MSK Flashcards
frozen shoulder
- clinical name
- imaging findings
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
what syndrome is caused by impungement of the ulnar nerve
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)
Garden classification
- what is it used for
- what are the stages
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
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?
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
define
Compound fracture
and
Stable fracture
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.
where does a Colle’s fracture occur
the wirist
* typically follows FOOSH
* causes dinner fork deformity
a pt comes in with a suspected scaphoid freacture following a FOOSH. tenderness in which area of the hand is a sign of this
anatomical snuffbox
Name the 6 bones with retrograde blood supply
scaphoid
femoral head
humeral head
talus, navicular,5th metatarsal in the foot
what complication is a risk following fracture to a bone with retrograde sblood supply
avascular necrosis
the Weber classification
1. what does it describe
2 what are the tupes
- 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)
- Type A – below the ankle joint (syndesmosis intact)
what is a common risk of pelvic ring fractures
significant intra-abdo bleed
name 2 common sites for pathological fractures
femur
vertebrae
give 3 bone disease which increase the chance fo gettign a pathological fracture
tumour
osteoporosis
Paget’s isease
what 5 main cancers metastesis to bone
Prostate, Renal, thyroid, breast, lung
PoRTaBLe ( the vowels dont imply anything =
the1st line Tx in fragility fracture prophylaxis is ACal & bisphosphonates. what med can be used where bisphosphonate CI/not tolerated
Denosumab ( mAb which works similarly, preventing osteoclast activity)
anti-Ro antibodies are associated with
Sjogrens
( Anti- Ro & anti-La)
anti-centromere antibodies are associated with …
limited systemic sclerosis. Particularly CRERST syndrome ( Calcinosis, Raynauds, Eosophageal dysmotility, Sclerodacttyly, Telangiectasia)
anti double stranded DNA antibiodies are associated with
SLE
ANA - in 85% of people with SLE, but not specific to SLE
anti-dsDNA - in 50% of SLE, specific
what are the 2 most significant complications of SLE
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)
antibodies against proteins in the cell nucleus create a chronic inflammatory response, leading to SLE. what antibodies are these?
ANA - anti-nuclear antibodies
ANA - in 85% of people with SLE, but not specific to SLE
anti-dsDNA - in 50% of SLE, specific
what type of arthritis is a sympom of SLE
non-erosive
Urine protein:creatinine ratio is conducted on a patient with SLE, showing proteinuria. What is the appropriate investigation to confirm the complication
renal biopsy
proteinuria in SLE = ? lupus nephritis ( glomerulonephritis caused by inflammationin SLE)
what antibody is most associated with systemic sclerosis
Anti-Scl-70
what condition causing a hypercoagulable state is found in 40% of SLE pts?
antiphospholipid syndrome
what causes of anaemia are associated with SLE
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)
Mx in SLE
rash
1st line
Tx resistant
Suncream & sun avoidance ( Mx of rash)
1st line: Hydroxychloroquine/NSAIDs/ Steroids ( e.g. prednisolone)
Tx resistance DMARDs (methotrexate, cyclophosphamide)
Biologic therapies
in what group of people does DLE
(discoid lupus erythematosus ) tend to occur
20-50 yo, dark skin, smoker
Mx in Discoid lupus erythematosus
sun protection ( lesions in face/scalp/ears are photosensitive)
topical steroids
intralesional steroid injection
hydroxychloroquine
what are the features of drug induced lupus
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
what antibodies are most associated with drug-induced lupus
- ANA (100%) ( they are ds-DNA -ve)
- anti-histone antibodies (80- 90%)
*anti-Ro, anti-Smith (5%)
give 5 meds which casue drug induced lupus
most common : procainamide
hydralazine
less common:
isoniazid
minocycline
phenytoin
what MSK side effect is associated with long-term steroid use
avascular necrosis e.g. of hip
lower back pain is aka
lumbago
1st line Mx in lower back pain
NSAIDs ( and encouraged to stay physically active)
4 features suggestive of cauda equina
1) saddle paraesthesia,
2) urinary retention,
3) incontinence 4) bilateral neurological signs
which spinal nerves form the sciatic nerve
L4-S3
Sciatic nerve
sensory supply
motor supply
sensory: lateral lower leg, foot
motor: posterior thigh, lower leg, foot ( sicatica = unilateral pain from buttock –> post. thigh –> below knee/feet)
the main causes of lumboscral nerve root compression leading to sciatica are: (x3)
herniated disc
spondylolisthesis (ant. displacement of vertebra out of line with the one below)
spinal stenosis
bilateral sciatica suggests
Cauda equina
back pain in < 40, with morning stiffness and night pain suggests
ankylosing spondyliltis
( night pain may also indicate cancer)
what test is used to diagnose sciatica
sciatic stretch test
pt lying down > lift one leg ( fully straight) @90degrees dorsiflex foot at ankle > sciatic pain (buttock, posterior leg, foot) = sciatica
Ix in lower back pain
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
what screening tool is used to assess the risk of back pain becoming chronic/
STarT back screenign tool ( scores of 9 >6=high risk)
scans are generally not offered in back pain. when should an MRI be offered ( x5)
malignancuy
infection
fracture
cauda equina
ank spon
what malignancy do pts with sjogrens have an increased risk of developing
lymphoid malignancies ( lymphoma)
what MSK condition causes secondary Sjogrens syndrome
rheumatoid arthritis
what are the red flags for lower back pain (x5)
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
4 causes of bursistis
- Friction (repetitive movements/ leaning)
- Trauma
- Inflammatory conditions (e.g., RA, gout)
- Infection – ( septic bursitis)
appropriate Ix in suspected infected bursa
aspiration of fluid
pus –> infection
straw coloured –> unlikely to be infection
blood stained –> trauma/infection/inflammation
milky –> (pseudo)gout
Mx of olecranon bursitis
conservative: rest, ice, compression, protection from further pressure/trauma
analgesia (simple)
fluid aspiration to relieve pressure
steroid injections if problematic
Abx in infection
1sr & 2nd line antibiotic in infected olecranon bursitis
flucloxacillin
clarithromycin
location of pain in trochanteric bursitis
outer hip: referred to as greater trochanteric pain syndrome.
typical pt in olecranon bursitis
student ( leaning on desk) / plumber ( leaning on elbow)
typical pt in olecranon bursitis
middle-aged, gradual onset lateral hip pain, radiating down outer thigh
aching/burnign pain
worse with activity/ prolonged standing, sitting, rossing leg, lying down
bursitis typically presents with swelling except
trochaterit=c bursitis
Mx options in trochanteric bursitis
conservative: rest, ice
analgesia: ibuprofen/ naproxen
physio
steroid injections
what is the most common cause of shoulder pain in middle-aged females
adhesive capsulitis (frozen shoulder)- shoulder pain, stiffness, loss of ROM
2 risk factors for adhesive capsulitis
middle aged
diabetes
give 3 secondary causes of adhesive capsulitis
Primary ( spontaneous)
* Secondary
trauma, surgery or immobilisation
what are the 3 phases of adhesive capsulitis
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)
X-ray findings in adhesive capsulitis
normal
US/CT/MRI - thickened joint capsule
Mx in dhesive capsulitis
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
what endo condition is a risk factor for pseudogout
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.
where do gouty tophi occur
gouty tophi - subcut uric acid deposits
hands, ears, elbows
high purine diets are risk factors for gout, what foods contain high purine levels
meat, seafood, alcohol
what joints are typically affected in gout
metatarsophalngeal ( MTP - base of big toes)
carpometacarpal ( CMC - base of thumb)
wrist
sometimes knee
Ix in suspected gout
aspirated joint fluid
- monosodium urate christals
( done to exclude septic arthritis)
how do the monosodium urate crystals in gout appear
needle-shaped, negatively birefringent or polarised light
moNosodium - Needle shaped, Negatively birefringent
what does an X-ray of a joint affected with gout show?
maintained joint space ( no loss)
lytic lesions in bone
punched out erosions
erosions have sclerotic borders with overhanging edges
1st, 2nd, 3rd line mx in gout acute flares
1st NSAID ( w/ PPI)
2nd Colchicine ( common SE: abdo sx & diarrhoae, can cause multipople organ failure so used short term)
3 Oral steroid ( pred)
prophylactic meds in gout
xanthine oxidase inhibitors
Allopurinol
Febuxostat
start prophylaxis weeks after acure attck result
continue prohpylaxis during an acute attack
what lifestyle changes can be used in gout
weight loss
hydration
avoiding foods high in purines
what crystals are deposited in Pseudogout and how do they appear
calcium pyrophosphate
rhomboid shape, positively bi-refringent in light
Pseudogout is also known as
chondrocalcinosis
features of chondrocalcinosis 9 psudogout)
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
how does chondrocalcinosis ( psudogout) appear on xray
- 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)
Mx of pseudogout
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)
general symptoms of vertebral disc degeneration in the lower back
leg pain ( worse than back pain)
on worse on sitting
Sx of prolapsed disc causing L3 nerve root compression
Sensory: loss of sensation in ant. thigh
Motor: weak -hip flexion, hip adduction, knee extension
Special test: reduced knee reflex
positive femoral stretch test
Sx of prolapsed disc causing L4 nerve root compression
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
Sx of prolapsed disc causing L5 nerve root compression
sensory: loss in dorsum of foot
motor: weakness in big toe & foot dorsiflexion (foot drop)
special test
reflexes intact
+ve sciatic nerve stretch test
Sx of prolapsed disc causing S1 nerve root compression
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
Mx in back pain from prolapsed disc
analgesia ( as w/ back pain - NSAID 1st line ( w/ PPI) physiotherapy, exercises
MRI in Sx >4-6wks
what classification is used for lateral malleolus fractures
weber classification
describes fractures in relation to the distal syndesmosis ( fibrous joint between tibia and fibula)
what are the categories within weber’s classification
Type A ( below ankle joint - syndesmosis intact)
Type B - level of ankle joint ( syndesmosis intact/partially torn)
Type C - above ankle (syndesmosis disrupted)
what are the Ottawa Rules for X-rays in ankle injuries
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
what is a serious complication of pelvic ring fractures
vascular injury –> sig. intra-abdo bleed
what mobnoclonal antibody is used in the management of osteoporosis
Denosumab ( alternative to bisphosphonates)
1st line imaginig in fractures
X-ray in 2 views
Give 5 potential early complications of fractures
- 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
what criteria is used for assessing fat embolism following a fracture
Gurds criteria
Gurd’s major criteria:
* Respiratory distress
* Petechial rash
* Cerebral involvement
Gurd’s minor criteria, including:
* Jaundice
* Thrombocytopenia
* Fever
* Tachycardia
what are the two types of neck of femur fractures
intracapsular ( within the capsule, proximal to intertrocheantericl line) ,
extra-capsular outside the capsule, distal to intertrocheantericl line
how does a hip fracture present
- Groin/ hip pain radiating to the knee
- Non-weight bearing
- Shortened, abducted and externally rotated leg
what presentation on an X-ray suggests a NOF
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.
what medication’s used in VTE prophylaxis in NOF
LMWH
what classification is used inNOF
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
where are growth plates ( epiphyseal plates) found
between the epiphysis ( head) and metaphysis ( neck) of long bones
in children alone
why are children’s bones more prone to greenstick fractures
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
what classification is used for paediatric fractures which cause a break in the growth plate
Salter-Harris classification ( the higher the grade, the more likely it is to disturb growth)
what are the stages of the salter harris classification
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)
What medication are used in pain management in fracture in a child
- Step 1: Paracetamol or ibuprofen
- Step 2: Morphine
( morphine - as codeine/tramadol metabolism are unpredictable in children & aspirin risks Reye’s syndrome)
pseudogout occurs with increasing age./ In pts <60 it is associated with certain conditions, what are these?
- haemochromatosis
- hyperparathyroidism
- low magnesium, low phosphate
- acromegaly, Wilson’s disease
what joints are most affected in osteoarthritis
(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
what Xray changes are found in OA
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
what is the pattern of pain and stiffness in OA
- worsen with activity
- worse at end of day
( think OA is more wear and tear)
causes more deformity, instability, reduced function of joint
what hand signs are found in OA
1) Heberdens nodes
2) Bouchards nodes
3) squaring of base of thumb
causing reduced grip strength & ROM
1st line medical Mx in OA
topical NSAIDs ( knee )
oral NSAIDs otherwise
paracetamol and opiates NOT recommendded for regular use in OA
most common triggers of reactive arthritis
gastroenteritis
STI ( chlamydia - reactive arthritis; gonorrhoea - septic arthritis)
Reactive arthritis is a seronegative spondyloarthropathy, what gene is it linked with
HLA B27 gene
the triad of conjunctivitis, urethritis and arthritis are found in
reiter’s syndrome ( Reactive arthritis)
circinate balanitis ( dermatitis of head of penis) is also associated
Management of reactive arthritis
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
what is the most severe form of psoriatic arthritis?
arthritis mutilans
osteolysis of phalanges around the joints –> progressive shortening of the joints ( leading to telescoping digit
seronegative spondyloarthropathies are absence of rheumatoid factor are associated with the HLA-B27 gene and are negative for RF. list the seronegative spondyloarthropathies
PEAR U
Psoriatic arthritis
Enteropathic arthritis (Ass. w/ IBD)
Ankylosing spondylitis
Reiters syndrome
Undifferentiated spondyloarthritis
what are the 5 recognised patterns of arthritis in psoriatic arthritis
- Asymmertrical oligoarthritis ( 1-4 joints at once, unilaterally) most common
- Symmetrical polyarthritis ( like RA, >4 joints
- DIPJ
- Spondylitis ( back stiffness & pain - axial skeleton (spine & sacroiliac joint)
- Arthritis mutilans ( most severe)
5 features of psoriatic arthritis
Psoriatic NODE
P - psoriasis plaques
N- nail pitting
O- onychoysis (separation from bed)
D- Dactylitis ( whole finger inflammation
E - Enthesitis ( inflammation of entheses)
X-ray findings in psoriatic arthritis
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)
Mx in psoriatic arthritis
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
what is the pattern of inflammation in RA
symmetrical polyarthritis ( multiple small joints across both sides of the body are affected)
In what group of people does RA present in
women
middle age
Hx smokijng, obesity
FHx RA
what gene is associated with RA
HLA DR4
what antibody/antibodies are associated with RA
RF - 70%
Anti-CCP (anti-cyclic citrullinated peptide antibodies) - 80%, more sensitive to RA
what joints are most commonly affected in RA
MCPJ - metacarpophalangeal
PIPJ - Proximal interphalangeal
Wrist
MTPJ - metatarsophalangeal ( foot)
features of RA
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
Palindromic rheumatism is
self-limiting episodes of inflammatory arthritis, with pain, stiffness and swelling
last a few days then completely resolve
hand signs in advanced RA
Z-shaped deformity to thumb
swan neck deformity ( hyperextended PIP, flexed DIP )
Boutonniere deformity ( hyperextended DIP, flexed PIP)
Ulnar deviation of fingers at MCPJ
what spinal complication may appear in RA
Atlantoaxial subluxation - synovitis and ligament damage around odontoid peg of the axis (C2)
can cause spinal cord compression
whats feltys syndrome
extra-articular manisfestation of RA
the triad of RA, Neutropenia, splenomegaly
mx in RA
- Monotherapy (methotrexate, leflunomide or sulfasalazine)
- Combination treatment with multiple cDMARDs (conventional DMARD)
- Biologic therapies (usually alongside methotrexate)
Hydroxychloroquine (mildest DMARD) may be used in mild disease and palindromic rheumatism.
what DMARDs are safest to use in pregnant woman with RA
hydroxychloroquine
sulfasalazine
what medication has to be co-prescribed with methotrexate, and what is the regime
folic acid ( as methotrexate impares folate metabolism)
methotrexate - 1/wk
5mg folic acid - 1/wk ( on different day)
key side effects of methotrexate
bone marrow suppression
leukopenia
highly teratogenioc
must co-prescribe 5mg folic acid ( taken on different day of the week )
key side effects of the DMARD leflunomide ( used in RA)
hypertension
peripheral neuropathy
leflunomide - immunosuppressant which impairs Pyrimidine ( component of RNA & DNA) production
key SE of DMARD sulfasalazine
orange urine
male infertility ( reduces sperm count)
can be used in pregnancy ( like hydroxychloroquine)
key SE of DMARD hydroxychloquine
retinal toxicity
blue-grey skin
hair bleaching
can be used in pregnancy ( like sulfasalazine)
Key SE of anti-TNF medications (adalimumab, infliximab, etanercept)
Tuberculosis reactivation
Key SE of mab Rituxximab
Night sweats and thrombocytopenia
rituximab targets CD20 proteins on surface fo Bcells
septic arthtritis presents with
- 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.
most common bacterial cause of septic arthritis
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).
medical Mx of septic arthritis
4-6wks IV (3-6 In paeds)
- Flucloxacillin (1st line)
- Clindamycin (2nd line )
- Vancomycin (if MRSA is suspected)
Ceftriaxone - N. gonorrhoea.
what IV medication is given in septic arthritis caused by N. gonorrhoea
Ceftriaxone
what is CREST syndrome
a subtype of limited systemic sclerosis
CREST
Calcinosis
Raynauds
Esophageal dysmotility
Sclerodactyly
Telangiectasia
what areas of the body are inflammed in osteomyelitis
bone and bone marrow
typically caused by bacterial infection
what is the common mode of infection in osteomyelitis
haematogenous osteomyelitis ( infection carried to the bone through blood)
other causes - direct bone infection ( fracture , ortho OP)
most common infective organism in osteomyelitis
staph aureus
best imaging Ix for osteomyelitis
MRI scan
x-rays often don’t show changes ( may have thinning/ surface changes/ destruction to areas of the bone)
bloods(inflammatory markers) & cultures
Mx in osteomyelitis
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
what conditions are associated with HLA B27
HIgh BARS
HLA B27
Ibd
Behcets disease
Ankylosing spondylitis
ReA (aka reiters)
Sarcoidosis
Mx undisplace intracapsular NOF
internal fixation
Hemiarthroplasty ( if unfit) - artificial restoration of joint
Mx displaced intracapsular hip fracture
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)
Mx extracapsular hip fracture
stable intertrochenter fracture - dynamic hip screw
reverse oblique/transverse/ subtrochanteric fractures - intramedullary device
