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Its the final countdown > MSK > Flashcards

MSK Flashcards

1
Q

frozen shoulder

  1. clinical name
  2. imaging findings
A

adhesive capsulitis ( gradual onset, pain and stiffness in shoulder joint, particularly affecting external rotation, in 40-60yo)

X-ray - normal.
caused by thickening & contraction of glomerohumeral joint capsule & adhesion formation causing pain & loss of mvmt

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2
Q

what syndrome is caused by impungement of the ulnar nerve

A

cubital tunnel syndrome

typical pt: sleeping on their front w/ hands tucked under chest ( elbow spends a lot of time in flexion –> impinges on ulnar nerve –> sensory Sx ( numbness in ring & little finger)

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3
Q

Garden classification

  • what is it used for
  • what are the stages
A

Garden classification of hip fractres is used to predict the development of avascular necrosis in hip fractures

Garden classification
The Garden classification (figure 2) classifies fractures according to the degree of displacement as seen on an AP radiograph:
* Stage I: incomplete fracture line or impacted fracture
* Stage II: complete fracture line, non-displaced
* Stage III: complete fracture line, partial displacement
* Stage IV: complete fracture line, complete displacement

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4
Q

A 7yo fell on an outstretched hand and is now crying of pain in his right forearm and now refusing to use his right hand.

Exam;
forearm is swollen and bruised.
Tenderness on palpation of the middle of the forearm.

X-ray:
angulated fracture in the mid-diaphysis of the right radius.
The fracture is incomplete (goes through the cortex on the convex side of a bone that has been bent)
The opposite cortex (concave surface) remains intact.

What type of fracture does this describe?

A

Greenstick fractures
occur in paediatric patients when force is applied to a bone and it bends in such way that the structural integrity of the cortex surface is overcome. However, the bending force applied does not break the bone completely, breaking only the convex part of the bone whilst the concave surface remains intact

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5
Q

define
Compound fracture
and

Stable fracture

A

Compound fracture - skin is broken and the broken bone is exposed to the air.

Stable fracture sections of bone remain in alignment at the fracture.

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6
Q

where does a Colle’s fracture occur

A

the wirist
* typically follows FOOSH
* causes dinner fork deformity

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7
Q

a pt comes in with a suspected scaphoid freacture following a FOOSH. tenderness in which area of the hand is a sign of this

A

anatomical snuffbox

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8
Q

Name the 6 bones with retrograde blood supply

A

scaphoid
femoral head
humeral head
talus, navicular,5th metatarsal in the foot

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9
Q

what complication is a risk following fracture to a bone with retrograde sblood supply

A

avascular necrosis

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10
Q

the Weber classification
1. what does it describe
2 what are the tupes

A
  1. weber classification - fracture s of the lateral malleolus
    • Type A – below the ankle joint (syndesmosis intact)
      • Type B – level of the ankle joint – (syndesmosis intact/partially torn)
      • Type C – above the ankle joint (syndesmosis disrupted)
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11
Q

what is a common risk of pelvic ring fractures

A

significant intra-abdo bleed

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12
Q

name 2 common sites for pathological fractures

A

femur

vertebrae

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13
Q

give 3 bone disease which increase the chance fo gettign a pathological fracture

A

tumour
osteoporosis
Paget’s isease

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14
Q

what 5 main cancers metastesis to bone

A

Prostate, Renal, thyroid, breast, lung

PoRTaBLe ( the vowels dont imply anything =

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15
Q

the1st line Tx in fragility fracture prophylaxis is ACal & bisphosphonates. what med can be used where bisphosphonate CI/not tolerated

A

Denosumab ( mAb which works similarly, preventing osteoclast activity)

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16
Q

anti-Ro antibodies are associated with

A

Sjogrens

( Anti- Ro & anti-La)

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17
Q

anti-centromere antibodies are associated with …

A

limited systemic sclerosis. Particularly CRERST syndrome ( Calcinosis, Raynauds, Eosophageal dysmotility, Sclerodacttyly, Telangiectasia)

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18
Q

anti double stranded DNA antibiodies are associated with

A

SLE

ANA - in 85% of people with SLE, but not specific to SLE
anti-dsDNA - in 50% of SLE, specific

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19
Q

what are the 2 most significant complications of SLE

A

CVD - leading cause of death ( chronic inflammation in blood vessls –> HTN –> coronary artery disease
infection

other SLE complications

CVD, infection ( disease & immunosuppresant meds) , pancytopenia, pericarditis, pleuritis, interstitial lung disease (can lead to PF), lupus nephritis ( can proceed to ESRF), neuropsychiatric SLE - inflammation of CNS: optic neuritis, transversemyelitis, psychosis, recurrent miscarriage, VTE (antiphospholipid syndrome)

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20
Q

antibodies against proteins in the cell nucleus create a chronic inflammatory response, leading to SLE. what antibodies are these?

A

ANA - anti-nuclear antibodies

ANA - in 85% of people with SLE, but not specific to SLE
anti-dsDNA - in 50% of SLE, specific

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21
Q

what type of arthritis is a sympom of SLE

A

non-erosive

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22
Q

Urine protein:creatinine ratio is conducted on a patient with SLE, showing proteinuria. What is the appropriate investigation to confirm the complication

A

renal biopsy

proteinuria in SLE = ? lupus nephritis ( glomerulonephritis caused by inflammationin SLE)

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23
Q

what antibody is most associated with systemic sclerosis

A

Anti-Scl-70

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24
Q

what condition causing a hypercoagulable state is found in 40% of SLE pts?

A

antiphospholipid syndrome

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25
Q

what causes of anaemia are associated with SLE

A

anaemia of chronic disease, antoimmune haemolytic, kidney disease/ bone marrow suppression by meds

other SLE complications

CVD, infection ( disease & immunosuppresant meds) , pancytopenia, pericarditis, pleuritis, interstitial lung disease (can lead to PF), lupus nephritis ( can proceed to ESRF), neuropsychiatric SLE - inflammation of CNS: optic neuritis, transversemyelitis, psychosis, recurrent miscarriage, VTE (antiphospholipid syndrome)

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26
Q

Mx in SLE

rash
1st line
Tx resistant

A

Suncream & sun avoidance ( Mx of rash)

1st line: Hydroxychloroquine/NSAIDs/ Steroids ( e.g. prednisolone)

Tx resistance DMARDs (methotrexate, cyclophosphamide)
Biologic therapies

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27
Q

in what group of people does DLE
(discoid lupus erythematosus ) tend to occur

A

20-50 yo, dark skin, smoker

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28
Q

Mx in Discoid lupus erythematosus

A

sun protection ( lesions in face/scalp/ears are photosensitive)

topical steroids

intralesional steroid injection
hydroxychloroquine

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29
Q

what are the features of drug induced lupus

A

arthralgia, myalgia, rash “symmetrical annular (ring-like) papulosquamous (raised scaly) lesions on sun-exposed areas”, pulomary involment

does not have most of the Sx of SLE

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30
Q

what antibodies are most associated with drug-induced lupus

A
  • ANA (100%) ( they are ds-DNA -ve)
  • anti-histone antibodies (80- 90%)

*anti-Ro, anti-Smith (5%)

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31
Q

give 5 meds which casue drug induced lupus

A

most common : procainamide
hydralazine

less common:
isoniazid
minocycline
phenytoin

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32
Q

what MSK side effect is associated with long-term steroid use

A

avascular necrosis e.g. of hip

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33
Q

lower back pain is aka

A

lumbago

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34
Q

1st line Mx in lower back pain

A

NSAIDs ( and encouraged to stay physically active)

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35
Q

4 features suggestive of cauda equina

A

1) saddle paraesthesia,
2) urinary retention,
3) incontinence 4) bilateral neurological signs

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36
Q

which spinal nerves form the sciatic nerve

A

L4-S3

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37
Q

Sciatic nerve

sensory supply

motor supply

A

sensory: lateral lower leg, foot

motor: posterior thigh, lower leg, foot ( sicatica = unilateral pain from buttock –> post. thigh –> below knee/feet)

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38
Q

the main causes of lumboscral nerve root compression leading to sciatica are: (x3)

A

herniated disc
spondylolisthesis (ant. displacement of vertebra out of line with the one below)
spinal stenosis

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39
Q

bilateral sciatica suggests

A

Cauda equina

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40
Q

back pain in < 40, with morning stiffness and night pain suggests

A

ankylosing spondyliltis

( night pain may also indicate cancer)

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41
Q

what test is used to diagnose sciatica

A

sciatic stretch test

pt lying down > lift one leg ( fully straight) @90degrees dorsiflex foot at ankle > sciatic pain (buttock, posterior leg, foot) = sciatica

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42
Q

Ix in lower back pain

A

generally clinical Dx

but X-ray/CT scan in spinal fractures
MRI - ?cauda equina
inflammatory markers ( ESR/CRP), X-ray of spine and sacrum ( bamboo spine), MRI spine ( bone marrow oedema) = ankylosing spondylitis

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43
Q

what screening tool is used to assess the risk of back pain becoming chronic/

A

STarT back screenign tool ( scores of 9 >6=high risk)

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44
Q

scans are generally not offered in back pain. when should an MRI be offered ( x5)

A

malignancuy
infection
fracture
cauda equina
ank spon

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45
Q

what malignancy do pts with sjogrens have an increased risk of developing

A

lymphoid malignancies ( lymphoma)

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46
Q

what MSK condition causes secondary Sjogrens syndrome

A

rheumatoid arthritis

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47
Q

what are the red flags for lower back pain (x5)

A

age: <20/>50
hx malignancy
night pain
hx traum ( inc. location in thoracic region, this is not typically a site of damage due to e.g. weightlifting, so may indicted pathology)
systemically unwell

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48
Q

4 causes of bursistis

A
  • Friction (repetitive movements/ leaning)
  • Trauma
  • Inflammatory conditions (e.g., RA, gout)
  • Infection – ( septic bursitis)
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49
Q

appropriate Ix in suspected infected bursa

A

aspiration of fluid

pus –> infection
straw coloured –> unlikely to be infection
blood stained –> trauma/infection/inflammation
milky –> (pseudo)gout

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50
Q

Mx of olecranon bursitis

A

conservative: rest, ice, compression, protection from further pressure/trauma

analgesia (simple)

fluid aspiration to relieve pressure

steroid injections if problematic

Abx in infection

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51
Q

1sr & 2nd line antibiotic in infected olecranon bursitis

A

flucloxacillin

clarithromycin

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52
Q

location of pain in trochanteric bursitis

A

outer hip: referred to as greater trochanteric pain syndrome.

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53
Q

typical pt in olecranon bursitis

A

student ( leaning on desk) / plumber ( leaning on elbow)

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54
Q

typical pt in olecranon bursitis

A

middle-aged, gradual onset lateral hip pain, radiating down outer thigh

aching/burnign pain

worse with activity/ prolonged standing, sitting, rossing leg, lying down

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55
Q

bursitis typically presents with swelling except

A

trochaterit=c bursitis

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56
Q

Mx options in trochanteric bursitis

A

conservative: rest, ice

analgesia: ibuprofen/ naproxen

physio

steroid injections

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57
Q

what is the most common cause of shoulder pain in middle-aged females

A

adhesive capsulitis (frozen shoulder)- shoulder pain, stiffness, loss of ROM

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58
Q

2 risk factors for adhesive capsulitis

A

middle aged
diabetes

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59
Q

give 3 secondary causes of adhesive capsulitis

A

Primary ( spontaneous)
* Secondary
trauma, surgery or immobilisation

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60
Q

what are the 3 phases of adhesive capsulitis

A

painful: shoulder pain ( worse at night)

stiff: stiffness inhibiting active and passive mvmt (external rotation is most affected) - pain subsodes

thawing phase - gradual improvement, returns to normal

( takes 1-3yrs)

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61
Q

X-ray findings in adhesive capsulitis

A

normal

US/CT/MRI - thickened joint capsule

62
Q

Mx in dhesive capsulitis

A

Non-surgical options for improving symptoms and speeding up recovery are:
* Continue using the arm but don’t exacerbate the pain
* Analgesia (e.g., NSAIDs)
* Physiotherapy
* Intra-articular steroid injections
* Hydrodilation (injecting fluid into the joint to stretch the capsule)

Surgery may be used in particularly resistant or severe cases. The options are:
* Manipulation under anaesthesia – forcefully stretching the capsule to improve the range of motion
* Arthroscopy – keyhole surgery on the shoulder to cut the adhesions and release the shoulder

63
Q

what endo condition is a risk factor for pseudogout

A

hemochromatosis

combined with the knee x-ray report of chondrocalcinosis is highly suggestive of pseudogout (calcium pyrophosphate deposition disease). Haemochromatosis is a relevant risk factor for pseudogout in which excess iron deposits in various tissues (such as the right knee joint in this patient) which can lead to calcium pyrophosphate crystal deposition.

64
Q

where do gouty tophi occur

A

gouty tophi - subcut uric acid deposits

hands, ears, elbows

65
Q

high purine diets are risk factors for gout, what foods contain high purine levels

A

meat, seafood, alcohol

66
Q

what joints are typically affected in gout

A

metatarsophalngeal ( MTP - base of big toes)

carpometacarpal ( CMC - base of thumb)

wrist

sometimes knee

67
Q

Ix in suspected gout

A

aspirated joint fluid
- monosodium urate christals

( done to exclude septic arthritis)

68
Q

how do the monosodium urate crystals in gout appear

A

needle-shaped, negatively birefringent or polarised light

moNosodium - Needle shaped, Negatively birefringent

69
Q

what does an X-ray of a joint affected with gout show?

A

maintained joint space ( no loss)
lytic lesions in bone
punched out erosions
erosions have sclerotic borders with overhanging edges

70
Q

1st, 2nd, 3rd line mx in gout acute flares

A

1st NSAID ( w/ PPI)
2nd Colchicine ( common SE: abdo sx & diarrhoae, can cause multipople organ failure so used short term)
3 Oral steroid ( pred)

71
Q

prophylactic meds in gout

A

xanthine oxidase inhibitors

Allopurinol
Febuxostat

start prophylaxis weeks after acure attck result
continue prohpylaxis during an acute attack

72
Q

what lifestyle changes can be used in gout

A

weight loss
hydration
avoiding foods high in purines

73
Q

what crystals are deposited in Pseudogout and how do they appear

A

calcium pyrophosphate

rhomboid shape, positively bi-refringent in light

74
Q

Pseudogout is also known as

A

chondrocalcinosis

75
Q

features of chondrocalcinosis 9 psudogout)

A

many pts ASx

or

65 years old with a rapid-onset hot, swollen, stiff and painful knee. Other commonly affected joints are the shoulders, hips and wrists

76
Q

how does chondrocalcinosis ( psudogout) appear on xray

A
  • L – Loss of joint space
  • O – Osteophytes (bone spurs)
  • S – Subarticular sclerosis (increased density of the bone along the joint line)
  • S – Subchondral cysts (fluid-filled holes in the bone)

( as with osteoartheritis)

77
Q

Mx of pseudogout

A

if Asx - no tx needed
( as tx targeted at sx)

Sx Mx

  • NSAIDs (e.g., naproxen) first-line (co-prescribed with a proton pump inhibitor for gastroprotection)
  • Colchicine
  • Intra-articular steroid injections (septic arthritis must be excluded first)
  • Oral steroids

( similar to gout, except w/o intraarticular steroid injections)

78
Q

general symptoms of vertebral disc degeneration in the lower back

A

leg pain ( worse than back pain)

on worse on sitting

79
Q

Sx of prolapsed disc causing L3 nerve root compression

A

Sensory: loss of sensation in ant. thigh

Motor: weak -hip flexion, hip adduction, knee extension

Special test: reduced knee reflex
positive femoral stretch test

80
Q

Sx of prolapsed disc causing L4 nerve root compression

A

sensory: loss of anterior knee & medial malleolus

motor: week knee extension & hip adduction same as L3, but L3 also has week hip flexion

special test:
reduced knee reflex as w/ L3
positive femoral stretch as w/ L3

81
Q

Sx of prolapsed disc causing L5 nerve root compression

A

sensory: loss in dorsum of foot

motor: weakness in big toe & foot dorsiflexion (foot drop)

special test
reflexes intact
+ve sciatic nerve stretch test

82
Q

Sx of prolapsed disc causing S1 nerve root compression

A

SENSORY: loss in posterolateral leg, lateral foot ( distribution of pain in sciatica)

Motor: weak plantar flexion

special test
reduced ankle reflex
positive sciatic nerve stretch test

83
Q

Mx in back pain from prolapsed disc

A

analgesia ( as w/ back pain - NSAID 1st line ( w/ PPI) physiotherapy, exercises

MRI in Sx >4-6wks

84
Q

what classification is used for lateral malleolus fractures

A

weber classification

describes fractures in relation to the distal syndesmosis ( fibrous joint between tibia and fibula)

85
Q

what are the categories within weber’s classification

A

Type A ( below ankle joint - syndesmosis intact)

Type B - level of ankle joint ( syndesmosis intact/partially torn)

Type C - above ankle (syndesmosis disrupted)

86
Q

what are the Ottawa Rules for X-rays in ankle injuries

A

X-ray required in pain in malleolar zone & one of:

  • bony tenderness around lateral malleolus
  • bony tenderness around medial malleolus
  • inability to walk four weight bearing steps immediately after the injury and at ED
87
Q

what is a serious complication of pelvic ring fractures

A

vascular injury –> sig. intra-abdo bleed

88
Q

what mobnoclonal antibody is used in the management of osteoporosis

A

Denosumab ( alternative to bisphosphonates)

89
Q

1st line imaginig in fractures

A

X-ray in 2 views

90
Q

Give 5 potential early complications of fractures

A
  • Damage to local structures
  • Haemorrhage > shock> death
  • Compartment syndrome (swelling/bleedinwithin a compartment contained by fascia > increased pressure on the capillaries, nerves, and muscles > reduced bloodflow)
  • Fat embolism (long bone fractures)
  • VTE (DVTs and PEs) due to immobility
91
Q

what criteria is used for assessing fat embolism following a fracture

A

Gurds criteria
Gurd’s major criteria:
* Respiratory distress
* Petechial rash
* Cerebral involvement

Gurd’s minor criteria, including:
* Jaundice
* Thrombocytopenia
* Fever
* Tachycardia

92
Q

what are the two types of neck of femur fractures

A

intracapsular ( within the capsule, proximal to intertrocheantericl line) ,

extra-capsular outside the capsule, distal to intertrocheantericl line

93
Q

how does a hip fracture present

A
  • Groin/ hip pain radiating to the knee
  • Non-weight bearing
  • Shortened, abducted and externally rotated leg
94
Q

what presentation on an X-ray suggests a NOF

A

disruption of Shenton’s line ( continuous curving line from medial border of femoral neck to inferior border of superior pubic ramus)

X-Ray is 1st line but may be -ve., so do MRI/CT if still suspected.

95
Q

what medication’s used in VTE prophylaxis in NOF

A

LMWH

96
Q

what classification is used inNOF

A

Pauwels classification ( Classifies based on angle of fracture from horizontal)

  • Type I: between 0 and 30 degrees
  • Type II: between 30 and 50 degrees
  • Type III: more than 50 degrees
97
Q

where are growth plates ( epiphyseal plates) found

A

between the epiphysis ( head) and metaphysis ( neck) of long bones

in children alone

98
Q

why are children’s bones more prone to greenstick fractures

A

children’s bone is more cancellous bone (spongy, highly vascular) - so more flexible

adult bone - cortical ( compact) and hard on the outside

greenstick fractures - commonly mid-diaphyseal, incomplete fractures of long bones in which it bends and breaks . breakage on one side of bone

99
Q

what classification is used for paediatric fractures which cause a break in the growth plate

A

Salter-Harris classification ( the higher the grade, the more likely it is to disturb growth)

100
Q

what are the stages of the salter harris classification

A

SALTR
o Type 1: Straight across ( may be seen as posterior/anterior displacement on X-ray)
o Type 2: Above
o Type 3: beLow
o Type 4: Through
o Type 5: cRush ( epiphyseal and metaphyseal plates will be pushed together, instead of havning the growth plate inbetween)

101
Q

What medication are used in pain management in fracture in a child

A
  • Step 1: Paracetamol or ibuprofen
  • Step 2: Morphine

( morphine - as codeine/tramadol metabolism are unpredictable in children & aspirin risks Reye’s syndrome)

102
Q

pseudogout occurs with increasing age./ In pts <60 it is associated with certain conditions, what are these?

A
  • haemochromatosis
  • hyperparathyroidism
  • low magnesium, low phosphate
  • acromegaly, Wilson’s disease
103
Q

what joints are most affected in osteoarthritis

A

(large joints & hands)

  • Hips, Knees, Lumbar spine, Cervical spine (cervical spondylosis)
  • Distal interphalangeal (DIP) joints in the hands
  • Carpometacarpal (CMC) joint at the base of the thumb
104
Q

what Xray changes are found in OA

A

Loss of joint space
Osteophytes
Subarticular sclerosis (increased density of the bone along the joint line)
Subchondral cysts ( fluid filled holes in bone)

subarticular sclerosis - A comes before C
subChondral Cysts - C’s go together

105
Q

what is the pattern of pain and stiffness in OA

A
  • worsen with activity
  • worse at end of day

( think OA is more wear and tear)

causes more deformity, instability, reduced function of joint

106
Q

what hand signs are found in OA

A

1) Heberdens nodes
2) Bouchards nodes
3) squaring of base of thumb

causing reduced grip strength & ROM

107
Q

1st line medical Mx in OA

A

topical NSAIDs ( knee )
oral NSAIDs otherwise

paracetamol and opiates NOT recommendded for regular use in OA

108
Q

most common triggers of reactive arthritis

A

gastroenteritis
STI ( chlamydia - reactive arthritis; gonorrhoea - septic arthritis)

109
Q

Reactive arthritis is a seronegative spondyloarthropathy, what gene is it linked with

A

HLA B27 gene

110
Q

the triad of conjunctivitis, urethritis and arthritis are found in

A

reiter’s syndrome ( Reactive arthritis)

circinate balanitis ( dermatitis of head of penis) is also associated

111
Q

Management of reactive arthritis

A

1 - exclude septic arthritis ( similar presentation, monoarthritis , hot painful, swollen knee )

  • Tx triggering infection
  • NSAIDs
  • Steroid injection into the affected joints
  • Systemic steroids may be required, particularly where multiple joints are affected
112
Q

what is the most severe form of psoriatic arthritis?

A

arthritis mutilans

osteolysis of phalanges around the joints –> progressive shortening of the joints ( leading to telescoping digit

113
Q

seronegative spondyloarthropathies are absence of rheumatoid factor are associated with the HLA-B27 gene and are negative for RF. list the seronegative spondyloarthropathies

A

PEAR U

Psoriatic arthritis
Enteropathic arthritis (Ass. w/ IBD)
Ankylosing spondylitis
Reiters syndrome

Undifferentiated spondyloarthritis

114
Q

what are the 5 recognised patterns of arthritis in psoriatic arthritis

A
  1. Asymmertrical oligoarthritis ( 1-4 joints at once, unilaterally) most common
  2. Symmetrical polyarthritis ( like RA, >4 joints
  3. DIPJ
  4. Spondylitis ( back stiffness & pain - axial skeleton (spine & sacroiliac joint)
  5. Arthritis mutilans ( most severe)
115
Q

5 features of psoriatic arthritis

A

Psoriatic NODE

P - psoriasis plaques
N- nail pitting
O- onychoysis (separation from bed)
D- Dactylitis ( whole finger inflammation
E - Enthesitis ( inflammation of entheses)

116
Q

X-ray findings in psoriatic arthritis

A

Periostitis - inflammed periosteum = thickened, irregular outline of bone

Ankylosis ( fixation/ fusion of bones at the joint)

Osteolysis ( destruction of bone)

Dactylistis ( whole digit soft tissue swelling)

arthritis mutilans = pencil-in-cup appearance - errosion of bones at the joint: central erosion at one side of the joint ( cup ), erosion at other side of the joint (pointed bone - pencil)

117
Q

Mx in psoriatic arthritis

A

Depending on the severity, treatment may involve:
* Non-steroidal anti-inflammatory drugs (NSAIDs)
* Steroids
* DMARDs (e.g., methotrexate, leflunomide or sulfasalazine)
* Anti-TNF medications (etanercept, infliximab or adalimumab)
* Ustekinumab is a monoclonal antibody that targets interleukin 12 and 23

118
Q

what is the pattern of inflammation in RA

A

symmetrical polyarthritis ( multiple small joints across both sides of the body are affected)

119
Q

In what group of people does RA present in

A

women
middle age
Hx smokijng, obesity
FHx RA

120
Q

what gene is associated with RA

A

HLA DR4

121
Q

what antibody/antibodies are associated with RA

A

RF - 70%
Anti-CCP (anti-cyclic citrullinated peptide antibodies) - 80%, more sensitive to RA

122
Q

what joints are most commonly affected in RA

A

MCPJ - metacarpophalangeal
PIPJ - Proximal interphalangeal
Wrist
MTPJ - metatarsophalangeal ( foot)

123
Q

features of RA

A

pain, stiffness, swelling in joints ( swelling gives boggy feeling on palpation)

symmetrical, polyarthritis.

generally small joints, but large joints may be involved

Fatigue, weight loss, flu-like illness, myalgia & weakness

Sx worse in morning ( with rest) and improve with mvmt

**RA rarely has DIPJ involvement, so if this is found, its likely to be heberden’s nodes in OA

124
Q

Palindromic rheumatism is

A

self-limiting episodes of inflammatory arthritis, with pain, stiffness and swelling

last a few days then completely resolve

125
Q

hand signs in advanced RA

A

Z-shaped deformity to thumb
swan neck deformity ( hyperextended PIP, flexed DIP )
Boutonniere deformity ( hyperextended DIP, flexed PIP)
Ulnar deviation of fingers at MCPJ

126
Q

what spinal complication may appear in RA

A

Atlantoaxial subluxation - synovitis and ligament damage around odontoid peg of the axis (C2)

can cause spinal cord compression

127
Q

whats feltys syndrome

A

extra-articular manisfestation of RA

the triad of RA, Neutropenia, splenomegaly

128
Q

mx in RA

A
  1. Monotherapy (methotrexate, leflunomide or sulfasalazine)
  2. Combination treatment with multiple cDMARDs (conventional DMARD)
  3. Biologic therapies (usually alongside methotrexate)

Hydroxychloroquine (mildest DMARD) may be used in mild disease and palindromic rheumatism.

129
Q

what DMARDs are safest to use in pregnant woman with RA

A

hydroxychloroquine
sulfasalazine

130
Q

what medication has to be co-prescribed with methotrexate, and what is the regime

A

folic acid ( as methotrexate impares folate metabolism)

methotrexate - 1/wk
5mg folic acid - 1/wk ( on different day)

131
Q

key side effects of methotrexate

A

bone marrow suppression
leukopenia
highly teratogenioc

must co-prescribe 5mg folic acid ( taken on different day of the week )

132
Q

key side effects of the DMARD leflunomide ( used in RA)

A

hypertension
peripheral neuropathy

leflunomide - immunosuppressant which impairs Pyrimidine ( component of RNA & DNA) production

133
Q

key SE of DMARD sulfasalazine

A

orange urine
male infertility ( reduces sperm count)

can be used in pregnancy ( like hydroxychloroquine)

134
Q

key SE of DMARD hydroxychloquine

A

retinal toxicity
blue-grey skin
hair bleaching

can be used in pregnancy ( like sulfasalazine)

135
Q

Key SE of anti-TNF medications (adalimumab, infliximab, etanercept)

A

Tuberculosis reactivation

136
Q

Key SE of mab Rituxximab

A

Night sweats and thrombocytopenia

rituximab targets CD20 proteins on surface fo Bcells

137
Q

septic arthtritis presents with

A
  • Hot, red, swollen and painful joint
  • Refusing to weight bear
  • Stiffness and reduced ROM
  • Systemic Sx (fever, lethargy and sepsis)
    Young children: can be subtle, so always consider it as dDx in child presenting with joint problems.
138
Q

most common bacterial cause of septic arthritis

A

staph. aureus

others

  • Neisseria gonorrhoea (gonococcus) in sexually active teenagers
  • Group A streptococcus (Streptococcus pyogenes)
  • Haemophilus influenza
  • Escherichia coli (E. coli)

In a young pt w/ a single acutely swollen joint, consider gonococcal septic arthritis until proven otherwise.
Urinary or genital sx = ? reactive arthritis (once gonococcal septic arthritis is excluded).

139
Q

medical Mx of septic arthritis

A

4-6wks IV (3-6 In paeds)

  • Flucloxacillin (1st line)
  • Clindamycin (2nd line )
  • Vancomycin (if MRSA is suspected)

Ceftriaxone - N. gonorrhoea.

140
Q

what IV medication is given in septic arthritis caused by N. gonorrhoea

A

Ceftriaxone

141
Q

what is CREST syndrome

A

a subtype of limited systemic sclerosis

CREST
Calcinosis
Raynauds
Esophageal dysmotility
Sclerodactyly
Telangiectasia

142
Q

what areas of the body are inflammed in osteomyelitis

A

bone and bone marrow

typically caused by bacterial infection

143
Q

what is the common mode of infection in osteomyelitis

A

haematogenous osteomyelitis ( infection carried to the bone through blood)

other causes - direct bone infection ( fracture , ortho OP)

144
Q

most common infective organism in osteomyelitis

A

staph aureus

145
Q

best imaging Ix for osteomyelitis

A

MRI scan

x-rays often don’t show changes ( may have thinning/ surface changes/ destruction to areas of the bone)
bloods(inflammatory markers) & cultures

146
Q

Mx in osteomyelitis

A

surgical debridement
antibiotics
- 6 wks fluclox
with
- rifampicin/ fusidic acid for 1st 2 weeks

fluclox altrnatives
Penecillin allergy –> clindamycin
MRSA –> vancomycin/ teicoplanin

3m of Abx if chronic osteomyelitis

if associated with prosthesis - replace

147
Q

what conditions are associated with HLA B27

A

HIgh BARS

HLA B27
Ibd

Behcets disease
Ankylosing spondylitis
ReA (aka reiters)
Sarcoidosis

148
Q

Mx undisplace intracapsular NOF

A

internal fixation
Hemiarthroplasty ( if unfit) - artificial restoration of joint

149
Q

Mx displaced intracapsular hip fracture

A

Arthroplasty ( total or hemi- hip replacement )

total
- if pt used to be able to walk independently ( can use stick, not cognitively impaired, is medically fit for anaesthesia)

150
Q

Mx extracapsular hip fracture

A

stable intertrochenter fracture - dynamic hip screw

reverse oblique/transverse/ subtrochanteric fractures - intramedullary device

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