Corrections 3 Flashcards
What is the key investigation in suspected septic arthritis?
Synovial fluid sampling
What is the most common organism implicated in a psoas abscess?
Staph. aureus
Features of a psoas abscess?
1) Lumbar tenderness (point of insertion of the psoas muscle is T12-L5)
2) Patient will prefer to lie with their knees slightly flexed
XR changes in osteoarthritis?
L - Loss of joint space
O - Osteophytes at joint margins
S - Subchondral cysts
S - Subchondral sclerosis
Cause of de Quervain’s tenosynovitis?
Inflammation of the tendons on the lateral aspect of the wrist and thumb.
What test is used to diagnose de Quervain’s tenosynovitis?
Finkelstein’s test
The hand should be deviated medially rapidly and sharp pain occurs along the distal radius.
What are 2 medications that commonly cause drug-induced lupus?
1) procainamide
2) hydralazine
What are 3 medications that less commonly cause drug-induced lupus?
1) isoniazid
2) minocycline
3) phenytoin
Cause of a shortened, internally rotated leg?
Hip dislocation (most likely posterior displacement of the femoral head).
Cause of a shortened, externally rotated leg?
NOF fractures
What abs are seen in limited systemic sclerosis?
Anti-centromere antibodies
What 2 fractures is compartment syndrome msot commonly associated with?
1) supracondylar fractures (arm)
2) tibial shaft fractures (leg)
Mx of plantar fasciitis?
1) weight loss
2) simple stretching
3) rest
What nerve injury is a common complication of a posterior hip dislocation?
Sciatic nerve injury
Are most hip dislocations anterior or posterior?
Posterior (90%)
How can sciatic nerve injury result in foot drop?
As the sciatic nerve supplies the common peroneal nerve.
What investigation is it important to do before starting biologics?
CXR - look for TB (can cause reactivation)
Mx of Paget’s disease of the bone?
Bisphosphonates
What type of reaction is allergic contact dermatitis? e.g. nickel
Type IV hypersensitivity (delayed)
Referral time for suspected cancer in children vs adults?
Children - 48h
Adults - 2w
What is a pharmacological option for Raynaud’s?
Nifedipine
1st line mx for pseudogout?
NSAIDs and colchicine (note - allopurinol is ineffective in pseudogout as uric acid is not implicated).
Risk factors for pseudogout?
1) age
2) haemochromatosis
3) hyperparathyroidisim
4) hypophosphataemia
5) hypothyroidism
6) hypomagnesaemia
What nerve is implicated in carpal tunnel syndrome?
Median nerve compression
Features of carpal tunnel syndrome?
1) pain/pins and needles in thumb, index, middle finger
2) symptoms may ‘ascend’ proximally
3) patient shakes hand to obtain relief, classically at night
What movement is weakened in carpal tunnel syndrome?
Thumb abduction (abductor pollicis brevis)
What is there wasting of in carpal tunnel syndrome?
Wasting of the thenar eminence (NOT the hypothenar)
What is Tinel’s sign?
Tapping of the median nerve causes paraesthesia
What is Phalen’s sign?
Flexion of the wrist causes symptoms
What 2 signs are seen in carpal tunnel?
1) tinel’s
2) phalen’s
What investigation is ankylosing spondylitis most supported by?
Sarco-ilitis on a pelvic XR
What is an important differential for tibial stress syndrome?
Stress fracture of the tibia –> get an XR!
What monitoring is required in methotrexate?
FBC, U&Es and LFTs every 3 months
What is the imaging modality of choice for suspected Achilles tendon rupture?
US
What is ‘Simmond’s test positive’?
Absence of plantar flexion on squeezing the calf on the affected leg –> this sign is pathognomonic of an Achilles tendon rupture.
What is cubital tunnel syndrome?
Compression of the ulnar nerve –> tingling/numbness of the 4th and 5th finger.
What is the purpose of Tinel’s test?
Used to diagnose nerve compression or damage.
What is the most common reason that a total hip replacement needs to be revised?
Aspectic loosening (hip or groin pain radiating down to the knee).
What radiculopathy causes weakness of hip abduction & foot drop?
L5 radiculopathy
Most common cause of an L5 radiculopathy?
Slipped disc compressing the nerve root.
What radiculopathy causes a reduced knee jerk?
L4
What radiculopathy causes a reduced ankle jerk?
S1
Are reflexes affected in L5 radiculopathy?
No
What is a Ewing’s scarcoma?
A malignant tumour that occurs most frequently in the diaphysis of the pelvis and long bones.
XR feature of a Ewing’s scarcoma?
‘Onion skin’ appearance on XR
What is Schober’s test used to investigate?
Reduced forward flexion in AS
What is Schober’s test?
Line is drawn 10cm above and 5cm below the back dimples.
The distance between the 2 lines should increase by >5cm when the patient bends forward.
What are some additional features that may be seen in AS? (the A’s)
- anterior uveitis
- apical lung fibrosis
- AV node block
- aortic regurgitation
- achilles tendonitis
What is the most useful investigation in establishing a diagnosis of AS?
Plain XR of sacroiliac joints –> sarco-ilitis
XR features in AS?
1) Sacroilitis: subchondral erosions, sclerosis
2) Squaring of lumbar vertebrae
3) ‘Bamboo spine’: late & uncommon
4) Syndesmophytes: due to ossification of outer fibers of annulus fibrosus
If the x-ray is negative for sacroiliac joint involvement in ankylosing spondylitis but suspicion for AS remains high, what is the next step?
MRI
Cause of a restrictive picture on spirometry in AS?
Combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints.
1st & 2nd line mx of AS?
1st –> NSAIDs, physio & regular exercise
2nd line –> DMARDs e.g. sulphalazine
What is a key risk factor for infective olecranon bursitis?
Immunosuppressed
What organism is most commonly responsible for infective olecranon bursitis?
Staph. aureus
What are 2 systemic conditions that can lead to olecranon bursitis?
1) RA
2) Gout
What may be present if olecranon bursitis is associated with gout?
Tophi
What movement causes pain in olecranon bursitis?
When elbow is in full flexion (swollen bursa is compressed)
Does straw-coloured fluid from a joint indicate an infection?
No
Normal synovial fluid is usually straw-colored, clear, and slightly sticky or stringy.
Local corticosteroid injections may be considered in cases of persistent, non-septic olecranon bursitis that do not respond to conservative measures.
However, what does this increase the risk of?
Infection & tendon rupture
What are the 2 fractures carrying the highest risk for compartment syndrome?
1) Tibial shaft
2) Supracondylar
Give 2 causes of compartment syndrome
1) Fractures
2) Ischaemia reperfusion injury in vascular patients
What intracompartmental pressure measurement is diagnostic of compartment syndrome?
≥40mmHg
Why may aggressive IV fluids be needed after a fasciotomy in compartment syndrome?
Due to potential myoglobinuria
What accumulates in joints in gout?
Monosodium urate (MSU) crystals
How can CKD cause gout?
Reduced renal excretion of urice acid
Are investigations always required in the fx of gout?
No - investigations not needed if features suggestive of gout and no suspicions of other conditions (e.g. septic arthritis)
Synovial fluid analysis in gout?
1) MSU crystals
2) Needle shaped
3) Negatively birefringent
When should serum uric acid levels be measured after an acute attack of gout?
4-6 weeks after
What may be seen on an XR in chronic gout?
Punched out, lytic lesions
What is the 2nd line agent for uric acid lowering in gout(when allopurinol is not tolerated or ineffective)?
Febuxostat: also a xanthine oxidase inhibitor
Give some risk factors for pseudogout
- increasing age
- haemochromatosis
- hyperparathyroidism
- low mg, low phosphate
- acromegaly
- Wilson’s
Key XR finding in pseudogout?
Chondrocalcinosis
What medications may be indicated in the mx of fibromyalgia?
1) duloxetine
2) pregabalin
3) amitriptyline
What has the strongest evidence base for mx of fibromyalgia?
Aerobic exercise
Results of osteomalacia blood tests?
- low calcium
- low phosphate
- high ALP
Mx of osteomalacia?
Vitamin D supplements
1st line mx of HTN in systemic sclerosis?
ACEi
Initial mx of suspected or confirmed scaphoid fracture?
1) immobilisation with a Futuro splint or standard below-elbow backslab
2) Referral to orthopaedics
Mx of suspected scaphoid fracture when initial imaging is inconclusive?
Clinical review with further imaging should be arranged for 7-10 days later
Orthopaedic mx of scaphoid fractures:
a) undisplaced
b) displaced
c) proximal scaphoid pole fractures
a) cast for 6-8 weeks
b) requires surgical fixation
c) require surgical fixation
What is Pott’s fracture?
Bimalleolar ankle fracture due to forced foot eversion
What is the main neurovascular structure that is compromised in a scaphoid fracture?
Dorsal carpal arch of the radial artery –> risk of avascular necrosis
Does a negative gram stain rule out septic arthritis?
No - Gram staining is negative in around 30-50% of cases of septic arthritis
What is a buckle fracture?
incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex.
What is found on the joint aspirate in reactive arthritis?
No organism growth on gram stain
1st line medical mx of Raynaud’s?
CCBs e.g. nifedipine
Describe phalen’s test
The patient’s wrist is held in maximum flexion (reverse prayer sign) for 30-60 second.
The test is positive if there is numbness in the median nerve distribution
What is the most common cardiac manifestation of SLE?
Pericarditis
What are 3 cardiac features that may be late signs of Lyme disease?
1) Heart block
2) Pericarditis
3) Myocarditis
What is an alternative to doxycycline in the mx of Lyme disease (e.g. in pregnancy)?
Amoxicillin
Mx of disseminated lyme disease?
Ceftriaxone
What may occur after initiating therapy in Lyme disease?
Jarisch-Herxheimer reaction
When can OA be diagnosed clinically without further investigations? (3)
1) age >45 y/o
2) exercise related pain
3) no morning stiffness or morning stiffness lasting > 30 minutes
What gait may be seen in osteomalacia?
Waddling gait due to proximal myopathy
Give some causes of 2ary osteoporisis
1) hyperparathyroidism
2) hyperthyroidism
3) alcohol
4) immobilisation
What are the 3 most common fractures occuring in osteoporosis?
1) NOF
2) Colles
3) Vertebral compression wedge fracture
What % of vertebral compression fractures are symptomatic?
Only 2/3
DEXA scan T score results:
a) normal
b) osteopenia
c) osteoporosis
a) > -1.0
b) -1.0 to -2.5
c) ≤ -2.5
Define severe osteoporosis
T score ≤ -2.5 AND a fragility fracture
What is a monoclonal antibody that can be used in the mx of severe osteoporosis?
Denosumab
Give some situations where oral bisphosphonates would be offered straight away in the mx of osteoporosis?
1) DEXA scan: T score ≤ -2.5
2) ≥75 y/o with a fragility fracture
3) Post-menopausal woman or man ≥50 y/o with a symptomatic osteoporotic vertebral fracture
4) Post-menopausal woman or man ≥50 y/o treated with steroids
What dose of steroids indicate the need for bisphosphonates?
if starting ≥7.5 mg/day prednisolone or equivalent for the next 3 months
Which SERM may be used in osteoporosis?
Raloxifene
NICE guidelines recommend referring people to a rheumatologist who present with atypical features of PMR.
What are some atypical features?
1) <60 y/o
2) red flags e.g. weight loss, night pain or neurological features
3) do not have the core symptoms of PMR
4) have unusual features of PMR e.g. limited response to steroids
What is the most common type of intracapsular fracture in the proximal femur?
Subcapital fracture (a break in the neck of the femur that occurs at the junction of the head and neck).
What medication is indicated in housebound patients?
Vitamin D
Next step in mx of AS if oral NSAIDs haven’t helped?
TNF-alpha blockers such as infliximab and etanercept.
What should be corrected before giving bisphosphonates?
Hypocalcaemia/vitamin D deficiency
How long should symptoms be present for before a diagnosis of chronic fatigue syndrome?
3 months
Which TB drug canc cause drug-induced lupus?
Isoniazid
Does an asymmetrical presentation suggests psoriatic arthritis or rheumatoid?
Psoriatic arthritis
When is a total hip replacement favoured to hemiarthroplasty?
If patients:
a) were able to walk independently out of doors with no more than the use of a stick and
b) are not cognitively impaired and
c) are medically fit for anaesthesia and the procedure.
Blood test results in APS? (2)
1) prolonged APTT (paraxodically)
2) low platelets
Is azathioprine safe to use in pregnancy?
Yes
Type A vs B v C ankle fractures (Weber classification)?
Type A: below the syndesmosis
Type B: fractures start at the level of the syndesmosis
Type C: above the syndesmosis
What is the most common cause of foot drop?
Common peroneal nerve lesion
Give some causes of foot drop
1) Common peroneal nerve lesion
2) L5 radiculopathy
3) Sciatic nerve lesion
4) Superficial or deep peroneal nerve lesion
What is a common peroneal nerve lesion often 2ary?
Compression at the neck of the fibula
e.g. certain positions such as leg crossing, squatting or kneeling
Baker’s cysts and plaster casts to the lower leg are also known to be precipitating factors.
What are the rotator cuff muscles?
Group of 4 shoulder muscles:
1) supraspinatus
2) infraspinatus
3) teres minor
4) subscapularis
Role of the rotator cuff muscles?
Their tendons originate from the scapula and attach to the humeral head.
Provide glenohumeral joint additional stability.
Typical location of pain in rotator cuff injury?
Subacromial pain
What is the most common cause of shoulder pain presenting to 1ary care?
Rotator cuff injury
What 2 groups can individuals with rotator cuff injuries be broadly divided into according to their presenting clinical features?
- Those with subacromial impingement symptoms (SAIS):
- Those with symptoms of a torn rotator cuff tendon:
Features of rotator cuff injury with subacromial impingement symptoms (SAIS)?
1) Pain typically localised to the anterior superior shoulder
2) Insidious onset over weeks to months
3) Painful arc of motion
Describe a painful arc of motion
During arm abduction, shoulder pain occurs between 60 to 120º.
Pain eases beyond 120º but can return when returning the arm back to its original position.
Reports of difficulty during daily activities such as combing hair or reaching up to open a cupboard.
Features of rotator cuff injury with symptoms of a torn rotator cuff tendon?
1) Usually due to trauma (fall, lifting or catching something heavy)
2) Chronic degenerative tears e.g. due to excessive repetitive motions and normal age-related muscular deterioration
3) Pain
4) Muscular weakness and atrophy (50-63%)
- Inability to abduct the arm above 90º
In patients with suspected rotator cuff tendon tears, what special tests can elucidate the tendon(s) affected?
1) Empty can test
2) Posterior cuff test
3) Gerber’s lift-off test
What does the empty can test evaluate?
Evaluates supraspinatus
1) Patient’s raise their arm to 90º in the scapular plane
2) The arm is internally rotated (thumbs down)
3) Downward pressure is applied to their arm
4) Presence of weakness or pain indicates a tear
What does the posterior cuff test evaluate?
Evaluates infraspinatus
Weakness or pain on resisted external rotation suggests a tear
What does Gerber’s lift-off test evaluate?
Evaluates subscapularis
1) Patient attempts to lift a hand from small of the back, while resistance is applied
2) Weakness or pain suggests a subscapularis tear
When should you refer to 2ary care in rotator cuff injury?
If patients continue to have symptoms after 6 weeks of non-surgical care
Signs & symptoms in frozen shoulder?
1) Pain (commonly deltoid) or stiffness (depending on phase)
2) Restriction in active AND passive external rotation
What is an appropriate rule out test for SLE?
ANA (high sensitivity but low specificity)
Why are anti-dsDNA antibodies not a useful rule out test in SLE?
Highly specific but less sensitive (there is a greater chance with these compared to ANA testing that a patient has SLE despite a negative test result).
What does a raised CRP in SLE indicate?
May indicate an underlying infection (as during active SLE disease CRP may be normal).
Does lung involvement point towards a diagnosis of limited or diffuse systemic sclerosis?
Diffuse
What is a derm manifestation of sarcoid?
Lupus pernio: an indurated, plaque-like eruption that most frequently occurs on the nose, cheeks, chin, and forehead
Low levels of which types of complement are associated with SLE?
C3 & C4
Which test is most SENSITIVE for SLE?
ANA
Which test is most SPECIFIC for SLE?
Anti-dsDNA
