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Phase 4 > MSK > Flashcards

MSK Flashcards

1
Q

What is ankylosing spondylitis?

A

a chronic progressive inflammatory arthropathy associated with HLA-B27 gene which ultimately may lead to radiographical changes in the spine and sacroiliac joints.

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2
Q

what percentage of patents with ankylosing spondylitis have HLA-B27 gene? what chromosome is it found on?

A

90%
autosomal dominant on chromosome 6

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3
Q

what are 3 risk factors for ankylosing spondylitis?

A

HLA-B27
FHx
male

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4
Q

what are 5 presentations of ankylosing spondylitis?

A

Severe inflammatory (improved by NSAIDs) back/ butt pain and stiffness
worse in morning (>30 mins) improves with activity
Systemic symptoms
Ethesitis - inflammation of where tendons or ligaments insert into bone
Dactylitis

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5
Q

what are 5 associated conditions with ankylosing spondylitis?

A

5As

Anterior uveitis
Aortic regurgitation
AV block
Apical lung fibrosis
Anaemia of chronic disease

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6
Q

what age group most commonly presents with ankylosing spondylitis?

A

late teens to 20s

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7
Q

what test can be done o/e for ankylosing spondylitis?

A

Schober’s test - assesses spinal mobility

may also have reduced lateral flexion and chest expansion

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8
Q

what are 4 investigations for ankylosing spondylitis?

A

spine and sacral Xray
HLA-B27 gene testing
Inflammatory markers
MRI spine - bone marrow oedema

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9
Q

what are 7 radiological signs of ankylosing spondylitis?

A

bamboo spine
squaring of vertebral bodies
subchondral sclerosis
subchondral erosions
Syndesmophtes - areas of bone growth where ligaments insert into bone
Ossifications
Fusions - facet, sacroiliac and costovertebral joints

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10
Q

what is the treatment for ankylosing spondylitis?

A

1 - NSAIDs

2- anti-TNF - infliximab, etancercept, adalimumab

3 - IL-17 MAB - secukinumab, ixekizumab
OR
JAK inhibitor - Upadacitinib

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11
Q

what are 5 complications of ankylosing spondylitis?

A

osteoporosis
vertebral fractures
anaemia
cauda equina
apical fibrosis and pulmonary involvement

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12
Q

what are the 5 seronegative spondyloarthropathies?

A

Psoriatic arthritis
ankylosing spondylitis
reactive arthitis
IBD associated arthritis
juvenile idiopathic arthritis

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13
Q

what are the 8 common symptoms of the seronegative spodyloarthropathies?

A

SPINE ACHE

sausage digits - dactylitis
Psoriasis
inflammatory back pain
NSAID responsive
Enthesitis - inflammation at point tendon attaches to bone
Arthritis
Crohn’s/Colitis/CRP elevated
HLA-B27
eyes - uveitis

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14
Q

what is fibromyalgia?

A

a chronic pain syndrome diagnosed by the presence of widespread body pain and tender points at specific anatomical locations

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15
Q

does fibromyalgia affect more men or women?

A

women

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16
Q

what are the overlapping pain conditions with fibromyalgia?

A

IBS
TMJD
interstitial cystitis
vulvodynia
tension headaches

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17
Q

what are 3 risk factors for fibromyalgia?

A

FHx
rheumatic conditions
age 30-60

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18
Q

what are 5 clinical manifestations of fibromyalgia?

A

chronic pain
diffuse tenderness on examination
fatigue unrelieved by rest/sleep disturbance
morning stiffness
headaches

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19
Q

what are 3 differentials for fibromyalgia?

A

rheumatoid arthritis
vitamin D deficiency
chronic fatigue syndrome

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20
Q

what is the treatment for fibromyalgia?

A

Education
exercise
CBT
Pregabalin
Duloxetine
Amitriptyline

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21
Q

what is the criteria for a fibromyalgia diagnosis?

A

American college of rheumatology 31 point questionnaire including widespread pain score and symptom severity score

Widespread pain index >7 and symptom severity scale score >5
OR
WPI 3-6 and SS scale score >9

Symptoms present for at least 3 months
No other explanation

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22
Q

where are the 9 tender sites in fibromyalgia?

A

Occiput
Lower cervical region
Trapezius
Supraspinatus
Second rib
Lateral epicondyle
Gluteal region
Greater trochanter
Knees

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23
Q

What is giant cell arteritis?

A

a granulomatous vasculitis of large and medium-sized arteries. It primarily affects branches of the external carotid artery, and it is the most common form of systemic vasculitis in adults

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24
Q

What is gout?

A

an inflammatory arthritis caused by deposition of monosodium urate crystals within joints

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25
Q

what are grout crystals like?

A

monosodium urate - negatively bifringent

needle shaped

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26
Q

what joints is most commonly associated with gout?

A

big toe - MTP (metatarsophalangeal)

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27
Q

what is gout most commonly caused by?

A

renal under excretion of urate - 90%

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28
Q

what are 3 risk factors for gout?

A

Diet of red meat, seafood and alcohol
Diuretics + low dose aspirin
Metabolic syndrome
impaired renal function

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29
Q

what is the pathophysiology of gout?

A

High urate levels result in super saturation and crystal formation => monosodium urate crystals in joint interact with undifferentiated phagocytes and trigger acute inflammation by inducing TNF-alpha and activating signalling pathways

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30
Q

what are 4 clinical manifestations of gout?

A

rapid onset of severe joint pain in few joints
joint stiff, red, hot
tophi

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31
Q

what renal disease can gout lead to?

A

Interstitial nephritis and eventually CKD due to urate crystal deposit

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32
Q

what are 3 investigations for gout?

A

joint aspiration - gold

serum uric acid levels - 4-6 weeks after attack

joint X-ray

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33
Q

what may be seen on x-ray in gout?

A

Usually normal

chronic -
Joint effusion but space maintained
Punched out erosions
Lytic lesions
Sclerotic margins
Outlines of tophi

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34
Q

what are 3 bloods needed in a gout work up?

A

U+E - assess renal function for appropriate dose orf allopurinol
FBC - WCC may be raised Fasting glucose and lipid profile

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35
Q

what are 3 differentials for gout?

A

pseudo gout
septic arthritis
rheumatoid arthritis

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36
Q

what is the management of an acute gout attack?

A

1 - NSAID - Naproxen 750mg one off then 250mg every 8 hours
OR
1 - Colchicine - 500 micrograms 2-4x a day - 3-6 days

2 - corticosteroids - 15mg Pred OD PO

continue allopurinol if already on it

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37
Q

what is an adverse effect of colchicine?

A

diarrhoea

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38
Q

who should colchicine be used with caution in?

A

renal impairment
dose reduction if eGFR 10-50
Avoid if eGFR <10

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39
Q

what is the management of gout chronically?

A

lifestyle advise

Uric acid lowering therapy - 1 - allopurinol - 100mg OD PO
2 - Febuxostat

Uricosuric agent - sulfinpyrazone

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40
Q

what is the serum urate target in gout?

A

<360 micromol/L

<300 micromol/L with tophi, arthritis or ongoing flares

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41
Q

what class of medication is allopurinol?

A

xanthine oxidase inhibitor

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42
Q

How long should you wait to start urate lowering therapy after an acute attack?

A

2 weeks - not lots of evidence but may precipitate further attack

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43
Q

what is the criteria for starting urate lowering therapy?

A

Can start after 1st attack

Definitely if:
2+ attacks
Tophi
Renal disease
uric acid renal stones
prophylaxis if on cytotoxics or diuretics

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44
Q

what are 3 complications of gout?

A

joint destruction + tophi
kidney disease - acute uric acid nephropathy
urate nephrolithiasis + CKD

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45
Q

what is osteoarthritis?

A

a non-inflammatory degenerative arthritis characterised by progressive synovial joint damage

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46
Q

what are 7 risk factors for osteoarthritis?

A

Older age - 50+
Obesity
Occupation
Physically demanding job/sport
Trauma
Family history
Female

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47
Q

what are the 5 X-ray manifestations of osteoarthritis?

A

JOSSA
joint space narrowing
osteophyte formation
subchondral sclerosis
subchondral cysts
abnormalities of bone contour

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48
Q

what is the pathophysiology of osteoarthritis?

A

there is a failure in maintaining the homeostatic balance of the cartilage matrix synthesis and degradation, resulting from reduced formation or increased catabolism

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49
Q

what are 5 presentations of osteoarthritis?

A

Pain
Functional difficulty and reduced ROM
Crepitus
Bony deformaities and joint enlargement
Effusions

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50
Q

what joints does osteoarthritis usually affect?

A

weight bearing joints asymmetrically

Hips, knees, DIPJ, CMC joint at base of thumb, Lumbar spine, cervical spine

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51
Q

What are 5 hand signs of OA?

A

Heberdens nodes - DIP joints
Bouchards nodes - PIP joints
Squaring of base of thumb - CMC joint
Weak grip
Reduced ROM

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52
Q

What is the criteria for OA diagnosis?

A

> 45 years old, typical pain, no /<30 mins of morning stiffness

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53
Q

what is the management for osteoarthritis?

A

Non pharma - therapeutic exercise, weight loss, occupational therapy

Pharma -
1 - Topical NSAIDs

2 - oral NSAIDs + PPI

3 - intra-articular steroid injections - 2-10 weeks relief

Surgical
- joint replacement

Weak opiates and paracetamol for short infrequent use

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54
Q

what are 5 side effects of NSAIDs?

A

Gastritis and peptic ulcers - GI bleeds
Renal - AKI (acute tubular necrosis), CKD
Cardio - HTN, heart failure, MI, stroke
Exacerbating asthma

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55
Q

what are heberden’s node?

A

osteoarthritic nodes of the DIP joints

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56
Q

what are Bouchard’s nodes?

A

osteoarthritic nodes of the PIP joints

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57
Q

what kind of appearance does erosive OA have on Xray?

A

gulls wing

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58
Q

What is osteomyelitis?

A

an inflammatory condition of bone caused by an infecting organism

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59
Q

what is the most common cause of osteomyelitis?

A

S. Aureus

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60
Q

what is the most common bacterial cause of Osteomyelitis in sickle cell?

A

Salmonella

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61
Q

what are the 3 paths of infection in osteomyelitis?

A

Direct inoculation

Contiguous spread from adjacent tissues

Haematogenous spread

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62
Q

what are 7 risk factors for Osteomyelitis?

A

Open fracture
orthopaedic operations - esp prosthetics
diabetes - esp with ulcers
peripheral arterial disease
IVDU
Immunosuppression
Sickle cell disease

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63
Q

what organisms mainly cause osteomyelitis in infants?

A

S. Aureus
group B strep
aerobic gram -ve bacili
candida albicans

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64
Q

what organisms mainly causes osteomyelitis in children?

A

1 - S. Aureus

2 - Strep pneumoniae

Haemophilus influenzae in unvaccinated children

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65
Q

what organisms mainly cause osteomyelitis in adults?

A

1 - S. Aureus

coagulase negative staph
aerobic gram negatives
anaerobic gram +ve peptostreptococci

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66
Q

what organisms mainly cause osteomyelitis in the elderly?

A

gram negative bacili

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67
Q

what organisms usually cause osteomyelitis in IVDU?

A

S. Aureus

Can also get pseudomonas in pelvis

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68
Q

what are 3 risk factors for osteomyelitis?

A

pHx of osteomyelitis
penetrating injury
IVDU

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69
Q

what is the presentation of acute osteomyelitis?

A

Symptoms over a few days

Pain, erythema, swelling, warmth
Fever
malaise

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70
Q

what are 3 presentations of chronic osteomyelitis?

A

Local symptoms - swelling, erythema, pain - no systemic symptoms

Draining sinus tract
Non-healing fractures
Diabetes ulcers >2cm

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71
Q

where is the most common location of osteomyelitis?

A

lower limb

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72
Q

what are 3 investigations for osteomyelitis?

A

Bloods - FBC, CRP, Cultures
X-ray - may be negative for first 2 weeks
MRI/CT

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73
Q

what are 3 signs of osteomyelitis on x-ray?

A

periosteal reaction - change in surface of bone
Localised osteopenia
Destruction of areas of bone architecture

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74
Q

what is the gold standard for osteomyelitis?

A

bone biopsy, cultures and histopathology

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75
Q

what is the treatment of osteomyelitis?

A

6 weeks IV Abx
- IV Flucloxacillin 8g /day
- Pen allergy - Clarithromycin

Debridement - surgery to remove necrotic bone

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76
Q

what is required for management of osteomyelitis with prosthetic joint involvement?

A

may require complete revision surgery

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77
Q

what are 3 complications of osteomyelitis?

A

drug reactions
amputation
recurrence

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78
Q

what is osteoporosis?

A

Systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue with consequent increase in bone fracture and fragility

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79
Q

how do bisphosphonates work?

A

slow down osteoclast activity => reduce bone breakdown

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80
Q

how does Denosumab work?

A

anti-resorbative - inhibits osteoclast activity

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81
Q

how does teriparatide work?

A

anabolic - synthetic parathyroid hormone, increases osteoblastic activity

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82
Q

what are the T score ranges?

A

> -1 = normal
-1 - -2.5 = osteopenia
< -2.5 = osteoporosis
< -2.5 + a fracture = severe osteoporosis

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83
Q

What is pseudogout?

A

an acute inflammatory arthritis of one or more joints due to calcium pyrophosphate deposition on joint surfaces

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84
Q

what are 7 risk factors for pseudogout?

A

advanced age >65
injury/trauma
hyperparathyroidism
haemochromatosis
wilsons disese
acromegaly
low magnesium and phosphate

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85
Q

what kind of crystals are deposited in psudogout?

A

calcium pyrophosphate crystals

positively bifringent rhomboid shaped crystals

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86
Q

what are 3 manifestations of pseudogout?

A

Most commonly knee, wrist and shoulders

red painful and tender joints
sudden worsening of osteoarthritis
joint effusion

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87
Q

what can be see on xray in pseudogout?

A

chondrocalcinosis - calcification in the hyaline and/or fibrocartilage - white line in joint space

can also have oesteoarthritis type changes

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88
Q

what are 3 investigations for pseudogout?

A

synovial fluid aspirate analysis - gold

joint X ray - chondrocalcinosis

serum calcium + PTH

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89
Q

what are 3 differentials for pseudogout?

A

gout
septic arthritis
osteoarthritis

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90
Q

what is the management for pseudogout?

A

1 - NSAIDs or Colchicine
corticosteroid intra-articular

Intra-articular steroids
Oral steroids

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91
Q

what is the general order of affected joints in pseudogout?

A

Knee > wrist > shoulders > ankles >elbows

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92
Q

What is psoriatic arthritis?

A

a seronegative chronic inflammatory joint disease associated with psoriasis

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93
Q

what are 5 different types of psoriatic arthritis?

A

Asymmetrical oligoarthritis - affecting 1-4 joints at a time
Symmetrical polyarthritis >4 joints
Distal interphalangeal predominant pattern
Spondylitis
Arthritis mutilans

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94
Q

what is arthritis mutilans?

A

most severe form form of psoriatic arthritis - causes osteolysis of bones around joints leading to progressive shortening of digits - telescoping digits

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95
Q

what are 3 risk factors for psoriatic arthritis?

A

psoriasis
FHx
Hx of joint/tendon trauma

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96
Q

what is one features of psoriatic arthritis that distinguishes it from RhA?

A

DIP joint involvement

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97
Q

what are 5 hand signs of psoriatic arthritis?

A

Psoriasis plaques
Nail pitting
onycholysis
Dactylitis
Enthesitis

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98
Q

what are 5 manifestations of psoriatic arthritis?

A

Painful stiff joints - DIP involvement
Symmetrical or asymmetrical
psoriatic skin lesions - though often precedes plaques
Nail changes

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99
Q

what screening tool can be used for psoriatic arthritis?

A

psoriasis epidemiological screening tool

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100
Q

What are 4 X-ray features of psoriatic arthritis?

A

Pencil in cup deformity
periostitis - inflammation of periosteum
ankylosis
osteolysis
dactylitis

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101
Q

what is the mangement for psoriatic arthritis?

A

NSAIDs - mild

DMARDs - methotrexate, sulfasalazine
anti0TNF-alpha inhibitors - infliximab
MAB - Ustekinumab

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102
Q

what are 3 complications of psoriatic arthritis?

A

Joint deformity
cardiovascular risks
malignancy- skin cancer

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103
Q

What is reactive arthritis?

A

A sterile inflammatory arthritis that occurs after exposure to certain gastrointestinal and genitourinary infections.

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104
Q

what is the classic triad of reactive arthritis? what is the way to remember it?

A

Arthritis
Urethritis + balantitis
Conjunctivitis/anterior uveitis

Can’t see, can’t wee, can’t climb a tree

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105
Q

is reactive arthritis usually asymmetrical?

A

YES - also usually only affects one joint - mono arthritis

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106
Q

who is reactive arthritis most common in?

A

Men with HLA-B27

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107
Q

what is one condition that is often associated with reactive arthritis?

A

HIV - should exclude in presenting patients

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108
Q

what are 5 causative organisms for reactive arthritis?

A

GU - chlamydia trachomatis, gonorrhoea

GI - salmonella, shingella, campylobacter

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109
Q

what are 4 risk factors for reactive arthritis?

A

HLA-B27
male
chlamydial/GI infection
HIV

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110
Q

what are 3 investigations for reactive arthritis?

A

ESR/CRP - elevated
joint aspiration
infectious serology/urine/stool

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111
Q

what are 3 differentials for reactive arthritis?

A

gout
pseudogout
septic arthritis

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112
Q

what is the management of reactive arthritis?

A

PRESUME SEPTIC UNTIL PROVEN OTHERWISE

NSAIDs - naproxen/ibruprofen
corticosteroids injections
Tx triggering infection

usually gone in 6 months

DMARDs - in recurrent cases

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113
Q

what are 3 complications of reactive arthritis?

A

circinate balanitis
uveitis
keratoderma blennorhagicum

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114
Q

What is rheumatoid arthritis?

A

An autoimmune chronic inflammatory condition of the synovial lining of joints, tendon sheaths and bursa

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115
Q

what are 4 risk factors for Rheumatoid arthritis ?

A

Female
Smoking
Obesity
Fhx - HLA DR4

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116
Q

what are 6 manifestations of RhA?

A

Symmetrical polyarthritis > 6 weeks
Morning stiffness lasting >30 mins
Joint deformities
Rheumatoid nodules

Systemic symptoms - fatigue, wt loss, flu like illness, muscle aches

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117
Q

what joints are usually spared in rheumatoid arthritis?

A

DIP

Lumbar spine

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118
Q

what is felt on palpating rheumatoid arthritis joint?

A

feel boggy

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119
Q

what are the 4 deformities associated with Rheumatoid arthritis?

A

Swan’s neck
Boutonniere - pip always bent
Ulnar deviation
Z-thumb deformity - hyperextension of thumb IPJ and flexed MCP joint

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120
Q

what are 12 extra-articular manifestations of rheumatoid arthritis?

A

Pulmonary fibrosis
Felty’s syndrome
Sjogrens syndrome
Anaemia of chronci disease
CVD
eye manifestations
rheumatoid nodules
Lymphadenopathy
Carpel tunnel
Amyloidosis
Bronchiolitis obliterans
Caplan syndrome

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121
Q

what are 6 ocular manifestations of rheumatoid arthritis?

A

Dry eye syndrome - keratoconjunctivitis sicca - most common
episcleritis
scleritis
keratitis
cataracts - secondary to steroids
retinopathy - secondary to hydroxychloroquine

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122
Q

what is Felty’s syndrome?

A

Triad

rheumatoid arthritis
Neutropenia
Splenomegaly

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123
Q

what is bronchiolitis obliterans?

A

small airway destruction and airflow obstruction in lungs

associated with rheumatoid arthritis

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124
Q

what is caplan syndrome?

A

pulmonary nodules in rheumatoid arthritis patient exposed to coal, silica, asbestos or dust

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125
Q

what are 2 autoantibodies present in Rheumatoid arthritis?

A

Rheumatoid factor
anti-CCP

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126
Q

what are 6 conditions associated with positive rheumatoid factor?

A

Felty’s syndrome
Sjorgren’s syndrome
infective endocarditis
SLE
Systemic sclerosis
General population

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127
Q

what is the most sensitive and specific autoantibody in Rheumatoid arthritis?

A

Anti-CCP (cyclic citrullinated peptide)

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128
Q

what is one serious cervical spine complication in rheumatoid arthritis?

A

Atlantoaxial subluxation - damage to ligaments around odontoid peg of axis allows for it to shift within atlas which can lead to subluxation and spinal cord compression

Need to be considered in general anaesthetic - visualise with MRI

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129
Q

what are 5 x-ray findings in rheumatoid arthritis?

A

Soft tissue swelling
periarticular osteopenia/porosis
joint space narrowing
Periarticular erosions
subluxation

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130
Q

what questionnaire can be used to assess functional ability and response to treatment in rheumatoid arthritis?

A

Health assessment questionnaire

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131
Q

What questionnaire can be used to monitor disease activity in rheumatoid arthritis?

A

Disease activity score 28 joints - DAS28

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132
Q

What is the management of 1st presentation of rheumatoid arthritis in GP?

A

NSAID cover
Urgent referral to Rheumatology
Physio and OT

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133
Q

what is the initial specialist therapy for rheumatoid arthritis?

A

DMARD monotherapy - methotrexate, sulfasalazine, leflunomide, hydroxychloroquine

+/- Prednisolone bridging

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134
Q

when are patients with rheumatoid arthritis trialled on a TNF-inhibitor?

A

Inadequate response to 2 DMARDs

Etanercept
Infliximab
Adalimumab

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135
Q

what are 2 rheumatoid arthritis medications that are safe in pregnancy?

A

Sulfasalazine
Hydroxychloroquine

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136
Q

after what gestation should NSAIDs not be used?

A

32 weeks - risks early closure of ductus arteriosus

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137
Q

what is the MOA of methotrexate?

A

inhibits dihydrofolate reductase - enzyme for synthesis of purines and pyrimidines

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138
Q

what are 5 adverse effects of methotrexate?

A

Mucositis
Myelosuppression
Pneumonitis
Pulmonary fibrosis
Liver fibrosis

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139
Q

How long before conception does methotrexate need to be stopped in both men and women?

A

6 months

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140
Q

How often is methotrexate taken?

A

ONCE A WEEK

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141
Q

how often should people on methotrexate be monitored?

A

FBC, U+E, LFT every 2-3 months

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142
Q

what should be prescribed with methotrexate?

A

5mg folic acid once a week

take >24h after methotrexate

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143
Q

what are 3 medications that CANNOT be prescribed with methotrexate?

A

Trimethoprim
Co-trimoxazole
High dose aspirin

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144
Q

what is the treatment of methotrexate toxicity?

A

Folinic acid

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145
Q

What is septic arthritis?

A

the acute infection of 1 or more joints caused by pathogenic inoculation of microbes. It occurs either by direct inoculation or via haematogenous spread and can destroy a joint in under 24 hours.

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146
Q

what is the most common joint to be infected with septic arthritis?

A

knee

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147
Q

what is the most common causative organism for septic arthritis?

A

S. Aureus

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148
Q

who 2 gram negative bacteria cause septic arthritis? what patients in?

A

E. COLI and PSEUDOMONAS AERUGINOSA

IVDU
immunosuppressed
neonates
elderly

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149
Q

what are 2 gram positive causative bacteria of septic arthritis? what patients affected?

A

Strep group A (pyogenes) - <5yrs

Staph epidermis - prosthetic joints

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150
Q

who gets neisseria gonorrhoea septic arthritis?

A

sexually active people

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151
Q

what are 6 risk factors for septic arthritis?

A

underlying joint disease/prosthetic joint
IVDU, indwelling catheters
immunosuppression
Skin infections
Extremes of age

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152
Q

what are 5 manifestations of septic arthritis?

A

hot, swollen, painful, red
restricted ROM
fever
affecting single joint (90%)

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153
Q

what are 3 investigations for septic arthritis?

A

joint aspiration - gold

FBC - leukocytosis
CRP and ESR - high
blood cultures

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154
Q

what are 3 differentials for septic arthritis?

A

osteoarthritis
pseudogout
Gout

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155
Q

what is the management of septic arthritis?

A

IV antibiotics - 4-6 weeks
- Fluclox, Clindamycin, Vancomycin

Surgical drainage either needle aspiration or arthroscopy

STOP methotrexate and anti-TNF alpha
double steroids (if on)
rest and splint

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156
Q

what is the aspirate WCC in septic arthritis usually?

A

> 50 000

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157
Q

what are 3 complications of septic arthritis?

A

sepsis
osteomyelitis
joint destruction

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158
Q

What is systemic lupus erythramatosus?

A

a chronic systemic autoimmune condition caused by a type 3 hypersensitivity reaction leading to immune complex deposition in many organs

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159
Q

what is the typical demographic for SLE

A

Female
Afro-Caribbean
20-40 years

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160
Q

what are 10 manifestations of SLE?

A

Malar (butterfly)/ photosensitive /discoid rash

Non-specific - fatigue, wt loss, arthralgia, myalgia, fever

lupus nephritis - oedema
Arthritis
Raynaud’s phenomenon

SOB, pleuritic chest pain
Splenomegaly
mouth ulcers
hair loss
lymohadenopathy

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161
Q

what are 3 antibody tests for SLE?

A

ANA (anti-nuclear antibodies) - most sensitive

Anti-dsDNA - most specific

Anti-smith antibodies - very specific, not sensitive

Anti-Ro, Anti-La
Anti-Scle-70
Anti-Jo-1

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162
Q

are complement levels high or low in SLE?

A

low in active disease as formation of immune complexes leads to consumption of complement

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163
Q

what blood clotting disorder can occur secondary to SLE?

A

Antiphospholipid syndrome

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164
Q

what are 3 differentials for SLE?

A

Rheumatoid Arthritis- SLE less symmetrical
antiphospholipid syndrome
mixed connective tissue disease

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165
Q

what is the management of SLE?

A

1 - hydroxychloroquine

NSAIDs
corticosteroids - prednisolone

2 - DMARDs - methotrexate, biologics - rituximab, belumumab

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166
Q

what are 9 complications of SLE?

A

Cardiovascular disease - due to chronic inflammation
Anaemia
Pericarditis
Pleuritis
interstitial lung disease
Lupus nephritis
Neuropsychiatric SLE
Recurrent miscarriage, IUGR, Pre-eclampsia, pre-term labour
VTE - anti-phospholipid syndrome

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167
Q

what antibodies are found in drug induced lupus?

A

anti-histone antibodies

ANA usually positive
dsDNA usually negative

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168
Q

what are 5 medications that can cause drug induced lupus?

A

Procainamide
hydralazine
isoniazid
minocycline
phenytoin

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169
Q

what is the most common form of lupus nephritis?

A

Diffuse proliferative glomerulonephritis

presents with haematuria, proteinuria, hypertension, oedema

most severe!

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170
Q

what can be seen on renal biopsy in SLE sclerosing glomreulonephritis?

A

Hypercellular glomerulus
Thickened basement membrane
Wire-loop appearance of endothelial and mesangial proliferation

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171
Q

what is the management of lupus nephritis?

A

lifestyle - stop smoking, exercise, diet
Corticosteroids
immunosuppression
Hydroxychloroquine

Dialysis
ACEi for renoprotection and HTN

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172
Q

how long does morning stiffness in OA last?

A

<30 mins

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173
Q

what is FRAX?

A

predicts risk of fragility fracture over the next 10 years

age, BMI, smoking, alcohol

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174
Q

what group of people does N. Gonorrhoea cause septic arthritis in?

A

sexually active young adults

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175
Q

what antibiotics are used in septic arthritis?

A

IV flucoxacillin - gram pos
(clindamycin in allergy)
IV cefotaxime - gram neg

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176
Q

what are 4 risk factors for SLE?

A

female
FHx
middle aged

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177
Q

what is the gold standard investigation of osteomalacia?

A

iliac bone biopsy with double tetracycline labelling

rare as invasive

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178
Q

what is osteomalacia?

A

a metabolic bone disease characterised by incomplete mineralisation of the underlying mature organic bone matrix (osteoid) following growth plate closure in adults

caused by vitamin D deficiency

rickets in children

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179
Q

what causes osteomalacia?

A

vitamin D deficiency

calcium or phosphate deficiency

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180
Q

what is the presentation for osteomalacia and vitamin D deficiency?

A

Fatigue
Bone pain
Muscle weakness
muscle aches
pathological or abnormal fractures

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181
Q

what are 3 skeletal changes that can be seen in osteomalacia?

A

Pseudofractures - Looser’s zones - radiolucent bands traversing part way though bones due to demineralisation

Bowing deformities

Vertebral fractures

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182
Q

what are 4 risk factors for osteomalacia?

A

risks for low vitamin D

Darker skin
low sunlight exposure
living in cold climates
spending most of time indoors

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183
Q

what is normal serum vitamin D?

A

50-75 nmol/L

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184
Q

what are 5 investigations for osteomalacia?

A

serum calcium and phosphate
serum 25-hydroxyvitamin D
PTH level - may be high
Alk phos - might be high

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185
Q

what is the treatment of osteomalacia?

A

Colecalciferol - 50 000 IU weekly for 6 weeks or 4000IU OD for 10 weeks

IM calcitrol - if suspected absorption issue

should check calcium in first month as low vitamin d may mask hypercalcaemia in primary hyperparathyroidism

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186
Q

How much vitamin d should everyone be taking?

A

400IU (10 micrograms)

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187
Q

which discs are most commonly affected in vertebral disc degeneration?

A

lower lumbar spine - L5/S1 then L4/L5

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188
Q

what are 5 risk factors for disc prolapse?

A

Increasing age
Smoking
genetics
High BMI
Occupation - heavy lifting, bending, operating machinery

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189
Q

what is the pathophysiology of disc prolapse?

A

Over time nucleus pulposus loses mechanical ability to withstand pressure
There is also weakening of posterior longitudinal ligament

prolapsed disc causes compression of nearby nerve roots and/or cauda equina

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190
Q

what are 5 manifestations of vertebral disc prolapse?

A

Lower back pain
Radiculopathy
Neurological weakness
Paraesthesia
Cauda equina

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191
Q

what is the presentation of a L3 nerve root compression?

A

Sensory - loss over anterior thigh

Motor - weak hip flexion, knee extension and hip adduction

Reflex - Knee reduced

Positive femoral stretch test

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192
Q

what is the presentation of L4 nerve root compression?

A

Sensory - loss of anterior aspect of knee and medial malleolus

Motor - weak knee extension and hip adduction

Reflex - reduced knee

Positive femoral stretch test

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193
Q

what is the presentation of L5 nerve root compression?

A

Sensory - loss to dorsum of foot

Motor - weakness in dorsiflexion

Reflexes - intact

Positive sciatic nerve stretch test

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194
Q

what is the presentation of S1 nerve root compression?

A

Sensory - loss of posterolateral leg and lateral foot

Motor - weak plantarflexion

Reflex - reduced ankle reflex

Positive sciatic nerve stretch test

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195
Q

what imaging is done for disc prolapse?

A

MRI spine

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196
Q

what is the conservative management of disc prolapse?

A

Continue with life but restrict painful activity
Physio
Analgesia - 1 - NSAIDs
1 - amitriptyline for radiculopathy

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197
Q

what are 3 indications for surgery in disc prolapse?

A

Cauda equina syndrome
Progressive neurological weakness
Pain >6 weeks not responding to conservative tx

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198
Q

what surgery can be done for disc prolapse?

A

Laminectomy and microdiscectomy

Spinal fusion if unstable

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199
Q

what are 5 complications of spinal surgery for disc prolapse?

A

Re-herniation
Infection - discitis, meningitis, abscess
Injury to adjacent structures
haematoma and spinal compression
Spondylolisthesis

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200
Q

what is Paget’s disease of the bone?

A

A disease of increased uncontrolled bone turnover thought to be due to excessive osteoclastic resorption followed by increased osteoblastic activity

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201
Q

what are 3 risk factors for Paget’s disease?

A

FHx
50+
infection

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202
Q

what are the 3 stages of Paget’s disease?

A

lytic phase - excessive osteoclast activity

mixed osteoclastic and osteoblastic phase - excessive resorption and disorganised bone formation

Sclerotic phase – osteoblast lay down excessive disorganised bone with osteoclasts being less active

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203
Q

what are 5 manifestations of Paget’s disease?

A

bone pain
growth of bones in face - leontiasis, hearing loss, vision loss
kyphosis
pathological fractures

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204
Q

what disease can cause cotton wool appearance of skull on x-ray?

A

Paget’s disease - due to osteoclastic activity and sclerotic lesions

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205
Q

what are 3 investigations for Paget’s disease of the bone?

A

X-ray - osteolytic lesions, fractures, slerotic changes, bone enlargement and deformity

Radionucleotide bone scan

LFTs - raised alk phos

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206
Q

what is the management of Paget’s disease of the bone?

A

1 - Bisphosphonates - alendronic or zolendronic acid

calcitonin
analgesia
calcium + vitamin D
surgery for severe deformity

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207
Q

what are 4 complications of Paget’s disease of the bone?

A

Hearing loss - if affecting ossicles/vestibulocochlear nerve
Heart failure - high output due to vascular new bone
osteosarcoma
spinal stenosis and cord compression

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208
Q

what chromosome is the mutation that causes Marfan’s on?

A

chromosome 15

Affects gene responsible for creating fibrillin - protein fibrillin-1

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209
Q

what is the inheritance pattern of marfans?

A

autosomal dominant

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210
Q

what are 10 symptoms of Marfan’s?

A

Tall, long arms, long legs, long nek
long fingers and toes
Pectus carinatum or excavatum
Hypermobility
downward slanting palpebral fissures
crowded teeth
stretch marks
High arched palate
Flat feet

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211
Q

what are 2 ways to test for arachnodactyly?

A

long fingers

Cross thumb cross palm - thumb crosses opposite edge

Wrap hand around wrist - fingers and thumb overlap

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212
Q

what are 3 cardiac conditions associated with Marfans?

A

Mitral valve prolapse and regurgitation
Aortic valve prolapse and regurgitations
Aortic aneurysm

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213
Q

what are 5 non-cardiac conditions associated with marfans?

A

Lens dislocation in eye
joint dislocation
scoliosis
Pneumothorax
GORD

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214
Q

How are people with marfans monitored?

A

Yearly echo
yearly ophthalmology review

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215
Q

where is type 1 collagen found?

A

skin, tendons, organs, bones

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216
Q

where is type 2 collagen found?

A

cartilage

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217
Q

where is type 3 collagen found?

A

supporting mesh of soft organs

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218
Q

where is type 4 collagen found?

A

basal lamina (basement membranes)

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219
Q

where is type 5 collagen found?

A

cells surfaces, hair, placenta

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220
Q

what are the 4 different types of Elhers-Danlos syndrome?

A

Hypermobile EDS
Classical EDS
Vascular EDS
Kyphoscoliotic EDS

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221
Q

what type of collagen is most affected in EDS?

A

type III

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222
Q

what is the inheritance pattern for all bar kyphoscoliotc EDS?

A

Autosomal dominant

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223
Q

what is the inheritance pattern for kyphosoliotic EDS?

A

autosomal recessive

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224
Q

what is the presentation of hypermobile EDS?

A

joint pain and hypermobility
Joint dislocation
soft and stretchy skin with stretch marks and easy bruising
Poor wound healing and bleeding
Chronic pain and fatigue
Autonomic dysfunction - POTS
GORD, abdo pain and IBS
Menorrhagia, dysmenorrhoea, PROM, pelvic organ prolapse
TMJ dysfunction

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225
Q

what scoring system is used to assess hypermobility in EDS?

A

Beighton score

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226
Q

what can be seen in classical EDS?

A

Stretchy, smooth, velvety skin
Joint hypermobility
joint pain
abnormal wound healing
Prone to hernia, prolapses, mitral regurg, aortic root dilation

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227
Q

what can be seen in kyphoscoliotic EDS?

A

hypotonia as a neonate
kyphoscoliosis as they grow
Joint hypermobility
joint dislocation

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228
Q

what is antiphospholipid syndrome?

A

antiphospholipid antibodies which cause clinical features characterised by thromboses and pregnancy related morbidity

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229
Q

what other condition is antiphospholipid syndome associated with?

A

SLE in 20-30% of cases

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230
Q

what sex is antiphospholipid syndrome more common in?

A

females

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231
Q

what are 4 signs of antiphospholipid syndrome?

A

CLOTs

Coagulation defects
Livedo reticularis - lace lie purple discolouration of skin
Obstetric issues - miscarriage
Thrombocytopenia

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232
Q

what are 3 investigations of antiphospholipid syndrome?

A

anticardiolipin test - IgG or IgM antibodies
lupus anticoagulant test
Anti-B2-glycoprotein test

233
Q

what is the management of antiphospholipid syndrome?

A

warfarin

pregnancy - aspirin and SC heparin

234
Q

what is the Z score?

A

bone density compared to average for their age and gender

235
Q

what drug class is allopurinol and what is its MOA?

A

Xanthine oxidase inhibitor

Xanthine oxidase metabolises xanthine into uric acid => inhibits metabolism so therefore lowers plasma uric acid

236
Q

where is hidden psoriasis found?

A

genitals
soles
scalp
ears

237
Q

what is the name of 1 bisphosphonate?

A

Alendronate

238
Q

how do you take bisphosphonates?

A

take on empty stomach once a week and remain upright for at least half an hour afterwards

239
Q

What are the bloods like in Paget’s disease?

A

ALP - high
Calcium - normal
Phosphate - normal

240
Q

what is the 1st line treatment of Paget’s disease?

A

bisphosphonates - alendronate

241
Q

what are 3 complications of Paget’s disease?

A

osteosarcoma
leontiasis
fractures

242
Q

what are 5 of the diagnostic criteria for giant cell arteritis?

A

50+
temporal artery abnormality
abnormal temoral artery biopsy
elevated ESR

243
Q

what is the name of the blotchy skin pattern in antiphospholipid syndrome?

A

Livedo reticularis

244
Q

what disease can antiphospholipid syndrome be mistaken for due to positive antibody test?

245
Q

what reflex comes from S1?

A

Ankle jerk

246
Q

what is Sjogren’s syndrome?

A

autoimmune disorder of diminished lacrimal and slivery gland secretions

presents with fatigue, dry eyes, dry mouth, dry vagina

247
Q

what antibodies are in sjogren’s syndrome?

A

anti-Ro (SS-A) - more sensitive
anti-La (SS-B) - more specific

rheumatoid factor
ANA

248
Q

what are conditions associated with secondary Sjögren’s syndrome?

A

rheumatoid arthritis
SLE

249
Q

what is a key eponymous test for sjorgren’s syndrome and what is it?

A

Schirmer’s test

filter paper placed in corner of eye to measure secretions <10mm is significant

250
Q

what is the treatment for Sjögren’s syndrome?

A

1 - artificial tears (polyvinyl alcohol and carbomer), salivary substitutes, vaginal lubricant

Pilocarpine - stimulates tear and saliva production

Hydroxychloroquine is associated joint pain

251
Q

what are 3 complications of Sjögren’s syndrome?

A

Eye - keratoconjuctivitis sicca and corneal ulcers

oral- dental cavities, candida

vagina - candida, sexual dysfunction

252
Q

what cancer does Sjögren’s syndrome increase risk of?

A

non-Hodgkin’s lymphoma 5x normal population

253
Q

what are the 5 extra-articular manifestations of AS?

A

5 As

Anterior uveitis
Autoimmune bowel disease
Apical lung fibrosis
Aortic regurgitation
Amyloidosis

254
Q

what test is used to determine spinal motility?

A

Schober’s test

find L5 and make mark 10cm above, ask patient to bend over as far as possible and mark 5cm below L5 => if distance between 2 marks <20cm =. reduced lumbar movement

255
Q

what is a compound fracture?

A

open fracture where skin is broken and bone exposed to air

256
Q

what is a stable fracture?

A

when section of bone remains in alignment at the fracture

257
Q

what is a salter-harris fracture?

A

a fracture occurring in children which affects the growth plate. Classified from 1-5

258
Q

what is a transverse fracture?

A

break in bone perpendicular to long axis (across bone)

259
Q

what is an oblique fracture?

A

a break diagonally across the width of the bone along the longitudinal axis

260
Q

what usually causes a spiral fracture?

A

twisting motion

261
Q

what is a spiral fracture?

A

fracture that wraps around bone

262
Q

what is a comminuted fracture?

A

breaking into multiple fragments

263
Q

what is a segmental fracture?

A

when a bone breaks in at least 2 places separating a segment of bone

264
Q

what is a greenstick fracture?

A

where a fracture occurs only on one side of the bone an does not go all the way through - happens in children <10 usually

265
Q

what is a buckle fracture?

A

force on one end of the bone makes the side of the bone bulge out sideways without breaking the bone all the way through - usually in children <10 years

266
Q

what is cole’s fracture?

A

transverse fracture of distal radius near wrist causing distal portion to displace posteriorly

Usually caused by a fall on to out stretched hands

causes dinner fork deformity - swan neck bendy wrist

267
Q

what is a smith’s fracture?

A

volar angulation of distal radius fragment - garden spade deformity

caused by falling backwards onto palm of outstretched hand or falling with wrists flexed

268
Q

what is a bennett’s fracture?

A

Intra-articular fracture at base of thumb metacarpal

impact on flexed metacarpal - fist fight

X-ray - triangular fragment at base of metacarpal

269
Q

what is a monteggia’s fracture?

A

dislocation of proximal radioulnar joint in association with ulnar fracture

fall on outstretched hand with forced pronation

270
Q

what is a galeazzi fracture?

A

radial shaft fraction with associated dislocation of distal radioulnar joint

fall onto hand with rotation force

X-ray - displaced fracture of radium and prominent ulnar head due to dislocation

271
Q

what is a barton’s fracture?

A

distal radius fracture (coles/smiths) with associated radiocarpal dislocation

fall onto extended pronated wrist

272
Q

what is a key sign of scaphoid fracture?

A

tenderness in the anatomical snuff box

273
Q

what is a key complication of a scaphoid fracture?

A

avascular necrosis and non-union of the scaphoid as there is retrograde blood supply to the scaphoid

274
Q

what system can be used to classify lateral melleolus (distal fibula) ankle fractures?

A

Weber classification

275
Q

what is Weber type a fracture?

A

fracture below level of ankle joint - syndesmosis intact

276
Q

what is Weber type B fracture?

A

fracture at level of ankle joint - syndesmosis intact or partially torn

277
Q

what is Weber type c fracture?

A

above ankle joint - syndemosis will be disrupted

278
Q

what are 5 common cancers that metastasise to bone?

A

PoRTaBLe

Prostate
Renal
Thyroid
Breast
Lung

279
Q

what are 4 adverse effects of bisphosphonates?

A

Acid reflux and oesophageal erosions
Atypical Fractures
Osteonecrosis of the jaw
Osteonecrosis of external auditory canal

280
Q

what is 1st principle of fracture management?

A

mechanical alignment - either closed reduction via manipulation of the limb or open reduction with surgery

281
Q

what is the 2nd principle of fracture management?

A

provide relative stability to allow healing to occur via fixation

282
Q

what are 6 different types of fracture fixation devices?

A

external casts
K wires
Intramedullary wires
intramedullary nails
screws
plate and screws

283
Q

what is the ottawa ankle rules?

A

assessment of whether an ankle Xray is indicated in ankle injury

284
Q

what are the 4 tenderness points in the ottawa ankle rules?

A

Posterior edge/tip of lateral malleolus (6cm above malleolus) tender
Posterior edge or tip of medial malleolus (and 6cm above) tender
Tenderness at base of 5th metatarsal
Navicular tenderness

285
Q

what is the component of the ottawa ankle rules about weight bearing?

A

inability to bear weight both immediately after injury and in ED - able to take <4 steps => X ray indicated

286
Q

what are 11 long term complications of fractures?

A

delayed union
malunion
non-union
avascular necrosis
infection
joint instability
joint stiffness
contractures
arthritis
chronic pain
complex regional pain syndrome

287
Q

what is a fat embolism and when do they occur?

A

occur following fracture of long bone - fat globules released into circulation from fracture leading to reduction in circulation to tissues

mortality 10% - supportive management

288
Q

what is Gurd’s criteria and what is it for?

A

Diagnosis of fat embolism
3 Major criteria
- Resp distress
- Petichial rash
- Cerebral involvement
Some minor
- jaundice
- thrombocytopenia
- fever
- tachy

289
Q

what arteries supply the head of the femur?

A

medial and lateral circumflex femoral arteries

branches off deep femoral artery

supplies retrograde blood supply to femoral head

290
Q

what is an intra-capsular hip fracture?

A

fracture of femoral neck within capsule of hip joint, proximal to intertrochanteric line

291
Q

what is the classfication system of intra-capsular NOF fractures?

A

Garden classification

292
Q

what is the garden classification from grade I-IV?

A

I - incomplete fracture and non-displaced
II - complete fracture and non-displaced
III - partial displacement
IV - full displacement

293
Q

what is the possible management of a garden grade I or II NOF fractures?

A

internal fixation to hold femoral head if blood supply intact

294
Q

what is the management of garden grade III or IV NOF fractures?

A

Hemiarthroplasty or total hip replacement (for more fit patients)

295
Q

what is the management of intertrochanteric fractures?

A

dynamic hip screw (sliding hip screw

296
Q

what is the management of subtrochanteric fractures?

A

Intramedullar nail - metal pole inserted through greater trochanter into the central cavity of the shaft of the femur

297
Q

what is the typical presentation of hip fracture? 3

A

pain in groin or hip which may radiate to knee
unable to weight bear
shorted abducted externally rotated leg

298
Q

what is shenton’s line?

A

continuous curving line on x-ray of inferior border of superior pubic ramus and medial border of femoral neck

disruption of shenton’s line is key sign in NOF fracture

299
Q

How quickly should hip fracture surgery be carried out?

A

within 48 hours

300
Q

How quickly should open fractures be debrided and washed out?

A

within 6 hours

301
Q

what are 5 presentations of rib fracture?

A

Severe, sharp chest wall pain worse on deep inspiration or coughing
chest wall tenderness and bruising
auscultation - crackles, reduced breath sounds
reduced O2 sats due to lung injury
pneumothorax

302
Q

what causes flail chest?

A

two or more rib fractures along 3+ consecutive ribs usually anteriorly

303
Q

what is a sign of flail chest?

A

paradoxical breathing

304
Q

what is the gold standard investigation of rib fracture?

305
Q

what is the management of rib fractures?

A

1 - conservative with good analgesia so breathing is not affected by pain

2 - if after 12 weeks of conservative management has failed surgical fixation can be considered to manage pain

306
Q

what grading system can be used to grade open fractures?

A

Gustilo and anderson system

307
Q

what is the management of buckle fractures?

A

typically self limiting so do not require surgery and can sometimes be managed with splining and immobilisation

308
Q

what is the management of patellar fracture?

A

non-operative management usually with a hinged knee brace for 6 weeks and full weight bearing

309
Q

what is a colle’s fracture?

A

Clasically after FOOSH

Distal radius fracture with dorsal displacement of fragments

Dinner fork type deformity

310
Q

what are early complication of colles fracture?

A

median nerve injury - carpal tunnel - weakness or loss of thumb or index finger flexion
compartment syndrome
vascular compromise
malunion
rupture of extensor pollicis longus tendon

311
Q

what is the blood supply to the scaphoid?

A

dorsal carpa branch of radial artery - retrograde supply

312
Q

what is the typical presentation of scaphoid fracture?

A

pain along radial aspect of wrist at the base of thumb
loss of grip/pinch strength

313
Q

what are 5 signs of scaphoid fracture?

A

Maximal tenderness in anatomical snuffbox

Wrist joint effusion

Pain on thumb telescoping (longitudinal compression)

Tenderness of scaphoid tubercle

Pain on ulnar deviation of wrist

314
Q

what is the initial management of scaphoid fracture?

A

Futuro splint or standard below elbow backslab immobilisation

Reereal to ortho - review 7-10 days later if Xray inconclusive

315
Q

what is the ortho management of scaphoid fracture?

A

undisplaced - cast for 6-8 weeks

displaced - surgical fixation

proximal scaphoid pole fractures - surgical fixation

316
Q

what is bennett’s fracture?

A

boxers fracture
intraarticular fracture of 1st carpometacarpal joint

xray - triangular fragment at ulnar base of metacarpal

317
Q

what is monteggia’s fracture?

A

dislocation of proximal radioulnar joint + ulnar fracture

fall on out stretched hand with forced pronation

318
Q

what usually causes 5th metatarsal fractures?

A

following inversion injuries of ankle - proximal avulsion fractures - most common

Jones fractures - ransverse fracture at metaphyseal diaphyseal junction

319
Q

what is a toddlers fracture?

A

oblique tibial fracture in infants

320
Q

Why do NSAIDs cause HTN?

A

inhibit prostaglandins which cause vasodilation leading to vasoconstriction

Use with caution in Hx of HTN

321
Q

How are he hand joints usually affected in OA?

A

usually CMC and DIP joints more affected than PIP joints, usually affects one joint at a time bilaterally over time

322
Q

what are 2 risk factors for developing polymyalgia rheumatica?

A

50+ years - peak 70-80
Female

323
Q

what other condition is polymyalgia rheumatica associated with?

A

Giant cell arteritis

324
Q

what is the clinical presentation of polymyalgia rheumatica ?

A

2-6 week Hx of

Shoulder / Pelvic girdle / Neck pain and stiffness >45 mins, worse in morning
Systemic symptoms - low grade fever, fatigue, anorexia, wt loss, depression

325
Q

when should patients with polymyalgia rheumatica be referred?

A

<60 years
Red flads - Wt loss, night pain, neuro features
Unusual features of PMR

326
Q

what investigations should be done for polymyalgia rheumatica ?

A

Clinical diagnosis but…

Bloods
- FBC
- U+E
- LFTs
- Calcium
- Serum protein electophoresis
- TSH
- CK
- Rheumatoid factor
- Urine dip

327
Q

what is the managemet of polymyalgia rheumatica ?

A

15mg Prednisone PO OD

Reducing regime
- Until symptoms fully controlled
taper 12.5mg for 3 weeks, 10mg 4-6 weeks, reducing 1mg every 4-8 weeks

Usually on prednisolone for 1-2 years

328
Q

what is the management of patients on long term steroids?

A

Don’t STOP

Don’t - don’t stop if >3 weeks steroid treatment, may precipitate adrenal crisis

Sick day rules - usually double dose

Treatment card - patient should carry

Osteoporosis prevention - bisphosphonates, calcium vitamin D

Protom pump inhibitors - gastroprotection

329
Q

what might be used 2nd line in secondary care for polymyalgia rheumatica?

A

DMARD treatment - methotrexate

3 - Tocilizumab

330
Q

what are 3 complications of polymyalgia rheumatica ?

A

Relapse
Corticosteroid risks - osteoporosis, infection, T2DM, HTN etc
GCA

331
Q

what are 7 risks of long term corticosteroids?

A

Osteoporosis
increased risk of infection
T2DM
Hypertension
Cataracts
Glaucoma
Skin changes - thinning, bruising

332
Q

what are 5 differentials for polymyalgia rheumatica?

A

Degenerative disorders and osteoarthritis
Thyroid/parathyroid disorders
Inflammatory disorders
Cancer - multiple myeloma, leukaemia, lymphoma, lung cancer
Drug related - myositis or myalgiaa due to statins

333
Q

what are Bursae?

A

Sacs created by synovial membrane filled with small amounts of synovial fluid

Found at bony prominences to reduce friction between bones and soft tissue during movement

334
Q

what are 6 risk factors for trochanteric bursitis?

A

Female
Trauma
Overuse/posture
Co-morbidities - lower back pain, prev surgery, osteoarthritis
Lifestyle - inactivity, obesity

335
Q

what is the other name for trochanteric bursitis?

A

greater trochanter pain syndrome

336
Q

what are 5 presentations of trochanteric bursitis?

A

Chronic, intermittent lateral hip/thigh/buttock pain
Exacerbated by weight bearing and lying on affected side
Pain on palpation
Trendelenburg test postive

337
Q

what 2 investigations can be used in trochanteric bursitis?

A

US hip
MRI Hip

338
Q

what is the trendelenburg test?

A

Pain on resisted abduction of high, resisted internal and external rotation of hip

Patient stands on affected leg and other side of pelvis drops due to weakness in hips

339
Q

what is the management of trochanteric bursitis?

A

Lifestyle - wt loss, avoidance of excessive hip adduction
Physio for gluteal muscle strengthening
Rest
Analgesia - paracetamol or NSAIDs

Peri-trochanteric corticosteroid injections

can take 6-9 months to recover

340
Q

what are 7 common locations for bursitis?

A

prepatellar
infrapatella
anserine
plecranon
trochanteric
subacromial
retrocalcaneal

341
Q

what are 3 clinical features of olecranon bursitis?

A

Swelling over olecranon process - posterior aspect of elbow
tenderness in full flexion
erythema

342
Q

why is tenderness at the base of the 5th metatarsal significant in ankle sprain?

A

Could indicate a jones fracture - transverse fracture at base of 5th metatarsal

343
Q

what is the management of ankle sprains?

A

RICE
rest, ice, compress, elevate

Orthosis, cast or crutches may be necessary for short term relief

344
Q

what does the Achilles tendon connect?

A

connects gastrocnemius to soleus

345
Q

what are the 2 different type of Achilles tendinopathy?

A

insertion tendinopathy
mid-portion tendinopathy

346
Q

what are 5 risk factors for Achilles tendinopathy?

A

Sports - basketball, tennis, athletics
Inflammatory conditions
Diabetes
Raised cholesterol
Fluoroquinolone antibiotics - ciprofloxacin, levofloxacin

347
Q

what are 5 presentations of Achilles tendinopathy?

A

Pain or aching in Achilles
stiffness
tenderness
swelling
nodularity on palpation of tendon

348
Q

what is the presentation of Achilles tendon rupture?

A

large pain in achilles, calf or ankle following an audible pop in ankle
Inability to walk or continue sport
Wwelling in calf
Weakness on plantarflexion
Unable to stand on tiptoes

349
Q

what is simmonds triad?

A

for Achilles rupture

Abnormal angle of declination - greater dorsiflexion of injured ankle and food
Palpation - Feel for gap in tendon
Calf squeeze test

350
Q

what is the Simmons calf squeeze test?

A

patient prone or kneeling with feet hanging freely off bench/couch
Squeezing calf muscle does not cause plantar flexion as it should

351
Q

what investigation is used for Achilles tendon rupture?

A

Ultrasound

352
Q

what is the surgical management of Achilles rupture?

A

surgical reattachment of Achilles followed by non-surgical management

353
Q

what is the non-surgical management of Achilles rupture?

A

boot immobilisation graduating from full plantar flexion poot to neutral position over 6-12 weeks

354
Q

what are 3 intrinsic risk factors for ACL injury?

A

Female - due to anatomical, hormonal and neuromuscular differences - wider intercondylar notch

Younger

Genetics

Biomechanical markers

355
Q

what are 3 extrinsic risk factors for ACL injury?

A

Sporting activity
Environmental conditions
Ergonomics

356
Q

where doe s the ACL attach?

A

At the anterior intercondylar area on tibia

357
Q

where does the PCL attach?

A

posterior intercondylar area on tibia

358
Q

what kind of injury usually causes a ACL injury?

A

twisting injury

359
Q

what 2 tests can be done for ACL injury?

A

Anterior draw test

Lachman test

360
Q

what is the anterior draw test?

A

for ACL injury

Patient supine with hips flexed 45 degrees, knees flexed 90 degrees and feet flat on couch

Examiner attempts to pull proximal tibia anteriorly - normally there is slight movement but in ACL injury there will be excessive movement due to instability of ligament

361
Q

what is the gold standard investigation for dx of cruciate ligament tear?

A

Arthroscopy

362
Q

what is the usual 1st line instigation for cruciate ligament injury?

363
Q

What is the conservative management of cruciate ligament injury?

A

RICE - rest, ice, compress, elevate
NSAIDs
Crutches and knee brace
physio

364
Q

what is the surgical management of cruciate ligament injury?

A

arthroscopic surgery
New ligament is formed from graft using hamstring, quadriceps or bone patellar tendon

365
Q

what are 5 features of meniscal tear?

A

pain worse on straightening knee
knee may give way
displaced meniscal tear may cause locking
tenderness along joint line
Thessaly’s test

366
Q

what is Thessaly’s test?

A

for meniscal tear

weight bearing at 20 degrees of knee flexion supported by doctor
positive if pain on twisting knee

367
Q

what is plantar fasciitis?

A

gradual onset of pain on plantar aspect of heel worse with pressure when standing or walking for prolonged periods

Manged with rest, ice, analgesia, physio

368
Q

How can ligamentous injury be categorised?

A

Grade I - mild - minimal fibre damage, no loss of function

Grade II - Moderate - partial tear, some loss of function

Grade III - Severe - complete tear, significant loss of function

369
Q

what is osgood-schlatter disease?

A

inflammation of the tibial tuberosity where patella ligament inserts causing anterior knee pain in adolescents - usually unilateral but can be bilateral. causes hard lump at front of knee

Common in 10-15 year olds

370
Q

what are 3 presentations of osgood-schlatter?

A

visible or palpable hard tender lump at tibial tuberosity
pain in anterior knee
pain exacerbated by activity, kneeling or extension of knee

371
Q

what is a complication of osgood-schlatters?

A

avulsion fracture - tibial tuberosity separated from tibia

372
Q

what is the management of osgood-schlaters?

A

reduction in physical activity
ice
NSAIDs

373
Q

what bacterium causes Lyme disease?

A

Borrelia burgdoferi

374
Q

what kind of ticks transmit Lyme disease?

375
Q

what kind of bacteria is borrelia burgdoferi?

A

spirochete

376
Q

what are the early (<30 days) features of Lyme disease? 5

A

Erythema migrans - bulls-eye rash 1-4 weeks after bite, painless and >5cm usually

Headache
lethargy
fever
arthralgia

377
Q

what are 5 late (>30 days) features of Lyme disease?

A

Cardiovascular
- heart block
- Peri/myocarditis

Neuro
- facial nerve palsy
- radicular pain
- meningitis

378
Q

how is Lyme disease diagnosed?

A

clinically with erythema migrans

Enzyme linked immunosorbent assay antibodies to borrelia burgdorferi

immunoblot test

379
Q

what is the management of Lyme disease?

A

1 - Doxycycline - 200mg OD 21 days - 400mg if neurology

Pregnancy - Amoxicillin - 1g TDS 21 days

Dissenimated disease - Ceftriaxone

380
Q

what is a complication of treatment of Lyme disease?

A

Jarisch-herxheimer reaction - fever, rash, tachycardia after 1st dose

more common in syphilis

381
Q

what are 5 complications of Lyme disease?

A

neuro - meningitis, encephalomyelitis, encephalopathy
heart block
Oligoarticular arthritis/errosive arthritis
keratitis

382
Q

what criteria can be used for diagnosis of septic arthritis in children?

A

Kocher criteria

383
Q

what is the kocher criteria?

A

for septic arthritis in children

score for:
non weight bearing
temp >38.5
ESR >40mm/hr
WCC >12

> 2 = 40% septic arthritis
3 = 90% septic arthritis

384
Q

what are the ottawa knee rules?

A

for imaging in knee trauma

> 55 years
patella tenderness without other tenderness
fibular head tenderness
cannot flex knee 90 degrees
cannot weight bear - 4 steps

385
Q

what is the first line investigation for meniscal tear?

386
Q

what is a baker’s cyst?

A

fluid filled sack in popliteal fossa due to leak out of knee joint

387
Q

what are 4 conditions that can be associated with baker’s cyts?

A

meniscal tears
osteoarthritis
knee injury
inflammatory arthritis

388
Q

what is the management of symptomatic bakers cysts?

A

modified activity
analgesia
physio
US aspiration
steroid injection
Surgery

389
Q

what is an acetabular labral tear?

A

a tear of the cartilaginous ring surrounding acetabulum usually due to trauma or chronic wear

390
Q

what are 3 features of acetabular labral tear tear?

A

Pain - in hip/groin usually worsening
Clicking, locking, giving way of hip
May also cause reduced range of movement

391
Q

what is the management of acetabular labral tear?

A

limited efficacy of conservative management

Surgery after 4 weeks - hip arthroscopy with either debridement or repair

392
Q

what is frozen shoulder?

A

adhesive capsulitis

Pain and stiffness in shoulder (glenohumeral) joint due to inflammation and fibrosis of joint capsule

393
Q

what is the typical course of frozen shoulder?

A

Painful phase - shoulder pain often 1st symptom, may be worse at night

Stiff frozen phase - stiffness in both active and passive movement

Thawing phase - gradual improvement

can take 1-3 years to resolve

394
Q

what movement is most affected by froze shoulder?

A

external rotation

395
Q

what test can be used to assess for supraspinatus tendinopathy?

A

empty can test - positive if arm gives way on resistance

396
Q

what test can be used to assess acromioclavicular joint arthritis?

A

scarf test - pain caused by wrapping arm around chest and opposite shoulder

397
Q

what is the management of frozen shoulder?

A

Continued use of arm
Analgesia - NSAIDs
Physio
Intra-articular corticosteroids
Hydrodilation

Surgery if resistant/severe
- manipulation under anaesthesia
- arthroscopy

398
Q

what are 3 risk factors for frozen shoulder?

A

diabetes
thyroid dysfunction
hyperlipidaemia

399
Q

what are the muscles of the rotator cuff?

A

SITS

Supraspinatus
Infraspinatus
Teres Minor
SUbscapularis

400
Q

what is the function of the supraspinatus?

A

Abducts arm before deltoid

Rotator cuff - most commonly injured

401
Q

what is the function of the infraspinatus?

A

Externally rotates arm

402
Q

what is the function of teres minor?

A

externally rotates arm

403
Q

what is the function of subscapularis?

A

internally rotates arm

404
Q

what is the presentation of a rotator cuff tear?

A

Either acute onset after injury or gradual onset

Shoulder pain
weakness and pain with specific movements relating to location of tear

Supraspinatus and infraspinatus atrophy in massive tears

405
Q

what is Gerber’s lift off test?

A

evaluates subscapularis - internal rotation

Patient attempts to lift hand from small of back against resistance

406
Q

what test will elicit pain/weakness in the infraspinatus or teres minor tear?

A

Resisted external rotation

407
Q

what is the painful arc test used to diagnose?

A

Subacromial impingement

408
Q

what are 2 examinations that can be done to test for subacromial impingement?

A

Neer’s impingement test - anterolateral shoulder pain during forward flexion with arm internally rotated

Hawkin’s test - forced internal rotation of arm held at shoulder height and elbow bent at 90 causes anterolateral shoulder pain

409
Q

when should patients with shoulder pain be imaged in GP?

A

Acute trauma presentation
symptoms > 4 weeks
Restriction of movement
severe pain

410
Q

what imaging can be done of a shoulder in primary care?

A

Plain film X-ray - True AP and lateral or scapular Y views

411
Q

When can patients with shoulder pain be referred to secondary care?

A

Pain >6 weeks of conservative management

Sudden inability to abduct arm - 2ww - suggestive of acute cuff tear

412
Q

what is the imaging modality for shoulders in secondary care?

A

MRI

Can also do US

413
Q

What are 3 possible findings on MRI in shoulder injury?

A

Hyperintense signal on T2 imaging extending to articular or bursal surfaces
Discontinuity within tendons
Evidence of inflammation - increased fluid in subacromial space and subdeltoid busa, thickening and increased signal of tendons

414
Q

what is the management of rotator cuff tear?

A

Mainly conservative in elderly/degenerative tears
- Rest, analgesia, physio

Surgery - arthroscopic rotator cuff repair

415
Q

what is sublaxation?

A

partial dislocation

416
Q

do shoulders more commonly dislocate anterior or posterior?

417
Q

what are 3 risk factors for posterior dislocation of the shoulder?

A

3 Es

electric shock
epilepsy
Ethanol - typically after a fall

418
Q

what are 5 structures that can be damaged in shoulder dislocation?

A

Glenoid labrum - rim of cartilage around glenoid cavity that can tear

Hill-sachs lesions - compression fractures of the posterolateral part of humeral head due to impact with the anterior rim of glenoid cavity

Axillary nerve damage

Fractures - humeral head, greater tuberosity of humerus, acromion, col

Rotator cuff

419
Q

what are bankart lesions?

A

tear to anterior portion of labrum in shoulder dislocation - occur with recurrent subluxation or dislocation

420
Q

what does anterior arm dislocation present like?

A

Arm slightly abducted and externally rotated

Loss of normal rounded appearance to shoulder
may be possible to palpate humeral head below position of coracoid process

421
Q

what does posterior dislocation present like?

A

Arm adducted and internally rotated

Posterior shoulder more prominent and anterior shoulder flattened

Inability to externally rotate

422
Q

what is the 1st line investigation for shoulder dislocation

A

X-ray:
AP
Lateral/scapular Y view
Axillary view

MRI used to assed other damage

423
Q

what is the management of shoulder dislocation?

A

Analgesia and sedation - gas and air may be used
Closed reduction after fractures are excluded
Post reduction x-ray
immobilisation period

surgery for open reduction if closed reduction fails

424
Q

what are 3 complications of shoulder dislocation?

A

Shoulder instability
Axillary nerve damage
bankart/hills-sachs lesions

425
Q

what are 2 clinical features of axillary nerve damage?

A

Loss of sensation of lateral shoulder - regimental badge area
Weakness of deltoid - weak arm abduction

426
Q

what nerve roots form the axillary nerve?

427
Q

what is epicondylitis?

A

inflammation at the point where the tendons of the forearm inset into the epicondyles at the elbow due to repetitive strain - AKA tennis/golfers elbow

428
Q

what 5 muscles insert onto medial epicondyle and what do they do?

A

Pronator teres
Flexor carpi radialis
Palmaris longus
Flexor digitorum superficialis
Flexor carpi ulnaris

Flex the wrist

429
Q

what do the muscles that inset onto the lateral epicondyle do?

A

extend wrist

430
Q

what is the other name for lateral epidondylitis?

A

tennis elbow

431
Q

what is the presentation of tennis elbow?

A

Pain over lateral epicondyle, radiating down forearm

can lead to weakness of grip strength

432
Q

what are 2 tests for tennis elbow?

A

Mills test - extend and pronate forearm and flex wrist with pressure on lateral epicondyle - pain = +ve

Cozen’s test - extended, pronated forearm with wrist deviated radially - hold elbow and put pressure on lateral epicondyle. Apply resistance to back of hand - pain = +ve

433
Q

what is the other name for medial epicondylitis?

A

golfers elbow

434
Q

what is the management of epicondylitis?

A

Rest and lifestyle adaption
Analgesia - NSAIDS
physio
orthotics
steroid injection

rarely surgery

435
Q

what is a t-score for osteoporosis?

436
Q

what is the t-score for osteopenia?

A

-1 to -2.5

437
Q

what is the z-score?

A

the number of standard deviations the patient is away from the average for their age, sex and ethnicity

438
Q

what are 5 medications that increase risk osteoporosis?

A

Corticosteroids (long term 7.5mg+ for 3 months+)
SSRIs
PPIs
antiepileptics
anti-oestrogens

439
Q

what are 3 chronic diseases that increase risk of osteoporosis?

A

ckd
hyperthyroidism
rheumatoid arthritis

440
Q

what are 7 risk factors for osteoporosis?

A

older age
post menopausal
reduced mobility and activity
lower bmi <19
low calcium or vitamin d
alcohol and smoking
FHx or personal history

441
Q

what are 5 groups who should be assessed for osteoporosis?

A

Long term corticosteroids
Prev fragility fractures
>50 with risk factors
Women >65
Men >75

442
Q

what are 7 lifestyle changes that can help in the management of osteoporosis?

A

increased exercise
maintain healthy weight
good ca intake
good Vit D intake
avoiding falls
stopping smoking

443
Q

what is the management of osteoporosis?

A

Address reversible risk factors

Add calcium (1000mg) and
vitamin D (400-800IU)

1 - Bisphosphonates (alendronate, risendronate, zoledronic acid)

444
Q

what are 4 side effeccts of bisphosphonates?

A

reflux and oesophageal erosions
atypical fractures
osteonecrosis of the jaw
osteonecrosis of external auditory canal

445
Q

how should bisphosphonates be taken?

A

on an empty stomach
with full glass of water
sit upright for 30 mins
30 mins before moving or eating

446
Q

what are 4 medications for osteoporosis started by a specialist?

A

denosumab - MAB targeting osteoclasts
Romosuzumab
Teriparatide - acts as parathyroid hormone
HRT
Raloxifene - selective oestrogen receptor modulator
strontium ranelate

447
Q

what are 2 side effects of strontium ranelate?

A

increased VTE risk
increased MI risk

448
Q

what 2 scores can be used to identify 10 year risk of osteoporotic fracture?

A

FRAX score

QFracture tool

449
Q

How do bisphosphonates work?

A

reduce osteoclastic activity

450
Q

what are 3 examples of bisphosphonates?

A

Alendronate (70mg once week)
risedronate (35mg once a week)
Zoledronic acid (5mg once yearly IV)

451
Q

what are 4 side effects of bisphosphonates?

A

reflux and oesophageal erosions
atypical fractures
osteonecrosis of the jaw
osteonecrosis of external auditory canal

452
Q

what follow up is necessary in osteoporosis?

A

follow up DEXA in 3-5 years

453
Q

what is T score?

A

the number of standard deviations the patient is away from an average healthy young adult

454
Q

what are 9 risk factors for secondary osteoporosis?

A

Hyperthyroidism
hyperparathyroidism
Hyperandrogenism in males
CKD
Immobility
Vitamin d deficiency
malabsorption
cushings
chronic liver failure

455
Q

what does DEXA stand for?

A

Dual-energy X-ray absorptiometry

456
Q

what are 4 causes of avascular necrosis of the hip?

A

long term steroid use
chemotherapy
alcohol excess
trauma

457
Q

what is the imaging modality of choice for avascular necrosis of the hip?

458
Q

what system is used to classify spinal fractures?

A

AO-Magerl system

A - compression
B - Distraction
C - Rotation

459
Q

what are 5 risk factors for spinal fractures?

A

osteoporosis
increased Age
Female - post-menopausal
Trauma
Cancer

460
Q

when is MRI indicated in spinal fractures?

A

with neurological symptoms

461
Q

what are 5 complications of spinal fractures?

A

Neurological deficits
Pulmonary complications - due to reduced mobility
Chronic pain
Kyphosis
VTE

462
Q

what are ganglion cysts?

A

sac of synovial fluid originating from tendon sheaths or joints

common on dorsal wrists and fingers but can form anywhere

463
Q

what is the presentation of ganglion cysts?

A

visible and palpable non-painful lump

Usually 0.5-5 cm
firm
well circumscribed
transilluminates

464
Q

what is the management of ganglion cysts?

A

usually conservative

Needle aspiration surgical excision

have high recurrence rate with aspiration

465
Q

what nerve is compressed in carpal tunnel syndrome?

A

median nerve

466
Q

what sensation is the branch of the median nerve which passes through the carpal tunnel responsible for?

A

sensory innervation of palmar aspect of thumb, index and middle fingers and lateral half of ring finger

467
Q

what motor function in the hand is the median nerve responsible for?

A

Abductor pollicis brevis - thumb abduction
Opponens pollicis - thumb opposition
Flexor pollicis brevis - thumb flexion

Thumb abduction, opposition and flexion

468
Q

what are 7 risk factors for carpal tunnel syndrome?

A

repetitive strain
obesity
perimenopause
rheumatoid arthritis
diabetes
acromegaly (bilateral)
hypothyroidism

469
Q

what is the presentation of carpal tunnel syndrome?

A

numbness
paraesthesia
burning sensation
pain

shaking hand to relive symptoms

Weakness of thumb movements
weakness of grip
difficulty with fine movements involving the thumb
wasting of thenar muscles

470
Q

what are 2 tests o/e for carpal tunnel syndrome?

A

Tinel’s test
Phalen’s test

471
Q

what questionnaire can be used to diagnose carpal tunnel syndrome?

A

Kamath and Stothard carpal tunnel questionnaire

472
Q

what is the 1st line investigation for carpal tunnel syndrome?

A

nerve conduction studies

473
Q

what is the management of carpal tunnel syndrome?

A

1 - 6 weeks conservative management

rest and altered activities
Wrist splints
Steroid injections

surgery - flexor retinaculum division

474
Q

what is systemic sclerosis?

A

autoimmune connective tissue disease due to inflammation and fibrosis of connective tissures, skin and internal organs

475
Q

what are the 2 main patterns of disease in systemic sclerosis?

A

limited systemic sclerosis
diffuse cutaneous systemic sclerosis

476
Q

what are 5 features of cutaneous systemic sclerosis?

A

CREST (used to be called crest syndrome)

Calcinosis
Raynaud’s phenomenon
Esophageal dysmotility
Sclerodactyly
Telangiectasia

477
Q

how are internal organs affected in diffuse systemic sclerosis?

A

cardiovascular problems - HTN, coronary artery disease
Lungs - Pulmonary HTN, fibrosis
Renal - scleroderma renal crisis

478
Q

what is scleroderma?

A

hardening of skin giving appearance of shiny tight skin without normal skin folds

479
Q

what is sclerodactyly?

A

skin tightening around joints restricting ROM, fat pads on fingers are lost and skin can break and ulcerate

480
Q

what are telangiectasia?

A

dilated blood vessels in skin >1mm

481
Q

what is calcinosis?

A

calcium deposits under skin - most common in fingertips

482
Q

what is oesophageal dysmotility?

A

atrophy and dysfunction of smooth muscle and fibrosis of oesophagus - causing swallowing difficulties, chest pain, acid reflux and oesophagitis

483
Q

what is the most common secondary cause of raynaud’s phenomenon?

A

systemic sclerosis

can also be seen in SLE

484
Q

what can be used to differentiate between raynaud’s disease and raynauds phenomenon caused by systemic sclerosis?

A

Nailfold capillaroscopy - magnify and examine peripheral capillaries at based of fingernail - abnormal capillaries suggest systemic sclerosis

485
Q

what is the management of raynaud’s disease?

A

Keep hands warm

Calcium channel blockers - nifedipine

other specialist drugs - losartan, ACEi, Sildenafil, fluoxetine

486
Q

what are 3 autoantibodies associated with systemic sclerosis?

A

Antinuclear antibodies (ANA) - non-specific but often +ve

Anti-centromere antibodies - associated with limited cutaneous systemic sclerosis

Anti-scl-70 antibodies - diffuse cutaneous systemic sclerosis

487
Q

what is the management of systemic sclerosis?

A

DMARDs - methotrexate
Biologics - rituximab

Avoid smoking
gentle skin stretching for ROM
regular emollients
Avoid cold triggers
Physio
OT

488
Q

What is takayasu’s arteritis?

A

Large vessel vasculitis characterised by granulomatous inflammation of aorta and it’s branches

489
Q

who is takayasu’s arteritis common in?

A

young females and Asian people

490
Q

what are 6 presentations of takayasu’s arteritis?

A

Systemic features - malaise, headache
Unequal BP in upper limbs
Carotid bruit and tenderness
Absent/weak peripheral pulses
Upper and lower limb claudication
Aortic regurgitation

491
Q

what investigations are used in takayasu’s arteritis?

A

BP upper and lower limbs

Vascular imaging of arterial tree - CTA or MRA

492
Q

what is the management of takayasu’s arteritis?

A

1 - Steroids
Low dose aspirin

2 - immunosuppressives

493
Q

what is Polyarteritis nodosa?

A

Vasculitis of medium sized vessels causing necrotising inflammation leading to thrombosis, aneurysm formation and organ ischaemia most commonly renal

494
Q

who is Polyarteritis nodosa common in?

A

Middle aged men

Can be idiopathic of often associated with Hep B infection

495
Q

what are 5 risk factors for Polyarteritis nodosa?

A

Middle age
Male
Hep B or C
Immunosuppression
Genetic predisposition - associated with familial Mediterranean fever

496
Q

what is the presentation of Polyarteritis nodosa?

A

Systemic symptoms - wt loss, fatigue, myalgia, fever

Numbness and paraesthesia, peripheral neuropathy
Renal failure
Vasculitic purpuric rash - livedo reticularis
Digital infarcts
HTN

497
Q

what is the gold standard investigation for Polyarteritis nodosa?

A

Biopsy - transmural inflammation with fibrinoid necrosis

498
Q

what is the management of Polyarteritis nodosa?

A

1 - High dose prednisolone

Antiviral therapy
ACEi

2 - Cyclophosphamide immunosuppression

For maintenance - azithioprine or methotrexate, corticosteroids

499
Q

what are 5 complications of Polyarteritis nodosa?

A

organ damage
haemorrhage
Infections
chronic pain
hypertension

500
Q

what are 3 ANCA associated vasculitises?

A

Granulomatosis with polyangiitis (wergner’s granulomatosis)
Eosinophilic granulomatosis with polyangiitis (churg-straus syndrome)
Microscopic polyangiitis

501
Q

what is Granulomatosis with polyangiitis?

A

Prev - Wegener’s granulomatosis

Small vessel necrotising vasculitis affecting respiratory tract and kidneys

502
Q

what is the presentation of Granulomatosis with polyangiitis?

A

URT - epistaxis, sinusitis, nasal crusting
LRT - SOB, Haemoptysis

Rapidly progressing glomerulonephritis

Saddle shaped nose deformity - ;ate sign due to chronic inflammation and erosion of upper airway

Vasculitis rash, proptosis, cranial nerve lesion

503
Q

what autoantibody is present in Granulomatosis with polyangiitis?

504
Q

what is the management of Granulomatosis with polyangiitis?

A

1 - high dose prednisolone
OR
Cyclophosphamide

Maintenance - Azathioprine, methotrexate

505
Q

what criteria can be used for diagnosis of Granulomatosis with polyangiitis?

A

ELK (ENT, Lung and kidney presentations)
AND
positive cANCA

506
Q

what are 6 complications of Granulomatosis with polyangiitis?

A

AKI
CKD
Lung damage
Scleritis
Mononeuritis multiplex
side effects of long term steroids

507
Q

what is eosinophilic granulomatosis with polyangiitis?

A

Prev. Churg-Strauss syndrome

Small-medium vessel vasculitis

508
Q

what is the presentation of eosinophilic granulomatosis with polyangiitis?

A

Worsening asthma
Sinusitis pain
Parasthesia or numbness, signs of peripheral neuropathy
Weight loss
vasculitis rash

509
Q

what are 4 investigations for eosinophilic granulomatosis with polyangiitis?

A

FBC - for eosinophilia
CXR
Autoantibodies
Biopsy

510
Q

what autoantibodies are present in eosinophilic granulomatosis with polyangiitis?

511
Q

what is the American college of rheumatology criteria for eosinophilic granulomatosis with polyangiitis?

A

at least 4/6 of

Asthma
eosinophilia >10%
Mononeuropathy or polyneuropathy
Non-fixed pulmonary infiltrates
paranasal sinus abnormalities
positive biopsy

512
Q

what is the management of eosinophilic granulomatosis with polyangiitis?

A

1 - corticosteroids

2 - immunosuppression

513
Q

what are 4 complications of eosinophilic granulomatosis with polyangiitis?

A

Long lasting peripheral neuropathy
Severe asthma
heart disease
side effects of long term steroids

514
Q

what is one medication that can precipitate eosinophilic granulomatosis with polyangiitis?

A

leukotriene receptor antagonists - montelukast

515
Q

what is Microscopic polyangiitis?

A

small vessel necrotising vasculitis typically affecting lungs and kidneys

NON-granulomatous

516
Q

what autoantibody is in Microscopic polyangiitis?

A

pANCA - 50-75%

cANCA - 40%

517
Q

what is seen on renal biopsy in Microscopic polyangiitis?

A

crescentic glomerulonephritis and small vessel vasculitis

518
Q

what is the presentation of Microscopic polyangiitis?

A

renal impairment - raised creatinine, haematuria, proteinuria
fever, lethargy, malaise, wt loss
Rash
Cough, SOB, haemoptysis

519
Q

what are 4 non-vasculitis conditions that are associated with positive pANCA?

A

UC
Primary sclerosing cholangitis
anti-GBM disease
Crohn’s

520
Q

what are myositoses?

A

autoimmune disorders causing muscle inflammation - polymyositis or dermatomyositis

Can be due to underlying cancers - paraneoplastic

521
Q

what is the presentation of Polymyositis ?

A

gradual onset symmetrical proximal muscle weakness

Difficulty standing from chair, climbing stairs, lifting overhead

Muscle pain

NO SKIN FEATURES

Can be raynauds and lung involvement

522
Q

what autoantibody is associated with Polymyositis ?

A

Anti-Jo-1 antibodies

AKA - histidine-tRNA ligase

523
Q

what muscle enzyme is significantly raised in Polymyositis and dermatomyositis?

A

Creatinine Kinase

524
Q

what is the management of polymyositis?

A

1 - High dose prednisolone

2 - immunosuppression - azathioprine, methotrexate

525
Q

what are 4 skin presentations of Dermatomyositis?

A

Gottron lesions - scaly erythematous patches on knuckles, elbows, knees

Helitrope rash - purple rash on face and eyelids

Periorbital oedema

Photosensitive erythematous rash on back, shoulders and neck - shawl sign

526
Q

what are 4 risk factors for Dermatomyositis?

A

female
40-50 years
Afro-Caribbean
Childhood

527
Q

what are 2 autoantibodies loosely related to Dermatomyositis?

A

Anti-Jo - 30%
Anti-M2

528
Q

what are 5 cancers related to myositis?

A

Ovarian
Lung
pancreas
stomach
Colon

529
Q

what is the management of Dermatomyositis?

A

1 - Prednisolone
exercise and physio
Sun protection

2 - immunosuppression, IVIG, biologics

530
Q

what is discitis?

A

inflammation in intervertebral disc space - can lead to sepsis or epidural abscess

531
Q

what are 3 features of discitis?

A

back pain
general - pyrexia, rigors, sepsis
Neuro features dependant on level

532
Q

what is the most common cause of discitis?

533
Q

what are 2 investigations for discitis?

A

MRI

CT guided biopsy for sensitivities

534
Q

what is the management of discitis?

A

6-8 weeks IV Abx - flucloxacillin, vancomycin
Assess for endocarditis - Transthoracic echo

535
Q

what are 5 risk factors for discitis?

A

Age - children more common due to better blood supply
Male
Recent invasive spinal procedure
Immunosuppression
Diabetes
IVDU

536
Q

what are 7 causes of pathological fracture?

A

Osteoporosis
CKS-metabolic bone disease
Hyperparathyroidism
Metastatic cancer
Infection
Primary bone tumours
bone biopsies

537
Q

what system can be used to assess risk of pathological fracture?

A

Mirels’ scoring system

score >9 = may need prophylactic fixation

538
Q

what scan can be used for looking for bone metastasis?

A

bon scintigraphy

539
Q

what is the mangement of pathological fractures?

A

orthopaedic stabilisation
radiotherapy or chemotherapy - malignancy
tx osteoporosis

540
Q

how long can it take for DMARDs to work?

A

2-3 months

541
Q

what are 5 notable side effect of leflunomide?

A

raised BP
rashes
peripheral neuropathy
teratogenic
bone marrow suppresion

542
Q

how does leflunomide work?

A

interferes production of pyrimidine used to make RNA and DNA

543
Q

how does hydroxychloroquine work as an immunosuppressant?

A

interferes with toll-like receptors disrupting antigen presentation

544
Q

what are 4 notable side effects of hydroxychloroquine?

A

nightmares
macular toxicity
liver toxicity
skin pigmentation

545
Q

what is a notable side effect of sulfasalazine?

A

male infertility - reduction in sperm count

546
Q

what is a notable side effect of anti-TNF?

A

reactivation of TB and hepatitis B

547
Q

what are 2 notable side effects of rituximab?

A

night sweats
thrombocytopenia

548
Q

what is Behcet’s syndrome?

A

Complex multisystem autoimmune inflammatory disorder of recurrent oral ulcer, genital ulcers and anterior uveitis

549
Q

what gene is there a link with in behcet’s disease?

A

HLA-B51

more common in eastern mediterranean people

550
Q

what are 8 features of behcet’s disease?

A

Oral ulcers - painful, well circumscribed erosions with red halo - at least 3 episodes in last year

genital ulcers
anterior uveitis

Erythema nososum
Arthritis
thrombophlebitis and DVT
Neuro involvement - aseptic meningitis
GI - Abdo pain, diarrhoea, colitis

551
Q

what test can be used to assess for Behcet’s disease?

A

pathergy test

sterile needle makes pin pricks on forearm - r/v in 24-48 hours for erythema, induration (thickening) and non-specific skin hypersensitivity

+ve in Behcet’s disease, sweet’s syndrome or pyoderma gangrenosum

552
Q

what is the management of Behcet’s disease?

A

Colchicine - for acute inflammation

Topical/systemic steroids - for acute outbreaks

Immunosuppression - azithioprine, methotrexate, cyclosporine

biologics - infliximab, adalimumab - in refractory cases

553
Q

what are 5 complications of Behcet’s disease?

A

Occular - uveitus, retinal vasculitises
Vascular - VTE, vasculitis
Neuro - aseptic meningitis
GI ulcers, perforation
Relapse - relapsing remitting course

554
Q

what are 7 causes of mechanical back pain?

A

muscle or ligament sprain
facet joint dysfunction
sacroiliac joint dusfunction
herniated disc
spondylolisthesis - anterior displacement of vertebra
scoliosis
degenerative changes

555
Q

what are 4 causes of neck pain?

A

muscle or ligamant strain
torticollis - muscle spasms causing stiff and painful neck
whiplash
cervical spondylosis

556
Q

what are 5 red flag causes of back pain?

A

spinal fracture
cauda equina
spinal stenosis
ankylosing spondylitis
spinal infection

557
Q

what nerves form the sciatic nerve?

558
Q

how many of each vertebrae are there?

A

7 cervical
12 thoracic
5 Lumbar
5 sacral (fused)
4 coccyx (fused)

559
Q

what is the pathway of the sciatic nerve?

A

exits pelvis through greater sciatic foramen
travels down back of leg to knee
divides into tibial nerve and common peroneal nerve

supplies sensation to lateral lower leg and foot and motor to posterior thigh, lower leg and foot

560
Q

what are 3 causes of sciatica?

A

herniated disc
spondylolisthesis
spinal stenosis

561
Q

what test can be used to assess sciatica?

A

Sciatic stretch test

patient lies on back with legs straight

examiner lifts leg from ankle with knee extended till maximum hip flexion then dorsiflexes ankle

reproduces sciatica pain indicating nerve root irritation

562
Q

what tool can be used to assess risk of chronic back pain from an acute presentation?

A

STarT back screening tool

563
Q

what is low, medium and high risk in the STarT back screening tool?

A

Low - total score <3, subscore <3

Medium - total score >3, subscore <3

high - total score >3, subscore >3

564
Q

what is the management of patients at low risk of chronic back pain presenting with pain?

A

self management
education
reassurance
analgesia
staying active and mobilising as tolerated

565
Q

what is the management for patients at medium to high risk of developing chronic back pain presenting with pain?

A

As with low risk PLUS

physiotherapy
group exercise
CBT

566
Q

what are 3 options for analgesia in back pain?

A

1 - NSAIDs - Naproxan, ibuprofen

codeine

benzodiazepine - for muscle spasms - up to 5 days

567
Q

what anaesthetic technique can be used for lower back pain due to facet joint dysfunction?

A

radiofrequency denervation

568
Q

what is the management of sciatica?

A

Amitriptyline
Duloxitine

569
Q

what are 4 specialist options for chronic sciatica?

A

epidural corticosteroid injections
local anaesthetic injections
radiofrequency denervation
spinal decompression

570
Q

what are 5 red flags for lower back pain?

A

age <20 or >50
Hx of malignancy
night pain
Hx of trauma
Systemically unwell

cauda equina symptoms

571
Q

what are the features of L3 nerve root compression?

A

sensory loss over anteior thigh
weak hip flexion, knee extension, hip adduction

reduced knee reflex
positive femoral stretch test

572
Q

what are the features of L4 nerve root compression?

A

sensory loss to anterior aspect on knee and medial malleolus

weak knee extension and hip adduction

reduced knee reflex
positive femoral stretch test

573
Q

what is the presentation of L5 nerve root compression?

A

sensory loss over dorsum of foot
weakness in foot and big toes dorsiflexion

reflexes intact
positive sciatic nerve stretch test

574
Q

what is the presentation of S1 nerve root compression?

A

sensory loss posteriolateral aspect of leg and lateral aspect of foot

weakness in plantar flexion of foot
reduced ankle reflex
positive sciatic nerve stretch test

575
Q

what is the femoral stretch test?

A

patient lies prone

maximal flexion of knee to end range
if no symptoms hip is extended with knee flexed

if pain is felt in posterior thigh, buttocks or lumbar region - +ve

576
Q

what is classed as acute backpain?

577
Q

what is classed as chronic back pain?

A

> 12 weeks

578
Q

what are 8 risk factors for back pain?

A

prev episode
obesity
physically demanding occupation
physical inactivity
psychological distress
other chronic health conditions
lower socio-economic status
smoking

579
Q

what is the most common level for a prolapsed disc?

Phase 4 (22 decks)

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