MSK Flashcards
1
Q
What is Paget’s disease of the bone
A
Osteitis deformans
- increased bone turnover
- disorganise remodelling, deformity, weakness
2
Q
cause of Pagets disease of the bone
A
- genes- SQSTM1, RANK
- viral- RSV,
3
Q
sx of pagets disease of the bone
A
- asx in most
- deep, boring pain
- deformity- pelvis, L spine, femur, tibia, frontal bossing of the skill
- headaches
- pathological #
- OA
- nerve compression
- malignancy, HF, kidney stones
4
Q
ix ?paget’s
A
- skeletal XR survery
- bloods - ALP raised, Ca PO4 normal
- **- boneturnover markers in urine
- **- bone scans
5
Q
tx paget’s
A
- analgesia
- bisphos- alendronic acid
- calcitonin 3m
- surgery- osteotomy, arthroplasty, # alignment
6
Q
What is osteomalacia
A
normal amount of bone, low minerl acontent
7
Q
causes of otseomalacia
A
- Vit D deficiency
- CKD- 1,25,dihroxy cholecalciferol deficiency
- liver disease- reduced hydroxylation of Vit D and malabs
- tumour induced- hyperphosphaturia
8
Q
describe the way in which UV, vitamin D is processed in the body and used
A
- UV on skin causes 7-dehydrocholesterol to be converted to pre- vit D3
- pre- vit D3 is converted into cholecaliferol (vit D3)
- vit D3 and D2 are eaten via supplements, fish and meat
- Vit D3 is converted in 25-hydoxyvitD3 in LIVER
- KIDNEYS release 1alpha hydroxylase, whihc converts hydroxy vit D3 into 1,25-dihydroxyvitmain D ie calcitriol
9
Q
what does calcitriol do
A
ie 1,25-dihydroxycholecalciferol
INCREASES SERUM CA
- increases Ca absorption in gut
- increases reabs of Ca in kidneys
- increases bone breakdown (osteoclasts)
10
Q
presentaiton of osteomalacia
A
- rickets
- hypocalcaemia- confusion, numbness, spasms, seizure, MI
- bone pain
- pathological #
- proximal myopathy- waddling
11
Q
ix osteomalacia
A
bloods- hypoCa, hypophosphataemia, increased ALP and PTH, decreased vit D
XR- loss of cortical bone, #
bone biopsy- poor mineralisation
12
Q
management of osetomalacia
A
- vit D
- Ca
- calcitriol
- phsophate
13
Q
What is oeseoporosis
A
- low bone mass and microarchitectural deterioration-
- thinned, disconnected trabeculae
14
Q
causes of OP
A
- inflammation- cytokines increase bone resorp
- endocrine- hyperthyroid, Cushing’s, steroids,
- oestrogen/testosterone
- poor skeletal loading (immobility, low body wt)
15
Q
ix OP
A
- FRAX score- 10 yr prob of hip/bone #
- dual energy XR- t-score
16
Q
what are the cut offs and definitions of a T-score
A
> -1 = normal
-1 to -2.5= Osteopenia
< -2.5 = OP
< -2.5 + # = severe OP
17
Q
Management of OP
A
Cause
- HRT in early menopause/hysterectomy
- control thyroid
- control inflammatory conditions
Bisphosphonates
- alendronate PO, Zoledronate IV
- Denosumab- monoclonal antibody to RANKL- blocks bone resorption
- Teriparatide-
- synthetic PTH analogue, daily injection
- increases osteoblast activity and bone formation (dont think too hard about it)
18
Q
what instructions do you give some taking oral alendronic acid
A
- dont lie down for 30min after
- have with water
- get dental appt before taking- linked with osteonecrosis of the jaw
19
Q
what is osteogenesis imperfecta
A
- disorder of type 1 collagen
- brittle , fragile bones
- bone heals with deformity
20
Q
types of osteogenesis imperfecta
A
Type 1- least severe
Type 3- severe, pogressively deforming
21
Q
presentation of oesteogenesis imperfecta
A
- #
- bowing of long bones
- blue sclera
- hearing loss
- short stature, scoliosis
- ***- ligamentous laxity– hyperextensible joints
22
Q
ix ?osteogenesis imperfecta
A
- foetal USS_ only picks up severe, type 3
- bloods- ALP raised
- genetic testing
- skin biopsy- assess collagen
- bone biopsy
- XR
23
Q
Management of osteogenesis imperfecta
A
- Ca
- bisphosphonates
- synthetic calcitonin (opposes PTH, usually produced by thyroid)
- intramedullary rods to prevent bowing
24
Q
What is Scheuermann’s disease
A
- slow growth of anterior spine
- leads to kyphosis, deformity
25
management of scheuermann's
- lifestyle- physio, back braces
| - surgery to manage pain
26
what is osteopetrosis
- inherited
| - increased bone density and abnormal growth
27
sx osteopetrosis
- neonatal bone marrow failure , pancytopenia
- incidental findings on XR
- #
* - short stature
* - nerve compression
* - hypocalcameia- confusion, seizures, spasms
28
management of osteopetrosis
- vit D
- EPO/bone marrow transplant
- surgery
29
what is achondroplasia
- autosomal dominant
- overproduction and deposition of collagen
- cartilage does not harden to bone on grwth plate
30
sx achondroplasia
Deformity
- dwarfism- short, enlarged head, frontal bossing
- kyphosis, lordosis
- leg bowing
31
management of achondroplasia
- GH therapy
| - limb lengthening surgery- controversial
32
OA sx
- painful joints- stiffness
- worse with activity
- srepitus
- herberdens and bouchards nodes
33
ix oA
```
XR
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
```
- bloods- bone profile (Ca, D, PO4, ALP- normal
- diagnostic injeciton
- arthroscopy
34
tx OA
- lifestyle- physio, wt loss, footwear
- ibuprofen gel
- analgeisia
- steroid intra-art injections
- DMARDS- if inflam element
- surgery- arthroplasty, fusion
35
RA sx
- symmterical, deforming, polyarthropathy
- swan neck (hyperextension PIP, flexion DIP)
- Boutonniere- flexion PIP, hyperextension DIP)
- ulnar deviation
- joint pain and stiffness worse in morning/inactivity , >30min
- swollen, red hot joint in flare
- fatigue, malaise, wt loss
Extra artiuclar
- Lungs- nodules, fibrosis= caplans syndrome
- skin- nodules, rashes, vasculitis
* **- eyes- sjogrens, scleritis/episcleritis
* **- neuro- peripehral neuro
- CVS- CVA, endocarditis/pericarditis/ CVD
- OP (cytokines increase bone turnover)
* *- glomerulonephritis
* *- hepatitis
36
ix ?RA
- CRP/ESR
- Anti-nuclear antibodies, RF, Anti-cyclic citrullinated peptide
```
XR
Loss of joint space
*Erosion of joint
Subchondral sclerosis
*Soft tissue swelling
```
* CXR if ?lung involvement
* MSU if ?renal involvement, echo
37
when to urgently refere RA
- small joints in hands/feet
- >1 joitn affecte
- delay in >3m between onset of sx and seeking medical advice
38
management RA
- smoking cessation
- walking aids, splints, physio, OT
- bridge DMARD with steroid
1. DMARD- methotrexate or sulfasalazine, or hydroxychloroquine
2. combination DMARDs
3. biological DMARDS +methotrexate - infliximab, rituximab, abatacept, tocilizumab
- surgery to improve function and prevent deformtiy
39
what monitoring is there of RA
- CRP until remission/low-activity disease
40
what crystals are involved in gout
- urate- purine breakdown pyproduct
41
causes of gout
Hyperuricaemia
- high purine diet
- drugs
- renal failure
- genes
```
Underexcretion of urate
- alcohol
- Renal impairement
genes
- ****diuretics, aspirin, anti-TB, lead
```
Overproduction of urate
- myeloproliferative
- ***CT
- **psoriasis
42
sx gout
- acute (overnight)- severe joint pain
- hallux MTP most commonly
- red, swollen joint
- reduced ROM
- tophi- aggregates, go in 2 years
43
ix ?gout
hx- meds, wt, HTN, alcohol
- bloods- UE, urate (NOT diagnostic)
- XR- effusion, punched out lesions (rat bites)
- synovial fluid aspiration polarised light micro
44
what do crystals look like in gout on synovial fluid aspiration, polarised light micro
- negatively birefringent needles
45
tx acute gout
Acute
- NSAID, PPI
- Colchicine
* *- aspiration
* *- IA steroid injection
* *- PO steroids
46
tx gout LT
Chronic
- Allopurinol/febuxosat (xanthine oxidase inhibitors)-- give >2w post latest attack, monitor UEs
- co-prescribe colchicine at 1st as can cause flare in uric acid in 1st w
- never give with azathioprine- can cause reaction
- diet-- reduce beer, purine high foods (fish, meats)
47
what crystals cause pseudogout
Ca pyrophosphate
48
sx pseudogout
- monoarthritis
- severe pain
- stiffness, swelling
- +-fever
trigger
49
trigger of gout/pseudogout
- trauma to joint
- dehydration
- illness
- post surgery
- endocrine/metabolic disorder
50
ix ?pseudogout
- XR_ chondrocalcinosis
- synovial aspiration- polarised light micro
- iron studies, bone profile, Mg
51
what ye see on polarised light microscopy for pseudo gout
positively birefringent rhomboids
52
management of pseudogout
- NSAIDs, PPI
- Colchicine
- arthrocentesis
* ***- IA steroid
* **- trial anti-rheumatic drug- hydrocychloroquine, methotrexate
* **- synovectomy, surgery
- physio
53
what causes juvenile gout
Lesch-Nyhan Syndrome
- genetic X linked
- enzyme deficiency
- build up of uric acid
54
What are seronegative spondyloarthropathies
- a group of conditions
- associated with HLAB27- human leukocyte antigen
- will NOT test positive for RF (seronegative)
- unknown disease mechanism
55
What are the seronegative spondyloarthropathic conditions?
- Ankylosing spondylitis
- Psoriatic Arthritis
- Enteropathic arthritis
- Reactive arthritis (Reiter's)
- Junvenile idiopathic arthritis
-
56
sx of ank spond
- stiffening and fusion of the spine (reduced neck movements, twisting, chronic flexion)
- pain in ilio-scaral joint
- alternating buttock pain
* *- stiffness- worse in morning
- insidious onset
* *- dactylitis
* *- enthesitis- achilles, elbow, knee, costochondritis
* *- spinal # predisposition
* *- iritis/anterio uveitis
- lung fibrosis (apical)
- aortic regurg, AV node block
* *- amyloidosis
- other AI cnoditions
- fatigue wt loss
57
ix for ?ankylosing spondylitis
- o/e- tenderness over spine/iliosacral joints, reduced lateral flexion, schober's positive (foward flexion), reduced chest expansion
- FBC- normocytic anaemia of chronic disease
- CRP/ESR
- RF negatvie
- XR spine- bamboo
- MRI- oedema
* *- DEXA- OP
* *- genetics- HLAB27
58
Management of ank spond
- smoking cessation
- physio, hydrotherapy, exercise
- NSAIDs, paracetemol, codeine
- anti-TNF biologics- etanercept, adalimumab
- steroid injections- ST relief of flares
- surgery- vertebral osteotomy to correct deformity
59
what proportion of psoriatic patients are affected by psoriatic arthritis
15%
60
sx of psoriatic arthritis
- large joint oligoarthritis
- DIP arthritis
- pain
- arthritis mutilans- floppy fingers poiting in wrong directions, osteolysis, telescoping, no pain anymore
* *- dactylltis- v. painful
- psoriasis- extensor surfaces
- genital , scalp and belly button psoriasis
NAILS - in 80%
- moth eaten looking
- onycholysis- lifting off, thickened, creamy
61
ix for ?psoriasis
- psoriasis epidemiological screening tool
- bloods- anaemia of chronic disease, CRP/ESR, RF -ve
- XR- DIP erosion (pencil in cup), periostitis, ankylosis, osteolysis
- MRI- dtects early changes
- HLA27
62
tx ank spond
- NSAID
- steroid injections
Immunosups (same as RA
1. DMARD- metho, ciclosporin, sulfalazine
2. 2x DMARD
3. Metho + anti-TNF (etanercept, infliximab, adalimumab
-
63
What is enteropathic arthritis
- arthritis associated with IBD
64
sx enteropathic arthritis
- sacroilitis
- peripheral arthritis- commonly symmetrical
- enthesitis (tendon/ligament insertion pain)
- GI sx
65
management of enteropathic arthritis
- treat IBD (pred/hydrocortisone (IBD), aminosalicylate (UC) methotrexate, azathioprine)
- DMARDs- methotrexate, azathioprine
66
What is reactive arthritis
- GI (salmonella, shigella) or STIs (chlamydia) trigger sterile inflammation of synovial membrane/fascia/tendons
- higher incidence in those with psoriasis
67
sx of reactive arthritis
- GI sx
- STI sx
```
Cant see, wee, climb a tree
Arthritis:
- sacroilitis, spondylitis
- datylitis
- enthesitis
```
Eye
- conjunctivitis
- iritis
- urethritis
- balanitis
skin- brownish scaling on palms/soles (keratoderma blennorrhagica)
68
ix ? reactive arthritis
- ESR/CRP,
* *- RF negative
- aspirate joint to exclude crystals, septic
- stool culture, urethral/vagina swab
* *+- XR/**MRI
* *- HLA b27
69
tx reactive arthritis
NSAIDs
- IA steroid injection
- recurrent cases- DMARD (sulfalazine, anti-TNF)
70
presentation of juvenile idiopathic arthritis
- Gradual Onset
- stiffness, pain after rest
- limp
- ant. uveitis (may be presenting sx)- photophobia, redness, tearing, blurring, floaters
- malaise, irritability, rash, fever, wt loss
- may have hx of sore throat, URTI, prev. infection
- fam hx of HLAB27 sx (iritis, arthritis, psoriasis)
71
diagnosis of junveline idiopathic arthritis
Of exclusion- rule out:
- septic arthritis (joint aspiration)
- reactive arthritis (swab/urine, stool)
* *- trauma (XR)
* *- malignancies (leukaemia, bone) (XR, FBC)
- 'Juvenile' <16yo
- idiopathic- no cause found
- arthritis- join swelling/painful restriction >56w
ix
- bloods- anaemia, ESR/CRP,
- antibodies (RG, ANA, anti-ccp)- negative
- infection screen, joint aspirate
- STI swabs, Stool culture
- XR, MRI
72
management of juvenile idiopathic arthritis
- NSAIDs, analgesia
- methotrexate
- corticosteroids (avoid if poss- growth, OP)
- biologics- TNFa, IL-6 blocker (tocilizumab)
73
complications of junvenile idiopathic arthritis
- increased BF due to inflammation--> bone overgrowth--> limp/deformity
- joint destruction needing replacement early
* *- severe visual impairment from uveitis
* *- anaemia of chronic disease
* *- OP
- growth failure
74
What is the pathophysiology of systemic lupus erythematosus
- multisystem autoimmune condition
- type 3 hypersensitivity
- immune complex formation
- these deposit in organs
- immune complex mediated inflammation--> tissue damage
75
key sx in presentation of SLE to look out for
- malar/butterfly rash (in 1/3)- across nose, cheeks, defined boarders
- discoid rash- scarring
- levedo reticularis- mottled skin
- photosensitivity- disease made worse by UV
76
other sx of SLE (not key)
- sicca- dry eyes/mouth
* *- oral ulcers
- alopecia
- resp- SOB, chest pain (pleuritis, pulm HTN, fibrosis)
- CV- HTN, CVA, raynauds, IHD
- GI- D+V, pain (peritonitis, pancreatitis)
- renal- HTN, renal failure
* *- MSK- arthritis, **tendon rupture
* *- Neuro- meningitis, MG, seizures
- psych issues
- anaemia, thrombocytopenia (bleeding), thrombosis
77
diagnosis of SLE
- no diagnostic test
- FBC- pancytopenia
* *- coomb's- haemolytic anaemia
- ESR
- UE- dysfunction, urinalysis
* *- coag
- anti-dsDNA antibody (specific), ANA, RF, **cardiolipin
- CXR, echo, MRI head
78
management of SLE
- statins, antiHTN, antiplatelets
- skin- sunscreen, topical steroids
- joints- NSAID, IA steroids
MILD- hydroxychloroqiune + NSAID
MODERATE- corticosteroids+ methotrexate/azathioprine, mycophenolate mofetil
SEVERE- corticosteroid +cyclophosphamide, biologics
79
What is antiphospholipid syndrome
- autoimmune attack on fat molecules
| - increase clot risk
80
sx antiphospholipid syndrome
- thrombosis- DVT, stroke, TIA, MI, PE
- HTN
* **- balance and mobility issues
* ** - vision/speech/memory issues
- parasethesia, migraines
- fatigue
- unexlpained miscarriage, PROM, severe pre-eclampsia
- livedo reticularis- mottled skin
81
antibodies may be present in antiphosphalipid syndrome
- lupus anticoagulant
- anti-apoliproprotein
- anti-cardiolipin
82
tx antiphospholipid syndrome
- anticoag/antiplatelets lifelong
| - acute - SC heparin
83
what is systemic sclerosis (scleroderma)
- autoimmune
| - microvasc damage
84
sx systemic sclerosis/scerloderma
CREST
Calcinosis (under skin, esp in fingers- infections, bumpy)
Raynaud's
oEsophageal dysmotility
Strictures/sclerodactylyl (white fingers)
Telangiectasia
- sx in the systems
85
ix scleroderma
- ANA
- anaemia of chronic disease (normo)
- ESR
- ix for systems if sx (ECG, echo, CXR, CT, XR)
86
tx scleroderma/systemic sclerosis
- smoking cessation
- stretch skin to keep ROM, emollient
- raynauds- vasodilators--- iloprost, sildenafil, nifedipine
- GORD- omeprazole
- renals- ACEI
- antihistamines for itch
- cyclophosphamide
- methotrexate
- organ transplant
87
what is sjorgrens
- lymphocytic infiltration of tear and salivary glands
| - can coincide with other autoimmune conditions
88
sx sjogrens
- sicca- dry mucous membranes
- enlarged salivary glands, stones
- cough, dyspareunia, oesophagitis
- systemic features (arthralgia, neuropathies, thyroid etc.)
89
ix ?sjogrens
- bloods- anaemia, ESR, **raised igG
* **- RF (100%)!!!!!!!!!
* **- anti-ro, anti-la (70%)
- ANA
* **- schirmer's test- filter paper 5 min on eye-- <10mm travel
- salivary gland biopsy- lymphocytes
90
tx sjogrens
- oral hygeine
- artificial tears, saliva, lube
- muscarinic agonist (pilocarpine)- increase saliva prod via parasymp stim.
- steroids, DMARDS
- hydroxychloroquine
91
what is polymyositis/dermatomyositis
- symmetrical inflammation of skin and striated muscle
| - can present as a paraneoplastic syndrome as underlying cancers in breast, lung, ovarian, gastric
92
sx polymyositis/dermatomyositis
dermato: - rash, Gottrons papules- red papules over knuckles
- muscle pain- proximal, symmetrical, shoulder, pelvis-- onset over weeks
- muscle weakness
- fever, arthralgia
* *- raynauds
* *- fibrosis, arrhythmias
* *- other AI conditions
93
ix polymyositis/dermatomyositis
- CK >1000
- ANA, Anti-SRP
* *- EMG - abnormal muscle activity
- raised WBC, ESR
- definitive -- skin/muscle biopsy
**- screen for malignancy- CXR, TFTs, CT
94
management of polymyositis/dermatomyositis
- PT/OT
- high dose steroids, OD/top
- methotrexate
- azathioprine
- IV ig
- infliximab, etanercept (biologics)
95
Name large vessel vasulitises
- Takyasu
| - Giant cell/temporal
96
Name small vessel vasulitises
- microscopic polyangitis
- granulomatosis with polyangitis (wegner's)
- eosinophilic granulomatosis with polyangitis (churg-strauss)
- buerger's/thomboangiitis obliterans
- polyarteritis nodosa
97
general presentation of vasculitis
- systemically unwell, fever
* *- arthralgia/arthritis
- wt loss, anorexia
- infarction (stroke, bowel, peripheral vasc, ulcers, gangrene)
- HTN, renal failure via glomerluonephritis
* *- scleritis, sight loss
* *- psychosis, chorea, seizures, impaired cognition
- angina
98
ix for ?vasculitis
- ANCA- small/medium
- cANCA
- pANCA
- vessel biopsy
- dopplers
- CT/MRI for larger vessels
99
tx for vasculitis (generally)
- smoking cessation
- steroids (cortico- pred)
- methotrexate
100
sx giant cel arteritis
- headache, scalp tenderness
- impalpable temporal arteries-- distended with reduced pulsation
- jaw/tongue cramp
- ischaemic optic neuro- sudden painless monocular and severe visual loss- irreversible- amaurosis fugax
- may be preceded by transient loss- emergency, reversible
- malaise, fatigue, wt loss
101
what conditions is giant cell arteritis assoc with?
- polymyalgia rheumatica (pain, stiffness in shoulder /neck/hip girdle muscles over days)
102
ix of ?giant cell arteritis
- bloods- ESR/CRP, FBC, UE
- temporal artery USS (thickening)
- temporal artery biopsy- skip lesions, mulitnucleated cells
103
diagnostic criteria fro giant cell arteritis
3 or more of
- >50yo
- new headache
- tmeporal artery tenderness/decreased pulsation
- ESR >50
- abnormal temptoral artery biopsy
104
tx giant cell
- pred 80mg PO OD
- azathioprine, metho, biologics
- Ca/vit D/bisphos/DEXA
- use falling ESR as guidance
105
sx of behcet's disease
- oral ulcer
- genital ulcer
* *- ant. uveitis
* *- arthritis
- systems sx- GI, cardiac, resp, neuro
- systemic sx
106
ix for ?behcet's
- Pathergy- skinprick-- swollen >5mm in 48hours
- XR, FBC, UE, ESR
- HLA B51
107
tx behcet's
- betamethasone oral
- lidocaine genital
- colchicine and steroids PO
108
what is polymyalgia rhuematica
- inflam of shoulder, neck and pelvic girdle
109
sx of polymyalgia rhuematica
- stiffness, worse at rest
- shoulder, neck, pelvic, arm (BL) pain
- fever, fatigue, anorexia, wt loss
- carpal tunnel, arthritis, oedema
- +- GCA sx
110
ix for ?polymyalgia rheumatica
- ESR/CRP raised
- CK (rhabdo/polymyositis), ALP, EMG, TFT, MSU (bence jones), ANA/anti-ccp, -- all normal
- response to steroids is often used to diagnose
111
tx polymyalgia rheumatica
- 15mg pred PO OD
- monitor ESR/CRP
- screen for giant cell arteritis
112
tx fibromyalgia
- exercise
- relxation/meitation
- CBT
- amitriptyline/pregablin
- duloxetine, SSRI
113
what is rheumatic fever
- inflam of skin, heart, eyes and joint
- 2-4w post strep infection of the throat (pyogens)
-
114
sx rheumatic fever
- fever, malaise, myalgia, fatigue
jOINTS- oligoarthritis, arthralgia
SKIN- non-itchy erythema marginatum- pink ring-like, torso and spread to limb, well defined
HEART- cnog HF sx- chest pain, SOB, tachy
- chorea
115
ix ?rhuematic fever
- throat cultures- Group A beta-haemolytic strep (pyogens)
- anti-streptolysin O tire- rasie (blood)
- echo (valve, large heart)
- ECG- arrhythmia
- CRP
116
tx rheumatic fever
- FeverPain score
- phenoxymethylpenicillin
- valve replacement/repair
117
tx of Raynaud's
- med review for causes (beta blockers, lidocaine, adrenaline, amphetamine, cocaine, cytotoxics, interferons)
- nifedipine- vasodilation (can cause severe hypotension
- admit urgently if ischaemia
118
signs on XR of primary bone cancer
- lytic/sclerotic lesions
- codman's triangle- peristeum lifted off with new bone formation underneath)
- sunburst- calcification of tumour BS
- onion-skin appearance- periosteum repeatedly liufted
- bone destruction
119
management of bone cancer
- CT/RT
- prophylactic plating
- removal - surgical, ablation
- bisphosphonates
120
what are the benign bone cancers, who do they occur in
- osteoid osteoma (child,teens)
- osteochondroma (child,teens)
- chondroma (adults)
- osteoclastomas/giant cell tumour (adults)
121
malignant bone cancers- name them, who do they occur in
- osteosarcoma (tween or older adult)
- chondrosarcoma (adults)
-
122
common sites of primary sites for bone mets
- renal
- thyroid
- lung
- prostate
- breast (most common)
123
presentation of primary or secondary bone malignancy
- bone pain- constant, progressive, mobility reduced
- #
- compression sx (spinal)
- hypercalcaemia sx- abdo pain, bone pain, stones, psych, constipation, polyuria
124
what nerve does carpal tunnel effect
median
125
what is physiological carpal tunnel
during pregnancy
126
sx carpal tunnel
PALMAR- THUMB, fore finger, index finer and 1/2 of ring finger:
- nocturnal dysaesthesia
- relieved by hand shaking (initially)
- weakness, clumsiness
127
signs of carpal tunnel
- wasting of thenar eminence
- weakness of thumb- opposition, abduction, flexion
- Tinel's- tapping exacerbatings
- Phalen's- reverse prayer
128
management of carpal tunnel
- rest, NSAIDs
- nigth splinting
- physio
- steroid injection
- decompression
129
what is trigger finger
- stenosing flexor tenosynovitis
| - assoc with AI conditions, and hx of use of hand
130
sx trigger finger
- clicking/locking when in flexion trying to extend
- cannot actively extend finger
- finger can be extended passively (unlike dupuytren's)
- +- pain
131
tx trigger finger
- small splint holding in extension
- analgesia
- steroid injection
- finger release, via needle, or surgical decomp if severe
- may recur
132
what is dupuytren's
- thickening/fibrosis of palmar fascia/ligaments
- causes nodules and digital contractures
- assoc w alcoholism, liver disease, fam hx, smoking, DM , peyronie's
133
sx dupuytren's
- FIXED flexion, cannot passively extend finger
- may be as subtle in ealry stages- finger can entend fully but there is a blanching/tight ligament on palmar aspect of hand-- FEEL palm
134
tx dupuytrens
- surgery with Z fasciotomy
135
sx dupuytrens of the foot
- plantar fibroma in arch
136
tx dupuytrens of the foot
- steroids
- orthotics
- surgery
137
what is de queviain's tenosynovitis
- extensor pollicis brevis and abductor pollicis longus-inflammation of tendons (radial aspect of hand, insert on thumb)
138
sx de quevains tenosynovitis
- pain over radial styloids
| - full ROM
139
ix and tx for de quevains
- finkeisteins test- pt hols thumb in fist and gently bands wrist ulnarly --- +=pain
tx
- rest, splint
- physio
- steroid injection
- surgical release
140
What is tennis elbow
- soft tissue tendinopathy - LATERAL epicondylitis
| - of ligaments of forearm extensors - insert onto lateral epicondyle of the humerus
141
what is golfer elbow
- soft tissue tendinopathy - MEDIAL epicondylitis
| - of ligaments of forearm extensors - insert onto medial epicondyle of the humerus
142
sx and hx of elbow epicondylitis, signs o/e
- hx of overuse of the forearm
- elbow pain
o/e
- epicondyle tenderness
- v.sensitive
- painful movements, but ROM fine if pushes
143
special test for elbow epicondylitis
Active wrist Flexion against resistant
- with elbow flexed 90 degrees
- palpate medial
- medial epicondyle (golFers)
Active exTension against resistant
- palpate laTeral
- laTeral epicondyle (Tennis)
144
Describe the brachial plexus
- C5-T1 roots
- combine into sup, middle, inf trunks
- continue behind subclavian artery, over lung apices and 1st rib
- behind the clavicle, each trunk splits into ***ant and post divisions****
- enter axilla
- these divisions (6) each split into **ant, medial and post cords***
- these divide and combine to form;
- Musculocutaneous
- Axillary
- Radial
- Median
- Ulnar
145
What does the axillary nerve to
- deltoid - shoulder abduction
- teres minor- humeral external rotation
- sensation over deltoid
146
what does the radial nerve do
- sensation on dorsum of hand (thumb, fore finger, middle finger, 1/2 ring)
- forearm and wrist extension
147
what does the median nerve do
- sensation to palmar aspect of thumb, fore,index, middle fingers and 1/2 of ring finger
- flexion of digits at MCP, thumb movements and forearm /wrist flexion
(test- break ok sign)
148
what does ulnar nerve do
- sensation of dorsal aspect of hand
- grip strength- finger flexion, extension, abduction, thumb adduction
(test grip and finger abduction)
149
describe where the nerve roots supply sensation to the skin of the upper limb
- C4- shoulder
- C5 lateral upper arm
- C6 lateral forearm and thumb
- C7- middle finger
- C8- little finger
- T1 inside of upper arm
- T2- axxila
150
common mechanism of radial, ulnar, axillary mononeuropathies
- inflammation
- trauma
ulnar- medial epicnodyle trauma
radial- saturday night (arm over back of chair), humeral shaft #
axillary- anterior dislocation of shuolder
151
sx of common upper limb mononeuropathies
Radial
- wrist drop
- decreased sensation/paraesthesia anatomical snuff box
Ulnar
- claw hand- cannot extend 4th and 5th digit- weak resisted finger abduction
- sensation over palmar aspect of hand
- the more proximal the injury, the less the deficit
Axillary
- cannt abduct arm
- regimental badge numbeness (over delt)
152
tx mononeurpathies upper limb
- splitnging
- physio
- decompression (not for axillary)
153
What bones are involved in the shoulder joint
```
Humerus
Scapular
- glenoid process
- acromion
Clavicle
```
154
what is frozen shoulder, sx
- inflam
- leads to fibrous tissue and sticky avascular capsule whihc sticks to humeral head
- very stiff shoulder
- aching pain worse at night
- external rotation is 1st movement to go
155
ix and tx frozen shoulder
- XR to exclude OA
- NSAIDs, physio
- IA injections
- anaesthetic manipulation
- arthroscopic electrodiathermy
156
what is impingement syndroem
- supraspinatus is caught and compressed between acromion and humeral
- particularly when arm is raised over head
157
sx impingement syndrome
- hx of repetitive overhead activity
| - pain on overhead movement
158
o/e signs of impingement syndrome
-- painful arc 45-160 degrees
Hawkin- kennedy
- pt shoulder and elbow at 90 degrees
- quickly move pt arm into internal rotation
- pain localised to subacromial space = +ve
159
ix and tx impingement
- XR exclude OA
MRI- rotator cuff
- NSAID
- physio
- steroid injection
- subacromial decompression.- basically shaving off the lower edge of the acromion
160
what is calfici tendonitis, sx , tx
Ca deposits in shoulder inflam RC
- pain, stiffness, catching
- gradual onset
- decompression
161
what are the rotator cuff muscles in the order they insert into humeral head , function
SITS
- supraspinatus- abd and int rot
- infraspinatus- ext rot
- teres minor- ext rotation,
- subscap (attaches posteriorly)- int rotation, abduction
TESTS:
you hail a taxi (horner blowers, teres minor)
you go for a drive (ext rot, teres minor/infraspinatus)
you have a drink (empty can, supraspinatus)
You get arrested (gerbers lift off, subscap)
162
how do you test supraspinatus
- empty can/jobe
163
how do you test infraspinatus
- resisted ext rotation
164
how do you test teres minor
- external rotation against resistance
| - horn blower- push arm down, pt weak
165
how do you test subscap
lift off
166
immediate management of open#
- CABCDE
- stop haemorrhage
- NV examination
- rmeove gross debris
- straightne and align
- repeat NV
- photograph wound
- cover wound with sterile, moist (slaine) dressing
- split
- repeat NV exmination
- IV coamox/clinda
- tetanus prophylaxis
167
what is not recommended in immeidat emanagement of open #
- mini debridement
- washing
- digital exploration of wound
168
sx scaphoid #
- snuff box tenderness
- pain on axial loading of thumb
- pain on scaphoid tubercle (prox. part of palm at base of thumb)
- pain on prayer/reverse prayer
169
tx of scpahoid #
- NSAIDs, elevation
- when confirmed #- scaphoid cast (below elbow backslab with thumb immobilised
- refer to # clinic for repeat XR in 2w as risk of necrosis
- surgicla fixation if necrosis or displaced
170
what is boxer's #
transverse # of 5th metacarpal neck
171
name the carpal bones of the hand
Some, Lover, Try , Positions , That , They , Can't , Handle
```
Scaphoid
Lunate
Triquetrum
Pisiform
Trapezium
Trapizoid
Capitate
Hamate
```
172
What is a colle's #
dorsal displacement of radial head # compared to radial shaft
fall onto extended wrist
173
what is smith's #
volar displacement of radial head compared to radial shaft
fall onto flexed wrist
174
what is a chauffer;s / hutchinson/backfire#
- radial styloid #
| - falling onto outstretched hand, compresison of scaphoid onto styloid
175
whats the terirble triad of theelbow
- humeral dislocation from humeroulnar joint
- coronoid # (ulnar bony buttress that, with the olecranon, acts as cup around humeral head)
- radial head/neck #
176
what is a complication of elbow #/dislocation
Anterior interosseous nerve injury
- branch of median nerve
- when asked to make ok sign, cannot round their thumb and forefinger
- need to go to theatre
177
what nerve is in danger of damage in humeral shaft #
radial
178
what shoulder dislocation is most common
anterior
179
complciation of anterior hsoulder dislocation
- axillary nerve injury
- brachial plexus injury
- longstanding instability
180
What is a Hill-sachs lesion
anterior shoulder dislocation
| - as humeral head has collided with anterior part of glenoid, bone is damaged and notched
181
what is a bankart lesion
anterior dislocation
| - anterior part of glenoid labrum is damaged, bony part of glenoid has broken off with the labral tear
182
tx of shoulder dislocation
- closed reduction
- ice then heat
- splint/sling 3w
- pendulum exercises
- collar and cuff in not stable
183
what sling do you use for humeral #
collar and cuff, so gravity and realign the broken bone
184
red flags for posterior shoulder dislocation
- post seizure
- unable to actively or passively externally rotate arm
- light bulb sign on XR
185
Special tests for shoulder instability
- apprehension test- abduct arm and put them into ext/ rot
- put your thumb on back of humeral head
- put anterior force
- pt will be umcomfortable
- pec will contract
Beighton scoring /9
186
what si the beighton scoring
hypermobility
- Major 4/9
- minor 1-3/9
- little fingers dorsiflexion >90 degrees (1,1)
- thumbs to arm (1,1)
- elbows- hyperentension (1,1)
- knees- hyperextension (1,1)
- touch floor with palms no knee bending (1)
187
what is a bakers cyst, ddx
- popliteal cyst
ddx
- popliteal aneurysm (pulsatile)
188
ACL tear sx
- popping heard r felt
- very painful
- immediate effusion, swelling
- giving way of joint
- painful to wt bear, reduced ROM
189
special tests for ACL, ix
Lachman
- pull tibia forward
Anterior draw
MRI
190
tx ACL
- non op- if young, not hgihly active, no subluxation
| - reconstruction
191
mechanism of ACL injury
- sudden deceleration , turning with foot planted
192
mechanism of meniscal tear
- forceful twist/rotation whilst fully weight bearing
193
sx of meniscal tear
- pain, swelling, stiffness
- mechanical ex- locking/cllinking
- trouble with knee extension
194
special test for meniscal tear
McMurrays
- Maximally flex hip and knee
- put valgus force on knee and turn toes out/ext rot- out into extension
- pain/locking/clicking= medial
varus force and internal rotation for lateral
195
ix for ?meniscal tear
MRI
| - absent bow tie sign
196
what are the bones of the ankle
tibia, fibula
- calcaneus (heel bone)
* *- talus
- navicular
- cuneiforms
- cuboid
- metatarsals
- phalanes
197
what are the sx of plantar fssciitis
- sharp heel pain
- insidious
- may prefer to walk on toes
- worse after standing
198
tx of plantar fasciitis
- analgesia, splinting, stretching
- shockwave
- gastrocneumius resection
- surgical plantar fasciotomy
199
what is mortons neuroma
- neuroma causing compression of interdigital nerve on plantar foot
200
sx and signs of mortons neuroma
- neuroma
- pain on weight bearing or narrow shoes
- sx relief on massaging, removal of shoes
- paraesthesia on plantar aspect of webspace
- positive webspace compression test- squeeze dorsally and ventrally - nerve pain
- MTPJ squeeze-- bursal click
201
tx mortons nueroma
- wide shoes with firm sole
- corticosteroid injection
- neurectomy
202
what is a bunion
hallux valgus
203
tx bunion
- shoe modification
| - osteotomy
204
management of achilles tendinopthay
- exclude rupture (thompsons)
- RICE
- NSAIDs
- gentle strecthing of front and back of lower leg
- physio
- eccentric heel drop
- avoid/stop quinolones eg cipro
205
achilles tendon rupture- sx
- going for a sprint
- sharp pain in back of leg
- may hear snap or pop
- thinks someone has kicked them in the leg
- inability to plantar flex foot (push off), or stand on toes
206
ahcilles rupture special test
thompsons test
207
tx ahcilles ruputre
if <1cm gap, non athlete, early presentation
- equinas boot
- increasing amounts of plantar flexion (wedges)
if >1cm gap, athlete, late presentation
- repair
208
what classificaiton is use for fibular #
weber
A- under syndesmosis
B- at syndesmosis
C- above syndesmosis (unstable)
209
what sign on XR suggests ligamentous injury and instability after an ankle #
talar shift (widening of tibiofibular joint space)
210
What is a Lisfranc injury
- torn lisfranc ligament
- between 2nd metatarsal and most medial cuneiform
- this ligament connect forefoot and hindfoot
- injured due to dislocation of the foot, due to dislocation of 2nd metatarsal
- on XR it'll look like the 1st metatarsal bone is very far away from the 2nd metatarsal bone, or all the metatarsals will look shifted laterally compared to cuneiform (homolateral)
211
mechanism of lisfranc injury
- axial loading through foot whilst on tip toes :)
| - twisting on a plantar flexed foot
212
hallmark sign of lisfranc injury
- plantar ecchymosis
213
XR sign of lisfranc injury
- widening of space between 1st and 2nd metatarsal
| or if homolateral all metatarsals shifted laterally
214
red flags CES
- lower back pain
- UL/BL lower limb sensory/motor abnomrality
* *- loss of reflexes legs
- bowel, bladder dysfunction- retention, incontinence
- saddle paraesthesia/perineal area
- sexual dysfunction
215
what are the sensory dermatomes of the lower leg and buttocks?
ANTERIOR
- L2- IFs
- L3 - hip, top of leg, medial thigh
- L4 - lateral upper thigh, knee, medial lower leg, ankle and foot
- L5- top of buttock, posterior hip, lateral edge of leg, anterior shin and top of foot, achilles
```
POSTERIOR
- S1- back of leg lateral 1/2
S2- back of leg medial 1/2
S3-S5- perineal area
S5- anus
```
S2/3- genitalia
216
ix ?CES, and tx
- urgent MRI
- immobilise if due to trauma
tx
- urgent spinal decompression
- abx if infection
- steroid- inflammation
- CT/RT- neoplasms
217
sx and signs septic arthitis
- severe pain
- red, hot, swollen joint
- cannot wt bear or move
Hip
- FABER position- flexed, abducted, ext. rot.
218
common causes of septic arthirits
S.aureus
- MRSA
- Staph epidermis
- N.gonorrhoea
- gram -ve bacilli-e.col, proteus, klebsiella
- strep
219
ix for septic arthritis
- Aspiration- WBC >50,000, stain, culture, polarised light microscopy-- crystal analysis, glucose level ***<60% of serum
- blood culture
- XR
* *- USS
* *- MRI if ?osteomyelitis
220
tx septic arthritis
fluclox IV 4-6w
or clinda
MRSA- vanc or teicoplanin
gonorrhoea/gram -ve-- cefotaxime
surgery- irrigation, drainage, culture, debridement
221
most common micro org to cause osteomyelitis?
Staph aureus
222
sx osteomyelitis
- fever, fatigue, nausea
- painful, red hot swelling
- decreased ROM
vertebral- severe back pain (esp at night)
223
ix ?osteomyelitis
- XR
- CT- ID necrotic bone
- MRI- best for early diagnosis and surgical planning
*****bone biopsy and culture-- gold standard
224
tx of osteomyelitis
Empirical- fluclox 6w, clinda if allergic
MRSA- vanc or teicoplanin
consider adding fusidic acid or rifampicin to all of the above for 1st 2 weeks
surgery- debridement/amputation/irrigation
225
sx and signs of hip OA
```
groin, lateral hip, deep buttck pain
- aggravated by movement
- stiffness
- grinding/crunching
Severe:
- reduced ROM
- fixed flexion deformity-- Thomas test (w max flexion of other hip the pathological leg flexes, woth
hand placed under lumbar spine)
- trendelenburg gait- weakness in hip abductors, dropping pelvis on other side when wt bearing
- trendelenburg sign
```
226
causes of osteonecorsis/AVN of the hip
- intra capsular #
- sickle cell
- steroids (LT use)
- alcoholism
- autoimmune
- chemotherapy
- hypercoag
- avscular nec of the hip in adolescents
227
sx osteonecrosis of the hip
- insidious pain
- stairs, incline, impact pain
- anterior hip pain
228
ix ?osteonecrosis of the hip
- XR- osteopenia, micro#s
- MRI
(- isotope Bone scan- not as sensitive as MRI)
229
tx osteonecrosis of the hip
- bisphos
- core decompression +- bone grafting-- core taken out of femoral head and tibial bone is inserted into the core .. :O
- osteotomy
- THR
- hip arthrodesis
230
sx hip labral tear
when happens:- sharp catching pain
- then dull pain, lateral hip (C sign)
- refrre pain- buttock, leg, lower back
- giving way of hip
- locking
- grinding, popping when ext. rotation
- ROM preserved
231
ix labral tear
- XR
| - MRI ***arthrogram with dye***
232
management of labral tear
- physio
- analgesia
- surgery- repair, reconstruction, debridement
233
pelvic ring #- sx
- deformity of pelvic
- sig pain
- swelling
- hypovolaemic shock
- inability to weight bear
****- bruising- perineal, scrotal, labial
234
ix of pelvic ring #
- CABCDE
- full NV assessment of lower limbs incl anal tone, perirectal sensation
- abdo examination
- urethral injuries-- UO
- internal open- rectum, vagina-- DRE and PV exams
CT
235
classification of pelvic ring#
***- young and burdess
antero posterior compression (pubis symphis separated)
****lateral compression (pubic tubercle/ilium wings #)
vertical shear (pubic tubercle and sacroiliac joint)
236
when type of hip # threatens blood supply to the head of femur
intracapsular (which includes subcaptial and transcervical NOF #)
237
interpretation of XR ?hip #
- shentons line
- levels of lesser trochs
- symmetry of fem head and neck laterally
238
blood supply to fem head
- profunda/deep branch of common femoral
- profunda splits into medial and laterlal circumflex
- form retinacular vessels- supply the head
- foveolar artery is in teres ligament (connects head to acetabulum)
- in adults , they rely on BS from one of the branches more, so at higher risk of necrosis
- younger people have more collateral flow, so the femoral head can be saved if quick
239
management of extracapsular (intertrochanteric, and subtrochanteric) hip #s
- dynamic hip screws-
| - can do intramed screw if further down humeral shaft
240
Management of intracapsular hip # (subcapital, trancervcal)
- old- hemiarthroplasty
- young- cannulated hip screws emergency to save femoral head
within 36 hours
241
what nerves cause foot drop
L5 (L4, S1 sometimes)
| peroneal nerve
242
causes of foot drop
compressiom:
- sciatica
- CES
Peripheral:
- peroneal nerve injury (sciatic branch)-- prox fibula #, knee dislocation, knee/hip replacement
- diabetes wth peripheral neuropathy
Central:
- stroke
- MS
- cerebral palsy
- brain malignancy
243
sx sciatica
- shooting pain
- lower back-- back of leg, outside/front of leg
* - sudden onset
* - usually after activity- heavy lifting
* - UL sx
- weakness/numbness in leg and foots
244
what nerve roots form the sciatic nerve
- L4,5,S1,2,3
245
causes of sciatica
- disc herniation
- spndololisthesis
- spinal stenosis
- pelvic tumour
- pregnancy
246
signs of sciatica
- straight leg raise- shotting pain is aggravated
247
management of sciatica
- exercises
- CBT
- NSAIDs
- amitryptyline
- radiofrquency denervation
- epidurals od local anaesthetic and stenois if acute and severe
- spinal decompression
248
signs of disc herniation
- Low back pain
- CES
- hip adduction and knee ext wekness (L3)
- ankle dorsiflesion and reduced patella reflex- L4
- - tradelenburg gait- hip abductors, anke dorsiflexion, extnsion of hallux (L5)
- plantar flexion of ankle, achilles relfex (S1)
- straight leg raise, aggravated by dorsiflexion
249
tx disc herniation
- NSAIDs
- physio
- nerve root corticosteroid injection
- laminitomy
- discectomy
250
sx discitis
- severe back pain (worse at night)
- children- refusal to walk, back arching
- no radiation
- fevers rigors
251
causes of discitis
- S aureus, TB, aseptic
252
ix ?discitis
- bloods- WCC, culture, CRP, ESR
| - MRI
253
tx discitis
- IV or oral cipro, vanc
| - little and often movement
254
most common site of compartment syndrome
lower limb
255
number of compartments in lower limb
```
lower leg- 4---
ant
lateral
superior post
deep post.
```
Thigh- 3
ant, medial, post
256
how to differentiate between different arteritises
Takayasu's
- large vessels
- intermittent limb claudication
- weak femorals
- young women, 20-40s (maybe asian)
- Aortic involvement- different BPs in each arm
GCA- yk
Goodpastures
- small vessles in lungs and kindeys
- haemoptysis
- glomerulonephritis- haematuria etc
Granulomatosis with polyangitis (wegner's)
- BVs in nose/sinus/throat, lungs, kidneys
- blocked/runny nose, nosebleeds, nostril crusting
- sinusitis
- earache, hearing loss
- cough, SOB, wheeze, chest pain
- nephropathy- haematuria, HTN
- skin rashes
Polyarteritis nodosa
- medium
- spares aorta
- kidney, heart, CNS, skin, GI
- rash, ulcers
- perpiheral neuropathy
- abdo pain, bleeding
- MI, CHF
257
what criteria is used to calculate likelihood of septic arthritis
```
The Kocher criteria
each is 1 point:
- Non weight-bearing.
- Temp > 38.5°C / 101.3°F
- ESR > 40mm/hr.
- WBC > 12,000 cells/mm3.
```
1-2- radiological and ortho input for ?aspiration
3-4- aspiraiton in the operating room
258
what classification system is used for NOF #
```
Garden
1- incomplete stable
2- compleye but non displaced
3- complete partial displacement
4- complete and completely displaced
```
259
what is the gartland classification used for
supracondylar (distal humerlal #) in children
260
what classification system is used to classify # of or around the growth plate in children
```
salter harris- SALTER
S- straight across, just above GP
A- Above (into bone above GP)
L- Lower (into the GP)
T- Two or through (from bone above GP into GP)
ER- cRush- GP compressed against bone
```
261
what rules are used to determine need for XR in ankle #
ottowa
262
what classification system is used for ankle/fibula # location
weber
263
what nerve wouldve been damaged in a patient with weak knee extension, hip flexion, loss of knee jerk and thigh numbness
femoral
264
what nerve is damaged in weak knee flexion and foot movements, pain and numbness from gluteal region to ankle
sciatic
265
what nerve would've been damaged in patient with weak hip adduction, numbness over medial thigh
obturator
forceps delivery
anterior hip dislocation
266
what nerve is damaged in patient with weak ankle dorsiflexion, numbness in calf and foot
lumbosacral trunk
267
sx of common peroneal nerve injury
- foot drop (loss of dorsiflexion)- also occurs with L5
- loss of foot eversion
sensation on dorsum of foot and lower lateral leg affected
fibula neck # or tightly applied lower limb plaster
268
what nerve injury causes positive trendelenburg test
superior gluteal nerve (controls hip abduction)
269
what nerve root and nerve root controls achilles tendon reflex
S1, tibial/sciatic
270
what nerve and nerve root controls patella reflex
L4, femoral
271
what nerve controls biceps reflex
C5
272
what nerve controls triceps reflex
C7-8
273
what nerve controls pronator reflex
C6-7
274
what is a Monteggia fracture
- dislocation of the proximal radial head/radioulnar joint from humerus with a PROXIMAL ULNAR fracture
- seen in children fallen on outstretched hand (4-10yrs old)
- Manchester (Monteggia) United (ulnar)
275
what is a Galeazzi #
- fracture of the DISTAL RADIUS with an associated dislocation of the distal radioulnar joint/radial head
- Galaxy Rangers
