretion of urate) then it is more likely to form crystals. Urate crystals are also more likely to form when blood pH is low * Xanthene oxidase is a key enzyme in the formation of urate, and drugs (e.g. allopurinol) exist that can block this enzyme * Overproduction of urate can be from a high purine diet, but also for people with lymphomas and leukaemias, and people on chemotherapy (breakdown of cells and increased purine production). Underexcretion of urate can be hereditary, due to diuretics, due to conditions that reduce GFR, or due to alcohol metabolism, which forms lactic acid that can block urate secretion by renal tubules * For people at risk of developing gout, triggers of gout can be direct trauma, surgery that triggers the acute phase response, dehydration, acidosis (including alcoholic binges), medications (including initiation of urate lowering therapy), and rapid weight loss

Answer 76

- Single (unilateral) - Acute - Hot - Swollen - Painful The number one differential diagnosis is Septic Arthritis

Answer 77

- Male - Family history - Obesity - High purine diet (e.g., meat and seafood) - Alcohol - Diuretics - Cardiovascular disease - Kidney disease

Answer 78

- The first metatarsophalangeal (MTP) joint is most commonly implicated in a gout attack - the base of toe - Also the carpometacarpal joint (CMC joint) - the base of the thumb - Wrist

Answer 79

When we have too much calcium pyrophosphate dihydrtae crystals, which deposit into tissues and cause inflammation. often idiopathic

Answer 80

Gouty tophi are subcutaneous uric acid deposits typically seen on the hands, elbows and ears. The crystals are not deposited into the joint but instead are deposited under the skin. - The most common place to see this is in the DIP in the hands

Answer 81

- Diagnosis can be made clinically or by aspirating fluid from the joint. It's usually done clinically. - It is important to exclude septic arthritis (because it is a potentially joint and life threatening diagnosis) - When you aspirate fluid from the joint in gout you'll see no bacterial growth. In gout you'll also see needle shaped crystals which are 'negatively birefringent of polarized light'. And on further investigation you find monosodium urate crystals. - If there is bacterial growth this is septic arthritis rather than gout.

Answer 82

-Maintained joint space (no loss of joint space) -Lytic lesions in the bone -Punched out erosions -Erosions can have sclerotic borders with overhanding edges

Answer 83

Firstly managing a acute flare, this is when patient is in pain with red, hot joint: -1st line: NSAIDs - Naproxen, Ibuprofen - 2nd line: COLCHICINE. This is used in situations where using NSAIDs would be inappropriate such as renal impairment and heart disease. Common side effect of this drug is diarrhoea - 3rd line: Steroids ( predinosolone) Secondly providing prophylaxis to reduce the risk of a flare: - ALLOPURINOL - Xanthane oxidase inhibitor. Works by reducing the uric acid level. - Lifestyle changes: Losing weight, stay hydrated and reducing the consumption of alcohol and purine rich food.

Answer 84

- People with septic arthritis present with painful, hot, swollen joints that develop quickly over 24 hours, making them unable to bend the joint or walk if it affects the knee, ankle, foot etc. - The most common joints affected are: - knees -the hip (more commonly affects large joints), and it most commonly only affects one joint - Cause: intravenous drug usage which may have caused the infection, or the patient may be presenting with sepsis Blood tests: - show high WBC and neutrophil levels - raised CRP - normal urate levels - a negative - RF and CCP levels

Answer 85

- SA is a infection within a joint - Pain - Swelling: is due to joint effusion, which is where the fluids in the tissues around your joint increase - fever - sweats - rigors - confusion - Its musculoskeletal emergency, as it causes rapid destruction of cartilage and bone, and can become life-threatening - Symptoms often last for around 2 weeks RISK FACORS FOR SA: - trauma - local infection - IV drug users - recent invasive procedures - medications: corticosteroids, immunosuppressants and antibiotics TREATMENT: - antibiotics (long course): 2 weeks of IV antibiotics, followed by 4 weeks of oral antibiotics may be needed to clear them

Answer 86

- Tenosynovitis is the inflammation of the synovium that surrounds a tendon. Symptoms include pain, swelling, and difficulty moving the particular joint where the inflammation occurs - Tenosynovitis most commonly results from the introduction of bacterial into a sheath through a small penetrating wound such as that made by the point of a needle or thorn.

Answer 87

- Bursitis is the inflammation of one or more bursae (small sacs) of synovial fluid in the body. They are lined with a synovial membrane that secretes a lubricating synovial fluid. - When bursitis occurs, movement relying on the inflamed bursa becomes difficult and painful. Moreover, movement of tendons and muscles over the inflamed bursa aggravates its inflammation - Bursitis causes local warmth at a joint and erythema, but it doesn’t cause joint effusion/swelling, and there isn’t any restriction of joint movement. This distinguishes it from septic arthritis

Answer 88

Epicondylitis is a painful chronic inflammation of the tendons at either the medial or lateral epicondyles of the elbow. These injuries are often referred to as: - golfer’s (medial) elbow - tennis (lateral) elbow although several recreational and occupational can cause these injuries.

Answer 89

Compartment syndrome is a condition in which increased pressure within one of the body’s anatomical compartments results in insufficient blood supply to tissue within that space. Compartment syndrome often occurs due to muscle swelling. The swelling muscle is confined in a fixed volume compartment and this causes an increase in pressure within the compartment. Over time the pressure in the compartment surpasses the arterial pressure, resulting in loss of arterial blood supply and secondary tissue ischaemia. Compartment syndrome can be acute or chronic, but it is most commonly due to trauma such as a bone fracture or crush injury. If left untreated, compartment syndrome will cause irreversible tissue ischaemia which can result in long term muscles contractures (known as Volkmann’s ischaemic contracture) or even the need for amputation. Typical clinical features of compartment syndrome include: Pain (progressive and disproportionate to the original injury/clinical findings) Paraesthesia (reduced sensation) Paralysis Pallor Pulselessness Pain and paraesthesia are early symptoms and should prompt initiation of treatment. If there are reduced or absent pulses, then this suggests severe ischaemic damage. Immediate treatment involves removing constrictive dressings and raising the limb above the level of the heart. Fasciotomy of the muscle compartments releases pressure and should be performed as soon as possible to minimise the risk of irreversible ischaemia.

Answer 90

DELTOID AND TERES MINOR Proximal humeral fractures can lead to injury to the axillary nerve, as it travels medially to the surgical neck of the humerus. The nerve damage affects the deltoid and teres minor muscles. Injury to the axillary nerve results in: - Weakness of the deltoid and teres minor muscles - paralysis of the deltoid and teres minor muscles resulting in weakness in shoulder abduction and external rotation. - Loss of sensation of the area of the skin over the lateral shoulder (regimental badge area) as the upper lateral cutaneous nerve of the arm will be affected. - Wasting of the deltoid muscle can occur over time and results in a loss of the rounded appearance of the shoulder giving the shoulder a flattened appearance.