MBChB Flashcards
Seropositive arthritis
Lupus Rheumatoid arthritis Scleroderma Vasculitis Sjogrens
Seronegative Arthritis
Ankylosing Spondylitis
Psoriatic Arthritis
Reactive arthritis
Inflammatory bowel disease arthritis
Most common form of arthritis?
Osteoarthritis
Second degree causes of OA
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
What is perthes?
A disease where the top of the thigh bone in the hip softens and breaks down
SUFE
Slipped upper femoral epiphyses
the growth plate is weak and the ball slips down and backwards
Radiographical findings of osteoarthritis?
L (loss of joint space)
O (osteophytes)
S (sclerosis)
S (subchondral cysts)
Diagnosis of rheumatoid arthritis
Clinical presentation, radiographic findings and serological analysis
The ACR/EULAR Rheumatoid Arthritis Criteria scoring system assists in the diagnosis.
Which internal organs can be affected in rheumatoid arthritis?
Rheumatoid Lung
Ischaemic heart disease
Operations performed for rheumatoid arthritis
Synovectomy Joint replacement Joint excision Tendon transfers Arthrodesis (fusion) Cervical spine stabilisation
Synovectomy
Removes inflamed synovium
Most likely places to get joint involvement in SLE?
Hands and knees
Avascular necrosis can also occur in the hip and knee
How would you treat tendon ruptures and severe symptomatic joint damage in SLE?
Surgery
but remember that they try to treat everything with drugs primarily
Which gender is more commonly affected in ankylosing spondylitis?
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
Conditions associated with ankylosing spondylitis
aortitis, pulmonary fibrosis and amyloidosis
Xrays show bony spurs from the vertebral bodies known as syndesmophytes which can bridge the intervertebral disc resulting in fusion producing a “bamboo spine”
Ankylosing Spondylitis
Treatment for ankylosing spondylitis
Treatment consists of physiotherapy, exercise, simple analgesia and DMARDs for more aggressive disease
onycholysis
Lifting of the nail from the nail bed
In psoriatic arthritis, some patients have a predilection for arthritis in which joints?
DIP
In psoriatic arthritis, 5% of patients with DIP arthritis develop a more aggressive and destructive form of this. What is this condition called?
Arthritis Mutilans
Enteropathic arthritis
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)
Treatment for Enteropathic Arthritis
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.
Some patients have a triad of symptoms of urethritis, uveitis and arthritis known as Reiter’s syndrome
Reactive Arthritis
What is gout usually due to?
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)
Gouty tophi
Painless white accumulations of uric acid can occur in the soft tissues and erupt through the skin
What can chronic gout result in?
Destructive erosive arthritis
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).
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.
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
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.
Where does gout tend to affect?
Knee, wrist and ankle
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
Which bacteria can infect osteocytes intracellularly and make osteomyelitis very hard to get rid of?
Staph. aureus
In which age group would you usually see an acute osteomyelitis in the absence of surgery?
Children
Also seen in immunocompromised
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
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
What might suppress chronic osteomyelitis?
Antibiotics
What well known historical disease could cause osteomyelitis?
Tuberculosis (particularly in spine from haematogenous spread from the primary lung infection)
Where might you see osteomyelitis occurring if you’ve had TB?
Spine
In which patients might you see an osteomyelitis caused by salmonella?
Sickle cell anaemia patients
Which groups of people are particularly susceptible to osteomyelitis of the SPINE?
Diabetics, intravenous drug users and other immunocompromised patients
What can be used to determine extent of infection in osteomyelitis?
MRI
Organism which usually causes osteomyelitis?
Staph aureus but atypical in immunocompromised
Which heart condition should you check for in osteomyelitis
Endocarditis should be considered (look for clubbing, splinter haemorrhages, murmur, consider ECHO
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.
Doughy Swelling?
Synovitis
You would see this in rheumatoid arthritis ;)
Synovectomy?
Surgery to remove inflamed synovium
Predominant feature of inflammatory arthritis?
Synovium inflammation
Which non-articular diseases would suggest spondyloarthritis?
psoriasis, iritis, inflammatory bowel disease, non-specific urethritis, recent dysentery
Anticyclic citrullinated peptide antibodies
Marker for erosive disease in RA
ESR and CRP raised in RA. You may also see normochromic normoctytic anaemia
Complications of Rheumatoid Arthritis
Bakers cysts (joint rupture) Ruptured tendons Joint infection Spinal cord compression AMYLOIDOSIS
Most common cause of secondary AA amyloidosis?
Rheumatoid Arthritis
Which procedure can excise all metatarsal heads in end stage rheumatoid foot?
Excision arthroplasty
What is arthrodesis gold standard for?
1st MTPJ OA
Which surgical procedure was originally used for TB hip and young OA hip?
Arthrodesis say whuuuut
Name a way in which you could fix malunion following a fracture?
Osteotomy
What is gold standard for hallux valgus?
Osteotomy
What is osteotomy?
Surgical realignment of bone
Antibodies in RA?
Antibodies to the Fc fragment of IgG (rheumatoid factor)
Antibodies to citrullinated cyclic peptide
Allele associated with RA?
HLA-DR4
Which type of RA is smoking an environmental risk factor for?
Seropositive RA
What drives the overproduction of TNF-a in RA?
The interaction between macrophages, B & T lymphocytes
interleukin 6 is also involved in RA
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
Histological appearance of RA synovium?
Hypertrophy of the tissues with infiltration by lymphocytes and plasma cells
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)
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)
When is pain and stiffness worse in RA?
In the morning
Complications of RA
Ruptured tendons, Ruptured joints (Baker's cysts) Joint Infection Spinal cord compression (atlantoaxial or upper cervical spine) Amyloidosis (rare)
What cells might you see in septic arthritis?
Neutrophil leucocytosis
abnormally high number of neutrophils
Finger deformities in RA?
Ulnar deviation
Boutonniere deformity
Swan-neck deformity
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
Soft tissue non-articular manifestations of RA
Rheumatoid nodules (typically elbow, finger joints and achilles tendon)
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)
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
Most common cause of secondary osteoporosis?
Corticosteroids
Can sulfasalazine be used during pregnancy?
Yes
What must you monitor for when on steroids?
Hypertension and diabetes
Side effects when using sulfasalazine?
Leucopania
Thrombocytopenia
Nausea
Skin rashes and mouth ulcers
“Gold standard” drug in RA
Methotrexate
If nausea/poor absorption limit the efficacy of methotrexate, how might you administer it?
Subcutaneously
What could you give in combination with methotrextae to minimise side effects?
Oral folic acid
Side effects of leflunamide?
Diarrhoea (leflunamide works in some patients who have failed to respond to methotrexate) Neutropenia and thrombocytopenia Alopecia Hypertension
Leflunamide and pregnancy?
Should avoid in pregnancy due to long half life
Anti-TNF is usually given in combo with..?
Methotrexate
List 5 anti-TNFs
Adalimumab Etanercept (s/c) Infliximab (IV) Certolizumab Golimumab (s/c) for severe RA
Side effects of methotrexate?
Nausea, mouth ulcers, diarrhoea
Neutropaenia and/or thrombocytopenia
Renal impaitment
Pulmonary fibrosis
Etanercept side effects?
Injection site reactions
Infections e.g. TB and septicemia
Adalimumab side effects?
Hypersensitivity reactions
Heart failure
Demyelination and autoimmune syndromes
Reversible lupus-like syndromes
Rituximab side effects?
Hypo/hypertension Skin rash Nausea Pruritis Back pain Rare: toxic epidermal necrolysis
Side effects of Tocilizumab?
Headache, skin eruption, stomatitis, fever, anaphylactic reactions
RA drugs to avoid in pregnancy?
Leflunamide, methotrexate, Gold, CYCLOPHOSPHAMIDE, penicillamine (women must not conceive when on leflunamide or methotrexate)
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
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)
Which DMARDS can be used during pregnancy?
Sulfasalazine, hydroxychloroquine, aziathioprine, cyclosporin A
These can be used if required to control inflammation
Drugs that can induce SLE
Hydralazine Procainamide Penicillamine Isoniazid (SLE is mild though, kidneys and CNS are not affected)
What kind of light can trigger flares of SLE?
Ultrviolet
Pathology of SLE
SLE of the skin is characterised by deposition of complement and IgG antibodies and influx of neutrophils and lymphocytes
Most common clinical feature of SLE?
Joint problems
Patients often present with similar features to RA
Hypocalcaemia Symptoms
Parasthesia Muscle cramps Irritability Fatigue Seizures Brittle nails
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.
Hypercalcemia Symptoms
fatigue, depression, bone pain, myalgia, nausea, thirst, polyuria, renal stones, osteoporosis
Test for Carpal Tunnel
Tinel’s Test: tapping nerve in carpal tunnel
Phalen’s Test: holding wrist in flexion position
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!!)
Carpal tunnel symptoms
numbness altered sensation dysaesthesia clumsiness night awakening pain
Investigations for Carpal Tunnel
Nerve conduction studies PV X-ray T4 blood glucose
Results (carpal tunnel) Free distribution, ulnar or radial?
Ulnar
Indications for Carpal Tunnel Syndrome decompression
Failed conservative treatment
Constant numbness
Weakness
What is the surgical treatment for carpal tunnel syndrome?
Standard open carpal tunnel release
Arthroscopic
endoscopic carpal tunnel release
mini-open carpal tunnel release
Which gender does cubital tunnel syndrome affect more?
Men
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
Which fingers are likely to tingle in cubital tunnel syndrome?
Ring and little fingers :) aw little
Test shown in lecture slide that you could use when assessing cubital tunnel syndrome?
Trying to get patient to hold paper between fingers
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 )
Treatment for Cubital Tunnel Syndrome
Splint Neurolysis Anterior transposition subcutaneous submuscular intra-muscular medial epicondylectomy
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.
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.
What is instability?
excessive motion caused by a degenerate disc, diagnosed typically on MRI
What type of motor neurone signs are reflexes?
Lower motor neurone
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”).
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
Treating an open fracture
ABx, tetanus, early debridement and operative stabilisation
Treating compartment syndrome
fasciotomy & operative stabilisation
Vascular injury # treatment
reduction, stabilisation and reassess circulation. May need revscularisation procedure
Pilon fracture
Inter-articular fracture of the distal tibia
Distal tibia fractures associated injuries
Spine, pelvis, calcaneus
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
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
Galeazzi fracture dislocation
If the radius is fractured in isolation, suspect a dislocation of the DRUJ
Monteggia fracture dislocation
If the ulna is fractured in isolation, suspect a dislocation of the radial head
What is polytrauma?
> 1 fracture (long bones +/- pelvis)
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
Treatment for repeat Patella dislocations
Surgery
(Lateral release / medial reefing
Patella tendon realignment)
Medial Reefing
A surgical procedure to tighten the tissues on the medial aspect of the patella
Lateral Release? (Patella dislocation treatment)
Loosening the tissues on the lateral side of the patella
What should you be aware of in patella dislocation spontaneous relocation?
Lateral collateral ligament injury and peroneal nerve injury
Nerve that could be damaged in knee dislocation?
Peroneal nerve
Associated fractures of hip dislocation
Posterior acetabular wall
Femoral #’s
Hip dislocation presentation
Flexed, internally rotated and adducted knee
Nerve that could be damaged in hip dislocation
Sciatic nerve
Hip Dislocation Complications
Sciatic nerve palsy
Avascular necrosis of the femoral head
Secondary osteoarthritis of hip
Myositis ossificans
What may cause an olecranon fracture?
Usually an avulsion fracture from triceps contraction
If you dislocate your elbow, which bone might you fracture?
The head of the radius
What is a nightstick fracture?
Isolated fracture of the Ulna
How might you fix a colles fracture?
K-wiring
Complications of Distal Radial Fracture
Median nerve compression, EPL rupture, CRPS, loss grip strength
Distal Radius Fractures: how would you fix a comminuted intra-articular fracture with small fragments?
External fixation +/- K-wires
How would you fix a Smith’s fracture?
ORIF
When might you consider looking for endocarditis in septi arthritis?
When you have multiple bones/joints affected by septic arthritis (septic emboli)
Who might get E.coli septic arthritis?
The elderly, IV drug users and seriously ill
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
Useful blood tests for bone and joint infection?
CRP and Plasma viscosity
Occasionally useful: blood cultures, white cell count, ESR
Most common causative organism in osteomyelitis?
Staph aureus
haemophilus in children
What antibiotics does our lecturer use for cellulitis?
He uses Flucloxacillin and benzylpenicillin
In cellulitis, what is crepitis a sign of?
Crepitus is a sign of infection most commonly observed with anaerobic organisms
Which cells produce granulation tissue in secondary cone healing?
Fibroblasts
Which cells form cartilage?
Chondroblasts
Which cells lay down bone matrix (collagen type 1)
Osteoblasts
Which process produces immature woven bone?
Calcium mineralisation
By what week is the soft callus usually formed?
2-3 weeks
How long does it take the hard callus to appear?
6-12 weeks
Why can smoking impair healing of a fracture?
It causes vasospasm (bones need good blood supply for nutrients, oxygen and stem cells etc)
Aside from smoking, what else can impair fracture healing?
Chronic ill health
Malnutrition
When do oblique fractures occur?
Obliques fractures occur with a shearing force (e.g. fall from a height, deceleration)
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
Why are spiral fractures most unstable?
They can rotate, may also angulate
Why do spiral fractures occur?
Spiral fractures occur due to torsional forces
Are segmental fractures stable or unstable?
Segmental fractures are very unstable and require stablisation with long rods or plates
Clinical signs of a fracture
Localised bony tenderness (not mild diffuse tenderness)
Swelling
Deformity
Crepitus (from bone ends grating with an unstable fracture)
Guidelines used for ankle injury?
Ottowa guidelines
Investigation for mandibular fracture?
Tomogram
Which fractures can an oblique x-ray be good for?
- Scaphoid
- Acetabulum
- Tibial plateau
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
Analgesia usually given for long bone fracture?
IV morphine
Initial management of long bone fracture
S (splintage/immobilisation)
I (investigation e.g. x-ray)
A (analgesia)
Another name for temporary plaster slab
Backslag
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)
Anaesthetic that can be used for reducing an unstable fracture
GA
Spinal
Peripheral nerve block
Bier’s block
When is a Bier block indicated?
For fractures of the forearm, wrist and hand (not appropriate for elbow)
Early complications of fractures
Compartment syndrome
Vascular injury with ischaemia
Nerve compression or injury
Skin necrosis
Early systemic complications of fractures
Hypovolaemia Fat embolism Shock ARDS Acute renal faiure Systemic Inflammatory Response Syndrome Multi-organ Dysfunction Syndrome Death
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
The main late systemic complication of a fracture
Pulmonary embolism
deep vein thrombosis is a late LOCAL complication of a fracture
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
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)
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
What artery is at risk if a child sustains an elbow fracture?
Brachial artery injury
Which artery can be affected in shoulder trauma
Axillary artery
Which fracture may be associated with life threatening haemorrhage from arterial or venous bleeding?
Pelvic fractures
How might you localise the site of arterial occlusion?
Urgent angiography
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
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
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)
Painful and tender lateral epicondyle with resisted middle finger and wrist extension?
Lateral epicondylitis (tennis elbow)
Which nerve could be damaged in a total hip replacement?
The sciatic nerve
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
Why would queen victoria get AVN of the hip?
She was fat (hyperlipidemia)
She had thrombophili
Patchy sclerosis of the weight bearing area with lytic lesions underneath formed by granulation tissue of an attempted repair
AVN
Hanging rope sign on x-ray?
AVN
Pain and tenderness in the region of the greater trochanter with pain on restricted abduction
Trochanteric bursits/gluteal cuff syndrome
What is complete knee dislocation?
When you rupture all 4 of the ligaments in your knee
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
Which way does the patella dislocate?
It dislocates laterally
When can patellar dislocation occur?
After a sudden blow to the knee or after a sudden turn
Risk factors for patella dislocation
- Ligamentous laxity
- Female gender
- Shallow trochlear groove
- Genu valgum
- Femoral neck anteversion
- High riding patella
When would you see a haemarthrosis?
Following dislocation of the patella
The word that is associated with bunions but I always forget?
Hallux valgus
Hallux valgus?
Medial deviation of the 1st metatarsal and lateral deviation of the toe itself
Mulder’s click test?
Squeezing the forefoot to produce a click (will happen if mortons neuroma is present)
-Ultrasound may be used for diagnosis
Can you use steroid and local anaesthetic injections in mortons neuroma?
Yes you can
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
Pain “like being kicked in the back of the leg”
Achilles tendon rupture
Gottron’s sign
- Erythematous, scaly eruption over the MCPs and interphalngeal joints
- Seen in dermatomyositis
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
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
Electromyography in polymyositis?
Increased fibrillations, abnormal motor potentials, complex repetitive discharges
What would you find in a muscle biopsy in polymyositis?
Perivascular inflammation and muscle necrosis
Polymyositis MRI?
Muscle inflammation, oedema, fibrosis and calcification
Treatment for polymyositis/dermatomyositis?
Glucocorticoids Azathioprine Methotrexate Ciclosporin IV immunoglobulin
Drugs that can cause polymyositis?
Statins, steroids
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!!!)
What is polymyalgia rheumatica associated with?
Temporal arteritis
Giant cell arteritis
Clinical findings of fibromyalgia
Tender 11/18 points
No other abnormality of musculoskeletal system
-No diagnostic tests
Perimysial inflammation?
Dermatomyositis
Endomysial inflammation?
Polymyositis
Endomysial inflammation and CD8+ cells?
Polymyositis
Perimysial inflammation and CD4 cells?
Polymyositis
Why does intoeing occur?
Anteversion of femoral head –> internal torsion of tibia –> metatarsus adductus
How can you check internal tibial torsion?
Thigh foot angle
Bow legs, photographs or x-rays?
Photographs!
What causes bow legs?
<2 years, fine
More than two years, think about internal tibial torsion
When should you refer for bow legs?
- asymmetry
- painful
- height <2SD
When do you refer for knock knees?
If the intermalleolar distance is greater than 8cm at 11 years old
Do insoles help knock knees?
No
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.
How do you fix curly toes?
With tenotomy (after 6 years old because fairly normal until then)
When can a baby sit unsupported?
10 months
Congenital vertical talus
Rocker bottom feet
Rocker bottom feet
Congenital vertical talus
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
Classifying skeletal dysplasias
The Wynne-Davies classification
(epiphyseal/metaphyseal/diaphyseal, bone density, spinal involvement, storage disease, fibrous disorder, dysplasia with a tumour like appearance)
FGF3 gene mutations?
Achondroplasia
Frontal bossing Midface hypoplasia Rhizomelic disproportion Genu varum Trident hand Normal intelligence Motor delay
Achondroplasia
Which part of the brain is damaged in cerebral palsy?
The encephalon
What is the leading cause of childhood disability?
Cerebral palsy
Drug treatment for spasticity (BBB)
Benzodiazepines
Botox
Baclofen
Surgery = rhizotomy
Features of upper motor neurone syndrome?
- Hyper-reflexia
- Clonus
- Co-contraction
- Spasticity
Management of cerebral palsy (grade I-III)
people who can walk
- orthothotics
- botox
- physio
- surgery
Management of tip-toe walking
Usually idiopathic Common before 3 years Physio/observation Splinting/casting Botox Surgery
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
- 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
How do you relieve spinal claudication?
-flexing
remember in comparison to claudication, going uphill and cycling are not that bad
Spinal stenosis/claudication on x-ray
Hypertrophic spine with narrowing of the interpedicular space and obliteration of the neural foramena
Investigation for spinal claudication?
X-ray
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
- 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
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
Worse with extension, better with activity
Facet arthropathy
Worse with flexion
Discogenic back pain
Relieved by flexion
Spinal claudication/stenosis
Feels like ‘walking on marbles’
Metatarsalgia
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
Deltoid ligament?
Medial side of the ankle.
Attaches the medial malleolus to multiple tarsal bones
The ligament complex on the lateral side of the foot?
The talofibular ligament complex
The dorsalis pedis pulse?
Lateral to the flexor hallucis longus
The posterior tibialis pulse?
Distal and posterior to the medial maleolus
Nerve supply to the foot?
Superficial peroneal nerve and deep peroneal nerve
Where does the deep peroneal nerve supply?
The gap between the big toes and he toe next to it
What is the tendo-Achilles and what does it do?
Tendinous extension of the gastrocnemius and soleus
-Plantar flexes the foot
De Quervain’s tenosynovitis affects which tendon sheaths?
Abductor pollicis longus
Extensor pollicis brevis
Give an example of when de Quervain’s tenosynovitis might hurt?
When you turn your wrist, make a fist, grasp anything etc etc
Which fracture causes pain in the snuffbox?
A scaphoid fracture
Ligaments of the elbow?
Medial and lateral collateral ligaments
Bursa at the elbow?
Olecranon bursa
The humero-ulna joint
Flexion/extension of the elbow
Radio-capitellar joint
Pronation/supination
Pain at insertion of the extensor muscles of the forearm?
Lateral epicondylitis
Pain at insertion of the common flexor origin?
Medial epicondylitis
Which elbow problem is associated with muscle wasting/weakness, sensory loss and provocation tests?
Cubital tunnel syndrome
What does the FDS flex?
The PIPJ
What does the FDP flex?
The DIPJ
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
What could a flat foot mean?
RA
Posterior tibialis dysfunction
Where can you use cartilage regeneration techniques?
Knee and ankle
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
What is Keller’s procedure?
Excision of the 1st MTPJ / hallux valgus
-often used for frail, elderly patients with OA
