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Elderly Years > Investigating and Managing Common Orthopaedic Presentations > Flashcards

Investigating and Managing Common Orthopaedic Presentations Flashcards

1
Q

Broadly describe the differentiation between inflammatory and non-inflammatory arthritis.

A
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2
Q

What are the different causes of inflammatory arthritis?

A
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3
Q

What are the different causes of non-inflammatory arthritis?

A
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4
Q

Which questions should you ask a patient presenting with joint pain?

A
  • 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?
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5
Q

Which specific question would you ask if querying rotator cuff impingement / tear?

A

Do you have pain in the front of your shoulder / side of your arm on activities such as brushing your hair?

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6
Q

Which specific question would you ask if querying medial epicondylitis (Golfer’s elbow / pitcher’s elbow)?

A

Pain in medial elbow with wrist flexion such as shaking hands or carrying suitcase?

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7
Q

Which specific question would you ask if querying lateral epicondylitis (tennis elbow)?

A

Pain in lateral elbow with wrist extension (using screwdriver, turning doorknobs)?

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8
Q

Which specific question would you ask if querying DeQuervain tenosynovitis?

A

Pain on dorsal thumb tendons with grasping?

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9
Q

Which specific question would you ask if querying prepatellar bursitis (Clergyman’s knee or Housemaid’s knee)?

A

Pain on patella with kneeling?

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10
Q

Which specific question would you ask if querying trochanteric bursitis?

A

Pain on lateral thigh while sleeping on that side?

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11
Q

Which specific question would you ask if querying achilles tendonitis?

A

Pain along the back of the heel and foot with stretching of ankle or standing on toes?

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12
Q

Which specific question would you ask if querying plantar fasciitis?

A

Pain in bottom of feet with first steps in the morning?

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13
Q

Pain on which actions would indicate that the most likely cause is the hip joint?

A
  • 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
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14
Q

Pain on which actions would indicate that the most likely cause is the knee joint?

A
  • Pain in the front of the knee while:
    • ​Walking up- or down-stairs
    • Getting up from a chair
    • Kneeling
    • Squatting
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15
Q

Pain in which area would indicate that the most likely cause is the back (spinal stenosis)?

A
  • Pain in buttock or leg with standing and walking that improves with rest and leaning forward on a grocery cart.
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16
Q

Describe the physical examination of a patient with joint pain.

A
  • 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.
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17
Q

What are the typical findings on examination of a patient with OA?

A
  • Bony enlargement
  • Heberden nodes
  • Bouchard nodes
  • Crepitus on motion
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18
Q

What are the typical findings on examination of a patient with gout / septic arthritis / injury / trauma?

A

Acute onset erythema and warmth

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19
Q

What are the typical findings on examination of a patient with rheumatoid arthritis?

A
  • Ulnar deviation
  • Boutonniere deformities
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20
Q

What are the typical findings on examination of a patient with psoriatic arthritis / spondyloarthritis?

A

Dactylitis

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21
Q

Which joints are affected by Heberden’s node and which by Bouchard’s node?

A
  • Proximal interphalangeal joint - Bouchard’s node.
  • Distal interphalangeal joint - Heberden’s node.
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22
Q

Explain how different types of arthritis can present based on pattern of presentation?

A

Monoarthropathies tend to be specific to trauma or OA.

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23
Q

What are the 4 signs of osteoarthritis?

KNOW THESE

A
  • Joint space narrowing
  • Osteophytes
  • Subchondral cysts
  • Bony sclerosis
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24
Q

What are the other findings to note on X-ray of an OA joint?

A
  • Bone loss / AVN
    • Loss of shape of femoral head
  • Previous surgery / implants
  • Deformity / alignment
25
Q

What are the X-ray changes in knee OA?

A
26
Q

What are the non-operative management options for OA?

A
  • Analgesia
    • Optimise
  • Activity modification
    • Change job
    • Less golf?
  • Walking aids
  • Physiotherapy
  • Intra-articular injection
    • Cortisone
    • Lubricant
27
Q

What are the operative management options for OA?

A
  • Osteotomy
    • Re-align the joint / limb
  • 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!
28
Q

What are the indications for joint replacement?

A
  • Disabling pain - despite analgesia
  • Functional restrictions - walking distance
  • Quality of life - night pain
  • Radiographic significant arthritis
29
Q

What are the complications of joint replacement?

A
  • Infection - 1-3%
  • DVT / PE
  • Peri-prosthetic fracture
  • Loosening
    • Knee >90% 15y survival
    • Hip >95% 15y survival
  • Knee
    • Limited ROM
      • ~15% residual pain & stiffness
  • Hip
    • Dislocation 1-5%
  • Dissatisfaction
    • 20% of patients are not happy with joint replacement even if function and pain are better
30
Q

What are the investigations you should do if querying rheumatoid arthritis?

A
  • Imaging
    • X-ray
    • USS
    • MRI
  • FBC and ESR
  • Other tests
    • RhF
    • Anti-CCP (antibodies)
31
Q

What is the first stage in management of rheumatoid arthritis?

A
  • 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
32
Q

What are the principles of using NSAIDs as pain relief in rheumatoid arthritis?

A
  • Use the lowest dose compatible with symptom relief.
  • Use gastroprotection in ‘at-risk’ patient.
  • Reduce and, if possible, withdraw when good response from DMARD.
33
Q

What are the benefits of using COX-2 inhibitors as pain relief in rheumatoid arthritis? Is there any risk?

A
  • 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??
34
Q

What is the second stage in the management of rheumatoid arthritis?

A
  • NSAIDs
  • COX-2 inhibitors
35
Q

What is the third stage in the management of rheumatoid arthritis?

A

Long-term suppressive drug therapy with disease modifying anti-rheumatic drugs (DMARDs).

36
Q

What are the benefits of using an early DMARD in rheumatoid arthritis?

A
  • Stabilise joint function as early as possible = better outcome.
  • Greater awareness of NSAID toxicity.
  • DMARDs slow disease progression.
37
Q

Which DMARDs have the best efficacy : toxicity ratio?

A
  • Methotrexate and Sulfasalazine
  • Increased use of combination therapy because it is better than sequential monotherapy.
38
Q

Which score can be used as a measure of disease activity in rheumatoid arthritis?

What does it assess?

A
  • DAS28
    • Swollen joints
    • Tender joints
    • ESR
    • Patient’s general health score
39
Q

What monitoring should a patient undergo while on a DMARD?

A
  • FBC
  • LFTs
  • U&E
  • BP
  • Urinalysis
40
Q

Describe the use of systemic corticosteroids in rheumatoid arthritis.

A
  • Not recommended for routine use
  • If necessary, use lowest dose for shortest time
  • Monitor due to side effect profile
41
Q

Describe the use of intra-articular corticosteroids in rheumatoid arthritis.

A
  • 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.
42
Q

What are the TNF α blockers used as DMARDs in rheumatoid arthritis?

A
  • Infliximab (human antichimeric antibody)
  • Etanercept (fusion protein)
  • Adalimumab (fully humanised monoclonal antibody)
  • Golimumab (human monoclonal antibody)
43
Q

What are the effects of blocking TNFα?

A
  • 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
44
Q

What do each of these suffixes mean:

  • ximab?
  • zumab?
  • umab?
  • cept?

Describe their immunogenicity.

A
  • Ximab - chimeric antibody
  • Zumab - humanised antibody
  • Umab - human antibody
  • Cept - fusion protein
  • Immunogenicity - the ability to provoke an inflammatory response.
45
Q

What are the eligibility criteria for biological therapy?

A
  • DAS28 >5.1
  • At least 2 previous DMARDs
  • Adequate response at 3 months
  • 3-monthly monitoring
46
Q

What effect should infection have on prescribing biologic therapy?

A
  • Do not initiate in the presence of serious active infection or in patients at high risk.
  • Discontinue in presence of serious infection.
47
Q

Describe the use of biologic therapies in patients with malignancy.

A
  • 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.
48
Q

How do you describe an X-ray of a fracture?

A
  • Say what you see
  • Location of fracture
  • Features of fracture:
    • Shape
    • Displacement description
    • Comminution
    • Intra-articular
    • Any dislocation of associated joint
49
Q

Why are paediatric fractures different to adult fractures?

A
  • Open physes - growth may be affected
  • Remodelling potential as they grow
  • The younger they are, the faster they heal
50
Q

What is a greenstick fracture?

A
  • Like breaking a root vegetable - it breaks on one side but not the other.
  • This is what paediatric bones do.
51
Q

What is a buckle fracture?

A
  • Looks like a buckle on the cortex.
  • Very stable.
  • Usually treat with just a cast or splint
52
Q

Describe each stage of the Salter Harris classification.

A
53
Q

Describe basic fracture management.

A
  • 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.
54
Q

Define acute compartment syndrome.

A
  • 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.
55
Q

What are the criteria for clinical diagnosis of acute compartment syndrome?

A
  • 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%
56
Q

What is the single cause of a poor outcome in acute compartment syndrome?

A

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.

57
Q

What is the ideal outcome for a patient with acute compartment syndrome?

A
  • Normal function of the extremity
  • Absence of deformity
  • Minimal cosmetic deformity
58
Q

What are the outcomes to avoid in acute compartment syndrome?

A
  • Contracture
  • Sensory deficit
  • Paralysis
  • Infection
  • Nonunion
  • Amputation
59
Q

Describe how acute compartment syndrome is diagnosed.

A
  • 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.

Elderly Years (28 decks)

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