MSk Flashcards
Describe Barlow’s test
Adduct hips and push posteriorly to see if femoral heads are dislocatable (Barlow = break)
Describe Ortolani’s test
Abduct hip and push femurs towards yourself to try and reduce a dislocated hip
What imaging is required for all babies in breech position regarding DDH?
US hip at 6 weeks
What is the main goal of management of Perthes?
Keep femoral head in the acetabulum by casting/bracing
Main treatment of Perthes?
Observation and symptom relief
Which system is used to classify fractures that involve growth plates?
Salter-Harris
Describe each stage of the Salter Harris classification
- # involving only physis
- # involving physis and metaphysis
- # involving physis and epiphysis (inc joint)
- # involving, physis, metaphysis, epiphysis
- crush injury involving physis
Which organism causes osteomyelitis? Which organism is more common in sickle cell patients?
Staphylococcus aureus most common
Salmonella in sickle cell patients
What is the preferred imaging for osteomyelitis?
MRI highly sensitive in early disease.
What is the hallmark of giant cell arteritis?
ESR and CRP raised
Treatment of giant cell arteritis?
Corticosteroid treatment is imperative to reduce risk of vision loss
What features are shared between Wegener’s and Churg Strauss?
Sinusitis
Dyspnoea
Vasculitis (weight loss, fever, night sweats)
What features differentiate between Wegener’s and Churg Strauss?
Wegeners: renal failure, epistaxis, cANCA
Churg-Strauss: asthma, eosinophilia, pANCA
Features of Behçet’s?
Genital ulcers
Oral ulcers
Anterior/posterior uveitis
Skin lesions
Association/additional features of AS?
Apical fibrosis Anterior uveitis Aortic regurgitation Achilles tendonitis AVN block Amyloidosis
1st line treatment for AS?
NSAIDs
Which organism most commonly causes post-STI reactive arthritis?
Chlamydia trachomatis
Which organism most commonly causes post-dysteric reactive arthritis?
Shigella/Salmonella
Which eye manifestation is seen in AS?
Anterior uveitis (aka iritis)
Which blood tests would you order to investigate osteoporosis?
- FBC, U&E, CRP
- TFT
- Vitamin D
- Bone profile: calcium, phosphate, ALP, albumin
- Testosterone
1st line treatment for osteoporosis?
oral bisphosphonates (alendronate)
Mechanism of action of bisphosphonates?
Inhibits osteoclasts
What can be given to post-menopausal women to reduce risk of osteoporosis?
oral SERM (raloxifene)
Side effect of bisphononates?
- Oesophagitis - take sitting up and drink plenty of water
- Osteonecrosis of jaw
What is given if bisphosphonates are not tolerated?
Strontium ranelate
Treatment of osteomalacia?
Vitamin D
Which bones are affected in Paget’s?
Spine, pelvis, skull, femur, tibia
Hallmark of Paget disease?
Increased ALP with normal calcium, phosphate, PTH
How is calcium, phosphate, ALP and PTH affected in osteomalacia?
- Decreased
- Decreased
- Increased
- Increased
Which drugs can induce SLE?
Hydralazine, isoniazid, procainamide, penicillamine
How do complement levels change during active SLE flares?
C3 and C4 levels decreased
Treatment for SLE?
NSAIDs for arthritis
Steroids
Hydroxychloroquine 1st line
What is given to treat severe SLE?
methotrexate, Rituximab
What malignancy are those with Sjogren’s at risk of?
Lymphoma
Features of Sjogrens?
- Dryness of eyes and mouth (some may have vaginal dryness)
- Painful joints and muscles
- Fatigue
- Raynauds
- Dysphagia and oesophageal dysmotility
Which 2 tests must be done in order to truly diagnose Sjogrens?
- Positive anti-Ro/anti-La Abs
- Parotid/Labial gland biopsy
Treatment for Sjogrens?
- Hydroxychloroquine for arthalgia and fatigue
- Artificial tears and saliva
Which antibodies are seen in antiphospholipid syndrome?
- Anticardiolipin
- b2 glycoprotein
- Lupus anticoagulant
What is the normal treatment for those with APS?
low dose aspirin
What treatment options are there for APS in pregnant women?
- Aspirin if patient has only had obstetric manifestations and no thrombosis
- LMWH instead of warfarin
What is the treatment for those with APS who have had VTE event?
lifelong warfarin
What additional features as seen in diffuse systemic sclerosis vs limited systemic sclerosis?
- Skin sclerosis is diffuse
- Myocardial fibrosis
- Scleroderma renal crisis
- Pulmonary fibrosis
What blood test results indicate myositis?
- raised CK
- raised ESR and CRP
Treatment of myositis?
-high dose glucocorticoids
IV Ig rescue
Which cancers are associated with development of dermatomyositis?
(LOOBC) Lung Ovary Oesophageal Breast Colon
Hallmark diagnostic feature of PMR?
Raised ESR and CRP
Treatment for PMR?
Prednisolone 15-20mg
Referral to ophthalmology
Symptoms of temporal arteritis?
- Headache with scalp tenderness
- Jaw claudication
- Vision loss
- Fatigue and pain in proximal muscles
- PMR
- Temporal artery tenderness
Investigations for temporal arteritis?
-Blood test shows raised ESR and CRP
Management for temporal arteritis?
- High dose 60mg prednisolone
- Referral to ophthalmology if vision is affected
Red flags for back pain?
- Onset before 20 or after 50
- Lasts >6 weeks
- Associated with systemic illness such as fever and weight loss
- Cauda equina symptoms
Which gene loci is associated with RA?
HLA-DR4, HLA-DR1
Which eye manifestations are seen in RA?
Scleritis and episcleritis, scleromalacia perforans
What cardiac manifestations are seen in RA?
- Ischaemic heart disease
- Pericarditis
- Endocarditis, myocardial disease
What is Felty’s syndrome?
Splenomegaly and neutropaenia
Which gene is associated with Felty syndrome?
HLA-DR4
X-ray findings in RA?
Early disease: juxta-articular osteopenia and decreased joint space
Late disease: bony erosions, subluxation, carpal destruction
What scoring system is used to assess RA severity?
DAS28
Which antibodies can be found in RA?
RF, anti-cyclic citrullinated protein antibody (anti-CCP)
What role do steroids have in the management of RA?
Slows down disease progression and treats acute exacerbations of joint inflammation
Main treatment regime for RA?
- NSAIDs, analgesics and steroids for joint pain
- Methotrexate
- Biologics if 2 DMARDs have failued
Side effects of methotrexate
- Teratogenic
- Liver fibrosis
- Myelosuppression
- Pulmonary fibrosis
What monitoring tests are needed during methotrexate use?
- CXR
- FBC for myelosuppression
- LFTs for liver fibrosis
Concurrent use of what drugs with methotrexate can cause bone marrow suppression and severe pancytopaenia?
Trimethoprim-containing antibiotics
Side effects of sulfasalazine?
- Hepatitis
- Reduced sperm count
- Myelosuppression
- Neutropaenia
Side effects of hydroxychloroquine?
- Irreversible retinopathy
- Nightmares
Side effects of leflunomide?
- Liver fibrosis
- Peripheral neuropathy
- Hypertension
- Myelosuppression
- Teratogenicity
When should biologics be considered for RA treatment
Failure to respond to 2 DMAIDs including methotrexate
Give examples of TNFalpha blockers
- Infliximab
- Adalimumab
- Etanercept
Side effects of TNFalpha blockers?
- Reactivation of TB
- Reactivation of hepatitis
How does rituximab work?
Monoclonal antibody against CD20 receptor of B cells
Side effects of rituximab?
- Nightmares
- Thrombocytopaenia
What indicates poor prognosis of RA?
- High titres of anti-CCP and RF
- X-ray shows early erosive damage
Which joint does gout most commonly occur in? What is this called?
1st MTP joint
Called podagra
What dietary foods increase the risk of gout?
Red meat, alcohol, seafood, sweeteners
What kind of drugs increase the risk of gout?
Thiazide diuretics
Joint fluid microscopy findings in gout?
Needle shaped, negatively birefringent crystals under polarised light
X-ray findings in gout?
- Soft tissue swelling
- Punched out appearance in juxta-articular bone in the long term
What is the treatment for acute gout?
- DO NOT START ALLOPURINOL
- High dose NSAIDs (colchicine is NSAIDs are contraindicated)
- Steroids if NSAIDs and colchicine are contraindicated
- RICE
What is the general management of gout?
-Allopurinol with NSAID/colchicine
What uric acid level is the target for gout patients?
Below 360micromol/L
Mode of action of allopurinol?
Xanthine oxidase inhibitor
Side effects of allopurinol?
Skin rash
GI intolerance
What are the crystals seen in pseudogout made of?
Calcium pyrophosphate dihydrate (CPPD)
What are the risk factors for pseudogout?
Age
Hyperparathyroidism
Haemochromatosis
Hypophosphataemia
Management of pseudogout?
NSAIDs/colchicine
Intra-articular steroids for acute attacks
Most common causative organism in septic arthritis?
Staph. aureus
Which joints are commonly affected in pseudogout?
Knee, wrist, shoulders
X-ray features of pseudogout?
Chondrocalcinosis
Which gene loci is associated with reactive arthritis?
HLA-B27
Which sexually transmitted organism is responsible for reactive arthritis in young adults?
Chlamydia trachomatis
What organism is responsible for septic arthritis in young, sexual active adults?
Neisseria gonorrhoeae
Which eye manifestation is seen in reactive arthritis?
Conjunctivitis
Anterior uveitis
What triad of symptoms is seen in reactive arthritis?
Reiter’s triad:
Urethritis/balanitis, conjunctivitis/anterior uveitis, arthritis
Which 2 types of infection are most common in reactive arthritis?
- Gastroenteritis
- STI
How to manage a suspected septic arthritis?
- Antibiotics
- Joint aspiration for gram staining, culture&sensitivity, crystal analysis
How can septic arthritis occur?
- Haematogenous spread of bacteria from other site of infection
- Pre-existing bone infection
- Penetrative injury and introduction of bacteria from environment
X-ray findings in psoriatic arthritis?
Pencil in cup appearance
Side effects of etanercept?
Encephalitis
Side effects of colchicine?
Diarrhoea, nausea, vomiting
Difference in presentation between PMR and polymyositis?
PMR has muscle tenderness/stiffness but no true weakness
Polymyositis has no muscle tenderness but reduced power
What is the management for undisplaced intracapsular hip fractures?
- Internal fixation if fit and well
- Hemiarthroplasty if unfit
What is the management for displaced intracapsular hip fractures?
- Hemiarthroplasty if unfit
- Total hip replacement if fit
What is the management for extracapsular hip fractures?
- Stable intertrochanteric fracture = DHS
- Reverse oblique, transverse, subtrochanteric = intramedullary nail
Which muscles carry how shoulder abduction and by how much?
- Supraspinatus 0-15deg
- Deltoid 15-90 deg
- Trapezius and serratus anterior past 90 (rotates scapula)
How to manage the renal complications of limited cutaneous systemic sclerosis? (hypertension & AKI)
ACE-i
Side effects of ciprofloxacin?
Tendonitis and tendon rupture
What are the myotome movements? (C5 to S2)
C5: shoulder abduction C5-6: pick up sticks C7-8: close the gate & wrist extension C8-T1: finger abduction/adduction L2-3: lift the knee L3-4: kick the door L4-5: toes point to the sky L5-S1: kick my bum S1-2: stand on my shoe
