MBChB Flashcards
1
Q
Seropositive arthritis
A
Lupus Rheumatoid arthritis Scleroderma Vasculitis Sjogrens
2
Q
Seronegative Arthritis
A
Ankylosing Spondylitis
Psoriatic Arthritis
Reactive arthritis
Inflammatory bowel disease arthritis
3
Q
Most common form of arthritis?
A
Osteoarthritis
4
Q
Second degree causes of OA
A
Congenital dislocation of the hip Perthes SUFE Previous intra‐articular fracture Extra‐articular fracture with malunion Osteochondral / hyaline cartilage injury Crystal arthropathy Inflammatory arthritis (can give rise to mixed pattern arthritis) Meniscal tears Genu Varum or Valgum
5
Q
What is perthes?
A
A disease where the top of the thigh bone in the hip softens and breaks down
6
Q
SUFE
A
Slipped upper femoral epiphyses
the growth plate is weak and the ball slips down and backwards
7
Q
Radiographical findings of osteoarthritis?
A
L (loss of joint space)
O (osteophytes)
S (sclerosis)
S (subchondral cysts)
8
Q
Diagnosis of rheumatoid arthritis
A
Clinical presentation, radiographic findings and serological analysis
The ACR/EULAR Rheumatoid Arthritis Criteria scoring system assists in the diagnosis.
9
Q
Which internal organs can be affected in rheumatoid arthritis?
A
Rheumatoid Lung
Ischaemic heart disease
10
Q
Operations performed for rheumatoid arthritis
A
Synovectomy Joint replacement Joint excision Tendon transfers Arthrodesis (fusion) Cervical spine stabilisation
11
Q
Synovectomy
A
Removes inflamed synovium
12
Q
Most likely places to get joint involvement in SLE?
A
Hands and knees
Avascular necrosis can also occur in the hip and knee
13
Q
How would you treat tendon ruptures and severe symptomatic joint damage in SLE?
A
Surgery
but remember that they try to treat everything with drugs primarily
14
Q
Which gender is more commonly affected in ankylosing spondylitis?
A
Males 3:1
chronic inflammatory disease of the spine and sacro‐iliac joints which leads to eventual fusion of the intervertebral joints and SI joints
May often develop knee and hip arthritis aswell
15
Q
Conditions associated with ankylosing spondylitis
A
aortitis, pulmonary fibrosis and amyloidosis
16
Q
Xrays show bony spurs from the vertebral bodies known as syndesmophytes which can bridge the intervertebral disc resulting in fusion producing a “bamboo spine”
A
Ankylosing Spondylitis
17
Q
Treatment for ankylosing spondylitis
A
Treatment consists of physiotherapy, exercise, simple analgesia and DMARDs for more aggressive disease
18
Q
onycholysis
A
Lifting of the nail from the nail bed
19
Q
In psoriatic arthritis, some patients have a predilection for arthritis in which joints?
A
DIP
20
Q
In psoriatic arthritis, 5% of patients with DIP arthritis develop a more aggressive and destructive form of this. What is this condition called?
A
Arthritis Mutilans
21
Q
Enteropathic arthritis
A
Enteropathic arthritis refers to an inflammatory arthritis involving the spine and peripheral joints occurring in patients with inflammatory bowel disease (Crohn’s disease and Ulcerative Colitis), coeliac disease, patients with extensive bowel resections and patients with a reactive arthritis from bacterial or parasitic infection of the GI tract (Shigella, Salmonella, Yersinia, Campylobacter, Cryptosporidium, Giardia and others)
22
Q
Treatment for Enteropathic Arthritis
A
10‐20% of IBD sufferers will experience spine or joint problems. Treatment includes treating the underlying condition (corticosteroids, antibiotics) and DMARDs can help. Any peripheral arthritis is usually self‐limiting and orthopaedic surgery is not required but steroid injection can help.
23
Q
Some patients have a triad of symptoms of urethritis, uveitis and arthritis known as Reiter’s syndrome
A
Reactive Arthritis
24
Q
What is gout usually due to?
A
Gout is a crystal arthropathy caused by deposition of urate crystals within a joint which is usually due to high serum uric acid levels (hyperuricaemia)
25
Gouty tophi
Painless white accumulations of uric acid can occur in the soft tissues and erupt through the skin
26
What can chronic gout result in?
Destructive erosive arthritis
27
How to diagnose gout
A definitive diagnosis can be made by analysing a sample of synovial fluid with polarised microscopy (the fluid is also analysed with Gram stain and culture to exclude infection). Uric acid crystals are needle shaped and display negative birefringence (change from yellow to blue when lined across the direction of polarization).
28
Treatment for Gout
Treatment for acute attacks includes NSAIDs, corticosteroids, opioid analgesics and colchicine for patients who cannot tolerate NSAIDs (though it can have GI side effects and interfere with other medications). For sufferers of recurrent attacks or those with joint destruction or tophi, allopurinol or probenecid can prevent attacks but they should not be started until an acute attack has settles as theoretically they could potentiate an acute attack.
29
What is Chondrocalcinosis
The term chondrocalcinosis is used when calcium pyrophosphate deposition occurs in cartilage and other soft tissues in the absence of acute inflammation
30
Treatment of Pseudogout
Treatment of acute attacks includes NSAIDs, corticosteroids (systemic and intra‐articular) and occasionally colchicine. There are no medications used as prophylaxis to prevent recurrence.
31
Where does gout tend to affect?
Knee, wrist and ankle
32
What can pseudogout coexist with?
Pseudogout can coexist with hyperparathyroidism, hypothyroidism, renal osteodystrophy, haemochromatosis and Wilson’s disease. It can also occur in some cases of OA however chronic CPPD can also result in osteoarthritic change
33
Which bacteria can infect osteocytes intracellularly and make osteomyelitis very hard to get rid of?
Staph. aureus
34
In which age group would you usually see an acute osteomyelitis in the absence of surgery?
Children
| Also seen in immunocompromised
35
Brodie's Abscess
Children can develop a subacute osteomyelitis with a more insidious onset where the bones react by walling off the abscess with a thin rim of sclerotic bone. This is known as a Brodie's abscess
36
Where does chronic osteomyelitis tend to occur in adults?
Chronic osteomyelitis tends to be in the axial skeleton (spine or pelvis) with haematogenous spread from pulmonary or urinary infections, or from infection from the intervertebral discs.
Chronic OM in adults/children can be peripheral from previous open fracture or internal fixation
37
What might suppress chronic osteomyelitis?
Antibiotics
38
What well known historical disease could cause osteomyelitis?
Tuberculosis (particularly in spine from haematogenous spread from the primary lung infection)
39
Where might you see osteomyelitis occurring if you've had TB?
Spine
40
In which patients might you see an osteomyelitis caused by salmonella?
Sickle cell anaemia patients
41
Which groups of people are particularly susceptible to osteomyelitis of the SPINE?
Diabetics, intravenous drug users and other immunocompromised patients
42
What can be used to determine extent of infection in osteomyelitis?
MRI
43
Organism which usually causes osteomyelitis?
Staph aureus but atypical in immunocompromised
44
Which heart condition should you check for in osteomyelitis
Endocarditis should be considered (look for clubbing, splinter haemorrhages, murmur, consider ECHO
45
Indications for surgery in osteomyelitis
Indications for surgery include inability to obtain cultures by needle biopsy, no response to antibiotic therapy, progressive vertebral collapse and progressive neurological deficit. Surgery involves debridement, stabilization and fusion of adjacent vertebrae.
46
Doughy Swelling?
Synovitis
| You would see this in rheumatoid arthritis ;)
47
Synovectomy?
Surgery to remove inflamed synovium
48
Predominant feature of inflammatory arthritis?
Synovium inflammation
49
Which non-articular diseases would suggest spondyloarthritis?
psoriasis, iritis, inflammatory bowel disease, non-specific urethritis, recent dysentery
50
Anticyclic citrullinated peptide antibodies
Marker for erosive disease in RA
| ESR and CRP raised in RA. You may also see normochromic normoctytic anaemia
51
Complications of Rheumatoid Arthritis
```
Bakers cysts (joint rupture)
Ruptured tendons
Joint infection
Spinal cord compression
AMYLOIDOSIS
```
52
Most common cause of secondary AA amyloidosis?
Rheumatoid Arthritis
53
Which procedure can excise all metatarsal heads in end stage rheumatoid foot?
Excision arthroplasty
54
What is arthrodesis gold standard for?
1st MTPJ OA
55
Which surgical procedure was originally used for TB hip and young OA hip?
Arthrodesis say whuuuut
56
Name a way in which you could fix malunion following a fracture?
Osteotomy
57
What is gold standard for hallux valgus?
Osteotomy
58
What is osteotomy?
Surgical realignment of bone
59
Antibodies in RA?
Antibodies to the Fc fragment of IgG (rheumatoid factor)
| Antibodies to citrullinated cyclic peptide
60
Allele associated with RA?
HLA-DR4
61
Which type of RA is smoking an environmental risk factor for?
Seropositive RA
62
What drives the overproduction of TNF-a in RA?
The interaction between macrophages, B & T lymphocytes
| interleukin 6 is also involved in RA
63
How does the pannus of inflamed synovium damage the underlying cartilage?
Blocks normal route for nutrition and it is also damaged through the direct effects of cytokines on the chondrocytes
64
Histological appearance of RA synovium?
Hypertrophy of the tissues with infiltration by lymphocytes and plasma cells
65
What is a useful predictor of prognosis of RA?
```
Rheumatoid factor
(persistently high titre in early disease implies more persistently active synovitis, more joint damage and a greater disability eventually)
```
66
Carpal tunnel syndrome
Carpal tunnel syndrome (CTS) is a median entrapment neuropathy that causes paresthesia, pain, numbness, and other symptoms in the distribution of the median nerve due to its compression at the wrist in the carpal tunnel
(10% of people with RA could present with this)
67
When is pain and stiffness worse in RA?
In the morning
68
Complications of RA
```
Ruptured tendons,
Ruptured joints (Baker's cysts)
Joint Infection
Spinal cord compression (atlantoaxial or upper cervical spine)
Amyloidosis (rare)
```
69
What cells might you see in septic arthritis?
Neutrophil leucocytosis
| abnormally high number of neutrophils
70
Finger deformities in RA?
Ulnar deviation
Boutonniere deformity
Swan-neck deformity
71
Foot deformities in RA?
- Foot becomes broader and hammer-toe deformity develops
- Exposure of metatarsal heads to pressure by forward migration of the protective fibrofatty pad causes pain
- Ulcers&calluses may develop under the metatarsal heads and over the dorsum of the toes
- flat medial arch and loss of flexibility
- ankle often assumes a valgus position
72
Soft tissue non-articular manifestations of RA
```
Rheumatoid nodules
(typically elbow, finger joints and achilles tendon)
```
73
Non-articuar manifestations of rheumatoid arthritis
```
Scleritis
Atlantoaxial subluxation rarely causing spinal compresison
Pleural effusion
Fibrosing alveolitis
Caplans syndrome
Small airways disease
Nodules
Anaemia
Carpal tunnel syndrome
Nail fold lesions of vasculitis
Splenomegaly
Leg ulcers
Ankle oedema
Amyloidosis
Tendon sheath swelling
Bursitis/nodules
Pericarditis
Lymphadenopathy
Sjogrens syndrome (dry eyes, dry mouth)
```
74
Poorly controlled RA with a persistently raised CRP and high cholesterol is a risk factor for premature what? (<3)
Premature coronary artery and cerebrovascular atherosclerosis
75
Most common cause of secondary osteoporosis?
Corticosteroids
76
Can sulfasalazine be used during pregnancy?
Yes
77
What must you monitor for when on steroids?
Hypertension and diabetes
78
Side effects when using sulfasalazine?
Leucopania
Thrombocytopenia
Nausea
Skin rashes and mouth ulcers
79
"Gold standard" drug in RA
Methotrexate
80
If nausea/poor absorption limit the efficacy of methotrexate, how might you administer it?
Subcutaneously
81
What could you give in combination with methotrextae to minimise side effects?
Oral folic acid
82
Side effects of leflunamide?
```
Diarrhoea
(leflunamide works in some patients who have failed to respond to methotrexate)
Neutropenia and thrombocytopenia
Alopecia
Hypertension
```
83
Leflunamide and pregnancy?
Should avoid in pregnancy due to long half life
84
Anti-TNF is usually given in combo with..?
Methotrexate
85
List 5 anti-TNFs
```
Adalimumab
Etanercept (s/c)
Infliximab (IV)
Certolizumab
Golimumab (s/c) for severe RA
```
86
Side effects of methotrexate?
Nausea, mouth ulcers, diarrhoea
Neutropaenia and/or thrombocytopenia
Renal impaitment
Pulmonary fibrosis
87
Etanercept side effects?
Injection site reactions
| Infections e.g. TB and septicemia
88
Adalimumab side effects?
Hypersensitivity reactions
Heart failure
Demyelination and autoimmune syndromes
Reversible lupus-like syndromes
89
Rituximab side effects?
```
Hypo/hypertension
Skin rash
Nausea
Pruritis
Back pain
Rare: toxic epidermal necrolysis
```
90
Side effects of Tocilizumab?
Headache, skin eruption, stomatitis, fever, anaphylactic reactions
91
RA drugs to avoid in pregnancy?
Leflunamide, methotrexate, Gold, CYCLOPHOSPHAMIDE, penicillamine (women must not conceive when on leflunamide or methotrexate)
92
When can oral NSAIDS and selective COX-2 inhibitors be used during pregnancy?
Oral NSAIDS and selective COX-2 inhibitors can be used after implantation up until the 3rd trimester
93
Can corticosteroids be used during pregnancy?
Yes, they can be used to control disease flares (the main maternal risks are hypertension, glucose intolerance and osteoporosis)
94
Which DMARDS can be used during pregnancy?
Sulfasalazine, hydroxychloroquine, aziathioprine, cyclosporin A
These can be used if required to control inflammation
95
Drugs that can induce SLE
```
Hydralazine
Procainamide
Penicillamine
Isoniazid
(SLE is mild though, kidneys and CNS are not affected)
```
96
What kind of light can trigger flares of SLE?
Ultrviolet
97
Pathology of SLE
SLE of the skin is characterised by deposition of complement and IgG antibodies and influx of neutrophils and lymphocytes
98
Most common clinical feature of SLE?
Joint problems
| Patients often present with similar features to RA
99
Hypocalcaemia Symptoms
```
Parasthesia
Muscle cramps
Irritability
Fatigue
Seizures
Brittle nails
```
100
What is a psuedofracture?
A dignostic form of osteomalacia
A condition seen in the radiograph of a bone as a thickening of the periosteum and formation of new bone over what looks like an incomplete fracture.
101
Hypercalcemia Symptoms
fatigue, depression, bone pain, myalgia, nausea, thirst, polyuria, renal stones, osteoporosis
102
Test for Carpal Tunnel
Tinel's Test: tapping nerve in carpal tunnel
| Phalen's Test: holding wrist in flexion position
103
Treatment for carpal tunnel syndrome?
Splint wrist in dorsiflexion overnight. This should resolve in a couple of weeks. If this doesn't then you can try a corticosteroid injection (avoid the nerve!!)
104
Carpal tunnel symptoms
```
numbness
altered sensation
dysaesthesia
clumsiness
night awakening
pain
```
105
Investigations for Carpal Tunnel
```
Nerve conduction studies
PV
X-ray
T4
blood glucose
```
106
Results (carpal tunnel) Free distribution, ulnar or radial?
Ulnar
107
Indications for Carpal Tunnel Syndrome decompression
Failed conservative treatment
Constant numbness
Weakness
108
What is the surgical treatment for carpal tunnel syndrome?
Standard open carpal tunnel release
Arthroscopic
endoscopic carpal tunnel release
mini-open carpal tunnel release
109
Which gender does cubital tunnel syndrome affect more?
Men
110
Symptoms of Cubital Tunnel Syndrome
Symptoms include numbness, tingling and/or pain in arm/hand/fingers
Symptoms often felt during the night or during the day when you've had your elbow bent for long periods of time
May have noticed clumsiness/weaker grip when using hand
111
Which fingers are likely to tingle in cubital tunnel syndrome?
Ring and little fingers :) aw little
112
Test shown in lecture slide that you could use when assessing cubital tunnel syndrome?
Trying to get patient to hold paper between fingers
113
Froment's Sign?
(thumb super bent when you try to get them to pinch stuff, because with ulnar nerve palsy, the patient will experience difficulty maintaining a hold and will compensate by flexing the FPL (flexor pollicis longus) of the thumb to maintain grip pressure causing a pinching effect.
Clinically, this compensation manifests as flexion of the IP joint of the thumb (rather than extension, as would occur with correct use of the adductor pollicis).
The compensation of the affected hand results in a weak pinch grip with the tips of the thumb and index finger, therefore, with the thumb in obvious flexion )
114
Treatment for Cubital Tunnel Syndrome
```
Splint
Neurolysis
Anterior transposition
subcutaneous
submuscular
intra-muscular
medial epicondylectomy
```
115
Causes of mechanical back pain
Causes implicated include obesity, poor posture, poor lifting technique, lack of physical activity, depression, degenerative disc prolapse, facet joint OA and spondylosis. Spondylosis is where the intervertebral discs lose water content with age resulting in less cushioning and increased pressure on the facet joints leading to secondary OA.
116
Explain disc degeneration and prolapse
The spinal disc tends to lose its water content during compressive loading – this is replaced during rest periods (when we are non weight-bearing) by absorbing tissue fluid from the adjacent vertebrae. In addition, as we age, the disc becomes less hydrated and loses its elasticity - ageing of the disc occurs early and can often be seen in the late teens or early twenties.
Everyday neck movements can squeeze a brittle disc, which forces the gel-like nucleus against the sides of the disc’s fibrous outer wall, the pulp material extrudes into the spinal nerve root or spinal canal causing a herniated or prolapsed disc – similarly this can occur due to a traumatic injury.
117
What is instability?
excessive motion caused by a degenerate disc, diagnosed typically on MRI
118
What type of motor neurone signs are reflexes?
Lower motor neurone
119
Commonest site for sciatica/lumbar radiculopathy
The commonest site for this to occur in the spine is the lower lumbar spine with the L4, L5 and S1 nerve roots contributing to the sciatic nerve and pain radiating to the part of the sensory distribution of the sciatic nerve (hence the term “sciatica”).
120
Prolapse in lumbar spine and resulting signs
L3/4 prolapse > L4 root entrapment > pain down to medial ankle (L4), loss of quadriceps power, reduced knee jerk
L4/5 prolapse > L5 root entrapment > pain down dorsum of foot, reduced power Extensor Hallucis Longus and tibialis anterior
L5/S1 prolapse > S1 root entrapment > pain to sole of foot, reduced power planarflexion, reduced ankle jerks
121
Treating an open fracture
ABx, tetanus, early debridement and operative stabilisation
122
Treating compartment syndrome
fasciotomy & operative stabilisation
123
Vascular injury # treatment
reduction, stabilisation and reassess circulation. May need revscularisation procedure
124
Pilon fracture
Inter-articular fracture of the distal tibia
125
Distal tibia fractures associated injuries
Spine, pelvis, calcaneus
126
Distal tibia fracture is a surgical emergency, how could you fix it?
Urgent bridging,
External fixation
(allows soft tissues to settle)
-Limited internal fixation
-CT scan to determine personality of fracture
-Internal fixation once soft tissues settle
127
Colles Fracture
A Colles' fracture, also raikar's fracture, is a fracture of the distal radius in the forearm with dorsal (posterior) and radial displacement of the wrist and hand
128
Galeazzi fracture dislocation
If the radius is fractured in isolation, suspect a dislocation of the DRUJ
129
Monteggia fracture dislocation
If the ulna is fractured in isolation, suspect a dislocation of the radial head
130
What is polytrauma?
>1 fracture (long bones +/- pelvis)
131
Causes/associations of patella dislocation
Hypermobility
Under-developed (hypoplastic) lateral femoral condyle
Increased Q-angle
Genu valgum
Increased femoral neck anteversion
Lateral quads insertions or weak vastus medialis
132
Treatment for repeat Patella dislocations
Surgery
(Lateral release / medial reefing
Patella tendon realignment)
133
Medial Reefing
A surgical procedure to tighten the tissues on the medial aspect of the patella
134
Lateral Release? (Patella dislocation treatment)
Loosening the tissues on the lateral side of the patella
135
What should you be aware of in patella dislocation spontaneous relocation?
Lateral collateral ligament injury and peroneal nerve injury
136
Nerve that could be damaged in knee dislocation?
Peroneal nerve
137
Associated fractures of hip dislocation
Posterior acetabular wall
| Femoral #'s
138
Hip dislocation presentation
Flexed, internally rotated and adducted knee
139
Nerve that could be damaged in hip dislocation
Sciatic nerve
140
Hip Dislocation Complications
Sciatic nerve palsy
Avascular necrosis of the femoral head
Secondary osteoarthritis of hip
Myositis ossificans
141
What may cause an olecranon fracture?
Usually an avulsion fracture from triceps contraction
142
If you dislocate your elbow, which bone might you fracture?
The head of the radius
143
What is a nightstick fracture?
Isolated fracture of the Ulna
144
How might you fix a colles fracture?
K-wiring
145
Complications of Distal Radial Fracture
Median nerve compression, EPL rupture, CRPS, loss grip strength
146
Distal Radius Fractures: how would you fix a comminuted intra-articular fracture with small fragments?
External fixation +/- K-wires
147
How would you fix a Smith's fracture?
ORIF
148
When might you consider looking for endocarditis in septi arthritis?
When you have multiple bones/joints affected by septic arthritis (septic emboli)
149
Who might get E.coli septic arthritis?
The elderly, IV drug users and seriously ill
150
Organisms which can cause a "low grade" infection in surgical implants (i.e. not the most common organism but the one that is most likely to be picked up later than should be)
Staph epidermidis
151
Useful blood tests for bone and joint infection?
CRP and Plasma viscosity
| Occasionally useful: blood cultures, white cell count, ESR
152
Most common causative organism in osteomyelitis?
Staph aureus
| haemophilus in children
153
What antibiotics does our lecturer use for cellulitis?
He uses Flucloxacillin and benzylpenicillin
154
In cellulitis, what is crepitis a sign of?
Crepitus is a sign of infection most commonly observed with anaerobic organisms
155
Which cells produce granulation tissue in secondary cone healing?
Fibroblasts
156
Which cells form cartilage?
Chondroblasts
157
Which cells lay down bone matrix (collagen type 1)
Osteoblasts
158
Which process produces immature woven bone?
Calcium mineralisation
159
By what week is the soft callus usually formed?
2-3 weeks
160
How long does it take the hard callus to appear?
6-12 weeks
161
Why can smoking impair healing of a fracture?
It causes vasospasm (bones need good blood supply for nutrients, oxygen and stem cells etc)
162
Aside from smoking, what else can impair fracture healing?
Chronic ill health
| Malnutrition
163
When do oblique fractures occur?
Obliques fractures occur with a shearing force (e.g. fall from a height, deceleration)
164
Why do oblique fractures have a slight advantage?
You can fix these with an interfragmentary screw.
| Remember also, oblique fractures tend to shorten and may angulate
165
Why are spiral fractures most unstable?
They can rotate, may also angulate
166
Why do spiral fractures occur?
Spiral fractures occur due to torsional forces
167
Are segmental fractures stable or unstable?
Segmental fractures are very unstable and require stablisation with long rods or plates
168
Clinical signs of a fracture
Localised bony tenderness (not mild diffuse tenderness)
Swelling
Deformity
Crepitus (from bone ends grating with an unstable fracture)
169
Guidelines used for ankle injury?
Ottowa guidelines
170
Investigation for mandibular fracture?
Tomogram
171
Which fractures can an oblique x-ray be good for?
- Scaphoid
- Acetabulum
- Tibial plateau
172
When are technetium bone scans useful?
Technetium bone scans can be useful to detect stress fractures (e.g. hip, femur, tibia, fibula, 2nd metatarsal) as these may fail to show up on x-ray until hard callus begins to appear
173
Analgesia usually given for long bone fracture?
IV morphine
174
Initial management of long bone fracture
S (splintage/immobilisation)
I (investigation e.g. x-ray)
A (analgesia)
175
Another name for temporary plaster slab
Backslag
176
When might you consider reducing fracture before waiting for x-rays?
If a fracture is grossly displaced, if there is an obvious fracture dislocation (e.g. of the ankle) or if there is a risk of skin damage
(x-ray will still be seen on x-ray post-reduction)
177
Anaesthetic that can be used for reducing an unstable fracture
GA
Spinal
Peripheral nerve block
Bier's block
178
When is a Bier block indicated?
For fractures of the forearm, wrist and hand (not appropriate for elbow)
179
Early complications of fractures
Compartment syndrome
Vascular injury with ischaemia
Nerve compression or injury
Skin necrosis
180
Early systemic complications of fractures
```
Hypovolaemia
Fat embolism
Shock
ARDS
Acute renal faiure
Systemic Inflammatory Response Syndrome
Multi-organ Dysfunction Syndrome
Death
```
181
Volkmann's Ischaemic Contracture
Volkmann's ischaemic contracture, is a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers
182
The main late systemic complication of a fracture
Pulmonary embolism
| deep vein thrombosis is a late LOCAL complication of a fracture
183
Why does secondary ischaemia occur in compartment syndrome?
Rising pressure compresses the venous system which results in congestion within the muscle. This means that oxygenated arterial blood cannot supply the congested muscle
184
What characterises muscle ischaemia in compartment syndrome?
Severe pain
Pressure rises can also compress nerves resulting in parasthesia and sensory loss.
THE CARDINAL CLINICAL SIGNS ARE (1) INCREASED PAIN ON PASSIVE STRETCHING OF THE INVOLVED MUSCLE AND (2) SEVERE PAIN OUTWITH THE ANTICIPATED SEVERITY IN THE CLINICAL CONTEXT
(loss of pulses is a feature of end stage ischaemia)
185
What happens if ischaemic muscle is left untreated?
If left untreated ischaemic muscle will necrose resulting in fibrotic contracture known as Volkmann's ischaemic contracture and poor function
186
What artery is at risk if a child sustains an elbow fracture?
Brachial artery injury
187
Which artery can be affected in shoulder trauma
Axillary artery
188
Which fracture may be associated with life threatening haemorrhage from arterial or venous bleeding?
Pelvic fractures
189
How might you localise the site of arterial occlusion?
Urgent angiography
190
How could you control ongoing haemorrhage from arterial injury in the pelvis?
Ongoing haemorrhage from arterial injury in the pelvis can be controlled by angiographic embolization performed by interventional radiologists
191
Where does the triceps insert at the elbow and what elbow movement does it produce?
The triceps is responsible for elbow extension and inserts at the olecranon process
192
Where do the brachialis and biceps insert and which elbow movement do they produce?
Brachialis inserts at the coronoid process and biceps inserts at the BICIPITAL TUBEROSITY of the radius. They produce flexion at the elbow. (the biceps also produces supination along with the supinator muscles)
193
Painful and tender lateral epicondyle with resisted middle finger and wrist extension?
Lateral epicondylitis (tennis elbow)
194
Which nerve could be damaged in a total hip replacement?
The sciatic nerve
195
Causes of avascular necrosis of the hip?
AVN of the hip may be primary/idiopathic
| -It can also be secondary to alcohol abuse, steroids, hyperlipidemia or thrombophilia
196
Why would queen victoria get AVN of the hip?
She was fat (hyperlipidemia)
| She had thrombophili
197
Patchy sclerosis of the weight bearing area with lytic lesions underneath formed by granulation tissue of an attempted repair
AVN
198
Hanging rope sign on x-ray?
AVN
199
Pain and tenderness in the region of the greater trochanter with pain on restricted abduction
Trochanteric bursits/gluteal cuff syndrome
200
What is complete knee dislocation?
When you rupture all 4 of the ligaments in your knee
201
In an obese patient, you may not be able to feel the palpable gap in an extensor mechanism, what could you do?
Do an ultrasound to determine the extent of the injury
202
Which way does the patella dislocate?
It dislocates laterally
203
When can patellar dislocation occur?
After a sudden blow to the knee or after a sudden turn
204
Risk factors for patella dislocation
* Ligamentous laxity
* Female gender
* Shallow trochlear groove
* Genu valgum
* Femoral neck anteversion
* High riding patella
205
When would you see a haemarthrosis?
Following dislocation of the patella
206
The word that is associated with bunions but I always forget?
Hallux valgus
207
Hallux valgus?
Medial deviation of the 1st metatarsal and lateral deviation of the toe itself
208
Mulder's click test?
Squeezing the forefoot to produce a click (will happen if mortons neuroma is present)
-Ultrasound may be used for diagnosis
209
Can you use steroid and local anaesthetic injections in mortons neuroma?
Yes you can
210
Where do metatarsal fractures most commonly occur?
The 2nd metatarsal followed by the 3rd
| Mortons neuroma most commonly occurs in the 3rd interspace nerve, and then the 2nd
211
Pain "like being kicked in the back of the leg"
Achilles tendon rupture
212
Gottron's sign
- Erythematous, scaly eruption over the MCPs and interphalngeal joints
- Seen in dermatomyositis
213
Diagnosis of polymyositis- history
Muscle weakness in symmetrical proximal muscles
May also have muscle pain
Weight loss, breathlessness, FEVER, RAYNAUDS PHENOMENON, polyarthritis
Other medical problems: DM, thyroid
Medications: steroids, statins
Family history
Social history: alcohol, illicit drugs
214
How to diagnose polymyositis?
MUSCLE BIOPSY IS THE DEFINITIVE TEST
Raised CK
(check electrolytes, calcium, PTH, TSH to exclude other causes)
Inflammatory markers
ANA, Anti-Jo-1
Electromyography (EMG): increased fibrillations, abnormal motor potentials, complex repetitive discharges
215
Electromyography in polymyositis?
Increased fibrillations, abnormal motor potentials, complex repetitive discharges
216
What would you find in a muscle biopsy in polymyositis?
Perivascular inflammation and muscle necrosis
217
Polymyositis MRI?
Muscle inflammation, oedema, fibrosis and calcification
218
Treatment for polymyositis/dermatomyositis?
```
Glucocorticoids
Azathioprine
Methotrexate
Ciclosporin
IV immunoglobulin
```
219
Drugs that can cause polymyositis?
Statins, steroids
220
Differences between polymyositis and inclusion myositis?
-CK lower in inclusion myositis than polymyositis
-Inclusion bodies in biopsy of inclusion myositis (perivascular inflammation and muscle necrosis in polymyositis)
-Inclusion body myositis responds poorly to therapy
-Weakness symmetrical in polymyositis, asymetrical in inclusion myositis
AGE AGE AGE (polymyositis >18 years, dermatomyositis child/adult, Inclusion myositis OVER 50!!!)
221
What is polymyalgia rheumatica associated with?
Temporal arteritis
| Giant cell arteritis
222
Clinical findings of fibromyalgia
Tender 11/18 points
No other abnormality of musculoskeletal system
-No diagnostic tests
223
Perimysial inflammation?
Dermatomyositis
224
Endomysial inflammation?
Polymyositis
225
Endomysial inflammation and CD8+ cells?
Polymyositis
226
Perimysial inflammation and CD4 cells?
Polymyositis
227
Why does intoeing occur?
Anteversion of femoral head --> internal torsion of tibia --> metatarsus adductus
228
How can you check internal tibial torsion?
Thigh foot angle
229
Bow legs, photographs or x-rays?
Photographs!
230
What causes bow legs?
<2 years, fine
| More than two years, think about internal tibial torsion
231
When should you refer for bow legs?
- asymmetry
- painful
- height <2SD
232
When do you refer for knock knees?
If the intermalleolar distance is greater than 8cm at 11 years old
233
Do insoles help knock knees?
No
234
An adolescent girl presents with anterior knee pain and localised patellar tenderness. It is worse when she squats or goes down stairs. What investigations would you like to carry out?
X-ray, check its not her hips!
| Give physio.
235
How do you fix curly toes?
With tenotomy (after 6 years old because fairly normal until then)
236
When can a baby sit unsupported?
10 months
237
Congenital vertical talus
Rocker bottom feet
238
Rocker bottom feet
Congenital vertical talus
239
NF diagnosis
```
-6 or more cafe au lait spots (pigmented birth marks)
>5mm pre puberty
>15 post puberty
-2 or more NF or 1 PNF
-axillary/groin freckling
-osteoporosis/osteomalacia/skeletal dysplasia
-kyphoscoliosis, sphenoid dysplasia
-pseudoarthrosis
-1st degree relative
-known genetic mutation 17q11.2
```
240
Classifying skeletal dysplasias
The Wynne-Davies classification
(epiphyseal/metaphyseal/diaphyseal, bone density, spinal involvement, storage disease, fibrous disorder, dysplasia with a tumour like appearance)
241
FGF3 gene mutations?
Achondroplasia
242
```
Frontal bossing
Midface hypoplasia
Rhizomelic disproportion
Genu varum
Trident hand
Normal intelligence
Motor delay
```
Achondroplasia
243
Which part of the brain is damaged in cerebral palsy?
The encephalon
244
What is the leading cause of childhood disability?
Cerebral palsy
245
Drug treatment for spasticity (BBB)
Benzodiazepines
Botox
Baclofen
Surgery = rhizotomy
246
Features of upper motor neurone syndrome?
- Hyper-reflexia
- Clonus
- Co-contraction
- Spasticity
247
Management of cerebral palsy (grade I-III)
| people who can walk
- orthothotics
- botox
- physio
- surgery
248
Management of tip-toe walking
```
Usually idiopathic
Common before 3 years
Physio/observation
Splinting/casting
Botox
Surgery
```
249
Spinal claudication
* Age 50+
* M:F 2:1
* Limited walking capacity (i.e can’t walk very far)
* Stoop/lean forward/sit to relieve symptoms
* “heavy or tired” legs
250
* Age 50+
* M:F 2:1
* Limited walking capacity (i.e can’t walk very far)
* Stoop/lean forward/sit to relieve symptoms
* “heavy or tired” lefgs
Spinal claudication
251
How do you relieve spinal claudication?
-flexing
| remember in comparison to claudication, going uphill and cycling are not that bad
252
Spinal stenosis/claudication on x-ray
Hypertrophic spine with narrowing of the interpedicular space and obliteration of the neural foramena
253
Investigation for spinal claudication?
X-ray
254
Deep seated low central back pain that gets worse as the day goes on
- Typically worse on coughing
- made worse by flexing
- worse with activity
Discogenic back pain
255
- Pain in the back (may radiate to buttocks and legs)
- Stiff in the morning, loosening up routine
- Restless --> difficulty sitting, standing, driving
- Worse with extension
- BETTER WITH ACTIVITY
Facet arthropathy
256
Facet Arthropathy
- Stiff in the mornings
- Loosening up routine
- Restless (difficulty sitting, standing, driving)
- WORSE WITH EXTENSION, relieved by activity
- Often radiates to buttocks and legs
257
Worse with extension, better with activity
Facet arthropathy
258
Worse with flexion
Discogenic back pain
259
Relieved by flexion
Spinal claudication/stenosis
260
Feels like 'walking on marbles'
Metatarsalgia
261
Which fracture can be associated with an ankle fracture?
Twisting of the ankle or foot can be associated with an avulsion fracture of the base of the 5th metatarsal
262
Deltoid ligament?
Medial side of the ankle.
| Attaches the medial malleolus to multiple tarsal bones
263
The ligament complex on the lateral side of the foot?
The talofibular ligament complex
264
The dorsalis pedis pulse?
Lateral to the flexor hallucis longus
265
The posterior tibialis pulse?
Distal and posterior to the medial maleolus
266
Nerve supply to the foot?
Superficial peroneal nerve and deep peroneal nerve
267
Where does the deep peroneal nerve supply?
The gap between the big toes and he toe next to it
268
What is the tendo-Achilles and what does it do?
Tendinous extension of the gastrocnemius and soleus
| -Plantar flexes the foot
269
De Quervain's tenosynovitis affects which tendon sheaths?
Abductor pollicis longus
| Extensor pollicis brevis
270
Give an example of when de Quervain's tenosynovitis might hurt?
When you turn your wrist, make a fist, grasp anything etc etc
271
Which fracture causes pain in the snuffbox?
A scaphoid fracture
272
Ligaments of the elbow?
Medial and lateral collateral ligaments
273
Bursa at the elbow?
Olecranon bursa
274
The humero-ulna joint
Flexion/extension of the elbow
275
Radio-capitellar joint
Pronation/supination
276
Pain at insertion of the extensor muscles of the forearm?
Lateral epicondylitis
277
Pain at insertion of the common flexor origin?
Medial epicondylitis
278
Which elbow problem is associated with muscle wasting/weakness, sensory loss and provocation tests?
Cubital tunnel syndrome
279
What does the FDS flex?
The PIPJ
280
What does the FDP flex?
The DIPJ
281
If you see a high arched foot what should you be thinking of?
You should be thinking of neurological conditions e.g. cerebral palsy, spina bifida, stroke, muscular dystrophy, Charcot-Marie tooth disease
282
What could a flat foot mean?
RA
| Posterior tibialis dysfunction
283
Where can you use cartilage regeneration techniques?
Knee and ankle
284
When can excision arthroplasty be used?
* 1st CMC (trapeziectomy) for OA in hand
* 1st MTPJ OA & hallux valgus in frail, elderly patients (Keller’s procedure)
* Can excise all metatarsal heads for end stage rheumatoid foot
285
What is Keller's procedure?
Excision of the 1st MTPJ / hallux valgus
| -often used for frail, elderly patients with OA
