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MBBS Orthopedics > Common conditions > Flashcards

Common conditions Flashcards

OA, RA, Gout, Osteoporosis and other metabolic conditions

1
Q

X ray presentation of OA

A

LOSS

  • Loss of joint space
  • Osteophytes (marginal)
  • Subchondral cyst
  • Subchondral sclerosis
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2
Q

Grading of OA chondral damage

A

Outerbridge classification

0: normal cartilage
1: cartilage softening and swelling
2: partial thickness defects with fissures on surface
3: fissuring to level of subchondral bone
4: exposed subchondral bone

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3
Q

Causes of OA

A 
Primary
- idiopathic
- senile (degen)
- post meno
Secondary (VITAMINCD)
- Vascular
- Infective: syphillis
- Trauma
- Autoimmune: RA
- Metabolic: hyperPTH, crystal
- Inflammatory, iatrogenic'
- Neoplastic
- Congenital
- Degenerative
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4
Q

What causes pain in OA

A

vascular congestion of subarticular bone
capsular fibrosis
muscular fatigue

(cartilage and synovium have no nerve supply)

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5
Q

DVT prevention

A

1) pre-operative: thromboembolic deterrent (TED) stockings
2) peri-operative: TED stockings, compression boots and foot pumps (eg. pneumatic intermittent compression devices), minimize length of surgery
3) post-operative: low dose LMW heparin, early mobilization (physio)

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6
Q

Conservative mgx of OA

A

Non pharm
- lifestyle: weight loss, exercise, avoid kneeling/ squatting
- physio: strengthen muscles
- occupational therapy: load reduction with walking stick, soft soled shoes
Pharm
- analgesia: paracetamol, NSAIDs w PPI
- Glucosamine
- Intraarticular H&L or hyaluronic acid viscosupplmentation

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7
Q

Sx indications and options for OA

A

Indications

  • v symptomatic (instability, pain, deformity, disability)
  • failure of conserv tx
  • can tolerate sx

Types

  • arthroscopic debridement and wash out with cartilage regeneration procedures
  • realignment osteotomy (younger)
  • arthrodesis
  • arthroplasty (lasts 15yrs): unicompartmental vs total

Post sx: physio + continuous passive movement (CPM)

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8
Q

Complications of joint replacement surgery (arthroplasty)

A

Intraop:

  • # e.g. acetabulum in THR
  • neuromuscular injuries: peroneal in TKR, sciatic n in HR
  • GA cx: AMI, stroke
  • blood loss

within 24h: dislocation

Early (within 30d)

  • infection
  • fat embolism
  • DVT/ PE
Late (after 30d)
- infection
- heterotopic ossification
- disuse osteoporosis
- tissue atrophy
- limb length discrepancy (THR)
implant failure
- periprosthetic fractures
- loosening of joint
- disruption of extensor mechanism
- wearing of articular surfaces
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9
Q

RF of OA knees

A
  • > 50yo
  • overweight
  • hereditary
  • competitive contact sports, meniscal injuries
  • deformities (genu valgus/ varum)
  • previous injuries
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10
Q

Types of OA knees

A 
Medial tibiofemoral compartment OA (TFOA): joint line tenderness
and
Patellofemoral OA (PFOA): patella medial or lateral facet tenderness
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11
Q

4 x ray views of knee

A
  1. weight bearing AP view
  2. skyline view
  3. lateral
  4. long film
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12
Q

Mechanical vs anatomical axis of knee

A

Mechanical: centre of hip to centre of ankle
Anatomical: line of femur to line of tibia

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13
Q

Mgx of infected implant

A

Removal of implant, plus 6 weeks IV antibiotics

Reimplantation after Abx completed

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14
Q

what is Kienbock disease

A

AVN of lunate

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15
Q

OA hand changes

A 
Herbeden nodes (DIPJ)
Bouchard nodes (PIPJ)
ulnar dev of fingers
CMCJ (trapezio-MC jt) of thumb: bony thickening and adduction > squaring (+ve grind test)
Mallet deformity (DIPJ)
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16
Q

Definition of osteoporosis

  • what is T score
  • what is Z score
A

Normal mineralisation (quality normal) but quantity deficient (decr bone mass per unit volume)

Bone mineral density > 2.5 SD below the mean seen in peak bone mass of young (25-30) normal subjects
(T-score ≤ -2.5SD)

T score: Number of sds below means of peak bone mass of young healthy adults (based on BMD of 25yo Caucasian females)

Z score: Number of standard deviations below average person of the same age

17
Q

What is Wolff’s law

A

Bone is deposited and resorbed in accordance with the stresses placed upon it.

18
Q

Interpretation of BMD T score

A

Normal: >-1
Osteopenia: -1 to -2.5
Osteoporosis:

19
Q

RF of osteoporosis

A

Non modifiable

  • family hx
  • hx of anorexia, amenorrhea
  • low peak bone mass in early adulthood
  • early menopause/ oophorectomy
  • previous # history

Modifiable

  • dietary insufficiency
  • alcohol, cigarette
  • chronic lack of exercise
  • drugs: steroids, thyroxine
  • low calcium
  • comorbids: hyperthyroid, hyperPTH, cushing, liver dz, CRF
  • lean people
20
Q

Screening guidelines for osteoporosis

  • when to screen?
  • frequency?
  • investigations
  • action
A

BMD for women > 65
or <65 with RF

osteoporosis self assessment tool for asians (OSTA): age-weight
x>20: measure BMD
x 0-20: measure if with RF
x+1: recheck BMD in 5 years
1 to -1: recheck in 2y
-1 to -2.5: osteopenia - prevention

method: dual energy x ray absorptiometry (DEXA)
- hip for diagnosis
- spine for monitoring of tx

21
Q

Tx for osteoporosis

A

Life style

  • good nutrition
  • exercise
  • stop smoking, alcohol
  • prevent falls

Pharm

  • calcium and vit D supplements
  • bisphosphonates
  • HRT
  • calcitonin
  • strontium ranelate
  • intermittent PTH
  • SERM
  • tibolone
22
Q

Bisphosphonates

  • examples
  • MOA
  • SE
  • advice
A

e.g. alendronate (fosamax), residronate

MOA: Potent inhibitors of osteoclasts, osteoclasts undergo apoptosis when they ingest it

SE: GIT (gastritis, ulceration, stricture, diarrhea, vomiting), esophageal rxn (eg. heartburn)
osteonecrosis of jaw (rare), dizziness, hypersensitivity.
Overuse will result in SSBT (severe suppression of bone turnover): bone would hence be brittle

advice:
Take medication sitting up, keep upright for 30min after swallowing, weekly dosing.
consider drug holiday in low risk pt after 3-5yrs

23
Q

Strontium ranelate

  • MOA
  • SE
A

MOA: Decreases bone resorption and stimulates bone formation
SE: Venous thromboembolism, contraindicated in patients with severe renal impairment

24
Q

X ray features of gout

A 
Asymmetric polyarthropathy
Periarticular erosions
Sclerotic margins
soft tissue calcifications (tophi)
overhanding bony edges
25
Q

X ray features of psoriatic arthritis

A

bilateral involvement

pencil in cup deformity

26
Q

Types of gout

A

Primary: idiopathic disorder of nucleic acid metabolism that leads to hyperuricemia and deposition of monosodium rate crystals in joint

Sec: dz with high metabolic turnover (psoriasis, haemolytic anemia, leukemia, chemotherapy)

27
Q

Tx of gout

A 
Acute
- indomethacin (NSAID)
- colchicine
- glucocorticoid
Chronic
- allopurinol (xanthine oxidase inhibitor)
- colchicine
28
Q

Pseudogout

  • what kind of crystals
  • radiographic findings
A
  • calcium pyrophosphate dehydrate (CPPD) crystals
  • weakly positively birefringent rhomboid shaped crystals

x ray:
- calcification of fibrocartilage structures
(TFCC in wrist, meniscus in knee)

29
Q

Associations of pseudogout

A 
hemochromatosis
wilson
hyperparathyroidism
SLE
gout
RA
hemophilia
long term hemodialysis
30
Q

Mgx of pseudogout

A 
Acute
- nsaids
- splint
- intraarticular steroids
Chronic
- intraarticular y90 injections
- colchicine
31
Q

Rickets and osteomalacia

  • causes
  • features
A

Causes:

  • calcium deficiency
  • hypophosphatemia
  • defect along vit D metabolism pathway (nutritional lack, lack of sunlight, intestinal malabsorption)

Features: ADULT

  • acetabuli protrusio
  • depressed bone density
  • under mineralization of osteoid
  • looser zone (pseudo#)
  • triradiate pelvis
32
Q

Causes of hyperPTH

A 
Primary: solitary adenoma
Secondary: PTH over secretion in response to chronic hypocalcemia
- kidney failure (phos high)
- calcium deficiency
- impaired phosphate breakdown
- vit D disorders
- absorption problems (phosphate low)

Tertiary: secondary hyperplasia leading to autonomous activity

33
Q

bone changes from hyperPTH

A
  • osteoporosis
  • osteitis fibrosa cystica: replacement of marrow spaces by vascular granulation and fibrous tissue
  • brown tumour: from excessive osteoclast activity (fibrous tissue, woven bone, vasculature)
34
Q

pathognomonic feature of Pri hyperPTH on x ray

A

subperiosteal cortical resorption of middle phalange

MBBS Orthopedics (13 decks)

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