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Bone and joints check > bone and joints > Flashcards

bone and joints Flashcards

1
Q

History of sore joints. Key questions to history?

A
  1. Which joints?
  2. Morning stiffness?
  3. night pain?
  4. joint swellings?
  5. associated with psoriasis, inflammatory bowel disease or other autoimmune disease.
  6. extraarticular features.
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2
Q

Clinical features of osteoarthritis?

A
  1. Bony tenderness
  2. Bony enlargement
  3. crepitus
  4. deformity
  5. lack of inflammatory features; boggy, joint swelling, or prolonged morning stiffness.

Locations:

  1. Hands: DIP and PIP joints, base of thumbs
  2. Hips
  3. Knees.
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3
Q

Other differentials of multiple joint pains?

A
  1. Non articular - bursitis
  2. Polyarticular
    • Crystal arthropathies - gout and pseudo gout
    • inflammatory arthropathies - rheumatoid arthritis, psoriatic arthritis
  3. Wide spread pain
    • fibromyalgia
    • polymyalgia rheumatoica.
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4
Q

Features of inflammatory arthritis?

A
  1. Pain at night
  2. Pain in the morning
  3. Prolonged stiffness >1 hour
  4. intermittent joint swelling
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5
Q

Investigations for suspected inflammatory arthritis?

A
  1. inflammatory markers: ESR or CRP
  2. Autoimmune serology: Rheumatoid factor, anti-CCP
  3. Imaging; x-ray and ultrasound
  4. Fluid biopsy
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6
Q

Osteoarthritis manamgenet:

A

Non-pharm

  1. Weight loss - dietitian referral
  2. Exercise - muscle strengthening
  3. Educations -
  4. Occupational therapy - splints, walking aids.

Pharma:

  1. Paracetamol
  2. NSAIDS
  3. PPI - in conjuction with NSAIDs
  4. Opioids
  5. Corticosteroid injections - minimal evidence -
  6. Hyaluronic acid - minimal evidence
  7. Topical NSAIDs and capsaicin cream -
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7
Q

What therapy is particular helpful in hand OA?

A

Topical naiads and capsaicin cream

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8
Q

Complementary or alternative therapy useful in OA?

A
  1. Chondroitin sulphate
  2. Glucosamine supphate

limited evidence in: every other complementary:

  1. Acupuncture
  2. Fish oil
  3. avocado
  4. greenlipped mussels, giner, indian frankincense, phytodolor, pine bark extracts, chinese herbal medicine, turmeric, vitamin A, C, E, B.
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9
Q

Indications for surgery in OA?

A
  1. significant functional disability and pain despite conservative measures.
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10
Q

What are features that would suggest inflammatory back pain? i.e. spondylar arthropathies

A
  1. morning stiffness >30min
  2. improvement
  3. awaking in the second half of the night
  4. alternating buttock pain
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11
Q

Ddx of spondyloarthritides

A
  1. ankylosing spondylitis
  2. psoriatic arthritis
  3. reactive arthritis
  4. arthritis of inflammatory bowel
  5. juvenile spondylar arthropathiees
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12
Q

Investigations of spondyloathritides?

A
  1. X-ray - AP pelvic, and lumbar spine X-ray
  2. HLA - B27
  3. inflammatory markers - ESR and CRP
  4. Renal and LFTs
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13
Q

How to diagnose Ankylosing Spondylitis

A

Sacroillitis on conventional X-ray +
History of inflammatory back pain

Non-radiographic axial SpA: lacking radiographic changes, but with history features - may warrant MRI spine

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14
Q

Management of Ankylosing Spondylitis?

A

NON-PHARM:

  1. Exercise
  2. Spinal stretching program
  3. Physio
  4. Smoking changes

PHARM:

  1. NSAIDs
  2. DMARDs
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15
Q

What DMARDS are used in AK?

A
  1. Sulphasalazine and methotrexate.
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16
Q

Side effects of sulphasalazine

A
  1. Rash
  2. GIT upset
  3. headaches
  4. Dizziness.
  5. Tinnitus
  6. Photosensitivity
  7. Orange discolouration of body secretions
17
Q

Do you need regular monitoring of sulphasalazine

A

Yes:

  1. LFTs and FBE
  2. every 2-4 weeks
  3. then every 3 months when stable
18
Q

DDX of mono arthritis?

A
  1. Crystal arthropathies
    - gout
    - pseudo gout
  2. Infection
    • septic joint
    • Reactive arthritis
  3. Osteoarthritis
  4. Seronegative arthritis: Psoriatic arthritis, reactive arthritis and inflammatory arthropathy associated with inflammatory bowel disease are also known to cause monoarthritis,
19
Q

Investigations of mono arthritis? Suspecting gout.

A

1.Serum uric acid
2. Joint aspiration for microscopy/culture and sensitivity, cell count and differential and crystal analysis.
3. FBE, LFTs, electrolytes
4 ESR and CRP -
5. Blood cultures if suspecting infection
6. radiographs to assess for erosions

20
Q

what does gout look like on aspiration?

A

Monosodium urate crystals are needle-shaped crystals with negative birefringence

21
Q

Management of gout?

A

NON-PHARM:
1 Diet - reduce purine - shellfish, offal,
- refrain from sugar-sweetened drinks
2. Reduce alcohol
2. Weight loss - consider dietician referral
3.

PHARMA: 
Acute setting: 
1. NSAIDs 
2. Colchicine 
3. Steroid - oral in polyarticular gout

Long term -
1. Allopurinol

22
Q

What is the target serum uric acid level?

A

Less than 0.36 for non-tophaceous gout

<0.3 for tophaceous gout

23
Q

What is allopurinol hypersensitivity syndrome?

A

Rare; estimated 0.1% - high mortality 27%
Symptoms: severe cutaneous reactive - Stevens-Johnson syndrome, eosinophilia, leukocytosis, fever and multi organ failure.

Risk factors: pre-existing renal impairment, diuresis, recent initiation of allopurinol.

24
Q

Alternative to allopurinol?

A

as adjunct to allopurinol - consider probenecid

Second like - instead of allopurinol

  1. febuxostat
  2. probenecid
25
Q

ottawa ankle rule for fracture

A

Plain X-ray of pain in the malleolar zone +
1. bony tenderness alone the distal 6cm of posterior edge of distal fibula and tibia.

Plain x-ray if: pain in the mid foot +
1. Tenderness over the navicular or 5th metatarsal

Plain x-ray if - inability to weight bear, or more than 4 steps.

26
Q

Management of avulsion fracture:

A 
Conservative management: 
Non-weight bearing as necessary 
progressing to partial then full weight bearing 
usually takes 3-4 weeks 
Simple analgesia
NSAIDs may impair fracture healing
27
Q

When to consider surgical referral

A

surgical assessment of avulsion fracture is indicated if fracture is displaced by more than 2mm, or involves greater than 30% of articulation with the cuboid

28
Q

When can she return to dancing?

A

Need to progress throat a structured rehabilitation program:

  1. Partial to full weight bearing
  2. Regaining normal ROM in ankle movement
  3. Regain calf strength
  4. regain normal balance and proprioception
  5. returning to dance drills that do not require jumping and landing.

Bone and joints check (4 decks)

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