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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
what are gout crystals like?
monosodium urate - negatively bifringent needle shaped
26
what joints is most commonly associated with gout?
big toe - MTP (metatarsophalangeal)
27
what is gout most commonly caused by?
renal under excretion of urate - 90%
28
what are 3 risk factors for gout?
Diet of red meat, seafood and alcohol Diuretics + low dose aspirin Metabolic syndrome impaired renal function
29
what is the pathophysiology of gout?
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
30
what are 4 clinical manifestations of gout?
rapid onset of severe joint pain in few joints joint stiff, red, hot tophi
31
what renal disease can gout lead to?
Interstitial nephritis and eventually CKD due to urate crystal deposit
32
what are 3 investigations for gout?
joint aspiration - gold serum uric acid levels - 4-6 weeks after attack joint X-ray
33
what may be seen on x-ray in gout?
Usually normal chronic - Joint effusion but space maintained Punched out erosions Lytic lesions Sclerotic margins Outlines of tophi
34
what are 3 bloods needed in a gout work up?
U+E - assess renal function for appropriate dose orf allopurinol FBC - WCC may be raised Fasting glucose and lipid profile
35
what are 3 differentials for gout?
pseudo gout septic arthritis rheumatoid arthritis
36
what is the management of an acute gout attack?
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
37
what is an adverse effect of colchicine?
diarrhoea
38
who should colchicine be used with caution in?
renal impairment dose reduction if eGFR 10-50 Avoid if eGFR <10
39
what is the management of gout chronically?
lifestyle advise Uric acid lowering therapy - 1 - allopurinol - 100mg OD PO 2 - Febuxostat Uricosuric agent - sulfinpyrazone
40
what is the serum urate target in gout?
<360 micromol/L <300 micromol/L with tophi, arthritis or ongoing flares
41
what class of medication is allopurinol?
xanthine oxidase inhibitor
42
How long should you wait to start urate lowering therapy after an acute attack?
2 weeks - not lots of evidence but may precipitate further attack
43
what is the criteria for starting urate lowering therapy?
Can start after 1st attack Definitely if: 2+ attacks Tophi Renal disease uric acid renal stones prophylaxis if on cytotoxics or diuretics
44
what are 3 complications of gout?
joint destruction + tophi kidney disease - acute uric acid nephropathy urate nephrolithiasis + CKD
45
what is osteoarthritis?
a non-inflammatory degenerative arthritis characterised by progressive synovial joint damage
46
what are 7 risk factors for osteoarthritis?
Older age - 50+ Obesity Occupation Physically demanding job/sport Trauma Family history Female
47
what are the 5 X-ray manifestations of osteoarthritis?
JOSSA joint space narrowing osteophyte formation subchondral sclerosis subchondral cysts abnormalities of bone contour
48
what is the pathophysiology of osteoarthritis?
there is a failure in maintaining the homeostatic balance of the cartilage matrix synthesis and degradation, resulting from reduced formation or increased catabolism
49
what are 5 presentations of osteoarthritis?
Pain Functional difficulty and reduced ROM Crepitus Bony deformaities and joint enlargement Effusions
50
what joints does osteoarthritis usually affect?
weight bearing joints asymmetrically Hips, knees, DIPJ, CMC joint at base of thumb, Lumbar spine, cervical spine
51
What are 5 hand signs of OA?
Heberdens nodes - DIP joints Bouchards nodes - PIP joints Squaring of base of thumb - CMC joint Weak grip Reduced ROM
52
What is the criteria for OA diagnosis?
>45 years old, typical pain, no /<30 mins of morning stiffness
53
what is the management for osteoarthritis?
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
54
what are 5 side effects of NSAIDs?
NSAIDs No urine Systolic dysfunction (HF) Asthma Indigestion Dyscrasia - clotting dysfunction
55
what are heberden's node?
osteoarthritic nodes of the DIP joints
56
what are Bouchard's nodes?
osteoarthritic nodes of the PIP joints
57
what kind of appearance does erosive OA have on Xray?
gulls wing
58
What is osteomyelitis?
an inflammatory condition of bone caused by an infecting organism
59
what is the most common cause of osteomyelitis?
S. Aureus
60
what is the most common bacterial cause of Osteomyelitis in sickle cell?
Salmonella
61
what are the 3 paths of infection in osteomyelitis?
Direct inoculation Contiguous spread from adjacent tissues Haematogenous spread
62
what are 7 risk factors for Osteomyelitis?
Open fracture orthopaedic operations - esp prosthetics diabetes - esp with ulcers peripheral arterial disease IVDU Immunosuppression Sickle cell disease
63
what organisms mainly cause osteomyelitis in infants?
S. Aureus group B strep aerobic gram -ve bacili candida albicans
64
what organisms mainly causes osteomyelitis in children?
1 - S. Aureus 2 - Strep pneumoniae Haemophilus influenzae in unvaccinated children
65
what organisms mainly cause osteomyelitis in adults?
1 - S. Aureus coagulase negative staph aerobic gram negatives anaerobic gram +ve peptostreptococci
66
what organisms mainly cause osteomyelitis in the elderly?
gram negative bacili
67
what organisms usually cause osteomyelitis in IVDU?
S. Aureus Can also get pseudomonas in pelvis
68
what are 3 risk factors for osteomyelitis?
pHx of osteomyelitis penetrating injury IVDU
69
what is the presentation of acute osteomyelitis?
Symptoms over a few days Pain, erythema, swelling, warmth Fever malaise
70
what are 3 presentations of chronic osteomyelitis?
Local symptoms - swelling, erythema, pain - no systemic symptoms Draining sinus tract Non-healing fractures Diabetes ulcers >2cm
71
where is the most common location of osteomyelitis?
lower limb
72
what are 3 investigations for osteomyelitis?
Bloods - FBC, CRP, Cultures X-ray - may be negative for first 2 weeks MRI/CT
73
what are 3 signs of osteomyelitis on x-ray?
periosteal reaction - change in surface of bone Localised osteopenia Destruction of areas of bone architecture
74
what is the gold standard for osteomyelitis?
bone biopsy, cultures and histopathology
75
what is the treatment of osteomyelitis?
6 weeks IV Abx - IV Flucloxacillin 8g /day - Pen allergy - Clarithromycin Debridement - surgery to remove necrotic bone
76
what is required for management of osteomyelitis with prosthetic joint involvement?
may require complete revision surgery
77
what are 3 complications of osteomyelitis?
drug reactions amputation recurrence
78
what is osteoporosis?
Systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue with consequent increase in bone fracture and fragility
79
how do bisphosphonates work?
slow down osteoclast activity => reduce bone breakdown
80
how does Denosumab work?
anti-resorbative - inhibits osteoclast activity
81
how does teriparatide work?
anabolic - synthetic parathyroid hormone, increases osteoblastic activity
82
what are the T score ranges?
>-1 = normal -1 - -2.5 = osteopenia < -2.5 = osteoporosis < -2.5 + a fracture = severe osteoporosis
83
What is pseudogout?
an acute inflammatory arthritis of one or more joints due to calcium pyrophosphate deposition on joint surfaces
84
what are 7 risk factors for pseudogout?
advanced age >65 injury/trauma hyperparathyroidism haemochromatosis wilsons disese acromegaly low magnesium and phosphate
85
what kind of crystals are deposited in psudogout?
calcium pyrophosphate crystals | positively bifringent rhomboid shaped crystals
86
what are 3 manifestations of pseudogout?
Most commonly knee, wrist and shoulders red painful and tender joints sudden worsening of osteoarthritis joint effusion
87
what can be see on xray in pseudogout?
chondrocalcinosis - calcification in the hyaline and/or fibrocartilage - white line in joint space can also have oesteoarthritis type changes
88
what are 3 investigations for pseudogout?
synovial fluid aspirate analysis - gold joint X ray - chondrocalcinosis serum calcium + PTH
89
what are 3 differentials for pseudogout?
gout septic arthritis osteoarthritis
90
what is the management for pseudogout?
1 - NSAIDs or Colchicine corticosteroid intra-articular Intra-articular steroids Oral steroids
91
what is the general order of affected joints in pseudogout?
Knee > wrist > shoulders > ankles >elbows
92
What is psoriatic arthritis?
a seronegative chronic inflammatory joint disease associated with psoriasis
93
what are 5 different types of psoriatic arthritis?
Asymmetrical oligoarthritis - affecting 1-4 joints at a time Symmetrical polyarthritis >4 joints Distal interphalangeal predominant pattern Spondylitis Arthritis mutilans
94
what is arthritis mutilans?
most severe form form of psoriatic arthritis - causes osteolysis of bones around joints leading to progressive shortening of digits - telescoping digits
95
what are 3 risk factors for psoriatic arthritis?
psoriasis FHx Hx of joint/tendon trauma
96
what is one features of psoriatic arthritis that distinguishes it from RhA?
DIP joint involvement
97
what are 5 hand signs of psoriatic arthritis?
Psoriasis plaques Nail pitting onycholysis Dactylitis Enthesitis
98
what are 5 manifestations of psoriatic arthritis?
Painful stiff joints - DIP involvement Symmetrical or asymmetrical psoriatic skin lesions - though often precedes plaques Nail changes
99
what screening tool can be used for psoriatic arthritis?
psoriasis epidemiological screening tool
100
What are 4 X-ray features of psoriatic arthritis?
Pencil in cup deformity periostitis - inflammation of periosteum ankylosis osteolysis dactylitis
101
what is the mangement for psoriatic arthritis?
NSAIDs - mild DMARDs - methotrexate, sulfasalazine anti0TNF-alpha inhibitors - infliximab MAB - Ustekinumab
102
what are 3 complications of psoriatic arthritis?
Joint deformity cardiovascular risks malignancy- skin cancer
103
What is reactive arthritis?
A sterile inflammatory arthritis that occurs after exposure to certain gastrointestinal and genitourinary infections.
104
what is the classic triad of reactive arthritis? what is the way to remember it?
Arthritis Urethritis + balantitis Conjunctivitis/anterior uveitis Can't see, can't wee, can't climb a tree
105
is reactive arthritis usually asymmetrical?
YES - also usually only affects one joint - mono arthritis
106
who is reactive arthritis most common in?
Men with HLA-B27
107
what is one condition that is often associated with reactive arthritis?
HIV - should exclude in presenting patients
108
what are 5 causative organisms for reactive arthritis?
GU - chlamydia trachomatis, gonorrhoea GI - salmonella, shingella, campylobacter
109
what are 4 risk factors for reactive arthritis?
HLA-B27 male chlamydial/GI infection HIV
110
what are 3 investigations for reactive arthritis?
ESR/CRP - elevated joint aspiration infectious serology/urine/stool
111
what are 3 differentials for reactive arthritis?
gout pseudogout septic arthritis
112
what is the management of reactive arthritis?
PRESUME SEPTIC UNTIL PROVEN OTHERWISE NSAIDs - naproxen/ibruprofen corticosteroids injections Tx triggering infection usually gone in 6 months DMARDs - in recurrent cases
113
what are 3 complications of reactive arthritis?
circinate balanitis uveitis keratoderma blennorhagicum
114
What is rheumatoid arthritis?
An autoimmune chronic inflammatory condition of the synovial lining of joints, tendon sheaths and bursa
115
what are 4 risk factors for Rheumatoid arthritis ?
Female Smoking Obesity Fhx - HLA DR4
116
what are 6 manifestations of RhA?
Symmetrical polyarthritis > 6 weeks Morning stiffness lasting >30 mins Joint deformities Rheumatoid nodules Systemic symptoms - fatigue, wt loss, flu like illness, muscle aches
117
what joints are usually spared in rheumatoid arthritis?
DIP Lumbar spine
118
what is felt on palpating rheumatoid arthritis joint?
feel boggy
119
what are the 4 deformities associated with Rheumatoid arthritis?
Swan's neck Boutonniere - pip always bent Ulnar deviation Z-thumb deformity - hyperextension of thumb IPJ and flexed MCP joint
120
what are 12 extra-articular manifestations of rheumatoid arthritis?
Pulmonary fibrosis Felty's syndrome Sjogrens syndrome Anaemia of chronci disease CVD eye manifestations rheumatoid nodules Lymphadenopathy Carpel tunnel Amyloidosis Bronchiolitis obliterans Caplan syndrome
121
what are 6 ocular manifestations of rheumatoid arthritis?
Dry eye syndrome - keratoconjunctivitis sicca - most common episcleritis scleritis keratitis cataracts - secondary to steroids retinopathy - secondary to hydroxychloroquine
122
what is Felty's syndrome?
Triad rheumatoid arthritis Neutropenia Splenomegaly
123
what is bronchiolitis obliterans?
small airway destruction and airflow obstruction in lungs associated with rheumatoid arthritis
124
what is caplan syndrome?
pulmonary nodules in rheumatoid arthritis patient exposed to coal, silica, asbestos or dust
125
what are 2 autoantibodies present in Rheumatoid arthritis?
Rheumatoid factor anti-CCP
126
what are 6 conditions associated with positive rheumatoid factor?
Felty's syndrome Sjorgren's syndrome infective endocarditis SLE Systemic sclerosis General population
127
what is the most sensitive and specific autoantibody in Rheumatoid arthritis?
Anti-CCP (cyclic citrullinated peptide)
128
what is one serious cervical spine complication in rheumatoid arthritis?
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
129
what are 5 x-ray findings in rheumatoid arthritis?
Soft tissue swelling periarticular osteopenia/porosis joint space narrowing Periarticular erosions subluxation
130
what questionnaire can be used to assess functional ability and response to treatment in rheumatoid arthritis?
Health assessment questionnaire
131
What questionnaire can be used to monitor disease activity in rheumatoid arthritis?
Disease activity score 28 joints - DAS28
132
What is the management of 1st presentation of rheumatoid arthritis in GP?
NSAID cover Urgent referral to Rheumatology Physio and OT
133
what is the initial specialist therapy for rheumatoid arthritis?
DMARD monotherapy - methotrexate, sulfasalazine, leflunomide, hydroxychloroquine +/- Prednisolone bridging
134
when are patients with rheumatoid arthritis trialled on a TNF-inhibitor?
Inadequate response to 2 DMARDs Etanercept Infliximab Adalimumab
135
what are 2 rheumatoid arthritis medications that are safe in pregnancy?
Sulfasalazine Hydroxychloroquine
136
after what gestation are NSAIDs contraindicated?
28 weeks - risks early closure of ductus arteriosus
137
what is the MOA of methotrexate?
inhibits dihydrofolate reductase - enzyme for synthesis of purines and pyrimidines
138
what are 5 adverse effects of methotrexate?
Mucositis Myelosuppression Pneumonitis Pulmonary fibrosis Liver fibrosis
139
How long before conception does methotrexate need to be stopped in both men and women?
6 months
140
How often is methotrexate taken?
ONCE A WEEK
141
how often should people on methotrexate be monitored?
FBC, U+E, LFT every 2-3 months
142
what should be prescribed with methotrexate?
5mg folic acid once a week take >24h after methotrexate
143
what are 3 medications that CANNOT be prescribed with methotrexate?
Trimethoprim Co-trimoxazole High dose aspirin
144
what is the treatment of methotrexate toxicity?
Folinic acid
145
What is septic arthritis?
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.
146
what is the most common joint to be infected with septic arthritis?
knee
147
what is the most common causative organism for septic arthritis?
S. Aureus
148
who 2 gram negative bacteria cause septic arthritis? what patients in?
E. COLI and PSEUDOMONAS AERUGINOSA IVDU immunosuppressed neonates elderly
149
what are 2 gram positive causative bacteria of septic arthritis? what patients affected?
Strep group A (pyogenes) - <5yrs Staph epidermis - prosthetic joints
150
who gets neisseria gonorrhoea septic arthritis?
sexually active people
151
what are 6 risk factors for septic arthritis?
underlying joint disease/prosthetic joint IVDU, indwelling catheters immunosuppression Skin infections Extremes of age
152
what are 5 manifestations of septic arthritis?
hot, swollen, painful, red restricted ROM fever affecting single joint (90%)
153
what are 3 investigations for septic arthritis?
joint aspiration - gold FBC - leukocytosis CRP and ESR - high blood cultures
154
what are 3 differentials for septic arthritis?
osteoarthritis pseudogout Gout
155
what is the management of septic arthritis?
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
156
what is the aspirate WCC in septic arthritis usually?
>50 000
157
what are 3 complications of septic arthritis?
sepsis osteomyelitis joint destruction
158
What is systemic lupus erythramatosus?
a chronic systemic autoimmune condition caused by a type 3 hypersensitivity reaction leading to immune complex deposition in many organs
159
what is the typical demographic for SLE
Female Afro-Caribbean 20-40 years
160
what are 10 manifestations of SLE?
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
161
what are 3 antibody tests for SLE?
ANA (anti-nuclear antibodies) - most sensitive Anti-dsDNA - most specific Anti-Sm(ith) antibodies - very specific, not sensitive Anti-Ro, Anti-La Anti-Scle-70 Anti-Jo-1
162
are complement levels high or low in SLE?
low in active disease as formation of immune complexes leads to consumption of complement
163
what blood clotting disorder can occur secondary to SLE?
Antiphospholipid syndrome
164
what are 3 differentials for SLE?
Rheumatoid Arthritis- SLE less symmetrical antiphospholipid syndrome mixed connective tissue disease
165
what is the management of SLE?
1 - hydroxychloroquine NSAIDs corticosteroids - prednisolone 2 - DMARDs - methotrexate, biologics - rituximab, belumumab
166
what are 9 complications of SLE?
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
167
what antibodies are found in drug induced lupus?
anti-histone antibodies ANA usually positive dsDNA usually negative
168
what are 5 medications that can cause drug induced lupus?
Procainamide hydralazine isoniazid minocycline phenytoin
169
what is the most common form of lupus nephritis?
Diffuse proliferative glomerulonephritis presents with haematuria, proteinuria, hypertension, oedema most severe!
170
what can be seen on renal biopsy in SLE sclerosing glomreulonephritis?
Hypercellular glomerulus Thickened basement membrane Wire-loop appearance of endothelial and mesangial proliferation
171
what is the management of lupus nephritis?
lifestyle - stop smoking, exercise, diet Corticosteroids immunosuppression Hydroxychloroquine Dialysis ACEi for renoprotection and HTN
172
how long does morning stiffness in OA last?
<30 mins
173
what is FRAX?
predicts risk of fragility fracture over the next 10 years age, BMI, smoking, alcohol
174
what group of people does N. Gonorrhoea cause septic arthritis in?
sexually active young adults
175
what antibiotics are used in septic arthritis?
IV flucoxacillin - gram pos (clindamycin in allergy) IV cefotaxime - gram neg
176
what are 4 risk factors for SLE?
female FHx middle aged
177
what is the gold standard investigation of osteomalacia?
iliac bone biopsy with double tetracycline labelling rare as invasive
178
what is osteomalacia?
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
179
what causes osteomalacia?
vitamin D deficiency | calcium or phosphate deficiency
180
what is the presentation for osteomalacia and vitamin D deficiency?
Fatigue Bone pain Muscle weakness muscle aches pathological or abnormal fractures
181
what are 3 skeletal changes that can be seen in osteomalacia?
Pseudofractures - Looser's zones - radiolucent bands traversing part way though bones due to demineralisation Bowing deformities Vertebral fractures
182
what are 4 risk factors for osteomalacia?
risks for low vitamin D Darker skin low sunlight exposure living in cold climates spending most of time indoors
183
what is normal serum vitamin D?
50-75 nmol/L
184
what are 5 investigations for osteomalacia?
serum calcium and phosphate serum 25-hydroxyvitamin D PTH level - may be high Alk phos - might be high
185
what is the treatment of osteomalacia?
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
186
How much vitamin d should everyone be taking?
400IU (10 micrograms)
187
which discs are most commonly affected in vertebral disc degeneration?
lower lumbar spine - L5/S1 then L4/L5
188
what are 5 risk factors for disc prolapse?
Increasing age Smoking genetics High BMI Occupation - heavy lifting, bending, operating machinery
189
what is the pathophysiology of disc prolapse?
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
190
what are 5 manifestations of vertebral disc prolapse?
Lower back pain Radiculopathy Neurological weakness Paraesthesia Cauda equina
191
what is the presentation of a L3 nerve root compression?
Sensory - loss over anterior thigh Motor - weak hip flexion, knee extension and hip adduction Reflex - Knee reduced Positive femoral stretch test
192
what is the presentation of L4 nerve root compression?
Sensory - loss of anterior aspect of knee and medial malleolus Motor - weak knee extension and hip adduction Reflex - reduced knee Positive femoral stretch test
193
what is the presentation of L5 nerve root compression?
Sensory - loss to dorsum of foot Motor - weakness in dorsiflexion Reflexes - intact Positive sciatic nerve stretch test
194
what is the presentation of S1 nerve root compression?
Sensory - loss of posterolateral leg and lateral foot Motor - weak plantarflexion Reflex - reduced ankle reflex Positive sciatic nerve stretch test
195
what imaging is done for disc prolapse?
MRI spine
196
what is the conservative management of disc prolapse?
Continue with life but restrict painful activity Physio Analgesia - 1 - NSAIDs 1 - amitriptyline for radiculopathy
197
what are 3 indications for surgery in disc prolapse?
Cauda equina syndrome Progressive neurological weakness Pain >6 weeks not responding to conservative tx
198
what surgery can be done for disc prolapse?
Laminectomy and microdiscectomy Spinal fusion if unstable
199
what are 5 complications of spinal surgery for disc prolapse?
Re-herniation Infection - discitis, meningitis, abscess Injury to adjacent structures haematoma and spinal compression Spondylolisthesis
200
what is Paget's disease of the bone?
A disease of increased uncontrolled bone turnover thought to be due to excessive osteoclastic resorption followed by increased osteoblastic activity
201
what are 3 risk factors for Paget's disease?
FHx 50+ infection
202
what are the 3 stages of Paget's disease?
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
203
what are 5 manifestations of Paget's disease?
bone pain growth of bones in face - leontiasis, hearing loss, vision loss kyphosis pathological fractures
204
what disease can cause cotton wool appearance of skull on x-ray?
Paget's disease - due to osteoclastic activity and sclerotic lesions
205
what are 3 investigations for Paget's disease of the bone?
X-ray - osteolytic lesions, fractures, slerotic changes, bone enlargement and deformity Radionucleotide bone scan LFTs - raised alk phos
206
what is the management of Paget's disease of the bone?
1 - Bisphosphonates - alendronic or zolendronic acid calcitonin analgesia calcium + vitamin D surgery for severe deformity
207
what are 4 complications of Paget's disease of the bone?
Hearing loss - if affecting ossicles/vestibulocochlear nerve Heart failure - high output due to vascular new bone osteosarcoma spinal stenosis and cord compression
208
what chromosome is the mutation that causes Marfan's on?
chromosome 15 Affects gene responsible for creating fibrillin - protein fibrillin-1
209
what is the inheritance pattern of marfans?
autosomal dominant
210
what are 10 symptoms of Marfan's?
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
211
what are 2 ways to test for arachnodactyly?
long fingers Cross thumb cross palm - thumb crosses opposite edge Wrap hand around wrist - fingers and thumb overlap
212
what are 3 cardiac conditions associated with Marfans?
Mitral valve prolapse and regurgitation Aortic valve prolapse and regurgitations Aortic aneurysm
213
what are 5 non-cardiac conditions associated with marfans?
Lens dislocation in eye joint dislocation scoliosis Pneumothorax GORD
214
How are people with marfans monitored?
Yearly echo yearly ophthalmology review
215
where is type 1 collagen found?
skin, tendons, organs, bones
216
where is type 2 collagen found?
cartilage
217
where is type 3 collagen found?
supporting mesh of soft organs
218
where is type 4 collagen found?
basal lamina (basement membranes)
219
where is type 5 collagen found?
cells surfaces, hair, placenta
220
what are the 4 different types of Elhers-Danlos syndrome?
Hypermobile EDS Classical EDS Vascular EDS Kyphoscoliotic EDS
221
what type of collagen is most affected in EDS?
type III
222
what is the inheritance pattern for all bar kyphoscoliotc EDS?
Autosomal dominant
223
what is the inheritance pattern for kyphosoliotic EDS?
autosomal recessive
224
what is the presentation of hypermobile EDS?
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
225
what scoring system is used to assess hypermobility in EDS?
Beighton score
226
what can be seen in classical EDS?
Stretchy, smooth, velvety skin Joint hypermobility joint pain abnormal wound healing Prone to hernia, prolapses, mitral regurg, aortic root dilation
227
what can be seen in kyphoscoliotic EDS?
hypotonia as a neonate kyphoscoliosis as they grow Joint hypermobility joint dislocation
228
what is antiphospholipid syndrome?
antiphospholipid antibodies which cause clinical features characterised by thromboses and pregnancy related morbidity
229
what other condition is antiphospholipid syndome associated with?
SLE in 20-30% of cases
230
what sex is antiphospholipid syndrome more common in?
females
231
what are 4 signs of antiphospholipid syndrome?
CLOTs Coagulation defects Livedo reticularis - lace lie purple discolouration of skin Obstetric issues - miscarriage Thrombocytopenia
232
what are 3 investigations of antiphospholipid syndrome?
anticardiolipin test - IgG or IgM antibodies lupus anticoagulant test Anti-B2-glycoprotein test
233
what is the management of antiphospholipid syndrome?
warfarin pregnancy - aspirin and SC heparin
234
what is the Z score?
bone density compared to average for their age and gender
235
what drug class is allopurinol and what is its MOA?
Xanthine oxidase inhibitor Xanthine oxidase metabolises xanthine into uric acid => inhibits metabolism so therefore lowers plasma uric acid
236
where is hidden psoriasis found?
genitals soles scalp ears
237
what is the name of 1 bisphosphonate?
Alendronate
238
how do you take bisphosphonates?
take on empty stomach once a week and remain upright for at least half an hour afterwards
239
What are the bloods like in Paget's disease?
ALP - high Calcium - normal Phosphate - normal
240
what is the 1st line treatment of Paget's disease?
bisphosphonates - alendronate
241
what are 3 complications of Paget's disease?
osteosarcoma leontiasis fractures
242
what are 5 of the diagnostic criteria for giant cell arteritis?
50+ temporal artery abnormality abnormal temoral artery biopsy elevated ESR
243
what is the name of the blotchy skin pattern in antiphospholipid syndrome?
Livedo reticularis
244
what disease can antiphospholipid syndrome be mistaken for due to positive antibody test?
Syphilis
245
what reflex comes from S1?
Ankle jerk
246
what is Sjogren's syndrome?
autoimmune disorder of diminished lacrimal and slivery gland secretions presents with fatigue, dry eyes, dry mouth, dry vagina
247
what antibodies are in sjogren's syndrome?
anti-Ro (SS-A) - more sensitive anti-La (SS-B) - more specific rheumatoid factor ANA
248
what are conditions associated with secondary Sjögren's syndrome?
rheumatoid arthritis SLE
249
what is a key eponymous test for sjorgren's syndrome and what is it?
Schirmer's test filter paper placed in corner of eye to measure secretions <10mm is significant
250
what is the treatment for Sjögren's syndrome?
1 - artificial tears (polyvinyl alcohol and carbomer), salivary substitutes, vaginal lubricant Pilocarpine - stimulates tear and saliva production Hydroxychloroquine is associated joint pain
251
what are 3 complications of Sjögren's syndrome?
Eye - keratoconjuctivitis sicca and corneal ulcers oral- dental cavities, candida vagina - candida, sexual dysfunction
252
what cancer does Sjögren's syndrome increase risk of?
non-Hodgkin's lymphoma 5x normal population
253
what are the 5 extra-articular manifestations of AS?
5 As Anterior uveitis Autoimmune bowel disease Apical lung fibrosis Aortic regurgitation Amyloidosis
254
what test is used to determine spinal motility?
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
what is a compound fracture?
open fracture where skin is broken and bone exposed to air
256
what is a stable fracture?
when section of bone remains in alignment at the fracture
257
what is a salter-harris fracture?
a fracture occurring in children which affects the growth plate. Classified from 1-5
258
what is a transverse fracture?
break in bone perpendicular to long axis (across bone)
259
what is an oblique fracture?
a break diagonally across the width of the bone along the longitudinal axis
260
what usually causes a spiral fracture?
twisting motion
261
what is a spiral fracture?
fracture that wraps around bone
262
what is a comminuted fracture?
breaking into multiple fragments
263
what is a segmental fracture?
when a bone breaks in at least 2 places separating a segment of bone
264
what is a greenstick fracture?
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
what is a buckle fracture?
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
what is cole's fracture?
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
what is a smith's fracture?
volar angulation of distal radius fragment - garden spade deformity caused by falling backwards onto palm of outstretched hand or falling with wrists flexed
268
what is a bennett's fracture?
Intra-articular fracture at base of thumb metacarpal impact on flexed metacarpal - fist fight X-ray - triangular fragment at base of metacarpal
269
what is a monteggia's fracture?
dislocation of proximal radioulnar joint in association with ulnar fracture fall on outstretched hand with forced pronation
270
what is a galeazzi fracture?
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
what is a barton's fracture?
distal radius fracture (coles/smiths) with associated radiocarpal dislocation fall onto extended pronated wrist
272
what is a key sign of scaphoid fracture?
tenderness in the anatomical snuff box
273
what is a key complication of a scaphoid fracture?
avascular necrosis and non-union of the scaphoid as there is retrograde blood supply to the scaphoid
274
what system can be used to classify lateral melleolus (distal fibula) ankle fractures?
Weber classification
275
what is Weber type a fracture?
fracture below level of ankle joint - syndesmosis intact
276
what is Weber type B fracture?
fracture at level of ankle joint - syndesmosis intact or partially torn
277
what is Weber type c fracture?
above ankle joint - syndemosis will be disrupted
278
what are 5 common cancers that metastasise to bone?
PoRTaBLe Prostate Renal Thyroid Breast Lung
279
what are 4 adverse effects of bisphosphonates?
Acid reflux and oesophageal erosions Atypical Fractures Osteonecrosis of the jaw Osteonecrosis of external auditory canal
280
what is 1st principle of fracture management?
mechanical alignment - either closed reduction via manipulation of the limb or open reduction with surgery
281
what is the 2nd principle of fracture management?
provide relative stability to allow healing to occur via fixation
282
what are 6 different types of fracture fixation devices?
external casts K wires Intramedullary wires intramedullary nails screws plate and screws
283
what is the ottawa ankle rules?
assessment of whether an ankle Xray is indicated in ankle injury
284
what are the 4 tenderness points in the ottawa ankle rules?
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
what is the component of the ottawa ankle rules about weight bearing?
inability to bear weight both immediately after injury and in ED - able to take <4 steps => X ray indicated
286
what are 11 long term complications of fractures?
delayed union malunion non-union avascular necrosis infection joint instability joint stiffness contractures arthritis chronic pain complex regional pain syndrome
287
what is a fat embolism and when do they occur?
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
what is Gurd's criteria and what is it for?
Diagnosis of fat embolism 3 Major criteria - Resp distress - Petichial rash - Cerebral involvement Some minor - jaundice - thrombocytopenia - fever - tachy
289
what arteries supply the head of the femur?
medial and lateral circumflex femoral arteries branches off deep femoral artery supplies retrograde blood supply to femoral head
290
what is an intra-capsular hip fracture?
fracture of femoral neck within capsule of hip joint, proximal to intertrochanteric line
291
what is the classfication system of intra-capsular NOF fractures?
Garden classification
292
what is the garden classification from grade I-IV?
I - incomplete fracture and non-displaced II - complete fracture and non-displaced III - partial displacement IV - full displacement
293
what is the possible management of a garden grade I or II NOF fractures?
internal fixation to hold femoral head if blood supply intact
294
what is the management of garden grade III or IV NOF fractures?
Hemiarthroplasty or total hip replacement (for more fit patients)
295
what is the management of intertrochanteric fractures?
dynamic hip screw (sliding hip screw
296
what is the management of subtrochanteric fractures?
Intramedullar nail - metal pole inserted through greater trochanter into the central cavity of the shaft of the femur
297
what is the typical presentation of hip fracture? 3
pain in groin or hip which may radiate to knee unable to weight bear shorted abducted externally rotated leg
298
what is shenton's line?
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
How quickly should hip fracture surgery be carried out?
within 48 hours
300
How quickly should open fractures be debrided and washed out?
within 6 hours
301
what are 5 presentations of rib fracture?
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
what causes flail chest?
two or more rib fractures along 3+ consecutive ribs usually anteriorly
303
what is a sign of flail chest?
paradoxical breathing
304
what is the gold standard investigation of rib fracture?
CT chest
305
what is the management of rib fractures?
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
what grading system can be used to grade open fractures?
Gustilo and anderson system
307
what is the management of buckle fractures?
typically self limiting so do not require surgery and can sometimes be managed with splining and immobilisation
308
what is the management of patellar fracture?
non-operative management usually with a hinged knee brace for 6 weeks and full weight bearing
309
what is a colle's fracture?
Clasically after FOOSH Distal radius fracture with dorsal displacement of fragments Dinner fork type deformity
310
what are early complication of colles fracture?
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
what is the blood supply to the scaphoid?
dorsal carpa branch of radial artery - retrograde supply
312
what is the typical presentation of scaphoid fracture?
pain along radial aspect of wrist at the base of thumb loss of grip/pinch strength
313
what are 5 signs of scaphoid fracture?
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
what is the initial management of scaphoid fracture?
Futuro splint or standard below elbow backslab immobilisation Reereal to ortho - review 7-10 days later if Xray inconclusive
315
what is the ortho management of scaphoid fracture?
undisplaced - cast for 6-8 weeks displaced - surgical fixation proximal scaphoid pole fractures - surgical fixation
316
what is bennett's fracture?
boxers fracture intraarticular fracture of 1st carpometacarpal joint xray - triangular fragment at ulnar base of metacarpal
317
what is monteggia's fracture?
dislocation of proximal radioulnar joint + ulnar fracture fall on out stretched hand with forced pronation
318
what usually causes 5th metatarsal fractures?
following inversion injuries of ankle - proximal avulsion fractures - most common Jones fractures - ransverse fracture at metaphyseal diaphyseal junction
319
what is a toddlers fracture?
oblique tibial fracture in infants
320
Why do NSAIDs cause HTN?
inhibit prostaglandins which cause vasodilation leading to vasoconstriction Use with caution in Hx of HTN
321
How are he hand joints usually affected in OA?
usually CMC and DIP joints more affected than PIP joints, usually affects one joint at a time bilaterally over time
322
what are 2 risk factors for developing polymyalgia rheumatica?
50+ years - peak 70-80 Female
323
what other condition is polymyalgia rheumatica associated with?
Giant cell arteritis
324
what is the clinical presentation of polymyalgia rheumatica ?
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
when should patients with polymyalgia rheumatica be referred?
<60 years Red flads - Wt loss, night pain, neuro features Unusual features of PMR
326
what investigations should be done for polymyalgia rheumatica ?
Clinical diagnosis but... Bloods - FBC - U+E - LFTs - Calcium - Serum protein electophoresis - TSH - CK - Rheumatoid factor - Urine dip
327
what is the managemet of polymyalgia rheumatica ?
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
what is the management of patients on long term steroids?
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
what might be used 2nd line in secondary care for polymyalgia rheumatica?
DMARD treatment - methotrexate 3 - Tocilizumab
330
what are 3 complications of polymyalgia rheumatica ?
Relapse Corticosteroid risks - osteoporosis, infection, T2DM, HTN etc GCA
331
what are 7 risks of long term corticosteroids?
Osteoporosis increased risk of infection T2DM Hypertension Cataracts Glaucoma Skin changes - thinning, bruising
332
what are 5 differentials for polymyalgia rheumatica?
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
what are Bursae?
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
what are 6 risk factors for trochanteric bursitis?
Female Trauma Overuse/posture Co-morbidities - lower back pain, prev surgery, osteoarthritis Lifestyle - inactivity, obesity
335
what is the other name for trochanteric bursitis?
greater trochanter pain syndrome
336
what are 5 presentations of trochanteric bursitis?
Chronic, intermittent lateral hip/thigh/buttock pain Exacerbated by weight bearing and lying on affected side Pain on palpation Trendelenburg test postive
337
what 2 investigations can be used in trochanteric bursitis?
US hip MRI Hip
338
what is the trendelenburg test?
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
what is the management of trochanteric bursitis?
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
what are 7 common locations for bursitis?
prepatellar infrapatella anserine plecranon trochanteric subacromial retrocalcaneal
341
what are 3 clinical features of olecranon bursitis?
Swelling over olecranon process - posterior aspect of elbow tenderness in full flexion erythema
342
why is tenderness at the base of the 5th metatarsal significant in ankle sprain?
Could indicate a jones fracture - transverse fracture at base of 5th metatarsal
343
what is the management of ankle sprains?
RICE rest, ice, compress, elevate Orthosis, cast or crutches may be necessary for short term relief
344
what does the Achilles tendon connect?
connects gastrocnemius to soleus
345
what are the 2 different type of Achilles tendinopathy?
insertion tendinopathy mid-portion tendinopathy
346
what are 5 risk factors for Achilles tendinopathy?
Sports - basketball, tennis, athletics Inflammatory conditions Diabetes Raised cholesterol Fluoroquinolone antibiotics - ciprofloxacin, levofloxacin
347
what are 5 presentations of Achilles tendinopathy?
Pain or aching in Achilles stiffness tenderness swelling nodularity on palpation of tendon
348
what is the presentation of Achilles tendon rupture?
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
what is simmonds triad?
for Achilles rupture Abnormal angle of declination - greater dorsiflexion of injured ankle and food Palpation - Feel for gap in tendon Calf squeeze test
350
what is the Simmons calf squeeze test?
patient prone or kneeling with feet hanging freely off bench/couch Squeezing calf muscle does not cause plantar flexion as it should
351
what investigation is used for Achilles tendon rupture?
Ultrasound
352
what is the surgical management of Achilles rupture?
surgical reattachment of Achilles followed by non-surgical management
353
what is the non-surgical management of Achilles rupture?
boot immobilisation graduating from full plantar flexion poot to neutral position over 6-12 weeks
354
what are 3 intrinsic risk factors for ACL injury?
Female - due to anatomical, hormonal and neuromuscular differences - wider intercondylar notch Younger Genetics Biomechanical markers
355
what are 3 extrinsic risk factors for ACL injury?
Sporting activity Environmental conditions Ergonomics
356
where doe s the ACL attach?
At the anterior intercondylar area on tibia
357
where does the PCL attach?
posterior intercondylar area on tibia
358
what kind of injury usually causes a ACL injury?
twisting injury
359
what 2 tests can be done for ACL injury?
Anterior draw test Lachman test
360
what is the anterior draw test?
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
what is the gold standard investigation for dx of cruciate ligament tear?
Arthroscopy
362
what is the usual 1st line instigation for cruciate ligament injury?
MRI knee
363
What is the conservative management of cruciate ligament injury?
RICE - rest, ice, compress, elevate NSAIDs Crutches and knee brace physio
364
what is the surgical management of cruciate ligament injury?
arthroscopic surgery New ligament is formed from graft using hamstring, quadriceps or bone patellar tendon
365
what are 5 features of meniscal tear?
pain worse on straightening knee knee may give way displaced meniscal tear may cause locking tenderness along joint line Thessaly's test
366
what is Thessaly's test?
for meniscal tear weight bearing at 20 degrees of knee flexion supported by doctor positive if pain on twisting knee
367
what is plantar fasciitis?
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
How can ligamentous injury be categorised?
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
what is osgood-schlatter disease?
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
what are 3 presentations of osgood-schlatter?
visible or palpable hard tender lump at tibial tuberosity pain in anterior knee pain exacerbated by activity, kneeling or extension of knee
371
what is a complication of osgood-schlatters?
avulsion fracture - tibial tuberosity separated from tibia
372
what is the management of osgood-schlaters?
reduction in physical activity ice NSAIDs
373
what bacterium causes Lyme disease?
Borrelia burgdoferi
374
what kind of ticks transmit Lyme disease?
Ixodes
375
what kind of bacteria is borrelia burgdoferi?
spirochete
376
what are the early (<30 days) features of Lyme disease? 5
Erythema migrans - bulls-eye rash 1-4 weeks after bite, painless and >5cm usually Headache lethargy fever arthralgia
377
what are 5 late (>30 days) features of Lyme disease?
Cardiovascular - heart block - Peri/myocarditis Neuro - facial nerve palsy - radicular pain - meningitis
378
how is Lyme disease diagnosed?
clinically with erythema migrans Enzyme linked immunosorbent assay antibodies to borrelia burgdorferi immunoblot test
379
what is the management of Lyme disease?
1 - Doxycycline - 200mg OD 21 days - 400mg if neurology Pregnancy - Amoxicillin - 1g TDS 21 days Dissenimated disease - Ceftriaxone
380
what is a complication of treatment of Lyme disease?
Jarisch-herxheimer reaction - fever, rash, tachycardia after 1st dose more common in syphilis
381
what are 5 complications of Lyme disease?
neuro - meningitis, encephalomyelitis, encephalopathy heart block Oligoarticular arthritis/errosive arthritis keratitis
382
what criteria can be used for diagnosis of septic arthritis in children?
Kocher criteria
383
what is the kocher criteria?
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
what are the ottawa knee rules?
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
what is the first line investigation for meniscal tear?
MRI knee
386
what is a baker's cyst?
fluid filled sack in popliteal fossa due to leak out of knee joint
387
what are 4 conditions that can be associated with baker's cyts?
meniscal tears osteoarthritis knee injury inflammatory arthritis
388
what is the management of symptomatic bakers cysts?
modified activity analgesia physio US aspiration steroid injection Surgery
389
what is an acetabular labral tear?
a tear of the cartilaginous ring surrounding acetabulum usually due to trauma or chronic wear
390
what are 3 features of acetabular labral tear tear?
Pain - in hip/groin usually worsening Clicking, locking, giving way of hip May also cause reduced range of movement
391
what is the management of acetabular labral tear?
limited efficacy of conservative management Surgery after 4 weeks - hip arthroscopy with either debridement or repair
392
what is frozen shoulder?
adhesive capsulitis Pain and stiffness in shoulder (glenohumeral) joint due to inflammation and fibrosis of joint capsule
393
what is the typical course of frozen shoulder?
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
what movement is most affected by froze shoulder?
external rotation
395
what test can be used to assess for supraspinatus tendinopathy?
empty can test - positive if arm gives way on resistance
396
what test can be used to assess acromioclavicular joint arthritis?
scarf test - pain caused by wrapping arm around chest and opposite shoulder
397
what is the management of frozen shoulder?
Continued use of arm Analgesia - NSAIDs Physio Intra-articular corticosteroids Hydrodilation Surgery if resistant/severe - manipulation under anaesthesia - arthroscopy
398
what are 3 risk factors for frozen shoulder?
diabetes thyroid dysfunction hyperlipidaemia
399
what are the muscles of the rotator cuff?
SITS Supraspinatus Infraspinatus Teres Minor SUbscapularis
400
what is the function of the supraspinatus?
Abducts arm before deltoid Rotator cuff - most commonly injured
401
what is the function of the infraspinatus?
Externally rotates arm
402
what is the function of teres minor?
externally rotates arm
403
what is the function of subscapularis?
internally rotates arm
404
what is the presentation of a rotator cuff tear?
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
what is Gerber's lift off test?
evaluates subscapularis - internal rotation Patient attempts to lift hand from small of back against resistance
406
what test will elicit pain/weakness in the infraspinatus or teres minor tear?
Resisted external rotation
407
what is the painful arc test used to diagnose?
Subacromial impingement
408
what are 2 examinations that can be done to test for subacromial impingement?
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
when should patients with shoulder pain be imaged in GP?
Acute trauma presentation symptoms > 4 weeks Restriction of movement severe pain
410
what imaging can be done of a shoulder in primary care?
Plain film X-ray - True AP and lateral or scapular Y views
411
When can patients with shoulder pain be referred to secondary care?
Pain >6 weeks of conservative management Sudden inability to abduct arm - 2ww - suggestive of acute cuff tear
412
what is the imaging modality for shoulders in secondary care?
MRI Can also do US
413
What are 3 possible findings on MRI in shoulder injury?
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
what is the management of rotator cuff tear?
Mainly conservative in elderly/degenerative tears - Rest, analgesia, physio Surgery - arthroscopic rotator cuff repair
415
what is sublaxation?
partial dislocation
416
do shoulders more commonly dislocate anterior or posterior?
anterior
417
what are 3 risk factors for posterior dislocation of the shoulder?
3 Es electric shock epilepsy Ethanol - typically after a fall
418
what are 5 structures that can be damaged in shoulder dislocation?
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
what are bankart lesions?
tear to anterior portion of labrum in shoulder dislocation - occur with recurrent subluxation or dislocation
420
what does anterior arm dislocation present like?
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
what does posterior dislocation present like?
Arm adducted and internally rotated Posterior shoulder more prominent and anterior shoulder flattened Inability to externally rotate
422
what is the 1st line investigation for shoulder dislocation
X-ray: AP Lateral/scapular Y view Axillary view MRI used to assed other damage
423
what is the management of shoulder dislocation?
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
what are 3 complications of shoulder dislocation?
Shoulder instability Axillary nerve damage bankart/hills-sachs lesions
425
what are 2 clinical features of axillary nerve damage?
Loss of sensation of lateral shoulder - regimental badge area Weakness of deltoid - weak arm abduction
426
what nerve roots form the axillary nerve?
C5/6
427
what is epicondylitis?
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
what 5 muscles insert onto medial epicondyle and what do they do?
Pronator teres Flexor carpi radialis Palmaris longus Flexor digitorum superficialis Flexor carpi ulnaris Flex the wrist
429
what do the muscles that inset onto the lateral epicondyle do?
extend wrist
430
what is the other name for lateral epidondylitis?
tennis elbow
431
what is the presentation of tennis elbow?
Pain over lateral epicondyle, radiating down forearm can lead to weakness of grip strength
432
what are 2 tests for tennis elbow?
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
what is the other name for medial epicondylitis?
golfers elbow
434
what is the management of epicondylitis?
Rest and lifestyle adaption Analgesia - NSAIDS physio orthotics steroid injection rarely surgery
435
what is a t-score for osteoporosis?
<-2.5
436
what is the t-score for osteopenia?
-1 to -2.5
437
what is the z-score?
the number of standard deviations the patient is away from the average for their age, sex and ethnicity
438
what are 5 medications that increase risk osteoporosis?
Corticosteroids (long term 7.5mg+ for 3 months+) SSRIs PPIs antiepileptics anti-oestrogens
439
what are 3 chronic diseases that increase risk of osteoporosis?
ckd hyperthyroidism rheumatoid arthritis
440
what are 7 risk factors for osteoporosis?
older age post menopausal reduced mobility and activity lower bmi <19 low calcium or vitamin d alcohol and smoking FHx or personal history
441
what are 5 groups who should be assessed for osteoporosis?
Long term corticosteroids Prev fragility fractures >50 with risk factors Women >65 Men >75
442
what are 7 lifestyle changes that can help in the management of osteoporosis?
increased exercise maintain healthy weight good ca intake good Vit D intake avoiding falls stopping smoking
443
what is the management of osteoporosis?
Address reversible risk factors Add calcium (1000mg) and vitamin D (400-800IU) 1 - Bisphosphonates (alendronate, risendronate, zoledronic acid)
444
what are 4 side effeccts of bisphosphonates?
reflux and oesophageal erosions atypical fractures osteonecrosis of the jaw osteonecrosis of external auditory canal
445
how should bisphosphonates be taken?
on an empty stomach with full glass of water sit upright for 30 mins 30 mins before moving or eating
446
what are 4 medications for osteoporosis started by a specialist?
denosumab - MAB targeting osteoclasts Romosuzumab Teriparatide - acts as parathyroid hormone HRT Raloxifene - selective oestrogen receptor modulator strontium ranelate
447
what are 2 side effects of strontium ranelate?
increased VTE risk increased MI risk
448
what 2 scores can be used to identify 10 year risk of osteoporotic fracture?
FRAX score QFracture tool
449
How do bisphosphonates work?
reduce osteoclastic activity
450
what are 3 examples of bisphosphonates?
Alendronate (70mg once week) risedronate (35mg once a week) Zoledronic acid (5mg once yearly IV)
451
what are 4 side effects of bisphosphonates?
reflux and oesophageal erosions atypical fractures osteonecrosis of the jaw osteonecrosis of external auditory canal
452
what follow up is necessary in osteoporosis?
follow up DEXA in 3-5 years
453
what is T score?
the number of standard deviations the patient is away from an average healthy young adult
454
what are 9 risk factors for secondary osteoporosis?
Hyperthyroidism hyperparathyroidism Hyperandrogenism in males CKD Immobility Vitamin d deficiency malabsorption cushings chronic liver failure
455
what does DEXA stand for?
Dual-energy X-ray absorptiometry
456
what are 4 causes of avascular necrosis of the hip?
long term steroid use chemotherapy alcohol excess trauma
457
what is the imaging modality of choice for avascular necrosis of the hip?
MRI
458
what system is used to classify spinal fractures?
AO-Magerl system A - compression B - Distraction C - Rotation
459
what are 5 risk factors for spinal fractures?
osteoporosis increased Age Female - post-menopausal Trauma Cancer
460
when is MRI indicated in spinal fractures?
with neurological symptoms
461
what are 5 complications of spinal fractures?
Neurological deficits Pulmonary complications - due to reduced mobility Chronic pain Kyphosis VTE
462
what are ganglion cysts?
sac of synovial fluid originating from tendon sheaths or joints common on dorsal wrists and fingers but can form anywhere
463
what is the presentation of ganglion cysts?
visible and palpable non-painful lump Usually 0.5-5 cm firm well circumscribed transilluminates
464
what is the management of ganglion cysts?
usually conservative Needle aspiration surgical excision have high recurrence rate with aspiration
465
what nerve is compressed in carpal tunnel syndrome?
median nerve
466
what sensation is the branch of the median nerve which passes through the carpal tunnel responsible for?
sensory innervation of palmar aspect of thumb, index and middle fingers and lateral half of ring finger
467
what motor function in the hand is the median nerve responsible for?
Abductor pollicis brevis - thumb abduction Opponens pollicis - thumb opposition Flexor pollicis brevis - thumb flexion Thumb abduction, opposition and flexion
468
what are 7 risk factors for carpal tunnel syndrome?
repetitive strain obesity perimenopause rheumatoid arthritis diabetes acromegaly (bilateral) hypothyroidism
469
what is the presentation of carpal tunnel syndrome?
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
what are 2 tests o/e for carpal tunnel syndrome?
Tinel's test Phalen's test
471
what questionnaire can be used to diagnose carpal tunnel syndrome?
Kamath and Stothard carpal tunnel questionnaire
472
what is the 1st line investigation for carpal tunnel syndrome?
nerve conduction studies
473
what is the management of carpal tunnel syndrome?
1 - 6 weeks conservative management rest and altered activities Wrist splints Steroid injections surgery - flexor retinaculum division
474
what is systemic sclerosis?
autoimmune connective tissue disease due to inflammation and fibrosis of connective tissures, skin and internal organs
475
what are the 2 main patterns of disease in systemic sclerosis?
limited systemic sclerosis diffuse cutaneous systemic sclerosis
476
what are 5 features of cutaneous systemic sclerosis?
CREST (used to be called crest syndrome) Calcinosis Raynaud's phenomenon Esophageal dysmotility Sclerodactyly Telangiectasia
477
how are internal organs affected in diffuse systemic sclerosis?
cardiovascular problems - HTN, coronary artery disease Lungs - Pulmonary HTN, fibrosis Renal - scleroderma renal crisis
478
what is scleroderma?
hardening of skin giving appearance of shiny tight skin without normal skin folds
479
what is sclerodactyly?
skin tightening around joints restricting ROM, fat pads on fingers are lost and skin can break and ulcerate
480
what are telangiectasia?
dilated blood vessels in skin >1mm
481
what is calcinosis?
calcium deposits under skin - most common in fingertips
482
what is oesophageal dysmotility?
atrophy and dysfunction of smooth muscle and fibrosis of oesophagus - causing swallowing difficulties, chest pain, acid reflux and oesophagitis
483
what is the most common secondary cause of raynaud's phenomenon?
systemic sclerosis can also be seen in SLE
484
what can be used to differentiate between raynaud's disease and raynauds phenomenon caused by systemic sclerosis?
Nailfold capillaroscopy - magnify and examine peripheral capillaries at based of fingernail - abnormal capillaries suggest systemic sclerosis
485
what is the management of raynaud's disease?
Keep hands warm Calcium channel blockers - nifedipine other specialist drugs - losartan, ACEi, Sildenafil, fluoxetine
486
what are 3 autoantibodies associated with systemic sclerosis?
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
what is the management of systemic sclerosis?
DMARDs - methotrexate Biologics - rituximab Avoid smoking gentle skin stretching for ROM regular emollients Avoid cold triggers Physio OT
488
What is takayasu's arteritis?
Large vessel vasculitis characterised by granulomatous inflammation of aorta and it's branches
489
who is takayasu's arteritis common in?
young females and Asian people
490
what are 6 presentations of takayasu's arteritis?
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
what investigations are used in takayasu's arteritis?
BP upper and lower limbs Vascular imaging of arterial tree - CTA or MRA
492
what is the management of takayasu's arteritis?
1 - Steroids Low dose aspirin 2 - immunosuppressives
493
what is Polyarteritis nodosa?
Vasculitis of medium sized vessels causing necrotising inflammation leading to thrombosis, aneurysm formation and organ ischaemia most commonly renal
494
who is Polyarteritis nodosa common in?
Middle aged men Can be idiopathic of often associated with Hep B infection
495
what are 5 risk factors for Polyarteritis nodosa?
Middle age Male Hep B or C Immunosuppression Genetic predisposition - associated with familial Mediterranean fever
496
what is the presentation of Polyarteritis nodosa?
Systemic symptoms - wt loss, fatigue, myalgia, fever Numbness and paraesthesia, peripheral neuropathy Renal failure Vasculitic purpuric rash - livedo reticularis Digital infarcts HTN
497
what is the gold standard investigation for Polyarteritis nodosa?
Biopsy - transmural inflammation with fibrinoid necrosis
498
what is the management of Polyarteritis nodosa?
1 - High dose prednisolone Antiviral therapy ACEi 2 - Cyclophosphamide immunosuppression For maintenance - azithioprine or methotrexate, corticosteroids
499
what are 5 complications of Polyarteritis nodosa?
organ damage haemorrhage Infections chronic pain hypertension
500
what are 3 ANCA associated vasculitises?
Granulomatosis with polyangiitis (wergner's granulomatosis) Eosinophilic granulomatosis with polyangiitis (churg-straus syndrome) Microscopic polyangiitis
501
what is Granulomatosis with polyangiitis?
Prev - Wegener's granulomatosis Small vessel necrotising vasculitis affecting respiratory tract and kidneys
502
what is the presentation of Granulomatosis with polyangiitis?
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
what autoantibody is present in Granulomatosis with polyangiitis?
cANCA
504
what is the management of Granulomatosis with polyangiitis?
1 - high dose prednisolone OR Cyclophosphamide Maintenance - Azathioprine, methotrexate
505
what criteria can be used for diagnosis of Granulomatosis with polyangiitis?
ELK (ENT, Lung and kidney presentations) AND positive cANCA
506
what are 6 complications of Granulomatosis with polyangiitis?
AKI CKD Lung damage Scleritis Mononeuritis multiplex side effects of long term steroids
507
what is eosinophilic granulomatosis with polyangiitis?
Prev. Churg-Strauss syndrome Small-medium vessel vasculitis
508
what is the presentation of eosinophilic granulomatosis with polyangiitis?
Worsening asthma Sinusitis pain Parasthesia or numbness, signs of peripheral neuropathy Weight loss vasculitis rash
509
what are 4 investigations for eosinophilic granulomatosis with polyangiitis?
FBC - for eosinophilia CXR Autoantibodies Biopsy
510
what autoantibodies are present in eosinophilic granulomatosis with polyangiitis?
pANCA
511
what is the American college of rheumatology criteria for eosinophilic granulomatosis with polyangiitis?
at least 4/6 of Asthma eosinophilia >10% Mononeuropathy or polyneuropathy Non-fixed pulmonary infiltrates paranasal sinus abnormalities positive biopsy
512
what is the management of eosinophilic granulomatosis with polyangiitis?
1 - corticosteroids 2 - immunosuppression
513
what are 4 complications of eosinophilic granulomatosis with polyangiitis?
Long lasting peripheral neuropathy Severe asthma heart disease side effects of long term steroids
514
what is one medication that can precipitate eosinophilic granulomatosis with polyangiitis?
leukotriene receptor antagonists - montelukast
515
what is Microscopic polyangiitis?
small vessel necrotising vasculitis typically affecting lungs and kidneys NON-granulomatous
516
what autoantibody is in Microscopic polyangiitis?
pANCA - 50-75% cANCA - 40%
517
what is seen on renal biopsy in Microscopic polyangiitis?
crescentic glomerulonephritis and small vessel vasculitis
518
what is the presentation of Microscopic polyangiitis?
renal impairment - raised creatinine, haematuria, proteinuria fever, lethargy, malaise, wt loss Rash Cough, SOB, haemoptysis
519
what are 4 non-vasculitis conditions that are associated with positive pANCA?
UC Primary sclerosing cholangitis anti-GBM disease Crohn's
520
what are myositoses?
autoimmune disorders causing muscle inflammation - polymyositis or dermatomyositis Can be due to underlying cancers - paraneoplastic
521
what is the presentation of Polymyositis ?
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
what autoantibody is associated with Polymyositis ?
Anti-Jo-1 antibodies AKA - histidine-tRNA ligase
523
what muscle enzyme is significantly raised in Polymyositis and dermatomyositis?
Creatinine Kinase
524
what is the management of polymyositis?
1 - High dose prednisolone 2 - immunosuppression - azathioprine, methotrexate
525
what are 4 skin presentations of Dermatomyositis?
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
what are 4 risk factors for Dermatomyositis?
female 40-50 years Afro-Caribbean Childhood
527
what are 2 autoantibodies loosely related to Dermatomyositis?
Anti-Jo - 30% Anti-M2
528
what are 5 cancers related to myositis?
Ovarian Lung pancreas stomach Colon
529
what is the management of Dermatomyositis?
1 - Prednisolone exercise and physio Sun protection 2 - immunosuppression, IVIG, biologics
530
what is discitis?
inflammation in intervertebral disc space - can lead to sepsis or epidural abscess
531
what are 3 features of discitis?
back pain general - pyrexia, rigors, sepsis Neuro features dependant on level
532
what is the most common cause of discitis?
S. aureus
533
what are 2 investigations for discitis?
MRI CT guided biopsy for sensitivities
534
what is the management of discitis?
6-8 weeks IV Abx - flucloxacillin, vancomycin Assess for endocarditis - Transthoracic echo
535
what are 5 risk factors for discitis?
Age - children more common due to better blood supply Male Recent invasive spinal procedure Immunosuppression Diabetes IVDU
536
what are 7 causes of pathological fracture?
Osteoporosis CKS-metabolic bone disease Hyperparathyroidism Metastatic cancer Infection Primary bone tumours bone biopsies
537
what system can be used to assess risk of pathological fracture?
Mirels' scoring system score >9 = may need prophylactic fixation
538
what scan can be used for looking for bone metastasis?
bon scintigraphy
539
what is the mangement of pathological fractures?
orthopaedic stabilisation radiotherapy or chemotherapy - malignancy tx osteoporosis
540
how long can it take for DMARDs to work?
2-3 months
541
what are 5 notable side effect of leflunomide?
raised BP rashes peripheral neuropathy teratogenic bone marrow suppresion
542
how does leflunomide work?
interferes production of pyrimidine used to make RNA and DNA
543
how does hydroxychloroquine work as an immunosuppressant?
interferes with toll-like receptors disrupting antigen presentation
544
what are 4 notable side effects of hydroxychloroquine?
nightmares macular toxicity liver toxicity skin pigmentation
545
what is a notable side effect of sulfasalazine?
male infertility - reduction in sperm count
546
what is a notable side effect of anti-TNF?
reactivation of TB and hepatitis B
547
what are 2 notable side effects of rituximab?
night sweats thrombocytopenia
548
what is Behcet's syndrome?
Complex multisystem autoimmune inflammatory disorder of recurrent oral ulcer, genital ulcers and anterior uveitis
549
what gene is there a link with in behcet's disease?
HLA-B51 more common in eastern mediterranean people
550
what are 8 features of behcet's disease?
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
what test can be used to assess for Behcet's disease?
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
what is the management of Behcet's disease?
Colchicine - for acute inflammation Topical/systemic steroids - for acute outbreaks Immunosuppression - azithioprine, methotrexate, cyclosporine biologics - infliximab, adalimumab - in refractory cases
553
what are 5 complications of Behcet's disease?
Occular - uveitus, retinal vasculitises Vascular - VTE, vasculitis Neuro - aseptic meningitis GI ulcers, perforation Relapse - relapsing remitting course
554
what are 7 causes of mechanical back pain?
muscle or ligament sprain facet joint dysfunction sacroiliac joint dusfunction herniated disc spondylolisthesis - anterior displacement of vertebra scoliosis degenerative changes
555
what are 4 causes of neck pain?
muscle or ligamant strain torticollis - muscle spasms causing stiff and painful neck whiplash cervical spondylosis
556
what are 5 red flag causes of back pain?
spinal fracture cauda equina spinal stenosis ankylosing spondylitis spinal infection
557
what nerves form the sciatic nerve?
L4-S3
558
how many of each vertebrae are there?
7 cervical 12 thoracic 5 Lumbar 5 sacral (fused) 4 coccyx (fused)
559
what is the pathway of the sciatic nerve?
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
what are 3 causes of sciatica?
herniated disc spondylolisthesis spinal stenosis
561
what test can be used to assess sciatica?
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
what tool can be used to assess risk of chronic back pain from an acute presentation?
STarT back screening tool
563
what is low, medium and high risk in the STarT back screening tool?
Low - total score <3, subscore <3 Medium - total score >3, subscore <3 high - total score >3, subscore >3
564
what is the management of patients at low risk of chronic back pain presenting with pain?
self management education reassurance analgesia staying active and mobilising as tolerated
565
what is the management for patients at medium to high risk of developing chronic back pain presenting with pain?
As with low risk PLUS physiotherapy group exercise CBT
566
what are 3 options for analgesia in back pain?
1 - NSAIDs - Naproxan, ibuprofen codeine benzodiazepine - for muscle spasms - up to 5 days
567
what anaesthetic technique can be used for lower back pain due to facet joint dysfunction?
radiofrequency denervation
568
what is the management of sciatica?
Amitriptyline Duloxitine
569
what are 4 specialist options for chronic sciatica?
epidural corticosteroid injections local anaesthetic injections radiofrequency denervation spinal decompression
570
what are 5 red flags for lower back pain?
age <20 or >50 Hx of malignancy night pain Hx of trauma Systemically unwell cauda equina symptoms
571
what are the features of L3 nerve root compression?
sensory loss over anteior thigh weak hip flexion, knee extension, hip adduction reduced knee reflex positive femoral stretch test
572
what are the features of L4 nerve root compression?
sensory loss to anterior aspect on knee and medial malleolus weak knee extension and hip adduction reduced knee reflex positive femoral stretch test
573
what is the presentation of L5 nerve root compression?
sensory loss over dorsum of foot weakness in foot and big toes dorsiflexion reflexes intact positive sciatic nerve stretch test
574
what is the presentation of S1 nerve root compression?
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
what is the femoral stretch test?
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
what is classed as acute backpain?
<6 weeks
577
what is classed as chronic back pain?
>12 weeks
578
what are 8 risk factors for back pain?
prev episode obesity physically demanding occupation physical inactivity psychological distress other chronic health conditions lower socio-economic status smoking
579
what is the most common level for a prolapsed disc?
L5/S1

Phase 4 (22 decks)

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