Investigating and Managing Common Orthopaedic Presentations Flashcards
Broadly describe the differentiation between inflammatory and non-inflammatory arthritis.
What are the different causes of inflammatory arthritis?
What are the different causes of non-inflammatory arthritis?
Which questions should you ask a patient presenting with joint pain?
- Exact location of pain
- When is the pain / swelling / stiffness in the joints worst?
- Do the joint symptoms improve with activity?
- Do you have morning stiffness? Does it last for < / > 60 minutes?
Which specific question would you ask if querying rotator cuff impingement / tear?
Do you have pain in the front of your shoulder / side of your arm on activities such as brushing your hair?
Which specific question would you ask if querying medial epicondylitis (Golfer’s elbow / pitcher’s elbow)?
Pain in medial elbow with wrist flexion such as shaking hands or carrying suitcase?
Which specific question would you ask if querying lateral epicondylitis (tennis elbow)?
Pain in lateral elbow with wrist extension (using screwdriver, turning doorknobs)?
Which specific question would you ask if querying DeQuervain tenosynovitis?
Pain on dorsal thumb tendons with grasping?
Which specific question would you ask if querying prepatellar bursitis (Clergyman’s knee or Housemaid’s knee)?
Pain on patella with kneeling?
Which specific question would you ask if querying trochanteric bursitis?
Pain on lateral thigh while sleeping on that side?
Which specific question would you ask if querying achilles tendonitis?
Pain along the back of the heel and foot with stretching of ankle or standing on toes?
Which specific question would you ask if querying plantar fasciitis?
Pain in bottom of feet with first steps in the morning?
Pain on which actions would indicate that the most likely cause is the hip joint?
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Pain in the groin area / outer thigh when:
- Getting into or out of the car
- Getting into the bath tub
- Difficulty in bending over while sitting to tie shoe laces
Pain on which actions would indicate that the most likely cause is the knee joint?
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Pain in the front of the knee while:
- Walking up- or down-stairs
- Getting up from a chair
- Kneeling
- Squatting
Pain in which area would indicate that the most likely cause is the back (spinal stenosis)?
- Pain in buttock or leg with standing and walking that improves with rest and leaning forward on a grocery cart.
Describe the physical examination of a patient with joint pain.
- Look - for redness, swelling or deformity
- Touch - for heat or warmth
- Palpate - for tenderness or effusion / swelling
- Move - to assess tenderness and limitation of ROM in the joint
- The presence of any one of these - swelling, warmth or erythema is diagnostic or arthritis, but the absence of all of these is diagnostic or arthralgia.
What are the typical findings on examination of a patient with OA?
- Bony enlargement
- Heberden nodes
- Bouchard nodes
- Crepitus on motion
What are the typical findings on examination of a patient with gout / septic arthritis / injury / trauma?
Acute onset erythema and warmth
What are the typical findings on examination of a patient with rheumatoid arthritis?
- Ulnar deviation
- Boutonniere deformities
What are the typical findings on examination of a patient with psoriatic arthritis / spondyloarthritis?
Dactylitis
Which joints are affected by Heberden’s node and which by Bouchard’s node?
- Proximal interphalangeal joint - Bouchard’s node.
- Distal interphalangeal joint - Heberden’s node.
Explain how different types of arthritis can present based on pattern of presentation?
Monoarthropathies tend to be specific to trauma or OA.
What are the 4 signs of osteoarthritis?
KNOW THESE
- Joint space narrowing
- Osteophytes
- Subchondral cysts
- Bony sclerosis
What are the other findings to note on X-ray of an OA joint?
- Bone loss / AVN
- Loss of shape of femoral head
- Previous surgery / implants
- Deformity / alignment
What are the X-ray changes in knee OA?
What are the non-operative management options for OA?
- Analgesia
- Optimise
- Activity modification
- Change job
- Less golf?
- Walking aids
- Physiotherapy
- Intra-articular injection
- Cortisone
- Lubricant
What are the operative management options for OA?
- Osteotomy
- Re-align the joint / limb
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Arthrodesis
- Make a stiff, painless joint
- Mostly smaller joints
- Excision arthroplasthy
- Remove arthritis
- Leaves a shorter joint with less mobility
-
Replacement arthroplasty
- Large joints
- But also small joints!
What are the indications for joint replacement?
- Disabling pain - despite analgesia
- Functional restrictions - walking distance
- Quality of life - night pain
- Radiographic significant arthritis
What are the complications of joint replacement?
- Infection - 1-3%
- DVT / PE
- Peri-prosthetic fracture
- Loosening
- Knee >90% 15y survival
- Hip >95% 15y survival
- Knee
- Limited ROM
- ~15% residual pain & stiffness
- Limited ROM
- Hip
- Dislocation 1-5%
- Dissatisfaction
- 20% of patients are not happy with joint replacement even if function and pain are better
What are the investigations you should do if querying rheumatoid arthritis?
- Imaging
- X-ray
- USS
- MRI
- FBC and ESR
- Other tests
- RhF
- Anti-CCP (antibodies)
What is the first stage in management of rheumatoid arthritis?
- Lifestyle - maintain where possible.
- This is an MDT effort.
- Physiotherapy
- Occupational therapy
- Podiatry
- NSAIDs
- More effective than simple analgesics
- Variation in response
- Balance efficacy and toxicity
- Related to dose and diration of therapy
- GI
- Renal
- CV
- Elderly are at greater risk
What are the principles of using NSAIDs as pain relief in rheumatoid arthritis?
- Use the lowest dose compatible with symptom relief.
- Use gastroprotection in ‘at-risk’ patient.
- Reduce and, if possible, withdraw when good response from DMARD.
What are the benefits of using COX-2 inhibitors as pain relief in rheumatoid arthritis? Is there any risk?
- Selectively block COX-2 isoenzyme.
- Provide pain relief (as efficacious as NSAIDs).
- Less GI bleeding than NSAIDs (less significant GI symptoms remain e.g. dyspepsia).
- CV risk??
What is the second stage in the management of rheumatoid arthritis?
- NSAIDs
- COX-2 inhibitors
What is the third stage in the management of rheumatoid arthritis?
Long-term suppressive drug therapy with disease modifying anti-rheumatic drugs (DMARDs).
What are the benefits of using an early DMARD in rheumatoid arthritis?
- Stabilise joint function as early as possible = better outcome.
- Greater awareness of NSAID toxicity.
- DMARDs slow disease progression.
Which DMARDs have the best efficacy : toxicity ratio?
- Methotrexate and Sulfasalazine
- Increased use of combination therapy because it is better than sequential monotherapy.
Which score can be used as a measure of disease activity in rheumatoid arthritis?
What does it assess?
- DAS28
- Swollen joints
- Tender joints
- ESR
- Patient’s general health score
What monitoring should a patient undergo while on a DMARD?
- FBC
- LFTs
- U&E
- BP
- Urinalysis
Describe the use of systemic corticosteroids in rheumatoid arthritis.
- Not recommended for routine use
- If necessary, use lowest dose for shortest time
- Monitor due to side effect profile
Describe the use of intra-articular corticosteroids in rheumatoid arthritis.
- Give in ‘target’ joint (i.e. 1/2 large joints affected), can avoid systemic steroid.
- Maximum number per joint / time - but no evidence for this theory.
- Evidence is lacking for this practice, but patients report benefit.
What are the TNF α blockers used as DMARDs in rheumatoid arthritis?
- Infliximab (human antichimeric antibody)
- Etanercept (fusion protein)
- Adalimumab (fully humanised monoclonal antibody)
- Golimumab (human monoclonal antibody)
What are the effects of blocking TNFα?
- Immunological
- ↓ Rheumatoid factor
- T cell function restored
- Inflammation
- ↓ Cytokine production in joints (IL1, IL6, TNF)
- Angiogenesis
- ↓ levels of angiogenesis
- Joint destruction
- ↓ damage to bone and cartilage
- Haematology
- ↓ Platelets . fibrinogen, restoration of Hb
What do each of these suffixes mean:
- ximab?
- zumab?
- umab?
- cept?
Describe their immunogenicity.
- Ximab - chimeric antibody
- Zumab - humanised antibody
- Umab - human antibody
- Cept - fusion protein
- Immunogenicity - the ability to provoke an inflammatory response.
What are the eligibility criteria for biological therapy?
- DAS28 >5.1
- At least 2 previous DMARDs
- Adequate response at 3 months
- 3-monthly monitoring
What effect should infection have on prescribing biologic therapy?
- Do not initiate in the presence of serious active infection or in patients at high risk.
- Discontinue in presence of serious infection.
Describe the use of biologic therapies in patients with malignancy.
- No increased risk of solid tumours or lymphoproliferative disease.
- Investigate / stop the therapy in patients with active malignancy.
- Exercise caution in pre-malignant conditions.
- Remember preventative skin care / ongoing surveillance.
How do you describe an X-ray of a fracture?
- Say what you see
- Location of fracture
- Features of fracture:
- Shape
- Displacement description
- Comminution
- Intra-articular
- Any dislocation of associated joint
Why are paediatric fractures different to adult fractures?
- Open physes - growth may be affected
- Remodelling potential as they grow
- The younger they are, the faster they heal
What is a greenstick fracture?
- Like breaking a root vegetable - it breaks on one side but not the other.
- This is what paediatric bones do.
What is a buckle fracture?
- Looks like a buckle on the cortex.
- Very stable.
- Usually treat with just a cast or splint
Describe each stage of the Salter Harris classification.
Describe basic fracture management.
-
First of all:
- ABC approach to emergency care of entire patient then ensure limb is neurovascularly intact.
- Analgesia
- Splintage - provides pain relief and resuces internal blood loss.
- Open wounds - dressings and ABx.
- X-rays in 2 planes.
- Definitive treatment:
- Stable - treatment without surgery - hold in correct position until heals (cast / splint / traction).
- Unstable - surgical fixation with metalwork - usually allows quicker mobilisation of the affected limb.
Define acute compartment syndrome.
- Intracompartmental pressure is elevated (relative to the end-capillary pressure) to a level and for such a duration that perfusion of intracompartmental structures is compromised and decompression is nevessary to prevent muscle necrosis.
- Pressure increases to such a level that blood cannot flow in.
- If blood cannot flow in - the tissue dies.
What are the criteria for clinical diagnosis of acute compartment syndrome?
- Pain
- Pain on passive stretch
- Paraesthesia
- Paralysis
- Pulses present
- Palpation
- Pain in 95% of conscious patients
- 35% unconscious or under anaesthetic at time of diagnosis
- Stretch pain 49%
- Neurological abnormality 53%
What is the single cause of a poor outcome in acute compartment syndrome?
Delay is the single cause of a poor outcome in acute compartment syndrome.
Compartment syndrome for >8 hours causes tissue death which will result in amputation.
What is the ideal outcome for a patient with acute compartment syndrome?
- Normal function of the extremity
- Absence of deformity
- Minimal cosmetic deformity
What are the outcomes to avoid in acute compartment syndrome?
- Contracture
- Sensory deficit
- Paralysis
- Infection
- Nonunion
- Amputation
Describe how acute compartment syndrome is diagnosed.
- Compartment monitoring - catheter in to monitor intra-compartment pressure.
- Need perfusion pressure of ~13mmHg to maintain a compartment.
- Continuous 24 hour monitoring.
- Delta p (diastolic - tissue pressure) <30mmHg.
