General Flashcards
what is Osteoarthritis
progressive loss of articular cartilage and remodelling of the underlying bone
pathophysiology of Osteoarthritis
degradation of cartilage and remodelling of bone due to active response by chondrocytes and inflammatory cells in the surrounding tissue
release of enzymes from these cells destroys the articular cartilage
the exposure of the underlying subchondral bone results in sclerosis, followed by reactive remodelling changes that lead to the formation of osteophytes and sunchondral bone cysts
the joint space is also progressively lost over time
What are the typical radiological features in Osteoarthritis
osteophyte formation
subchondral bone cysts
reduced joint space
subchondral sclerosis
risk factors for osteoarthritis
obesity
advancing age
female gender
manual labour jobs
what are the most common joints affected by OA
small joints of the hands and feet
hip joint
knee joint
clinical features/symptoms of OA
symptoms are chronic and gradually worsening
pain and stiffness in joints - worsened with activity and relieved by rest
pain that worsens throughout the day
bouchard nodes and heberden nodes
heberden vs bouchard nodes
heberden = swelling of DIPJs
bouchard = swelling of PIPJs
osteoathritis vs rheumatoid arthritis
OA = morning stiffness lasting less than 30 mins, pain worsens with activity, stiffness returns after resting joint for a long period of time, asymmetrical effect
RA = morning stiffness lasting longer than 30 mins, stiffness and pain improve with activity, symmetrical effect
key differential to look out for (and what to look out for) when examining for OA
septic arthritis
hot, swollen, inflamed joint with rapid onset symptoms
management of OA; conservative, medical and surgical
conservative = weight loss, physio, strengthening exercises
medical = analgesia and NSAIDs, intra-articular steroid injections
surgical = arthroplasty (replace joint)
what 3 words form the basis of surgical fracture management
Reduce
Hold
Rehabilitate
what is reduction of a fracture
reduction involves restoring the anatomical alignment of a fracture or dislocation of the deformed limb
the main principle of reduction is to correct the deforming forces that resulted in the injury
what does reduction of a fracture allow for
the main principle is to correct the deforming forces that resulted in the injury
it allows for;
- tamponade of the bleeding
- reduction in the traction of surrounding soft tissues
- reduction in the traction on the traversing nerves
- reduction in the traction on the traversing blood vessels
what does ‘hold’ mean when talking about fracture management
hold refers to the immobilisation of the fracture
what are the most common ways to immobilise a fracture
simple splints
plaster casts
when applying a plaster cast what are the 2 most important principles to remember
- for the first 2 weeks - plasters are not circumferential
- they need and area which is covered by only the overlying dressing to allow the fracture to swell, if not the fracture will swell and become very painful and tight, and if left the patient would be at risk of compartment syndrome - if there is axial instability (whereby the fracture is able to rotate along its long axis) e.g. combined radius/ulna and combined tibia/fibula fractures, the plaster should cross both the joint above and below
when should an above elbow or above knee plaster cast be used
casts that cross both the joint above and below should only be used when the fracture is able to rotate along its long axis e.g. a combined radius/ulna fracture and a combined tibia/fibula fracture
what important clinical points should you inform the patient of or think about regarding fracture immobilisation
weight bearing - depends on fracture
thromboprophylaxis - if a patient is immobilised and non-weight bearing, it is common to provide thromboprophylaxis
inform patient of symptoms of compartment syndrome and warn them that if they see any symptoms to immediately return to A&E
what does rehabilitate mean in terms of fracture management
intensive period of physiotherapy following fracture management
when faced with acute monoarthritis, what is the first differential you should immediately consider
septic arthritis
what is key to obtain in the history of a patient presenting with an acutely swollen joint
onset, site and timeframe
any precipitating factors e.g. trauma
any systemic symptoms e.g. fever, rigors, lethargy
relieving or aggravating factors
previous joint problems in this area (acute exacerbation of chronic issue)
ability to weight bear
past medical history
what framework is used when examining affected joints
look, feel, move
what investigations should be carried out in a patient presenting with an acutely swollen joint
routine bloods - FBC, CRP for infection + ESR (rheumatological cause) + serum urate (gout)
X-ray - especially if history of trauma to evaluate any fracture
joint aspiration
what is the most important investigation to do in a patient with acute monoarthritis - and what specific investigations should it be sent for
joint aspiration
visually inspect it first for opacity, colour and presence of frank pus
then the aspirate can be sent for white cell count, microscopy, culture and sensitivity and light microscopy (for crystals)
briefly describe the difference in aspirate appearance and composition (white cell count and neutrophils) in non-inflammatory, inflammatory and septic arthritis
non-inflammatory = clear/straw coloured, normal white cell count and low neutrophils
inflammatory = clear or cloudy yellow, moderate white cell count and moderate neutrophils
septic = turbid, very high white cell count and high neutrophils
what is gout and what is it caused by
gout is an inflammatory arthritis caused by the collection of monosodium urate crystals in a joint
caused by hyperuricemia leading to crystilisation of the urate in the joint space
clinical features/symptoms of gout
affects the first MTP joint
often episodic with flare ups lasting days or weeks, usually brought on by triggers including stress, illness and dehydration
what investigations are used to confirm the diagnosis of gout and what is the management
investigations = joint aspiration and light microscopy - to determine the presence of monosodium urate crystals in the synovial fluid
management = acute gout treated with NSAIDs, patients who have had multiple episodes can be prescribed prophylactic agents such as allopurinol for prevention
what is pseudogout and how is it different to gout
inflammatory arthritis caused by deposits of calcium pyrophosphate crystals
more likely to affect proximal joints with the knee and wrist being most commonly affected
risk factors include hyperparathyroidism, advanced age and hypophosphataemia
presentation of rheumatoid arthritis
swollen, painful joints with stiffness that is usually worse in the morning
pain improves on activity
associated fatigue, lethargy, pyrexia or weight loss
in patients with an acutely swollen joint following a trauma, what should initially be suspected
haemarthrosis - bleeding into a joint cavity
when a fracture is referred to as an ‘open’ fracture, what does this mean
when there is direct communication between the fracture site and the external environment
what are the 4 main important things to think about when a patient requires surgery for an open fracture
skin - is the skin loss significant to the point where it will require the aid of plastics surgery
soft tissues - is there significant muscle/tendon/ligament loss such that it requires reconstructive surgery
neurovascular injury - are any blood vessels or nerves compressed or have been transected all together
infection - risk of infection is very high
what classification is used when looking at open fractures
Gustillo-Anderson classification
describe the Gustillo-Anderson classification
Type 1 = <1cm and clean
Type 2 = 1-10cm and clean
Type 3A = >10cm wound and high-energy, but with adequate soft tissue coverage
Type 3B = >10cm wound and high-energy, but with inadequate soft tissue coverage
Type 3C = all injuries with vascular injury
***simple summary is;
3A = managed by orthopaedics alone
3B = requires plastics input
3C = requires vascular input
investigations into open fractures
routine bloods + clotting screen
group and save
X-ray of affected areas
for comminuted fractures a CT scan may aid management
management of an open fracture
following suitable resuscitation, urgent realignment and splinting of the limb is required
broad spectrum antibiotics and tetanus injection then given
photograph the wound and remove any gross debris
then definitive surgical management required - debridement and washed with copious amounts of saline
if there is vascular compromise it requires immediate surgical exploration by vascular surgeons
