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MSK Flashcards

1
Q

What are the clinical findings of ankylosing spondylitis?

A

reduced chest expansion, reduced lateral flexion and reduced forward flexion (Schober’s test)

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2
Q

Sulfasalazine can cause what?

A

Reduced sperm count -> usually returns to normal upon stopping the medication

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3
Q

What would joint aspiration of rheumatoid arthritis show?

A
  • High WBC
  • Polymorph neutrophils
  • Cloudy/Yellow appearance
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4
Q

What is previous chemo a big risk factor for?

A

Avascular necrosis

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5
Q

Methotrexate plus trimethoprim can cause what?

A

Bone marrow suppression and panycytopenia

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6
Q

DIP swelling and dactylitis with arthritis suggests what?

A

Psoriatic arthritis

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7
Q

Which antibody is specific for anti-phospholipid syndrome?

A

Anticardiolipin antibody

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8
Q

What are the smoking cessation drugs?

A
  1. Nicotine replacement (causes N+V, headaches, flu symptoms)
  2. Varenicline (causes nausea and C/I in pregnancy/BF)
  3. Bupropion (reduces seizure threshold)
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9
Q

What type of shock does tension pneumothorax cause?

A

Obstructive

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10
Q

Which lung cancer is gynaecomastia associated with?

A

Adenocarcinoma of the lung

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11
Q

What does an isolated rise in ALP suggest?

A

Pagets disease of the bones

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12
Q

What is Paget’s disease of the bone?

A

Increased but uncontrolled bone turnover- XS osteoclast resorption and increased osteoblastic activity

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13
Q

What is most commonly affected in Paget’s

A

Skull, spine/pelvis, long bones of lower extremities

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14
Q

Paget’s predisposing factors?

A

Age, male, northern latitude, FHx

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15
Q

Paget’s CP

A
  • 5% symptomatic
  • older male with bone pain and raised ALP
  • bone pain: pelvis, lumbar, femur
  • bowing of tibia, bossing of skull
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16
Q

Paget’s Ix

A
  • bloods
  • other markers of bone turnover
  • x-ray= osteolysis in early disease; mixed lytic/sclerotic lesions later. Skull= thickened vault, osteoporosis circumscripta
  • Bone scintigraphy (increased uptake at sites of active bone lesions)
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17
Q

Bloods in Paget’s?

A
  • Raised ALP
  • Ca and phosphate normal (sometimes hypercalcaemia with prolonged immobilisation)
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18
Q

Other markers of bone turnover in Paget’s?

A
  • procollagen type I N-terminal propeptide (PINP)
  • serum C-telopeptide (CTx)
  • urinary N-telopeptide (NTx)
  • urinary hydroxyproline
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19
Q

Paget’s Mx?

A
  • Bisphosphonate (oral risedronate or IV zoledronate)
  • calcitonin less common
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20
Q

Paget’s indications for Mx

A

Bone pain, skull or long bone deformity, fracture, periarticular Paget’s

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21
Q

Paget’s Cx

A

Deafness, bone sarcoma, fractures, skull thickening, high-output cardiac failure

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22
Q

subchondral erosions, sclerosis
and squaring of lumbar vertebrae

A

Anklyosing spondylitis

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23
Q

What is the most common site of metatarsal stress fractures?

A

2nd metatarsal

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24
Q

hyperpigmentation of the palmar creases indicates what?

A

Addisons

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25
Q

How should proximal scaphoid pole fracture be managed?

A

Refer to orthopaedics for surgical fixation

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26
Q

Features of a acetabular labral tear?

A
  • Following trauma
  • Hip/groin pain
  • Snapping sensation
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27
Q

Features of a femoroacetabular impingement?

A
  • More chronic history
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28
Q

Long term steroid use/chemo therapy + someone with hip pain suggests?

A

Avascular necrosis of the hip

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29
Q

Pain following tibial surgery?

A

Compartment syndrome

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30
Q

What is the management of AVN?

A

If displaced: total hip replacement for anyone who is mobile, no co-morbidities etc otherwise hemiarthroplasty
If not displaced: internal fixation

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31
Q

Rheumatic vs psoriatic arthritis?

A

Psoriatic will be asymmetrical

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32
Q

When should uric acid levels be measured again with gout?

A

2 weeks after the flare has settled

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33
Q

X-ray findings for rheumatoid arthritis

A

L – loss of joint space
E – erosions
S – soft tissue swelling
S – soft bones (periarticular osteopenia)

+ juxta-articular osteoporosis
subluxation

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34
Q

Extra-articular manifestations of RA?

A

Nodules, scleritis, episcleritis, pleural effusion, Felty, anaemia, Raynaud’s, carpal tunnel

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35
Q

RA, Splenomegaly and neutropenia?

A

Felty

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36
Q

Antibody of choice for RA

A

Anti-ccp

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37
Q

Hand signs for RA

A
  • Ulnar deviation
  • Swan neck deformity
  • Z neck thumb
  • Muscle wasting
  • Wrist subluxation
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38
Q

What organism can cause septic arthritis with metal joint?

A

Early stages after surgery - staph aureus
Later onset - staph epidermidis

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39
Q

What are risk factors for septic arthritis?

A

RA, DM, Immunosuppression, Penetrating injury, infection elsewhere

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40
Q

What are the rotator cuff muscles?

A

Supraspinatus
Infraspinatus
Teres minor
Subscapularis

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41
Q

What muscles are responsible for shoulder abduction?

A

0-15 degrees: supraspinatus
15 - 90 degrees: deltoid
90 degrees+: Trapezius and serratus anterior

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42
Q

Which muscles does the accessory nerve innervate?

A

Deltoid and teres minor

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43
Q

Investigations to assess for supraspinatus impingement?

A

US and MRI

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44
Q

Proximal muscle weakness + raised CK + no rash

A

Polymyositis

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45
Q

Dermatomyositis vs polymyositis

A

Dermatomyositis would have a rash

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46
Q

What would be seen on X-ray to support a diagnosis of ankylosing spondylitis?

A

Sacro-ilitis

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47
Q

What should be given to women >75 with a fragility fracture?

A

Bisphosphonates

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48
Q

When should a referral for sciatica be considered?

A

4-6 weeks after analgesia + physio treatment

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49
Q

What are the features of ankylosing spondylitis?

A

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
and cauda equina syndrome

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50
Q

Pain worse on walking on tip toes?

A

Plantar fasciitis

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51
Q

Fever + back pain + IVDU

A

Iliopsoas abscess

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52
Q

What is the treatment for psoas abscess?

A

Abx + percutaneous drainage

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53
Q

muscle wasting of the hands, numbness and tingling and possibly autonomic symptoms

A

Neurogenic thoracic outlet syndrome

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54
Q

What is osteomalacia?

A

Softening of the bones secondary to vit D deficiency

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55
Q

How does osteomalacia present?

A
  • Bone pain/tenderness
  • Fractures e.g NOF
  • Proximal myopathy: waddling gait
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56
Q

How would osteomalavcia present on investigations?

A
  • Low Vit D
  • Low calcium and phosphate
  • Raised ALP
  • Translucent bands over the X-ray
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57
Q

Management of NOF fractures

A

Non-displaced + intracapsular: cannulated screw fixation
Stable + extra capsular: dynamic hip screw
Displaced + Intacapsular if not very mobile older patient: Hemiarthroplaty
Displaced + intracapsular if young/mobile older patient: Total hip arthroplasty

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58
Q

flexion deformities of his 4th and 5th digit which cannot be passively corrected

A

Duputrynes contracture

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59
Q

What is often the earliest sign of Dupuytrens?

A

Firm, thickened palmar nodule over the metacarpal head

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60
Q

What are risk factors for Dupuytrens?

A
  • Diabetes
  • Alcohol
  • FH
  • AIDS
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61
Q

Limited vs diffuse cutaneous systemic sclerosis

A

Diffuse will have widespread skin and organ involvement (lungs and kidneys)

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62
Q

What is fat embolism?

A

A syndrome secondary to trauma/fractures/orthopaedic surgery

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63
Q

How does fat embolism present?

A

Pulmonary: PE like symptoms
Neuro: altered mental status, seizures, coma
Derm: petechial rash on upper body
Managed with supportive treatment/prophylaxis

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64
Q

What are common precipitants of gout?

A
  • Surgery
  • Dehydration
  • Alcohol
  • Trauma
  • Infection
  • Foods rich in purines
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65
Q

What are x-ray findings of gout?

A
  • Normal joint space
  • Soft tissue swelling
  • Periarticular erosions
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66
Q

What can be some examination findings of osteoarthritis?

A
  • Antalgic gait
  • Joint swelling
  • Joint tenderness
  • Pain on movement
  • Crepitus
  • Reduced ROM
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67
Q

purple discolouration of eyelids in dermatomyositis?

A

Heliotrope

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68
Q

What are Gottron’s papules?

A

Rough, red papules over the knuckles -> dermatomyositis

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69
Q

What antibodies are associated with dermatomyositis?

A

Anti-Jo, Anti-MI, RF, ANA

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70
Q

What is Raynauds phenomenon?

A

Peripheral digital ischaemic caused by vasospasm which is precipitated by cold/emotion

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71
Q

What are some causes of Raynauds phenomenon?

A
  • SLE
  • Raynaud’s disease
  • RA
  • Ehler-Danlos
  • Beta blockers
  • Atherosclerosis
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72
Q

What are the features of CREST?

A

Calcinosis
Raynaud’s
Oesophageal dysmotility
Sclerodactyly
Telangiectasia

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73
Q

What respiratory condition is associated with AS?

A

Pulmonary fibrosis

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74
Q

What is mononeuritis multiplex?

A

Damage to 2+ peripheral nerves

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75
Q

What are causes of mononeuritis multiplex?

A
  • HIV/AIDS
  • Diabetes
  • RA
  • Sarcoidosis
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76
Q

What is the definitive investigation for Sjogrens?

A

Salivary gland biopsy

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77
Q

What is the most common cause of cauda equina syndrome?

A

Lumbar disc herniation at L4/L5/ or L5/S1

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78
Q

Pseudogout is strongly associated with what?

A

Haemochromatosis

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79
Q

What are the most specific markers for SLE?

A

anti-dsDNA and anti-SM
ANA - most sensitive

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80
Q

Erb’s palsy has injury to which myotomes?

A

C5 and C6 (11 erbs and spices)

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81
Q

How does Erb’s palsy present?

A

Imparied wrist extension and elbow flexion - waiters tip

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82
Q

Carbamazepine increases risk of what?

A

Osteoporosis

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83
Q

Back pain red flags?

A
  • Thoracic or cervical spine pain
  • Progressive pain not relieved by rest
  • Fevers, chills, weight loss
  • Early morning stiffness > 30 mins
  • Bowel/bladder/neuro dysfunction
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84
Q

What should be given for cord compression secondary to bone metastases?

A

Dexamethasone

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85
Q

Osteoporosis risk factors?

A

Steroids
Hyperthyroidism/Hyperparathyroidism
Alcohol/Smoking
Thin
Testosterone deficiency
Early menopause
Renal failure
Erosive bone disease
Diabetes

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86
Q

What is a Colles fracture?

A

Fracture of the distal radium with dorsal angulation of the distal fracture fragments

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87
Q

Septic Arthritis in a prosthetic joint?

A

Admit patient and arrange ortho review

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88
Q

pain and swelling at the base of the thumb and along the radial aspect of the wrist, often worsened by thumb movement or grasping in a YOUNG person

A

De Quervain;s tenosynovitis

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89
Q

What should take place before starting anyone on biologics?

A

Quantiferon test - assess for TB as biologics can reactivate latent TB

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90
Q

Abx regiment for septic arthritis?

A

2 weeks of IV plus 4 weeks of orals

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91
Q

Which antibodies are specific for anti phospholipid

A

Anti-beta-2-glycoprotein I antibody

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92
Q

What is a common early finding in professional players who have had trauma?

A

Osteoarthritis

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93
Q

What cover should be given to those receiving allopurinol?

A

NSAIDs cover for 3 months as allopurinol can acutely raise urate levels

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94
Q

‘rain-drop skull’

A

Myeloma

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95
Q

‘pepper pot skull’

A

Hyperparathyroidism

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96
Q

What are the most common side effects of colchicine?

A

Diarrhoea, nausea + vomiting

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97
Q

What scoring system can be for RA and what does it indicate?

A

Disease-activity score
<2.6 - remission
>5.1 - high disease activity

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98
Q

What is the dose for steroids in GCA?

A

60mg of prednisolone

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99
Q

How would lumbar spondylosis present?

A
  • Arthritis like pain which gets worse throughout the day in older patients
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100
Q

What is recommended in patients with GCA with CVD risk factors/IHD?

A

Aspirin 75mg as prophylaxis

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101
Q

What is the inheritance of Marfans?

A

Autosomal dominant

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102
Q

How should methotrexate be monitored?

A

FBC, Renal function and LFTs weekly until established then every 2-3 months

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103
Q

What can patients with limited systemic sclerosis develop as a late manifestation?

A

Interstitial lung disease

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104
Q

What investigation should be done for women with polymyalgia due to steroid use?

A

DEXA

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105
Q

What are the 4 features of antiphospholipid syndrome?

A

Clots - VTE/PE
Livedo reticularis
Obstetric loss
Thrombocytopenia

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106
Q

c-ANCA positive?

A

Granulomatosis with polyangiitis

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107
Q

What are features of granulomatosis with polyangiitis?

A
  • Resp involvement
  • Kidney involvement: glomerulonephritis
  • Systemic symptoms
  • Ocular manifestations e.g. scleritis
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108
Q

How is granulomatosis with polyangiitis managed?

A
  • Cyclophosphamide/rituximab in acute
  • Azathioprine/Methotrexate during remission
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109
Q

asthma, nasal polyps and a mononeuritis multiplex

A

Eosinophilic granulomatosis with polyangiitis

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110
Q

Recurrent oral and genital ulcers with uveitis and erythema nodosum?

A

Behcet’s disease- HLA B51

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111
Q

Common sites where osteoporotic fragility fractures occur?

A
  • Pubic ramus
  • Hip
  • Distal radium
  • Proximal humerus
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112
Q

What are side effects of bisphosphonates?

A
  • Abdominal pain
  • Dyspepsia
  • Nausea
  • Abdominal distension
  • Oesophageal ulceration
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113
Q

What is the first line imaging in myeloma?

A

MRI

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114
Q

Acute back pain in a patient with osteoporosis?

A

Think osteoporotic verterbral fracture -> X-ray needed

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115
Q

What is the Z score adjusted for in patients with DEXA scans?

A

Age, gender and ethnic factors

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116
Q

What antibodies are found in CREST syndrome?

A

Anti-centromere

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117
Q

What is Behcet’s syndrome?

A
  • Common in young Turkish men
  • Oral ulcers, genital ulcers and anterior uveitis
  • Erythema nodosum also present
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118
Q

Which DMARD is associated with retinopathy?

A

Hydroxychloroquine

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119
Q

What is Caplan syndrome?

A

Massive fibrosis in patients with RA and pneumoconiosis

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120
Q

What is polyarteritis nodosa?

A

Medium vessel vasculitis common in middle aged men with Hep B
Can cause testicular pain, weight loss, HTN, renal failure
PANCA positive

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121
Q

Ejection systolic murmur with SLE?

A

Libman-Sacks endocarditis

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122
Q

What are some skin changes with dermatomyositis?

A
  • Heliotrope rash of eyelids
  • Periorbital oedema
  • Dilated capillary loops under the fingernails
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123
Q

What are some symptoms of dermatomyositis?

A
  • Muscle swelling
  • Muscle tenderness
  • Arthralgia
  • Fatigue
  • Weakness
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124
Q

What are some symptoms of fibromyalgia?

A
  • Pain
  • Sleep disturbance
  • Paraesthesia
  • Memory disturbance
  • Headaches
  • Dizziness
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125
Q

What are some skin changes with Reiters?

A
  • Mouth ulcers
  • Erythema nodosum
  • Keratoderma blennorrhagica (yellow/brown papules on soles of feet)
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126
Q

What are some cardiac complications of Reiters?

A
  • Pericarditis
  • Aortic regurg
  • Aortitis
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127
Q

What is there not in someone with polymyalgia?

A

True weakness of muscles -> normal power

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128
Q

Management of a prolapsed disc?

A

Analgesia + Physio

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129
Q

Painful click on McMurrays test?

A

Think twisted knee injury - meniscal tear

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130
Q

What is a Galeazzi fracture?

A

Dislocation of the distal radioulnar joint with an associated fracture of the radius

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131
Q

tenderness in the anatomic snuffbox dorsally

A

Scaphoid fracture

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132
Q

What should be corrected before giving bisphosphonates?

A

Calcium level / Vit D deficiency

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133
Q

Pain on the radial side of the wrist/tenderness over the radial styloid process in a young women?

A

De Quervain’s tenosynovitis

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134
Q

What does co-trimoxazole contain?

A

Trimethoprim -> think about methotrexate

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135
Q

Most likely places for bone mets?

A

Women - breast
Men - prostate

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136
Q

What are major risk factors for osteoporosis?

A
  • Steroid use
  • RA
  • Alcohol excess
  • Low BMI
  • Smoking
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137
Q

What will the blood test values be with osteoporosis?

A

Everything normal

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138
Q

Imaging of choice for osteomyelitis?

A

MRI

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139
Q

lead pipe appearance of the colon

A

Ulcerative colitis

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140
Q

popping sensation, immediate swelling and immediate unable to weight-bear

A

ACL injury - Lachmans test

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141
Q

Knee locking and giving-way

A

Meniscal lesions

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142
Q

What is the management of newly diagnosed RA?

A

Methotrexate and oral steroids

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143
Q

Z score is helpful for what?

A

Diagnosing secondary osteoporosis

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144
Q

Compartment syndrome produces what?

A

Pain on passive stretch

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145
Q

What is the management of flares of rheumatoid arthritis?

A

Steroids oral or IM

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146
Q

When can reactive arthritis present and how long do symptoms last?

A
  • Can develop upto 4 weeks after initial infection
  • Symptoms last around 4-6 months
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147
Q

dull shoulder pain, that often disturbs sleep, followed by
stiffness and loss of shoulder mobility

A

Frozen shoulder - Adhesive capsulitis

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148
Q

Management of undisplaced scaphoid fractures?

A

Cast for 6-8 weeks

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149
Q

What are some hand signs of psoriatic arthritis?

A
  • Dactylitis
  • Nail pitting
  • Onchylosis
  • Nail discolouration
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150
Q

What are some X-ray findings of psoriatic arthritis?

A
  • Soft tissue swelling
  • Bony erosions
  • Pencil in cup deformity
  • Loss of joint space
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151
Q

What is the most severe form of psoriatic arthritis?

A

Arthritis mutilans

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152
Q

What is the treatment of psoriatic arthritis?

A
  • NSAIDs if mild
  • Methotrexate
  • anti-TNF biologics
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153
Q

Chalky nodules in someone with gout?

A

Gouty tophi

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154
Q

What HLA type is rheumatoid?

A

HLA-DR4 / HLA-DR1

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155
Q

Risk factors for pseudogout?

A
  • Steroid use
  • Hyperparathyroidism
  • Haemochromatosis
  • Wilson’s
  • Acromegaly
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156
Q

What is the prognosis of pseudogout?

A

Resolves within 10 days

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157
Q

What are some complications of eosinophilic granulomatosis with polyangiitis?

A
  • HF
  • Myocarditis
  • HTN
  • Stroke
  • Bowel ischaemia
  • Pancreatitis
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158
Q

Prophylactic bisphosphonates should be offered to who?

A

Those with T score <1.5 if they are on steroids for more than 3 months

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159
Q

What should alendronate be changed to if patients are experiencing bad GI side effects?

A

Risedronate

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160
Q

SGLT-2 inhibitors can increase the risk of what?

A

Ulcers or infection -> increased risk of amputation

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161
Q

Which organism causes osteomyelitis in sickle cell?

A

Salmonella

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162
Q

anti-histone antibodies can be a sign of what?

A

Drug induced lupus - common causes include isoniazid, phenytoin

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163
Q

Lace like rash on shins is a sign of what?

A

Livedo reticularis -> associated with anti-phospholipid syndrome

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164
Q

raised CRP in a patient with known SLE

A

Can suggest underlying infection

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165
Q

What is an early x ray finding of rheumatoid arthritis?

A

Juxta-articular osteopenia

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166
Q

What is a fragility fracture?

A

A fracture from a fall from standing height or less

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167
Q

What are examples of fragility fracture?

A
  • Vertebral compression fractures
  • Hip
  • Distal radium
  • Proximal humerus fracture
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168
Q

Nerve and which fracture they are associated with?

A

Radial - fracture of shaft of humerus (wrist drop)
Ulnar - supracondylar fracture of humerus
Axillary - fracture of proximal humerus

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169
Q

Bilateral carpal tunnel?

A

Rheumatoid

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170
Q

Lateral knee pain in a runner?

A

Iliotibial band syndrome -> treat with stretches

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171
Q

Lateral epicondylitis causes what?

A
  • Pain worse on supination of the wrist
  • Pain worse on wrist extension against resistance
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172
Q

What is the main structure which is damaged in scaphoid fractures?

A

dorsal carpal branch of the radial artery

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173
Q

dislocation of the proximal radioulnar joint in association with an ulnar fracture

A

Monteggia fracture

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174
Q

Most common sites of osteomyelitis in children and adults?

A

Children - Metaphysis
Adults - Epiphysis

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175
Q

What are different management options for carpal tunnel?

A
  • Night splints
  • Intraarticular steroid injections
  • Carpal tunnel decompression
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176
Q

Bruised, swollen, deformed and painful elbow?

A

Think supracondylar fracture

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177
Q

What would Perthes disease x-ray show?

A
  • Widening of joint space
  • Decreased femoral head size
  • Flattening
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178
Q

What are surgical management options for osteoarthritis?

A
  • Osteotomies
  • Arthroplasty
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179
Q

What is duputryens?

A

Thickening of the palmar fascia which eventually causes a fixed flexion deformity

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180
Q

What is the most common type of shoulder dislocation?

A

Anterior dislocation

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181
Q

What is the weight bearing status after NOF surgeries?

A

Cannulated screws - less than full initially
Everything else - full weight bearing

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182
Q

Radiculopathy vs myelopathy

A

Radiculopathy - compression of a single nerve root which has exited the spinal cord
Myelopathy - pain due to compression of the spinal cord

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183
Q

Which nerve roots correspond to reflexes?

A

Ankle - S1/2
Knee - L3/L4
Bicep - C5/C6
Tricep - C7/C8

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184
Q

Simmonds test - calf squeeze

A

Achilles tendon rupture

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185
Q

Which knee compartment is most commonly affected in osteoarthritis?

A

Medial

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186
Q

Open tibial fractures should be covered with what?

A

Sterile saline gauze

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187
Q

Which muscle is responsible for the weakness in thumb abduction in carpal tunnel?

A

Abductor pollicis brevis

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188
Q

Haematogenous vs direct contamination?

A

Haematogenous - infection reaches bone through bloodstream
Direct contamination - infection spreads directly from adjacent tissues/structures to the bone

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189
Q

Bakers cysts occur secondary to what?

A

Degeneration

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190
Q

Imaging for achilles tendon rupture?

A

US

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191
Q

What is the test of choice for Duputryen’s?

A

Table top test

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192
Q

Which arteries are at risk in NOF?

A

Circumflex arteries

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193
Q

Soft, non-tender swelling near joints or tendons, containing clear,
viscous fluid

A

Ganglionic cyst

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194
Q

Sciatic nerve originates from?

A

L4-S3

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195
Q

What is RICE mnemonic for soft tissue injuries?

A

Rest, ice, compression, elevation

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196
Q

Synovial fluid aspiration in someone with reactive arthritis?

A

No organisms will be recovered + cloudy/yellow colour

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197
Q

What is the most common mechanism of ankle sprains?

A

Inversion

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198
Q

Any MSK pain/Osteoarthritis first line treatment?

A

Topical NSAIDs/Oral NSAIDs

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199
Q

What is spondylolisthesis?

A

One vertebra slips out of line with one above it, usually in the lumbar spine

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200
Q

Pain on painful arc with normal X ray?

A

Painful arc syndrome / subacromial bursitis / impingement syndrome

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201
Q

Trigger finger management?

A
  1. Rest and splint
  2. NSAIDs
  3. Steroid injections
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202
Q

What are examination findings of NOF?

A

Affected side shortened
Externally rotated
Abducted

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203
Q

S/E of bisphosphonates

A
  • Oesophageal erosions
  • Osteonecrosis of jaw
  • Atypical fractures
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204
Q

CREST antibodies?

A
  • Anti-centromere
  • Anti-Scl70
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205
Q

What are pulmonary complications of CREST?

A
  • Pulmonary fibrosis
  • Pulmonary HTN
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206
Q

What are causes of sciatica?

A
  • Spinal stenosis
  • Disc herniation
  • Pelvic tumours
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207
Q

Greenstick fractures are unique to who?

A

Children - usually under 10s

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208
Q

3rd line management for acute gout in renal disease?

A

Steroids

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209
Q

What is the investigation of choice for Takayasu’s arteritis?

A

CT angio

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210
Q

What is Caplan syndrome?

A

RA plus pulmonary nodules

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211
Q

What is the diagnostic test for Behcet’s disease?

A

Pathergy test

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212
Q

Diabetics are susceptible to what infections?

A

Staphylococcal

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213
Q

diffuse thickening of the pancreatic body and tail

A

Sausage pancreas sign -> autoimmune pancreatitis

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214
Q

Antiphospholipid causes prolonged what?

A

APTT

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215
Q

What drug makes Raynaud’s worse?

A

Propranolol

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216
Q

RA spares which joint?

A

DIP

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217
Q

Progressive shoulder pain with reduced ROM in middle aged?

A

Frozen shoulder

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218
Q

Management of achilles tendonitis?

A

Rest, NSAIDs and physio if symptoms persistent beyond 7 days

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219
Q

What is Simmonds triad?

A
  • palpation
  • examining the angle of declination at rest
  • squeeze test
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220
Q

Investigation for suspected hip fracture if X-ray is normal?

A

MRI

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221
Q

What can be done for NOF fractures?

A

Iliofascial nerve block

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222
Q

What is the most common reason for revising a total hip replacement?

A

Asceptic loosening of the implant

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223
Q

Joint aspirate with high WBC count, mainly neutrophils with well patient?

A

Rheumatoid

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224
Q

Gold standard diagnostic investigation for Ankylosing spondyliitis?

A

MRI of sacroiliac joints

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225
Q

Methotrexate can cause what when not given folate alongside?

A

Macrocytic anaemia due to folate deficiency

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226
Q

What is the treatment for reactive arthritis?

A

NSAIDs

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227
Q

Management of patients who do not respond to steroids in poly myalgia?

A

Refer to specialist

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228
Q

Compartment syndrome can cause what?

A

Rhabdomyolysis

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229
Q

Management of undisplaced patella fracture with intact extensors?

A

Conservative with knee immobilisation

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230
Q

Management of renal hypertensive crises in systemic sclerosis?

A

ACE inhibitors

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231
Q

What are S/E of leflunomide?

A

Raised BP and peripheral neuropathy

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232
Q

What is the anticoagulant of choice in antiphospholipid?

A

Warfarin

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233
Q

Kids born to mums with SLE/Sjogrens can get what?

A

Congenital heart block -> neonatal lupus syndrome

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234
Q

Axial spondyloarthritis?

A

group of clinically heteriogeneous chronic inflam rheumatologic conditions that may cause MSK and extra MSK manifestations

features of axial (saroiliac joints and spine) and peripheral spondyloarthritis can overlap and coexist

eg. alkylosing spondylitits

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235
Q

Radiographic axial spondyloarthritis is characterised by?

A

signs of sacroilitis and structural changes on x-ray (aka ankylosing spondylitis)

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236
Q

Non-radiographic axial spondyloarthritis?

A

no x-ray changes but possible sarcoilitis on MRI

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237
Q

Extra-MSK manifestations of axial spondyloarthritis?

A

acute anterior uveitis, IBD, psoriasis

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238
Q

Ankylosing spondylitis?

A

HLA-B27 associated sponyloarthropathy

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239
Q

When does ankylosing spondylitis typically present?

A

20-30yrs

men>women

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240
Q

Spondyloarthropathy?

A

group of chronic inflam diseases that affects the joints

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241
Q

Features of ankylosing spondylitis?

A
  • typically young man with lower back pain and stiffness of insidious onset
  • stiffness worse in morning and improves with exercise
  • may be pain at night which improves on getting up
  • extra-MSK manifestations
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242
Q

Stiffness in ankylosing spondylitis?

A

worse in morning and improves with exercise

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243
Q

Clinical exam in ankylosing spondylitis?

A
  • reduced lateral flexion
  • reduced forward flexion (Schober’s test)
  • reduced chest expansion
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244
Q

What test is used in ankylosing spondylitis?

A

Schober’s= reduced forward flexion

line is drawn 10 cm above and 5 cm below the back dimples (dimples of Venus). The distance between the two lines should increase by more than 5 cm when the patient bends as far forward as possible

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245
Q

Extra-MSK features of ankylosing spondylitis?

A

Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
cauda equina syndrome
peripheral arthritis (25%, more common if female)

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246
Q

When to suspect and refer for ankylosing spondylitis?

A
  • low back pain, spinal stiffness, <45yrs and >3m with:
  • 4+ of: started before 35yrs, waking at night with pain, buttock pain, improves with movement and within 48hrs of NSAIDs, FHx, current/past arthritis or/+ psoriasis

or

  • with 3 criteria and +ve HLA-B27 blood test

or

  • suspected dactylitis
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247
Q

Ix for ankylosing spondylitis?

A
  • Bloods= inflam markers raised; HLA-B27 +ve (positive in 90%)
  • Plain x-ray of sacroiliac joints= diagnosis (may be normal in early disease)
  • If X-ray -ve then MRI
  • spirometry= restrictive defect
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248
Q

Later changes of ankylosing spondylitis on plain x-ray of sacroiliac joints?

A

sacroiliitis: subchondral erosions, sclerosis

squaring of lumbar vertebrae

‘bamboo spine’ (late & uncommon)

syndesmophytes: due to ossification of outer fibers of annulus fibrosus

chest x-ray: apical fibrosis

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249
Q

What would MRI in ankylosing spondylitis show?

A

signs of early inflam invl. sacroiliac joints (bone marrow oedema)

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250
Q

Why in ankylosing spondylitis does spirometry show a restrictive defect?

A

combination of pulmonary fibrosis, kyphosis and ankylosis of costoverebral joints

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251
Q

Mx of ankylosing spondylitis?

A
  • regular exercise eg. swimming
  • 1st= NSAIDs
  • physio
  • if peripheral joint invl. may consider DMARDs eg. sulphasalazine
  • Anti-TNF therapy if persistent high disease despite other Tx eg. entanercept and adalimumab
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252
Q

Follow up for pt with ankylosing spondylitis?

A
  • risk of osteoporosis and screening every 2yrs
  • same day referral to opthal if acute anterior uveitis suspected
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253
Q

Compartment sydrome?

A

raised pressure within a closed anatomical space; will eventually compromise tissue perfusion resulting in necrosis

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254
Q

Compartment syndrome is a Cx that may occur following what?

A

fractures
or ischaemia reperfusion injury in vascular pts

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255
Q

2 fractures that may cause compartment syndrome?

A

supracondylar fractures and tibial shaft injuries

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256
Q

Sacroiliac joints?

A

joints that connect the sacrum (the base of the spine) to the ilium (the pelvis)

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257
Q

Features of compartment syndrome?

A
  • Pain= esp on movement (even passive), XS use of breakthrough analgesia
  • paraesthesia
  • pallor
  • paralysis of muscle group may occur
  • arterial pulse may still be felt
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258
Q

Why may arterial pulsation still be felt in compartment syndrome?

A

as the necrosis occurs as a result of microvascular compromise

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259
Q

What does NOT rule out compartment syndrome?

A

presence of a pulse

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260
Q

Pt has fracture, has pain on movement (even passive) and is using excessive use of breakthrough analgesia?

A

think compartment syndrome

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261
Q

Diagnosis of compartment syndrome?

A
  • measure intracompartmental pressure; >20mmHg pressure is abnormal and >40 is diagnostic
  • typically no pathology on x-ray
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262
Q

fasciotomy?

A

surgical procedure that involves cutting the fascia, or connective tissue, around a muscle to relieve pressure and increase blood flow

limb saving procedure

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263
Q

Mx of compartment syndrome?

A
  • prompt and extensive fasciotomies
  • aggressive IV fluids
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264
Q

Compartment syndrome: why do pts require aggressive IV fluids?

A

Myoglobinuria may occur following fasciotomy and result in renal failure.

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265
Q

What may happen in fasciotomy for compartment syndrome?

A

if operator is inexperienced, smaller incisions may be performed and in the lower limb the deep muscles may be inadequately be decompressed

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266
Q

Compartment syndrome: what if muscle groups are frankly necrotic at fasiotomy?

A

should be debrided and amputation may be considered

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267
Q

How quick does death of muscle groups occur in compartment syndrome?

A

within 4-6hrs

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268
Q

Gout?

A

type of arthritis caused by monosodium urate crystals forming inside and around joints, causing sudden flares of severe pain, heat and swelling

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269
Q

Joints affected in gout?

A

any joint but most commonly= distal joints eg. toes, knees, ankles, finger joints

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270
Q

Most important RF for the development of gout?

A

hyperuricaemia

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271
Q

RFs for gout?

A
  • hyperuricaemia
  • increasing age
  • FHx
  • genetics
  • obesity
  • male
  • diet
  • postmenopausal
  • medications
  • CKD, HTN, DM
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272
Q

What type of diet is a RF for gout?

A

XS alcohol, sugary drinks, red meat, seafood

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273
Q

What drugs are RFs for gout?

A

diuretics (thiazides, furosemide), low-dose aspirin, ciclosporin, alcohol, cytotoxic agents, pyrazinamide

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274
Q

Cx of gout?

A
  • CVD
  • chronic arthritis
  • CKD
  • joint damage
  • reduced QOL
  • renal stones
  • tophi
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275
Q

Tophi?

A

hard, stone-like deposits of monosodium urate crystals that form in the soft tissues, cartilage, tendons, or bones near joints

usually painless

eg. in gout

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276
Q

Presentation of gout?

A

rapid onset severe pain, redness and swelling in one or both first metatarsophalangeal joints. May be midfoot, ankle, knee, hand, wrist or elbow.

tophi

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277
Q

Ix for gout?

A
  • clinical exam
  • serum urate 6mg/dL (360micromol/L) or more confirms diagnosis
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278
Q

Mx for gout?

A

acute= NSAIDs or colchicine (until 1-2d after flare resolved) or short course oral corticosteroid (pred 30-35mg od 3-5d)

long term= urate-lowering therapy eg. allopurinol or febuxostat

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279
Q

Who should urate-lowering therapy eg. allopurinol be offered to pts with gout?

A

multiple/troublesome flares

CKD stage 3-5

on diuretic therapy

have tophi

or have chronic gout

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280
Q

Where can tophi in gout appear?

A

extensor surfaces of affected joints, Achilles tendons, dorsal aspect of hands and feet and in the helix of the ears. They suggest longstanding, untreated gout.

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281
Q

Most common joint affected in gout?

A

1st metatarsophalangeal joint (big toe)

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282
Q

Is gout monoarticular?

A

usually bit can be oligoarticular or rarely polyarticular

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283
Q

When does flare severity reach max intensity in gout?

A

within 24hrs

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284
Q

When to measure serum urate level for gout diagnosis?

A

diagnosis= 360micromol/L or more

  • if lower but suspect gout repeat serum urate in 2-4w after flare settled
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285
Q

Diagnosis of gout?

A
  • serum urate level 2-4w after flare has settled

if uncertain then:
- joint aspiration and microscopy of synovial fluid
- still uncertain the x-ray

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286
Q

Gout differential diagnosis?

A
  • bursitis, tenosynovititis, cellulitis
  • haemochromatosis
  • psuedogout
  • osteoarthritis
  • psoriatic arthritis
  • reactive arthritis
  • RA
  • septic arthritis
  • trauma
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287
Q

What must be considered in any person who is systemically unwell (with or without a temperature) and an acutely painful, hot, swollen joint?

A

septic arthritis

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288
Q

Self-care advice for gout?

A
  • rest and elevate limb
  • keep joint exposed and in cool environment
  • consider ice pack
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289
Q

Follow up following acute flare of gout?

A

4-6w after settled:
- serum urate
- review meds

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290
Q

form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium

A

gout

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291
Q

What causes gout?

A

chronic hyperuricaemia (uric acid >0.45mmol/l)

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292
Q

Gout episodes?

A

typically flares that can last several days then often symptom free episodes in between

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293
Q

Name 4 commonly affected joints in gout?

A

1st MTP joint= big toe
knee
ankle
wrist

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294
Q

Synovial fluid analysis in gout?

A

needle shaped negatively bifringent monosodium urate crystals under polarised light

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295
Q

X-ray findings in gout?

A
  • joint effusion (early sign)
  • well-defined ‘punched-out’ erosions with sclerotic margins in a juxta-articular distribution, often with overhanging edges
  • relative preservation of joint space until late disease
  • eccentric erosions
  • no periarticular osteopenia (in contrast to rheumatoid arthritis)
  • soft tissue tophi may be seen
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296
Q

MOA of colchicine used for acute flares of gout?

A

inhibits microtubule polymerization by binding to tubulin, interfering with mitosis. Also inhibits neutrophil motility and activity

Slow onset of action

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297
Q

Main side effect of colchicine?

A

diarrhoea

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298
Q

When should colchicine for acute gout be used with caution?

A

in renal impairment: reduce dose if GFR 10-50 and avoid if <10ml/min

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299
Q

Acute flare of gout, if pt is on allopurinol should this be continued alongside other drugs for acute flares?

A

yes continue allopurinol

if havent started it before, start once acute flare settled

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300
Q

Urate lowering therapy is particularly recommended for pts with gout when?

A

Now offer to all pts after 1st attack.
Esp:
- >= 2 attacks in 12 months
- tophi
- renal disease
- uric acid renal stones
- prophylaxis if on cytotoxics or diuretics

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301
Q

Allopurinol dose for gout?

A

initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 360 µmol/l

a lower target uric acid level below 300 µmol/L may be considered for patients who have tophi, chronic gouty arthritis or continue to have ongoing frequent flares despite having a uric acid below 360 µmol/L

a lower initial dose if pt has a reduced eGFR

colchicine cover should be considered when starting allopurinol. NSAIDs can be used if colchicine cannot be tolerated.

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302
Q

Avoid what foods in gout?

A

food high in purines eg. liver, kidneys, seafood, oily fish (mackerel, sardines), red meat, yeast products

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303
Q

Other considerations in the Mx of gout?

A
  • high vit C may lower serum uric acid
  • maybe stop precipitating drugs eg. thiazides
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304
Q

Lesch-Nyhan syndrome?

A

hypoxanthine-guanine phosphoribosyl transferase (HGPRTase) deficiency

x-linked recessive therefore only seen in boys

features: gout, renal failure, neurological deficits, learning difficulties, self-mutilation

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305
Q

What may cause hyperuricaemia (increased levels of uric acid)?

A

secondary to increased cell turnover or reduced renal excretion of uric acid

may be associated with hyperlipidaemia and HTN and metabolic syndrome

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306
Q

Hyperuricaemia caused by increased synthesis examples?

A

Lesch-Nyhan disease
myeloproliferative disorders
diet rich in purines
exercise
psoriasis
cytotoxics

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307
Q

Hyperuricaemia caused by decreased excretion examples?

A

drugs: low-dose aspirin, diuretics, pyrazinamide

pre-eclampsia
alcohol
renal failure
lead

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308
Q

Pseudogout?

A

form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium.

aka acute calcium pyrophosphate crystal deposition disease

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309
Q

Pseudogout RFs?

A
  • increasing age
  • haemochromatosis
  • hyperparathyroidism
  • low magnesium, low phosphate
  • acromegaly
  • Wilsons
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310
Q

Features of pseudogout?

A

knee, wrist and shoulders most commonly affected like gout just different cause

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311
Q

Gout vs pseudogout?

A

Gout is caused by monosodium urate monohydrate crystals; pseudogout is caused by calcium pyrophosphate (CPP) crystals

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312
Q

Joint aspiration findings in psuedogout?

A

weakly-positively birefringent rhomboid-shaped crystals

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313
Q

X-ray findings in pseudogout?

A

chondrocalcinosis
- in the knee this can be seen as linear calcifications of the meniscus and articular cartilage

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314
Q

Mx of psuedogout?

A

aspiration of joint fluid, to exclude septic arthritis

NSAIDs or colchicine intra-articular, intra-muscular or oral steroids as for gout

can use long term low dose colchicine in chronic to reduce flares

TUC eg. magnesium supplement if hypomagnesaemia

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315
Q

Ix for pseudogout?

A
  • joint aspiration for microscopy diagnostic
  • x-ray affected joints

can screen for RFs= ferritin (haemochromatosis), magnesium, thyroid function (hypothyroidism), inflam markers +ve, Ca and PTH (hyperparathyroidism)

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316
Q

Correct name now used instead of pseudogout?

A

calcium pyrophosphate deposition disease

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317
Q

Greater trochanteric pain syndrome?

A

regional pain syndrome where chronic intermittent pain is felt around the greater trochanter

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318
Q

What is the greater trochanter?

A

bony prominence on lateral aspect of the hip

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319
Q

tronchanteric bursitis?

A

inflam of a bursa adjacent to greater trochanter

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320
Q

Greater trochanteric pain syndrome is caused by what?

A

inflam or physical trauma in muscles, tendons, fascia or bursae

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321
Q

Common population affected by greater trochanteric pain syndrome?

A

women>men
40-60yrs

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322
Q

What other conditions is greater trochanteric pain syndrome typically seen with?

A

low back pain, osteoarthritis of knee, RA and fibromyalgia

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323
Q

Mx of greater trochanteric pain syndrome?

A

> 90% recover fully with conservative Tx eg. rest, pain relief, physio or corticosteroid injection

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324
Q

RFs for a poorer outcome of greater trochanteric pain syndrome?

A

higher initial pain intensity, longer duration of pain, greater movement restriction, higher functional impairment, older age

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325
Q

Diagnosis of greater trochanteric pain syndrome?

A

clinical

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326
Q

CP of greater trochanteric pain syndrome?

A
  • lateral hip pain, worse with exercise
  • point tenderness adjacent to greater trochanter
  • when tendons & muscles attached to greater trochanter are put under tension on exam= point tenderness and pain
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327
Q

What should be excluded when diagnosing greater trochanteric pain syndrome?

A

sports hernia, osteoarthritis, lumbar nerve root compression, infection of bursa

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328
Q

Advice for greater trochanteric pain syndrome?

A
  • usually self-limiting
  • avoid activity that may worsen pain
  • ice pack applied 10-20mins several times a day
  • analgesia= paracetamol, NSAIDs
  • weight loss

if initial Mx doesnt help then= peri-trochanteric corticosteroid injection and physio

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329
Q

Emergency referral in greater trochanteric pain syndrome?

A
  • hip pain with systemic symptoms
  • infection s&s
  • known primary malignancy
  • suspicion of pathological fracture
  • sudden inability to bear weight
  • Hx of fall
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330
Q

Urgent referral to ortho in greater trochanteric pain syndrome?

A

severe pain unresponsive to analgesia and persistent loss of function

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331
Q

Referral to ortho for greater trochanteric pain syndrome?

A

<40, persistent, affects ADLs, not responded to 3m physio

painful irritable and stiff hip affecting ADLs

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332
Q

Features of greater trochanteric pain syndrome?

A
  • chronic lateral hip/thigh/buttock pain
  • intermittent or persistent
  • gradual
  • worsen over time
  • may radiate down lateral aspect of thigh but rarely below knee
  • aggravated by physical activity eg. walking and with pressure on that side of body eg. lying down
  • pain on palpation of greater trochanter
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333
Q

Tests to examine for greater trochanteric pain syndrome?

A
  • Trendelenburg’s
  • Single leg stance
  • Hip flexion, abduction, external rotation (FABER)
  • Hip flexion, adduction, external rotation (FADER)
  • resisted active abduction
  • resisted internal rotation
  • resisted external rotation
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334
Q

Gait in greater trochanteric pain syndrome?

A

Antalgic gait — there is a shortened stance on the affected leg, and when walking, less time is spent bearing weight on the affected side than on the other.

Trendelenburg gait — there is a lateral trunk lean towards the supported limb during the stance phase.

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335
Q

On palpation of the greater trochanter in greater trochanteric pain syndrome, where is tenderness elicited?

A

at a point over the gluteus medius tendon or its insertion into the greater trochanter.

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336
Q

Pain on greater trochanter palpation?

A

greater trochanteric pain syndrome

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337
Q

Trendelenburgs test

A

With the person standing, they are observed from behind while lifting each foot off the ground in turn.

A positive test is the pelvis dipping (rather than staying horizontal or rising slightly) on lifting the unaffected leg.

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338
Q

Single leg stance test?

A

The person is asked to remain standing on their affected leg with their contralateral knee flexed to 90 degrees for 30 seconds using a finger on the unaffected side on a wall for balance.

The test is positive if there is lateral hip pain within the 30 seconds.

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339
Q

Hip flexion, abduction, external rotation (FABER test)

A

The lateral malleolus of the test leg is placed above the patella of the contralateral leg, the pelvis stabilized via the opposite anterior superior iliac spine and the knee passively lowered so the hip moves into abduction and external rotation. If there is lateral hip pain, the test is positive.

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340
Q

Hip flexion, adduction, external rotation (FADER test)

A

With the person lying supine, the hip is passively flexed to 90°, adducted, and externally rotated to end of range. If there is lateral hip pain, the test is positive.

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341
Q

Resisted active abduction

A

With the person lying supine their hip joints are placed in the neutral position (legs together and straight out). The affected hip joint is abducted by 45 degrees while the person resists the movement. If there is lateral hip pain, the test is positive.

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342
Q

Resisted internal rotation

A

With the person lying supine, the affected hip joint is positioned at 45 degrees flexion and maximal external rotation. The hip joint is internally rotated while the person resists the movement. If there is lateral hip pain, the test is positive.

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343
Q

Resisted external rotation

A

With the person lying supine, the affected hip joint is positioned at 45 degrees flexion and maximal internal rotation. The hip joint is externally rotated while the person resists the movement. If there is lateral hip pain, the test is positive.

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344
Q

What may greater trochanteric pain syndrome be referred to as?

A

trochanteric bursitis

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345
Q

What is greater trochanteric pain syndrome due to?

A

repeated movement of the fibroelastic iliotibial band and is most common in women aged 50-70 years.

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346
Q

2 features of greater trochanteric pain syndrome?

A

1) pain over the lateral side of hip/thigh
2) tenderness on palpation of the greater trochanter

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347
Q

Juvenile idiopathic arthritis (JIA)?

A

arthritis occurring in pt <16yrs and lasts for >6m

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348
Q

3 types of Juvenile idiopathic arthritis (JIA)?

A
  • systemic onset= aka Still’s disease
  • polyarticular= more than 4 joints
  • pauciarticular= 4 or less joints
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349
Q

Pauciarticular JIA?

A

4 or less joints are affected

60% of cases of JIA

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350
Q

Features of pauciarticular JIA?

A

joint pain and swelling: usually medium sized joints e.g. knees, ankles, elbows

limp

ANA may be positive in JIA - associated with anterior uveitis

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351
Q

Another name for systemic onset JIA?

A

Still’s disease

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352
Q

Features of systemic onset JIA?

A

pyrexia
salmon-pink rash
lymphadenopathy
arthritis
uveitis
anorexia and weight loss

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353
Q

Ix for systemic onset JIA?

A

ANA may be positive, especially in oligoarticular JIA

rheumatoid factor is usually negative

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354
Q

What is used to rule out clinically significant foot and ankle fractures to reduce the use of x-ray imaging?

A

Ottawa Ankle Rule:
1) location of pain= malleolar or midfoot
2) bone tenderness location
2) inability to weight bear both immediately after injury AND in ED

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355
Q

When is an ankle x-ray only required in ?ankle fracture?

A

if any pain in malleolar zone and any one of:
- bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)

  • bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
  • inability to walk four weight bearing steps immediately after the injury and in the emergency department
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356
Q

In what pts is the hip a common site of fracture?

A

esp in osteoporotic elderly females

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357
Q

What is a risk in displaced hip fractures?

A

avascular necrosis as the blood supply to the femoral head runs up the neck

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358
Q

Features of hip fracture?

A
  • shortened and externally rotated leg
  • pain
  • may be able to weight bear if non-displaced or incomplete neck of femur fracture
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359
Q

Pts with non-displaced or incomplete neck of femur fractures may be able to do what?

A

weight bear

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360
Q

Classification of hip fractures based on location?

A

intracapsular (subcapital) or extracapsular

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361
Q

Intracepsular (subcapital) hip fractures?

A

from the edge of the femoral head to the insertion of the capsule of the hip joint

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362
Q

Extracapsular hip fracture?

A

can either be trochanteric or subtrochanteric (lesser trochanter is the dividing line)

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363
Q

Classification of hip fractures?

A

Garden system

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364
Q

Garden system classification for hip fractures?

A

Type I: Stable fracture with impaction in valgus

Type II: Complete fracture but undisplaced

Type III: Displaced fracture, usually rotated and angulated, but still has boney contact

Type IV: Complete boney disruption

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365
Q

What type of hip fracture according to the Garden system classification is blood supply disruption most common?

A

types III and IV

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366
Q

2 types of intracapsular hip fracture?

A
  • undisplaced fracture
  • displaced fracture
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367
Q

Mx of intracapsular undisplaced hip fracture?

A

internal fixation

or hemiarthroplasty if unfit

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368
Q

Mx of intracapsular displaced hip fracture?

A

replacement arthroplasty (total hip replacement or hemiarthroplasty) to all pts

total hip replacement favoured over hemiarthoplasty if pt= able to walk idependently outdoors with no more than use of a stick; not cognitively impaired and med fit for anaesthesia and the procedure

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369
Q

Mx of extracapsular hip fracture?

A

if stable intertrochantic fractures= dynamic hip screw

if reverse oblique, transverse or subtrochanteric fractures= intramedullary device

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370
Q

Most common site of stress fracture?

A

metatarsals

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371
Q

Stress fracture?

A

when fracture occurs due to repeated mechanical stress

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372
Q

Metatarsal fractures>

A

quite common; can be limited to 1 metatarsal or multiple eg. by direct trauma or crush injuries

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373
Q

Most common metatarsal affected in fracture?

A

proximal 5th (also most common site of midfoot fractures)

1st is least commonly fractured

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374
Q

5th metatarsal fractures?

A

Proximal avulsion fractures (pseudo-Jones fractures)= most common type. Occurs at the proximal tuberosity. Usually associated with a lateral ankle sprain and often follow inversion injuries of the ankle.

Jones fractures= much less common. This is a transverse fracture at the metaphyseal-diaphyseal junction.

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375
Q

Metatarsal stress fractures?

A

occurs in otherwise healthy athletes eg. runners

most common site of met stress fractures is 2nd metatarsal shaft

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376
Q

5th metatarsal fractures usually associated with what?

A

lateral ankle sprain and often follow inversion injuries of the ankle

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377
Q

Features of metatarsal fracture?

A

pain and bony tenderness
swelling
antalgic gait

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378
Q

Ix for metatarsal fractures?

A
  • x-rays
  • isotope scan or MRI= in case of stress fractures as x-ray often normal.
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379
Q

When may isotope scan or MRI be preferred to x-ray in metatarsal fractures?

A

help establish stress fractures, may appear normal on x-ray

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380
Q

x-ray for metatarsal fractures?

A

distinguish between displaced and non-displaced fractures to help guide Mx

stress fractures normally appear normal but sometimes there is a periosteal reaction seen 2-3w later

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381
Q

Patella

A

sesamoid bone that develops within the the quadriceps tendon (dividing it into the quadriceps tendon superiorly and the patella ligament inferiorly).

Protects the knee from physical trauma and plays important role in the extensor mechanism of the knee.

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382
Q

How does the patella increase efficieny of quadriceps movement (extensor mechanism of knee)?

A

The quadriceps apply force around a centre of rotation (the knee joint). The patella increases the distance of the quadriceps tendon from this centre of rotation thereby increasing its efficiency (if you imagine it is easier to open a door by pushing or pulling near the handle as opposed to near the door hinge).

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383
Q

Patella anatomy?

A

roughly triangular in coronal and axial planes. The anterior surface is flat and the posterior surface is composed of a medial and lateral facet and articulates with the femur at the patellofemoral joint.

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384
Q

How can the patella be injured?

A
  • direct or indirect means
  • consider in the context of the entire extensor mechanism of the knee
  • consider posterior surface of the patella as any disruption of the patellofemoral joint may lead to secondary osteoarthritis down the line.
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385
Q

On the posterior surface of the patella, any disruption of the patellofemoral joint may lead to what?

A

secondary osteoarthritis down the line

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386
Q

Direct injury causing patella fracture?

A

direct blow or trauma to front of knee eg. fall or dashboard injury

usually an undisplaced crack or comminuted fracture, but with an intact extensor mechanism

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387
Q

Indirect injury causing patella fracture?

A

when quads forcefully contract against a block to knee extension

eg. when someone catches their foot against a solid obstacle and in order to prevent themselves from falling the quads contract forcefully

results in transverse patella fracture with possible disruption of the extensor mechanism

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388
Q

Direct injury to patella may result in what?

A

undisplaced crack or comminuted fracture, but with an intact extensor mechanism

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389
Q

indirect injury to patella may result in what?

A

transverse patella fracture with possible disruption of the extensor mechanism.

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390
Q

Clinical features of patella fracture?

A
  • swelling and bruising
  • open wound= ? open fracture (more urgent Mx)
  • pain and tenderness around knee, localised to patella and palpable gap may be appreciable
  • if able to straight leg raise= extensor mechanism is grossly intact; may be difficult due to pain so have pt lie on side to eliminate gravity
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391
Q

Ix for patella fractures?

A

plain films, min of 2 views required (AP and lateral)

if diagnosis still in doubt, skyline views can be taken but is uncomfortable and difficult to obtain

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392
Q

Mx of undisplaced patella fractures, particularly vertical fractures with an intact extensor mechanism?

A

can be managed non-operatively in a hinged knee brace for 6w and pt allowed to fully weight bear

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393
Q

Mx of displaced patella fractures and those with loss of extensor mechanisms?

A

consider operative Mx with either tension band wire, inter-fragmentary screws or cerclage wires
then pt placed in hinged knee brace for 4-6w and allowed to fully weight bear

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394
Q

Tendinopathy?

A

term describing pain, swelling and impaired function of the tendon

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395
Q

Achilles tendon?

A

thickest and strongest tendon in the body; made up of fibres from the gastrocneumius and soleus muscles

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396
Q

Achilles tendon pathology is common in who?

A

active people

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397
Q

Cx of achilles tendon injury?

A

tendon rupture, negative impact on a pts ability to work and carry out ADLs, limitation in sports activity

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398
Q

Signs and symptoms of Achilles tendinopathy?

A
  • aching (or sharp) pain in heel, aggravated by activity or pressure to the area
  • stiffness in the tendon, may occur in morning or after period of prolonged sitting
  • tenderness, swelling, crepitus along the tendon
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399
Q

Suspected achilles tendon rupture?

A

same day assessment by ortho specialist

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400
Q

Mx of achilles tendinopathy?

A
  • Mx of underlying cause
  • cold packs/ice after acute injury
  • analgesia for pain relief eg. paracetamol
  • rest, exercise when pain allows
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401
Q

What if symptoms of Achilles tendinopathy fails to improve within 7-10d?

A

refer to physio

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402
Q

Chronic achilles tendinopathy or fails to respond to Mx?

A

refer to sports physician or ortho

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403
Q

Pain in achilles tendinopathy?

A

ache or sharp pain in heel

  • worse with activity or pressure to area
  • Gradual onset of pain 2–6 cm proximal to the Achilles tendon insertion that limits activity suggests mid-portion Achilles tendinopathy.
  • Pain and swelling at the insertion to the posterior calcaneus with impairment of function suggests insertional tendinopathy.
  • some symptoms at both the insertion and mid-portion.
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404
Q

Stiffness in achilles tendinopathy?

A

may occur in morning or after period of prolonged sitting

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405
Q

What can be used to assess pain and severity with activity win people with achilles tendinopathy?

A

Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire

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406
Q

RFs for achilles tendinopathy?

A

DM, dyslipidaemia, fluoroquinolone use

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407
Q

Diagnosis of achilles tendinopathy?

A
  • clinical: examine if no rupture
  • imaging not usually recommended
  • Ix for ULC= lipid profile, HbA1c, ?fluoroquinolone use
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408
Q

Examination findings for achilles tendinopathy (do not examine if achilles tendon rupture)?

A

redness, swelling, and asymmetry

Palpate along the length of the tendon for tenderness, heat, crepitus, thickening, and nodularity.

Tenderness on palpation of the mid-portion of the tendon is indicative of mid-portion Achilles tendinopathy.

Tenderness on palpation around the distal 2 cm of the tendon is usually found in insertional Achilles tendinopathy.

Evaluate the range of motion of the ankle. Pain worsens with passive dorsiflexion of the ankle.

Hop and heel-raise endurance tests, as appropriate.

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409
Q

CP of achilles tendinopathy?

A
  • sudden pain back of leg, may be audible snap
  • may occur with running or exercise, may be like being kicked or hit by a racket
  • 1/3 with complete rupture say no pain
  • aching of calf, swelling, mild bruising, weakness when pushing off with affected foot
  • difficulty weight bearing
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410
Q

In some cases, why may pt with achilles tendinopathy be able to walk?

A

other plantar flexors may mask the tendon injury

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411
Q

How to exclude achilles tendon rupture?

A

Simmonds triad (angle of declination, palpation, and the calf squeeze test)

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412
Q

Simmonds triad examination to exclude achilles tendon rupture?

A

(angle of declination, palpation, and the calf squeeze test)

  • abnormal angle of declination= rupture may lead to greater dorsiflexion of the injured ankle and foot compared with the uninjured limb.
  • Feel for a gap in the tendon. No gap may be felt because of local swelling or bleeding. Bruising may be seen.
  • Gently and sequentially squeeze the calf muscles= in acute rupture of the Achilles tendon the injured foot will typically remain in the neutral position when the calf is squeezed.
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413
Q

Why may the diagnosis of chronic achilles tendon rupture be difficult?

A
  • pain and swelling often subsided and the gap may have filled with fibrous tissue.
  • Calf muscles may be wasted.
  • Other muscles may facilitate plantar flexion.
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414
Q

Differential diagnosis for achilles tendoninopathy?

A

True tendon pain (from rupture or tendinopathy) is usually confined to the tendon itself.

Retrocalcaneal bursitis.
Plantaris tendinopathy.
Dislocation of the peroneal or other plantar flexor tendons.
Posterior ankle impingement.
Haglund’s deformity.
Os trigonum syndrome.
Fascial tears.
Calcaneal fracture.
Irritation or neuroma of the sural nerve.
Fat pad irritation.
Systemic inflammatory disease.

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415
Q

Tx for achilles tendinopathy in secondary care (if conservative measures fail)?

A

non-surgical= Eccentric exercise, or a heavy-load, slow-speed (concentric/eccentric) exercise programme (if not already tried); Extracorporeal shock-wave therapy (ESWT) — acoustic shockwaves are passed through the skin to the affected tissue.

Surgery= if chronic or not responsive to Tx; debridement and removal of diseased areas of tendon

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416
Q

Most common cause of posterior heel pain?

A

achilles tendon disorders

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417
Q

Examples of achilles tendon disorders?

A

tendinopathy (tendinitis), partial tear, complete rupture

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418
Q

What are associated with achilles tendon disorders?

A

floroquinolone use eg. ciprofloxacin

hypercholesterolaemia (predisposes to tendon xanthomata)

DM

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419
Q

Gradual onset of posterior heel pain that is worse following activity; morning pain and stiffness common?

A

achilles tendinopathy (tendiniti)

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420
Q

3 supportive Mx for achilles tendinopathy?

A
  • simple analgesia
  • reduction in activities
  • calf muscle eccentric exercies
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421
Q

playing a sport or running; an audible ‘pop’ in the ankle, sudden onset significant pain in the calf or ankle or the inability to walk or continue the sport

A

achilles tendon rupture

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422
Q

How is Simmond’s triad examination be conducted to exclude achilles tendon rupture?

A

ask pt to lie prone with their feet over the edge of the bed. Look for an abnormal angle of declination; Achilles tendon rupture may lead to greater dorsiflexion of the injured foot compared to the uninjured limb.
Feel for a gap in the tendon and gently squeeze the calf muscles if there is an acute rupture of the Achilles tendon the injured foot will stay in the neutral position when the calf is squeezed.

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423
Q

Imaging of choice for suspected achilles tendon rupture?

A

USS

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424
Q

Suspected achilles tendon rupture?

A

acute referral to ortho and USS

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425
Q

Bony components of ankle joint include what

A

distal tibia and fibula and the superior aspect of the talus
- form a mortise with the body of the talus acting as the tendon
- arrangement is secured by ligamentous structures

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426
Q

Ligaments in the ankle?

A

1) syndesmosis binds the distal tibia and fibula together (another example of a syndesmosis is the distal radio-ulnar joint). It is composed of the anterior inferior tibiofibular ligament (AITFL), posterior inferior tibiofibular ligament (PITFL), interosseous ligament (IOL) and the interosseous membrane.

2) Distal fibular= secured to the to the talus by the anterior and posterior talofibular ligaments (ATFL and PTFL) and to the calcaneus by the calcaneofibular ligament.
Sometimes referred to collectively as the lateral collateral ligaments.

3) Distal tibia= secured to the talus by the deltoid ligament, in view of its triangular shape.

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427
Q

Sprain?

A

stretching, partial or complete tear of a ligament

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428
Q

Types of ankle sprains?

A
  • high ankle sprain= invl syndesmosis
  • low ankle sprain= invl lateral collateral ligaments
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429
Q

Presentation of low ankle sprain?

A
  • injury to ATFL most common
  • inversion injury common mechanism
  • pain, swelling, tenderness over affected ligaments and sometimes bruising
  • able to weight bear unless severe
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430
Q

Most common type of ankle sprain?

A

low sprain

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431
Q

Inversion injury to the ankle can cause what?

A

low ankle sprain

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432
Q

Grades of low ankle sprain?

A

Grade I (mild)= stretch or micro tear to ligament; minimal bruising/swelling; weight bearing normal

Grade II= partial tear; moderate bruising/swelling; minimal pain on weight bearing

Grade III (severe)= complete tear; severe swelling and bruising; severe pain on weight bearing

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433
Q

Ix for low ankle sprain?

A
  • 15% associated with fracture so x-ray according to Ottawa ankle rules
  • MRI if persistent pain= can evaluate perineal tendons
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434
Q

Tx for low ankle sprain?

A
  • RICE= rest, ice, compression, elevation
  • occasionally= removable orthosis, cast and/or crutches may be needed short term
  • fails or signif joint instability= MRI and surgery but rare
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435
Q

Presentation of high ankle sprain?

A
  • injury to syndesmosis
  • rare and severe
  • caused by external rotation of food causing talus to push fibula laterally
  • weight bearing painful
  • pain when tibia and fibula squeezed together at mid calf (Hopkin’s squeeze test)
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436
Q

Hopkin’s squeeze test?

A

high ankle sprain

Pain when the tibia and fibula are squeezed together at the level of the mid-calf

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437
Q

Injury to ankle caused by external rotation of foot causing talus to push fibula laterally?

A

high ankle sprain

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438
Q

Ix for high ankle sprain?

A
  • x-ray= may show widening of tibiofibular joint (diastasis) or ankle mortise
  • MRI= if high suspicion but normally just plain films
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439
Q

Tx of high ankle sprain?

A
  • if no diastasis= non weight bearing orthosis or cast until pain stops
  • diastasis or failed non-op Mx= operative fixation
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440
Q

What are isolated injuries to the deltoid ligament in ankle associated with?

A

they are rare

fracture so look for Maisonneuve fracture of the proximal fibula.

Ankle mortise anatomically reduced= same Tx as low ankle sprain
- if not then reduction and fixation

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441
Q

Common cause of lateral knee pain in runners?

A

iliotibial band syndrome

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442
Q

iliotibial band syndrome?

A

common cause of lateral knee pain in runners (1 in 10 regular runners)

tenderness 2-3cm above lateral joint line

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443
Q

Mx of iliotibial band syndrome?

A
  • activity modification and iliotibial band stretches
  • no improvement then physio
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444
Q

Causes of knee pain?

A

osteoarthritis, injuries (muscle strain, ligament damage, fractures); inflam conditions; infection; tumours; referred pain from hip or lumbosacral spine; bursitis

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445
Q

RFs for knee pain?

A
  • increasing age
  • obesity
  • knee-straining work
  • participation in sport
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446
Q

Red flags for knee pain?

A
  • infection (septic arthritis or osteomyelitis)
  • tumours
  • inflam polyarthritis
  • signif bony or soft tissue injury eg. fractures, dislocation and tendon/ligament rupture
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447
Q

When is admission or referral for immediate hospital assessment indicated in knee pain?

A

septic arthritis, slipped capital femoral epiphysis, fracture, neurovascular damage, quadriceps or patellar tendon rupture, severe soft tissue injury with gross instability, first-time traumatic patellar dislocation, or a recurrent dislocation associated with moderate or severe swelling.

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448
Q

When is admission or referral for immediate hospital assessment indicated in knee pain in a child?

A

limp or suspected Henoch-Schönlein purpura.
infection (such as fever, erythema, swelling) or severe pain, swelling, instability or inability to weight bear in association with an acute injury.

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449
Q

What if signif soft tissue injury is suspected in pt with acute knee pain following trauma?

A

acute knee clinic (admission or immediate assessment)

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450
Q

Ottawa knee rule?

A

determine whether an X-ray is needed in people over 2 years with a suspected knee fracture.

Only required after a knee injury for people with any of these findings:
1) Inability to weight bear both immediately and during the consultation for four steps (inability to transfer weight twice onto each lower limb regardless of limping).
2) Inability to flex the knee to 90 degrees.
3) Tenderness of the head of the fibula.
4) Isolated tenderness of the patella (no bone tenderness of the knee other than the patella).
5) Age 55 years or older.

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451
Q

Direct blow to the knee can cause what?

A

anterior knee= patellar fracture or if knee in flexion can cause PCL injury; hyperextended knee can cause ACL injury

lateral knee= medial collateral ligament injury or patellar dislocation

medial knee= lateral collateral ligament injury (uncommon) or patellar dislocation

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452
Q

Knee injury: what can sudden decleration or stopping cause?

A

ACL injury

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453
Q

Twisting or pivoting can injury the knee how?

A

can injure the menisci or cause ACL injury. If twisted when the knee is extended, patellar subluxation or dislocation can occur.

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454
Q

Hyperextension of the knee can cause what?

A

ACL and PCL injury

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455
Q

Anterior knee pain may be caused by what?

A

Patellar subluxation or dislocation.
Osgood-Schlatter disease.
Patellar tendonitis.
Patellofemoral pain syndrome.
Patellar or quadriceps tendon rupture.
Patellofemoral joint arthritis.

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456
Q

Medial knee pain may be caused by what?

A

Medial collateral ligament sprain.
Medial meniscal tear.
Pes anserine bursitis.
Medial plica syndrome.
Medial compartment arthritis.

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457
Q

Lateral knee pain may be caused by what?

A

Lateral collateral ligament sprain.
Lateral meniscal tear.
Iliotibial band tendonitis.
Lateral compartment arthritis.

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458
Q

Posterior knee pain may be caused by what?

A

Baker’s cyst.
Posterior cruciate ligament injury.
Posterior horn meniscal tears.

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459
Q

What does Lachman’s test test for?

A

ACL tear

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460
Q

What does the anterior drawer/draw test test for?

A

ACL tear

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461
Q

What does the pivot shift test test for?

A

ACL tear

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462
Q

What does the posterior drawer/draw test test for?

A

PCL tear

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463
Q

What does the posterior sag test test for?

A

PCL tear

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464
Q

What does the valgus stress test test for?

A

Medial collateral ligament injury

(Joint line tenderness may also indicate meniscal tear)

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465
Q

What does the varus stress test test for?

A

Lateral collateral ligament injury

(Joint line tenderness may also indicate meniscal tear)

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466
Q

What does the patellar apprehension test test for?

A

Subluxing or dislocating patella

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467
Q

What does the McMurray test test for?

A

meniscal tear

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468
Q

What does the Thessaly test test for?

A

meniscal tear

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469
Q

Testing for effusion in knee?

A
  • patellar tap test
  • stroke test
  • cross fluctuance test for larger effusions
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470
Q

Most commonly injured knee ligament?

A

ACL

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471
Q

Common mechanisms of injury to the ACL?

A
  • lateral blow to knee
  • skiing
  • non-contact= sudden twisting or awkward landing (most common) eg. hyperextension
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472
Q

Features of ACL injury?

A
  • sudden popping sound
  • knee swelling
  • instability
  • feeling that knee will give way
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473
Q

2 tests to test for ACL injury?

A

anterior draw test and Lachman’s test

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474
Q

Anterior draw test to test for ACL injury?

A

the patient lies supine with the knee at 90 degrees

the examiner should place one hand behind the tibia and the other grasping the patient’s thigh. It is important that the examiner’s thumb be on the tibial tuberosity

the tibia is pulled forward to assess the amount of anterior motion of the tibia in comparison to the femur

an intact ACL should prevent forward translational movement

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475
Q

Lachman’s test to test for ACL injury?

A

variant of anterior draw test, but the knee is at 20-30 degrees

evaluate the anterior translation of the tibia in relation to the femur and is considered a variant

more reliable than anterior draw test

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476
Q

Knee pain= meniscal tear typically results from what?

A

twisting injuries

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477
Q

Knee pain= meniscal tear features?

A

pain worse on straightening the knee

knee may ‘give way’

displaced meniscal tears may cause knee locking

tenderness along the joint line

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478
Q

Test to test for meniscal tear (knee pain)?

A

Thessaly’s test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee

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479
Q

Thessaly’s test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee
Condition?

A

meniscal tear

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480
Q

Common knee problems in children and young adults?

A
  • Chondromalacia patellae
  • Osgood-Schlatter disease
    (tibial apophysitis)
  • Osteochondritis dissecans
  • Patellar subluxation
  • Patellar tendonitis
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481
Q

Referred knee pain may come from where?

A

hip problems such as slipped upper femoral epiphysis

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482
Q

Key features of chondromalacia patellae?

A

Softening of the cartilage of the patella
Common in teenage girls
Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
Usually responds to physiotherapy

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483
Q

Key features of Osgood-Schlatter disease
(tibial apophysitis)?

A

seen in sporty teens

pain, tenderness and swelling over tibial tubercle

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484
Q

Key features of osteochondritis dissecans?

A

Knee pain after exercise
Intermittent swelling and locking
In children and young adults

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485
Q

Key features of Patellar subluxation?

A

Medial knee pain due to lateral subluxation of the patella
Knee may give way

in children and young adults

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486
Q

Key features of Patellar tendonitis?

A

More common in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination

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487
Q

Osgood-Schlatter disease?

A

apophysitis of the tibial tuberosity that causes anterior knee pain during adolescence and is usually self-limiting

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488
Q

Osgood-Schlatter disease is thought to occur as a result of what?

A

repetitive strain from the patella tendon at its insertion on the ossification centre (apophysis) of the tibial tuberosity

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489
Q

Apophysis?

A

a normal developmental outgrowth of a bone which arises from a separate ossification centre, and fuses to the bone later in development; usually where muscle, tendon or ligament inserts

apophysitis= inflam of this

ossification= process of making new bone

ossification centre= area this happens

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490
Q

RFs for Osgood-Schlatter disease?

A

age= during growth spurts in adolescence

sports eg. running, jumping, repetitive bending of knee

biomechanical factors= quad muscle tightness, reduced flexibility of hamstrings

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491
Q

Type of knee pain in Osgood-Schlatter disease?

A
  • unilateral (70%)
  • during growth spurts (8-12yrs girls, 12-15yrs boys)
  • develops slowly, mild and intermittent but can progress to continuous and severe
  • fluctuates
  • exacerbated by activity eg. running, jumping, kneeling
  • improves with rest and skeletal maturity
  • settles over w to m but can take 1-2yrs to resolve
  • 10% persist into adulthood= chronic pain, decreased lower body strength
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492
Q

Exam findings in Osgood-Schlatter disease?

A

tenderness over tibial tuberosity that is provoked by knee extension against resistance, swelling or bony enlargement of the tibial tuberosity

normal passive ROM and absence of effusion

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493
Q

tenderness over tibial tuberosity that is provoked by knee extension against resistance, swelling or bony enlargement of the tibial tuberosity

A

Osgood-Schlatter disease

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494
Q

Ix for Osgood-Schlatter disease?

A
  • clinical unless features of other causes of knee pain eg. persists at night or after rest, systemic symptoms, sudden after trauma, bone/joint pain at other sites
  • routine x-ray not recommended to confirm diagnosis
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495
Q

Mx of Osgood-Schlatter disease?

A
  • paracetamol +/or NSAIDs
  • protective knee pads when kneeling
  • intermittent ice packs over tibial tuberosity (10-15mins up to 3x d)
  • exercise modification & muscle stretching exercises= swimming, cycling, straight leg raises
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496
Q

Osgood-Schlatter disease: what if pain does not improve or it worsens despite Mx?

A
  • reassess cause: refer to paeds or ortho surgon
  • physio referral
  • persist into adulthood= ortho surgeon is symptoms affecting functioning
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497
Q

Differential diagnosis for Osgood-Schlatter disease (knee pain)?

A
  • tumour
  • juvenile idiopathic arthritis
  • referred pain from hip= SUFE, transient synovitis; perthes
  • trauma
  • infection= septic arthritis or osteomyelitis
  • osteochondritis dissecans, patellofemoral pain syndrome, chondromalacia patellae, and patellar dislocation or subluxation.
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498
Q

Preventative strategies for Osgood-Schlatter disease?

A

regular quadriceps and hamstring stretching and cross-training (swimming, cycling)

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499
Q

Most common cause of heel pain seen in adults?

A

plantar fasciitis

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500
Q

Pain in plantar fasciitis?

A

heel pain usually worse around the medial calcaneal tuberosity

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501
Q

Mx of plantar fasciitis?

A

rest feet where possible

wear shoes with good arch support and cushioned heels

insoles and heel pads may help

  • analgesia and ice pack; consider short term USS guided corticosteroid injections
  • if no better= refer to ortho or podiatrist or physio
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502
Q

Plantar fasciitis?

A

persistent pain associated with degeneration of plantar fascia as result of repetitive microtears in the contracted fascia

common 40-60yrs

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503
Q

Characteristic symptoms of plantar fasciitis?

A
  • insidious onset
  • intense pain during 1st steps after waking or period of inactivity
  • pain reduces with moderate activity but worsens later during day or after long periods of standing/walking
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504
Q

Signs of plantar fasciitis?

A

Tenderness on palpation of the plantar heel area (esp localized around the medial calcaneal tuberosity).

Limited ankle dorsiflexion range (with the knee in extension).

Positive ‘Windlass test’ (reproduction of pain by extension of the first metatarsophalangeal joint).

Tightness of the Achilles tendon.

An antalgic gait (abnormal walking to avoid pain) or limping.

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505
Q

Differential diagnosis of plantar fasciitis?

A

Achilles tendonitis.
Calcaneal stress fractures.
Fat pad atrophy.
Sub-calcaneal bursitis.

Other less common neuro and MSK causes, such as nerve entrapment, peripheral neuropathy, plantar fibromatosis, and plantar fascia rupture.

Neoplasm and vascular insufficiency (very rare).

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506
Q

Diagnosis of plantar fasciitis?

A

clinical

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507
Q

Most people with plantar fasciitis will make full recovery within how long?

A

1yr

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508
Q

Osteoarthritis (OA)?

A

long term disorder of synovial joints which occurs when damage triggers repair processes leading to structural changes within a joint, with features of localised cartilage loss, remodelling of adjacent bone and formation of osteophytes, and mild synovitis

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509
Q

3 symptoms of osteoarthritis?

A

pain, stiffness and loss of function

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510
Q

What joints can be involved in osteoarthritis?

A

any synovial joint= knees, hips, small joints of hand most common

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511
Q

Flare of osteoarthritis?

A

sudden, sustained increase in symptoms for at least 24hrs, worse than usual patterns and lasts 3-8d

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512
Q

Causes of osteoarthritis?

A

multifactorial: genetics, biological (age, obesity), biomechanical (joint injury and damage)

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513
Q

Flares of osteoarthritis?

A

acute-on-chronic flares
may fluctuate

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514
Q

Cx of osteoarthritis?

A

joint deformity and chronic pain

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515
Q

Features of osteoarthritis?

A
  • activity related joint pain= 1 or few joints at any one time; develops over m-yrs
  • no morning stiffness or for <30mins
  • functional limitation

Signs:
- bony swelling
- joint deformity
- restricted and painful ROM
- mild synovitis/joint effusion
- crepitus
- joint instability

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516
Q

Diagnosis of osteoarthritis?

A
  • clinical= typical features, posture, gait, BMI, atypical features, other sources of pain
  • if uncertain= joint x-ray
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517
Q

Mx of osteoarthritis?

A
  • self care
  • simple analgesia= topical NSAIDs (ibuprofen 5% gel 3x d); or oral 2nd line
  • refer to MSK MDT= intra-articular corticosteroid injections (work for 2-10w); assistive aids; therapeutic exercise with education (‘structured Tx package’)
  • ineffective after 3m= ortho surgeon (?joint replacement)
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518
Q

Hand OA?

A

typically affects 1st carpometacarpal joint (CMC) at base of thumb, distal interphalangeal (DIP) joint and the proximal interpahalngeal (PIP) joint

  • wasting of thenar muscles at base of thumb
  • CMC= fixed flexion deformity with hyperextension of distal joints
  • advanced= squaring at joint; ulnar or radial deviation
  • mucoid cysts
  • Heberden’s and Bouchard’s nodes
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519
Q

Why in advaced hand OA may you get ‘squaring’ at the joint?

A

caused by subluxation (partial dislocation), formation of osteophytes and remodelling of bone

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520
Q

Mucoid cysts in OA of hand?

A

(painful mucus-filled cysts) adjacent to the joint on the dorsum of the finger, which may cause longitudinal ridging of the nail.

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521
Q

Nodes in OA of the hand?

A

Heberden’s= bony nodules on the dorsum of the finger next to the DIP joints

Bouchard’s nodes= next to the PIP joints

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522
Q

Hip OA may present with what?

A

deep pain in anterior groin on walking or climbing stairs

possible referred pain to lateral thigh, buttock, anterior thigh, knee and ankle

painful restriction of internal rotation with hip flexed

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523
Q

painful restriction of internal rotation with hip flexed

A

OA of the hip

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524
Q

What may be present in hip OA when the disease is advanced?

A

Trendelenburg gait

A fixed flexion external rotation deformity, with compensatory increased lumbar lordosis and pelvic tilt. The lower limb can be significantly shortened.

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525
Q

Trendelenburg gait?

A

in advanced hip OA

a lurch towards the affected hip with less time spent weight-bearing on that side and the pelvis tilting down on the unaffected side, caused by wasting and weakness of the gluteal and anterior thigh muscles

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526
Q

Knee OA?

A

typically bilateral and symmetrical

medial tibiofemoral (causes anteromedial pain on walking), lateral tibiofemoral (anterolateral pain on walking) or patellofemoral compartments (anterior knee pain worsened on incline or going down stairs; aching on prolonged sitting relieved my standing)

pain localsied to affected compartment

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527
Q

Associated features in knee OA?

A

Giving way — due to altered patella tracking, weak quadriceps muscles, severe patellofemoral involvement, and altered load-bearing mechanics.

Locking (inability to straighten the knee) — suggests loose meniscal cartilage in the joint.

Crepitus and tenderness along the joint line or with pressure on the patella.

Restricted flexion and extension.

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528
Q

weakness of the quadriceps is suggested if…

A

passive extension of the knee joint is greater than active extension

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529
Q

What may be present in advanced knee OA?

A

Bony swelling of the femoral condyles and lateral tibial plateau.

Varus (bow-legged), or less commonly valgus (knock-knee), deformity.

An antalgic gait.

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530
Q

X-ray findings in OA (done if uncertain or atypical features)?

A

subchondral bone thickening and/or cysts

osteophyte formation (new bone formation at joint margins)

loss or narrowing of the joint space (provides an estimate of the severity of cartilage damage).

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531
Q

Self care advice for pt with OA?

A
  • self-care= info, weight loss, good footwear
  • exercise= aerobic and muscle strengthening
  • physiological support
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532
Q

Common joints affected in osteoarthritis?

A

DIPs
CMC joint (base of thumb)
Knees
Hips
L spine
C spine (c spondylosis)

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533
Q

DIPS or PIPS in osteoarthritis?

A

DIPS

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534
Q

Mneumonic for X-ray changes in osteoarthritis?

A

L.oss of joint space
O.steophytes
S.ubarticular scleorsis
S.ubchondral cysts

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535
Q

Signs in the hands in osteoarthritis?

A
  • Heberden’s nodes (DIPs)
  • Bouchard’s nodes (PIPs)
  • Squaring at base of thumb (CMC joint)
  • weak grip and reduced ROM
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536
Q

When can osteoarthritis be diagnosed clinically?

A

> 45yrs, typical pain and no morning stiffness (or <30mins)

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537
Q

What should be co-prescribed alongside oral NSAIDs (eg. in osteoarthritis when topical NSAIDs don’t work)?

A

PPI for gastroprotection

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538
Q

NSAIDs should be used in caution with pts with high BP, why?

A

they cause HTN by blocking prostaglandins (prostaglandins cause vasodilation)

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539
Q

Why should NSAIDs (ibuprofen and naproxen) be used cautiously in older pts and those on anticoags (aspirin, DOAC) eg. for osteoarthritis?

A

use short term for flares as:

  • GI Cx= peptic ulcers, gastritis
  • Renal= AKI (eg. acute tubular necrosis) and CKD
  • CVD= HTN, HF, MI, stroke
  • exacerbate asthma
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540
Q

Most common presentation of OA (joint)?

A

knee
then hip

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541
Q

RFs for OA of the hip?

A
  • increasing age
  • female
  • obesity
  • developmental dysplasia of hip
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542
Q

chronic history of groin ache following exercise and relieved by rest

A

osteoarthritis of hip

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543
Q

Red flags that may suggest an alternative cause in OA of the hip?

A

rest pain
night pain
morning stiffness >2hrs

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544
Q

What can be used to assess severity of OA of the hip?

A

Oxford Hip Score

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545
Q

Ix for OA of hip?

A

clinical

if atypical features= plain x-rays

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546
Q

Definitive Tx for OA of the hip?

A

total hip replacement

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547
Q

Cx of total hip replacement?

A

perioperative= VTE,
intraoperative fracture, nerve injury, surgical site infection

leg length discrepancy

posterior dislocation= may occur during extremes of hip flexion; typically presents acutely with a ‘clunk’, pain and inability to weight bear
on examination there is internal rotation and shortening of the affected leg

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548
Q

Most common reason for revision of total hip replacement?

A

aseptic loosening
- prosthetic joint infection

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549
Q

Summary of osteoarthritis Mx?

A

1) weight loss; local muscle strenthening exercises & aerobic fitness

1) topical NSAIDs
2) oral NSAIDs + PPI
3rd line) intra-articular steroid injections (2-10w relief)

4) fail= joint replacement

+ walking aids
can use paracetamol short term for flares (only if infrequent) but DO NOT use opioids

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550
Q

Osteomalacia?

A

softening of bones secondary to low vit D that in turn lead to decreased bone mineral density

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551
Q

Osteomalacia in children vs adults?

A

children= called rickets
adults= osteomalacia

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552
Q

Causes of osteomalacia?

A
  • vit D def= malabsorption, lack of sunlight, diet
  • CKD
  • drug induced eg. anticonvulsants
  • liver disease eg. cirrhosis
  • coeliac
  • inherited
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553
Q

inherited cause of osteomalacia?

A

hypophosphatemic rickets (aka vit D-resistant rickets)

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554
Q

Features of osteomalacia?

A
  • bone pain
  • bone/muscle tenderness
  • fractures: esp femoral neck
  • proximal myopathy= waddling gait
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555
Q

What fracture is common in osteomalacia?

A

femoral neck

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556
Q

Ix for osteomalacia?

A
  • bloods= low vit D; low Ca and phosphate (30%) and raised ALP
  • x-ray= translucent bands (Looser’s zones or pseudofractures)
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557
Q

Tx for osteomalacia?

A
  • vit D supplementation= loading dose initially needed
  • Ca supplementation if dietary inadequate
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558
Q

Osteomyeleitis?

A

infection of the bone

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559
Q

Osteomyelitis may be classified into what?

A

Haematogenous osteomyelitis and non-haematogenous osteomyelitis

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560
Q

Haematogenous osteomyelitis?

A

results from bacteraemia

is usually monomicrobial

most common form in children

vertebral osteomyelitis is the most common form of haematogenous osteomyelitis in adults

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561
Q

Most common form of osteomyelitis in children?

A

Haematogenous osteomyelitis

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562
Q

Haematogenous osteomyelitis RFs?

A

sickle cell anaemia, intravenous drug user, immunosuppression due to either medication or HIV, infective endocarditis

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563
Q

Non-haematogenous osteomyelitis?

A

results from the contiguous spread of infection from adjacent soft tissues to the bone or from direct
injury/trauma to bone

is often polymicrobial

most common form in adults

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564
Q

Most common form osteomyelitis in adults?

A

Non-haematogenous osteomyelitis

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565
Q

Non-haematogenous osteomyelitis RFs?

A

diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease

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566
Q

Most common cause of osteomyelitis (microbio)?

A

staph.aureus

(except if pt has sickle cell anaemia)

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567
Q

Most common cause of osteomyelitis in sickle cell anaemia pts?

A

Salmonella species

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568
Q

Ix for osteomyelitis?

A

MRI

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569
Q

Mx for osteomyelitis?

A

flucloxacillin for 6 weeks

clindamycin if penicillin-allergic

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570
Q

Mneumonic for ankylosing spondylitis?

A

S.ausage digitis
P.soriasis
I.nflam back pain
N.SAID responsive
E.nethesis (heel pain)

A.rthritis
C.rohns/UC
H.LA-B27
E.yes (uveitis)

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571
Q

Osteoporosis?

A

disease characterised by low bone mass and structural deterioration of bone tissue, causing increase in bone fragility and susceptibility to fracture

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572
Q

Does pt know they have osteoporosis?

A

it is asymptomatic so remains undiagnosed normally until a fragility fracture occurs

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573
Q

Osteoporotic fracture occurs as a consequence of…

A

increased bone fragility

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574
Q

Characteristic fractures occur where in pt with osteoporosis?

A

wrist, spine, hip

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575
Q

Fragility fracture?

A

fracture following a fall from standing height or less

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576
Q

Vertebral fractures in pt with osteoporosis?

A

may occur spontaneously or as a result of routine activities

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577
Q

RFs for osteoporosis?

A

Female sex.
Increasing age.
Menopause.
Oral corticosteroids.
Smoking.
Alcohol.
Previous fragility fracture.
Rheumatological conditions, eg. RA and other inflammatory arthropathies.
Parental history of hip fracture.
BMI less than 18.5 kg/m2.

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578
Q

What should be done in pt with fragility fracture prior to calculating fracture risk (osteoporosis)?

A

Ix to check for non-osteoporotic causes eg. metastatic bone ca and undiagnosed secondary causes eg. hyperthyroidism

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579
Q

Pt presents with fragility fracture, what Ix do you do?

A

1) rule out non-osteop causes and undiagnosed 2 causes eg. hyperthroidism

2) 10yr fragility fracture risk score PRIOR to arranging DXA scan to measure BMD or starting bisphosphonate except in certain pts (if ‘high risk eg. due to age or RFs then just straight to DXA)

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580
Q

What pts with suspected osteoporosis do you not bother calculating 10-yr fragility fracture risk score for (‘high risk’)? In these pts you just do DXA scan straight away without calculating risk.

A

> 50yrs with Hx of fragility fracture= offer DXA scan

<40yrs with major RF for fragility fracture= DXA scan then refer to specialist in Tx of osteop depending on BMD T-score

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581
Q

What is the BMD T-score?

A

the number of standard deviations below the mean BMD of young adults at their peak bone mass.

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582
Q

How to calculate 10 yr fragility fracture risk in pt with suspected osteoporosis? What do you do with the results?

A
  • QFracture or FRAX

High risk= DXA scan to confirm osteop

Intermediate risk= close to threshold and have RFs (eg. taking high dose oral corticosteroids)= DXA scan

Low risk= lifestyle advice and NO scan

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583
Q

What RF for osteoporosis may not be included in FRAX?

A

pt taking high dose oral corticosteroids

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584
Q

Who should be offered bisphosphonates in suspected osteoporosis?

A

with BMD T-score of -2.5 or lower

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585
Q

Mx of osteoporosis?

A

1) 10yr fragility fracture risk score unless ‘high risk’

2) DXA scan for BMD if high risk score/intermediate

3) BMD T-score -2.5 or lower= bisphosphonates
- consider HRT in younger postmen women to reduce risk of fracture

4) manage RFs= smoking, alcohol, Ca & vit D def; falls risk

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586
Q

Why is follow up needed following starting Tx for osteoporosis?

A
  • adverse effects of bone-sparing Tx
  • adherence
  • need for continuing bisphosphonate after 5yrs
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587
Q

Consider assessing fragility fracture risk in who?

A
  • all women 65yrs+ and all men 75yrs+
  • < them ages if RF= previous frag fracture; Hx of falls; current/freq use of oral corticosteroids; FHx hip fracture; BMI <18.5; smoking; alcohol >14units; have secondary causes for osteoporosis
  • Do not assess if <50yrs or <40yrs unless major RF
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588
Q

Do not routinely assess fracture risk in pt <50yrs unless they have what major RFs?

A

Current or frequent use of oral corticosteroids.

Untreated premature menopause.

A previous fragility fracture.

589
Q

Do not routinely assess fracture risk in pt <40yrs unless they have what major RFs?

A

Current or recent use of high-dose oral corticosteroids equivalent to, or more than, 7.5 mg prednisolone daily for 3 months or more.

A previous major osteoporotic fracture.

History of multiple fragility fractures.

590
Q

Consider assessing fracture risk in pt taking what meds, esp in presence of other RFs?

A
  • SSRI
  • anti-epileptic= carbamazepine
  • aromatase inhib eg. exemastane, anastrozole
  • gonadotropin-releasing hormone agonists eg. goserelin
  • PPI
  • thiazolidinediones eg. pioglitazone
  • glitazones
591
Q

Non-osteoporotic causes for fragility fracture?

A
  • met bone ca
  • multiple myeloma
  • osteomalacia
  • Pagets
592
Q

Secondary causes of osteoporosis (eg. pt with fragility fracture despite being low risk)?

A
  • endocrine= untreated premature menopause; DM; hyperthyroidism; hypogonadism in men
  • RA
  • GI that cause malabsorption= crohns; UC; coeliac; chronic pancreatitis
  • chronic liver disease= hep B, hep C, NAFLD
  • COPD
593
Q

Osteoporosis: offer a dual-energy X-ray absorptiometry (DXA) scan to measure bone mineral density (BMD) without calculating the fragility fracture risk in people….

A

Over 50 years of age with a history of fragility fracture.

Younger than 40 years of age who have a major risk factor for fragility fracture — depending on the BMD T-score, refer to a specialist experienced in the treatment of osteoporosis.

594
Q

Osteoporosis: when can drug Tx without a DXA scan be considered?

A

in pts with vertebral fracture

595
Q

Osteoporosis: offer oral bisphosphonates to pt taking corticosteroid therapy without waiting for BMD assessment (should follow later) if they have what RFs?

A

A prior fragility fracture.

Women age 70 years or over.

Postmenopausal women, and men age 50 years or over taking high dose glucocorticoids (7.5 mg or more of prednisolone daily or equivalent over 3 months).

Postmenopausal women, and men age 50 years or over with a FRAX probability of major osteoporotic fracture or of hip fracture exceeding the intervention threshold.

596
Q

What pts are at risk of Vit D def?

A

> 65yrs

not exposed to much sunlight (indoors or wear clothes that cover whole body)

597
Q

Recommended calcium intake for pt at increased risk of fragility fracture (osteoporosis)?

A

1000mg/day at least

598
Q

What are the QFracture and FRAX risk assessment toold for osteoporosis?

A

predict the absolute risk of hip fracture, and major osteoporotic fractures (spine, wrist, or shoulder) over 10 years.

599
Q

What score is considered high, intermediate and low risk according to the QFracture and FRAX score for a fragility fracture (osteoporosis)?

A

QFracture:
- High= 10% or more
- I= below 10% but close
to
- Low= below 10%

FRAX:
- high= red zone of risk chart
- i= amber
- low= green

600
Q

What factors foes the FRAX score underestimate (when calculating fragility fracture risk)?

A

Regular use of corticosteroids equivalent to or less than 5 mg prednisolone daily.

Use of corticosteroids more than or equivalent to 7.5 mg prednisolone daily for more than 3 months.

A history of multiple fragility fractures.

High alcohol intake.

Heavy smoking.

601
Q

Osteoporosis: fracture risk above the recommended threshold eg. 10%?

A

offer DXA scan

602
Q

DXA scan stands for?

A

dual-energy x-ray absorptiometry scan

603
Q

DXA scan in osteoporosis= T score -2.5 or less?

A

offer bisphosphonates (bone-sparing drug Tx)

604
Q

DXA scan in osteoporosis= T score greater than -2.5?

A

modify RFs, treat underlying conditions and repeat DXA at appropriate interval eg. 2yrs

605
Q

Fragility fracture risk intermediate eg. close to 10% but below, and they have RFs that may be underestimated by FRAX?

A

DXA scan to measure BMD and offer Tx if T-score -2.5 or less

606
Q

Drug Tx for osteoporosis?

A

alendronate 70 mg once weekly, or risedronate 35 mg once weekly first-line

  • 2nd line= ibandronate 150mg once monthly
  • still not tolerated= specialist referral for eg. zoledronic acid or denosumab

?vit D and Ca supplements depending on current intake

607
Q

Calcium management in osteoporosis?

A

If the person’s calcium intake is adequate (700 mg/day)= 10 micrograms (400 international units) of vitamin D (without calcium) for people not exposed to much sunlight.

Inadequate=
- 10 micrograms (400 international units) of vitamin D with at least 1000 mg of calcium daily.
- Prescribe 20 micrograms (800 international units) of vitamin D with at least 1000 mg of calcium daily for elderly people who are housebound or living in a nursing home

608
Q

Lifestyle advice for pt with osteoporosis?

A
  • regular exercise to improve muscle strenth
  • balanced diet
  • stop smoking
  • cut down alcohol
609
Q

After starting bone-sparing Tx for osteoporosis, what should you do?

A
  • follow up: check tolerance after 12-16w
  • then at 12m
  • then at 5yrs
610
Q

Atypical fracture in osteoporosis?

A

new onset hip, groin or thigh pain= stop osteop Tx and arrange x-ray of femur

611
Q

What if pt has osteoporosis but requires oral corticosteoirds?

A

maintain bone protection

612
Q

What when pt has been on bisphosphonates for osteoporosis for 5yrs?

A

follow up

  • if still high risk (started Tx at 70yrs+; previous hip/vertebral fracture or 1+ fracture after starting Tx)= continue for at least 10yrs
  • in others= DXA scan: continue for another 5yrs if T score -2.5 or less; if greater then pause treatment for 1.5-3yrs then reasssess
613
Q

When to reassess fracture risk at anytime in pt with osteoporosis?

A

if re-fracture occurs or clinical RFs change

614
Q

Pt sustained osteoporotic fracture whilst on bisphosphonates?

A

check adherence and exclude secondary causes for oestop; refer to specialist for drug Tx advice

615
Q

Osteoporosis: If bisphosphonate treatment is discontinued and no new fracture occurs?

A

reassess fracture risk after 18 months for risedronate and ibandronate, 2 years for alendronate, and 3 years for zoledronate to inform whether treatment should be restarted.

616
Q

Bisphosphonates MOA?

A

Analogues of pyrophosphate, a molecule that decreases demineralisation in bone. They inhibit osteoclasts by reducing recruitment and promoting apoptosis

617
Q

Clinical uses for bisphosphonates?

A
  • prevention and Tx of osteoporosis
  • hypercalcaemia
  • Paget’s disease
  • pain from bone mets
618
Q

Adverse effects of bisphosphonates?

A
  • oesophagitis and oesophageal ulcers
  • osteonecrosis of the jaw
  • increased risk of atypical stress fractures of proximal femoral shaft
  • acute phase response
  • hypocalcaemia
619
Q

Osteonecrosis of the jaw with bisphosphonates?

A

greater risk for pts having IV in Tx of ca rather than for osteoporosis or Pagets

poor dental hygiene/prior dental procedure also RF

620
Q

All pts with cancer before bisphosphonate treatment should have what?

A

if poor dental status then they should have dental check up as it is a RF for osteonecrosis of the jaw

621
Q

Acute phase response when taking bisphosphonates eg. for osteoporosis?

A

fever, myalgia and arthralgia may occur following administration

622
Q

Why is hypocalcaemia an adverse effect of bisphosphonates?

A

due to reduced calcium efflux from bone; usually clinically unimportant

623
Q

How should pt take bisphosphonates for osteoporosis?

A

‘Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking tablet’

624
Q

What should be done before starting a pt on bisphosphonates for osteoporosis?

A

hypocalcaemia/vit D def should be corrected

but for osteoporosis, calcium should only be prescribed if dietary intake is inadequate; Vit D supplements are normally given

625
Q

Sometimes bisphosphonates are recommended to be stopped at 5yrs in who?

A

patient is < 75-years-old

femoral neck T-score of > -2.5

low risk according to FRAX/NOGG

626
Q

Patients who’ve had a fragility fracture and are >= 75 years of age are presumed to have….

A

underlying osteoporosis and should be started on first-line therapy (an oral bisphosphonate), without the need for a DEXA scan

If a patient is under the age of 75 years a DEXA scan should be arranged. These results can then be entered into a FRAX assessment (along with the fact that they’ve had a fracture) to determine the patients ongoing fracture risk.

627
Q

79-year-old woman falls over on to an outstretched hand and sustains a Colles’ fracture (fracture of the distal radius).

A

Given her age she is presumed to have osteoporosis and therefore started on oral alendronate 70mg once weekly. No DEXA scan is arranged.

628
Q

Osteoporosis: A DEXA scan should be offered without calculating the fragilty risk score in the following situations?

A

> 50 years of age with a history of fragility fracture

< 40 years of age who have a major risk factor for fragility fracture - these patients should be referred to a specialist depending on the T-score

before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer)

629
Q

QFracture
if the 10-year fracture risk is ≥ 10% then

A

a DEXA scan should be arranged

630
Q

FRAX
patients in the orange zone should have…
red zone…

A

patients in the orange zone should have a DEXA scan if not already done to further refine their 10-year risk

patients in the red zone should also have a DEXA scan if not already done to act as a baseline and guide drug treatment

631
Q

Osteoporosis: NICE recommend that we recalculate a patient’s risk (i.e. repeat the FRAX/QFracture)?

A

if the original calculated risk was in the region of the intervention threshold for a proposed treatment and only after a minimum of 2 years, or

when there has been a change in the person’s risk factors

632
Q

Osteoporosis: risk factors that are used by major risk assessment tools such as FRAX…

A

history of glucocorticoid use
rheumatoid arthritis
alcohol excess
history of parental hip fracture
low body mass index
current smoking

633
Q

RFs for osteoporosis other than those including in FRAX?

A
  • sedentary lifestyle
  • premature menopause
  • Caucasians and Asians
  • hyperthyroid, hypogonadism (eg. Turners, testosterone def), growth hormone def, hyperparathyroidism, DM
  • multiple myeloma, lymphoma
  • IBD, malabsorption (coeliac), gastrectomy, liver disease
  • CKD
  • osteogenesis imperfecta, homocystinuria
634
Q

What bloods should be done as a minimum in suspected osteoporosis following a fragility fracture (eg. to rule out other causes)?

A

FBC
U&Es
LFTs
Bone profile
CRP
TFTs

635
Q

DEXA scan: T score?

A

based on bone mass of young reference population

T score of -1.0 means bone mass of one standard deviation below that of young reference population

636
Q

DEXA scan: Z score?

A

adjusted for age, gender and ethnic factors

637
Q

DEXA scan: T score values?

A

> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis

638
Q

DEXA scan: osteoporosis?

A

< -2.5

639
Q

DEXA scan: osteopaenia?

A

-1.0 to -2.5

640
Q

DEXA scan: normal?

A

> -1.0

641
Q

Most important RF for osteoporosis?

A

use of corticosteroids

risk rises significantly once a patient is taking the equivalent of prednisolone 7.5mg a day for 3 or more months.

642
Q

if it likely that the patient will have to take steroids for at least 3 months then we should start what

A

bone protection straight away rather than waiting until 3m has elapsed

643
Q

patient with newly diagnosed polymyalgia rheumatica. As it is very likely they will be on a significant dose of prednisolone for greater than 3 months what should be started immediately

A

bone protection

644
Q

Management of patients at risk of corticosteroid-induced osteoporosis: patients can be divided into what 2 groups?

A
  1. Patients over the age of 65 years or those who’ve previously had a fragility fracture should be offered bone protection.
  2. Patients under the age of 65 years should be offered a bone density scan, with further management dependent
645
Q

Management of patients at risk of corticosteroid-induced osteoporosis= ? for pts under 65yrs who had bone density scan and now need Mx?

A

T >0= reassure

T 0- -1.5= repeat scan in 1-3yrs

T <-1.5= offer bone protection

646
Q

First line for bone protection eg. corticosteroid-induced osteoporosis?

A

alendronate
may need Ca and Vit D too

647
Q

1st line bone protection following hip fracture?

A

IV zoledronate

648
Q

Postmenopausal women, and men age ≥50, who are treated with oral glucocorticoids: what should you do?

A

if starting ≥7.5 mg/day prednisolone or equivalent for the next 3 months, start bone protective treatment at the same time (alendronate or risedronate)

don’t wait for DEXA scan before starting Tx

+ general osteoporosis Mx

649
Q

How long should you plan to prescribe oral vs IV bisphosphonates?

A

oral= at least 5yrs

IV= at least 3yrs

650
Q

How do bisphosphonates work?

A

bind to hydroxyapatite in bone, inhibiting osteoclast-mediated bone resorption

651
Q

Denosumab MOA eg. for osteoporosis?

A

human monoclonal antibody that inhibits RANK ligand, which in turn inhibits the maturation of osteoclasts

also used for cancer patients with bone metastases to reduce skeletal-related events.

given as a single subcutaneous injection every 6 months

652
Q

Raloxifene eg. for osteoporosis MOA?

A

selective oestrogen receptor modulator (SERM)

has been shown to prevent bone loss and to reduce the risk of vertebral fractures, but has not yet been shown to reduce the risk of non-vertebral fractures

has been shown to increase bone density in the spine and proximal femur

may worsen menopausal symptoms

increased risk of thromboembolic events

may decrease the risk of breast cancer

653
Q

Strontium ranelate eg. for osteoporosis MOA?

A

‘dual action bone agent’ - increases deposition of new bone by osteoblasts (promotes differentiation of pre-osteoblast to osteoblast) and reduces the resorption of bone by inhibiting osteoclasts

concerns regarding the safety profile of strontium have been raised recently. It should only be prescribed by a specialist in secondary care

should only be used by people for whom there are no other treatments for osteoporosis

increased risk of cardiovascular events: any history of cardiovascular disease or significant risk of cardiovascular disease is a contraindication

not used in patients with a history of venous thromboembolism

may cause serious skin reactions such as Stevens Johnson syndrome

654
Q

Teriparatide MOA eg. for osteoporosis?

A

recombinant form of parathyroid hormone

very effective at increasing bone mineral density but role in the management of osteoporosis yet to be clearly defined

655
Q

Romosozumab MOA eg. for osteoporosis?

A

a monoclonal antibody that inhibits sclerostin, thereby increasing bone formation and decreasing bone resorption

this dual action significantly improves bone density and reduces fracture risk.

656
Q

Definition of osteoporosis?

A

presence of bone mineral density (BMD) of less than 2.5 standard deviations (SD) below the young adult mean density.

657
Q

Around ?% of post-menopausal women will suffer an osteoporotic fracture at some point.

A

50%

658
Q

What does the DEXA scan look at?

A

hip and lumbar spine

659
Q

Polymyalgia rheumatica (PMR)?

A

relatively common condition seen in older pts characterised by muscle stiffness and raised inflam markers

660
Q

Cause of polymyalgia rheumatica?

A

condition is closely related to temporal arteritis but underlying cause not understood, does not appear to be vasculitic process

661
Q

Features of polymyalgia rheumatica?

A
  • typically >60yrs
  • rapid onset eg. <1m
  • aching, morning stiffness in proximal limb muscles
  • WEAKNESS NOT CONSIDERED A SYMPTOM
  • mild polyarthralgia, lethargy, depression, low grade fever, anorexia, night sweats
662
Q

Pt with new temporal arteritis with a history of aching and morning stiffness in proximal limb muscles eg. neck and shoulders and pelvic girdle- what is the background condition?

A

polymyalgia rheumatica

663
Q

Ix for polymyalgia rheumatica?

A

raised inflam markers eg. ESR >40

creatine kinase and EMG normal

664
Q

Tx for polymyalgia rheumatica?

A

prednisolone eg. 15mg/od

typically respond dramatically, if they don’t then consider alternative diagnosis

665
Q

Definition of polymyalgia rheumatica?

A

chronic, systemic, rheumatic inflam disease characterised by pain and morning stiffness in neck, shoulder and pelvic girdle

666
Q

RFs for polymyalgia rheumatica?

A
  • older age
  • female
  • northern european
  • infection eg. mycoplasma, chlamydia, pneumonia and parovirus B19
667
Q

One of most common indications for long term corticosteroid Tx?

A

polymyalgia rheumatica

668
Q

Cx of polymyalgia rheumatica?

A

GCA (may be abrupt in early course of PMR)

Cx of long term corticosteroids

669
Q

Prognosis of polymyalgia rheumatica?

A

usually resolves after few days of steroid Tx; treatment is often needed for 1-2yrs and some need low dose for several yrs

relapse is common but responds to restarting/increasing steroid dose

670
Q

Key features of polymyalgia rheumatica?

A

Bilateral shoulder and/or pelvic girdle pain lasting more than 2 weeks.

Morning stiffness (for more than 45 minutes).

Evidence of an acute phase response.

Other more general symptoms, such as low-grade fever, fatigue, anorexia, weight loss, or depression.

671
Q

Diagnosis of PMR?

A

working diagnosis in the combination of:
- core features
- exclusion of differentials
- +ve response to oral corticosteroids within 1w
- normal inflam markers within 4w

672
Q

Mx of person with working diagnosis of PMR involves what?

A

Gradually reducing the dose of corticosteroids when symptoms are fully controlled, adjusting the magnitude of each dose reduction and the duration at each dose to avoid relapses.

Assessing for, and managing, symptoms of relapse, GCA, and steroid-related adverse effects.

Assessing and managing the risk of osteoporosis.

673
Q

Referral to rheumtology in pts with PMR if?

A
  • not possible to reduce steroids at reasonable intervals without causing relapse
  • steroids needed for >2yrs
674
Q

Type of pain in PMR?

A

unilateral then quickly is bilateral

worsens with movement

interferes with sleep

shoulder pain may radiate to elbows

hip and neck pain; hip pain may radiate to knees

675
Q

Stiffness in PMR?

A

at least 45mins after waking or periods of rest

may be difficult to turn over in bed, rise from chair or raise arms above shoulders

676
Q

Morning stiffness >45mins and difficulty rising from a chair?

A

?polymyalgia rheumatica

muscle strength not impaired but pain may restrict movement

677
Q

What additional symptoms may be present in polymyalgia rhuematica?

A

peripheral MSK signs:
- carpal tunnel
- peripheral arthritis (knees and wrists): asymmetric and self limiting
- swelling with pitting oedema of hands, wrists, feet and ankles

678
Q

PMR follow up?

A

after 1w of pred

then 3-4w of Tx: consider reducing dose, recheck ESR/plasma viscosity and/or CRP to assess Tx response

679
Q

Pt with core symptoms of PMR and is >50yrs what should you do?

A
  • request ESR/plasma viscosity and/or CRP= raised supports diagnosis but can be normal
  • Exclude GCA immediately (as may cause vision loss)
  • arrange tests in all pts to rule out other conditions before starting steroids= FBC, U&E, LFT, Ca, ALP, protein electrophoresis, TSH, creatine kinase, RF, urine dip; consider= urine sample for Bence Jones protein, ANA and anti-CCP, CXR
  • if PMR most likely= trial prednisolone
680
Q

When can you make a working diagnosis of PMR?

A

if pt reports improvement of 70%+ within 1w of steroids and normalisation of inflam markers within 4w

if lesser response, consider uping dose to 20mg

681
Q

Typical course of Tx for PMR?

A

Typically, treatment is required for between 1–2 years.

Continue prednisolone 15 mg each day until symptoms are fully controlled (usually 3 weeks), then

Reduce the dose to 12.5 mg each day for 3 weeks, then

Reduce the dose to 10 mg each day for 4–6 weeks, then

Reduce the dose by 1 mg every 4–8 weeks until treatment is stopped.

682
Q

What must pt with PMR be provided with when started on prednisolone?

A

blue steroid card= don’t stop abruptly; avoid close contacts who have chickenpox, shingles or measles if no immunity

683
Q

What to measure at 3 monthly reviews for PMR?

A

FBC, ESR/CRP, U&E, BP and glucose

684
Q

Differential diagnosis for PMR?

A
  • degenerative disorders= cervical and L spondylosis, osteoarthritis, bilateral adhesive capsulitis (frozen shoulder) and rotator cuff disorders
  • thyroid disease and hyperparathyroidsm
  • viral illness
  • chronic osteomyelitis
  • TB
  • infective endocarditis
  • RA
  • spondyloarthropathy
  • SLE
  • Ca
  • myositis or myalgia due to statins
  • PMR like syndrome due to quinidine
  • osteomalacia
  • fibromyalgia
  • chronic fatigue syndrome
685
Q

Reactive arthritis is part of what group of conditions?

A

HLA-B27 seronegative spondyloarthropathies

686
Q

What was reactive arthritis previously called?

A

Reiter’s triad

687
Q

(Reiter’s) Triad in reactive arthritis?

A

urethritis, conjunctivitis and arthritis

‘can’t see, pee or climb a tree’

688
Q

Reactive arthritis?

A

arthritis that develops following an infection where the organism cannot be recovered from the joint

eg. post-STI or post-dysenteric (GI disease)

689
Q

Cant see, pee or climb a tree….

Conjunctivitis, urethritis and arthritis

A

reactive arthritis

690
Q

Organisms most commonly associated with reactive arthritis?

A

Post-STI (m>f)= chlamydia trachomatis

Post-dysenteric form (m&f same)= shigella flexneri; salmonella typhimurium; salmonella enteritidis; yersina enterocolitica; campylobacter

691
Q

Mx of reactive arthritis?

A
  • analgesia, NSAIDs, intra-articular steroids
  • persistent= sulfasalazine and methotrexate
  • rarely lasts more than 12m
692
Q

Features of reactive arthritis?

A
  • arthritis= asymmetrical oligoarthritis of lower limbs
  • urethritis symptoms
  • eye= conjunctivitis (10-30%); anterior uveitis
  • dactylitis
  • skin= circinate balanitis and keratoderma blenorrhagica

“cant see, wee or climb a tree”

693
Q

Circinate balanitis in reactive arthritis?

A

painless vesicles on the coronal margin of the prepuce (foreskin/skin surrounding clitoris)

694
Q

Keratoderma blenorrhagica in reactive arthritis?

A

waxy yellow/brown papules on palms and soles

695
Q

Methotrexate MOA?

A

antimetabolite that inhibits dihydrofolate reductase, an enzyme essential for synthesis of purines and pyrimidines

696
Q

Why is careful prescribing and close monitoring of methotrexate important?

A

very effective in controlling disease but the side-effects can be life threatening

697
Q

Indications for methotrexate?

A
  • inflam arthritis, esp RA
  • psoriasis
  • some chemo ALL
698
Q

Adverse effects of methotrexate?

A
  • mucositis
  • myelosuppression
  • pneumonitis
  • pulmonary fibrosis
  • liver fibrosis
699
Q

Most common pulmonary adverse effect of methotrexate?

A

pneumonitis

  • similar disease pattern to hypersensitivity pneumonitis secondary to inhaled organic antigens
  • typically develops within a year of starting treatment, either acutely or subacutely
  • presents with non-productive cough, dyspnoea, malaise, fever
700
Q

Methotrexate in pregnancy?

A

avoid pregnancy for at least 6m after stopping methotrexate

men using methotrexate need to use effective contraception for at least 6m after Tx

701
Q

How is methotrexate taken?

A

7.5mg weekly starting dose (not daily)

  • only one strength of methotrexate tablet should be prescribed (2.5mg)
  • co-prescribed with 5mg folic acid
702
Q

What needs to be co-prescribed with methotrextae?

A

5mg folic acid once weekly, take >24hrs after methotrexate dose

703
Q

What needs to be monitored in pts taking methotrexate?

A

FBC, U&E (renal function) and LFTs before starting, then repeated weekly until therapy stabilised and then monitor every 2-3m

704
Q

Methotrexate interactions?

A

trimethorpim and
co-trimoxazole = avoid as increases risk of marrow aplasia

high dose aspirin

705
Q

What increases the risk of methotrexate toxicity?

A

high dose aspirin increases risk of methotrexate toxicity secondary to reduced excretion

706
Q

Tx for methotrexate toxicity?

A

folinic acid

707
Q

Rheumatoid arthritis (RA)?

A

chronic systemic inflam disease

708
Q

How does RA present?

A

inflam arthritis affecting small joints of hands and feed symmetrically and equally; any synovial joint can be involved

as it progresses, any system can be affected so increased risk of premature death

709
Q

Cx and cormorbidities of RA?

A

CVD, osteoporosis, anaemia, infection

710
Q

What population does RA typically affect?

A

women > men
peak onset 30-50yrs

711
Q

Clinical features of synovitis in RA?

A

pain, swelling heat and stiffness in affected joints

712
Q

synovitis vs arthritis?

A

Synovitis is swelling in the synovial membrane that lines some of your joints that leads to arthritis (acute or chronic joint inflammation in the joint)

713
Q

Ix for RA?

A
  • clinical= if suspected refer urgently within 3d for specialist assessment to confirm within 3w

to speed up diagnosis:
- bloods= rheumatoid factor +ve in 60-70%
- if -ve in RF= test for anti-CCP (80%)
- x-rays of hands and feet= severity

714
Q

When should you suspect RA and so refer the pt for assessment?

A

1 or more of…
- small joints of the hands or feet affected
- more than 1 joint affected
- present for 3m+

715
Q

Mx for RA?

A

1) NSAIDs + PPI whilst waiting specialist assessment

2) specialist MX:
cDMARD monotherapy eg. oral methotrexate, leflunomide or sulfasalazine. Dose increased depending on tolerance.

2) may give short-term oral/intramuscular/intra-articular corticosteroids whilst waiting for DMARD to start working

3) not responded= combination of DMARDs

4) severe and still not responded= methotrexate + biological DMARDs

716
Q

Mx of RA flare?

A
  • exclude septic arthritis
  • specialist advice
  • short term corticosteroids intra-articular= methylprednisolone acetate ; if can’t then intramuscular; if can’t then oral
717
Q

When to refer pt with RA for surgical opinion?

A
  • no response to Mx
  • persistant pain: joint damage or soft tissue cause
  • worsening joint function
  • progressive deformity
  • persistent localised synovitis
  • if Cx= imminent or actual tendon rupture, nerve compression, stress fracture
718
Q

CP of RA?

A

symmetrical synovitis= pain, swelling, heat and stiffness in affected joints

most common in small joints of small hands and feet, but any synovial joint can be affected

pain worse at rest

swelling= around joint ‘boggy’ on palpation not boney

siffness= early morning >1hr

  • may have rheumatoid nodules; systemic features (fever, fatigue, sweats, weight loss); FHx and extra-articular features
719
Q

Rheumatoid nodules in RA?

A

hard firm swellings over extensor surfaces

720
Q

Extra-articular features in RA?

A

vasculitis or invl of other body systems eg. eye, lungs and heart

721
Q

Type of presentation in RA?

A

normally insidious but can be rapid or relapsing and remitting (palindromic presentation)

722
Q

In RA, persistent synovitis and poor prognosis is more likey when…

A
  • greater number of joints affected
  • swelling and tenderness
  • PIPs and MCP joints affected and there is symmetry
  • +ve MCP squeeze test
723
Q

What presentation is associated with ability to diagnose RA from other diagnoses?

A

inability to make a fist or flex fingers in RA

724
Q

What Ix can be done in RA to speed up diagnosis and act as baseline measure prior to Tx?

A
  • FBC, renal (U&E) and LFTs
  • CRP or ESR (normal in 40%)
725
Q

Clinically suspect RA (have 1 of: small joints of hand or feet affected, more than one joint, been >3m) but normal acute phase response, negative anti-CCP and RF?

A

still refer urgently within 3d for specialist assessment within 3w as clinically suspect

726
Q

Can you prescribe glucocorticoids in primary care for RA whilst awaiting for specialist assessment?

A

no they may mask the clinical features and delay diagnosis, wait until assessment carried out

727
Q

Target of Tx in RA?

A

achieve a target of remission of low disease activity if remission cannot be achieved

728
Q

What does cDMARD stand for?

A

conventional disease-modifying anti-rheumatic drug

729
Q

What can be alternative to a DMARD eg. methotrexate in RA if pt has mild or palindromic disease?

A

hydroxychloroquine

730
Q

How long until DMARD takes affect in RA?

A

can take 2-3m

731
Q

Other causes of worsening joint symptoms in RA other than a flare?

A
  • avascular necrosis= sudden pain in pt taking steroids in absence of synovitis
  • nerve root compression
  • anaemia, infection
  • failure of meds to control symptoms
  • failure to take meds regularly
  • osteoporotic fracture
  • secondary osteoarthritis
  • psychological/social problems
732
Q

Differential diagnosis for RA?

A
  • connective tissue disorders eg. SLE
  • fibromyalgia
  • infectious arthritis
  • osteoarthritis
  • polyarticular gout
  • PMR
  • psoriatic arthritis
  • reactive arthritis
  • sarcoidosis
  • septic arthritis
  • seronegative spondyloarthritis= ?psoriais, back pain or bowel problenms
733
Q

Symmetrical distal polyarthritis

A

RA

734
Q

Most common gene associated with RA?

A

HLA DR4

735
Q

Rheumatoid factor (RF)?

A

autoantibody present in around 70% of RA patients. It targets the Fc portion of the immunoglobulin G (IgG). All antibodies (immunoglobulins) have an Fc portion that interacts with other parts of the immune system. Rheumatoid factor causes immune system activation against the patient’s own IgG, resulting in systemic inflammation. Rheumatoid factor is most often IgM but can be other types of immunoglobulin.

736
Q

what does anti-CCP antibodies stand for (in RA)?

A

Anti-cyclic citrullinated peptide antibodies

737
Q

Anti-CCP antibodies?

A

More sensitive and specific than rheumatoid factor in RA. They are positive in around 80% of patients with rheumatoid arthritis. They often pre-date the development of rheumatoid arthritis and indicate that a patient will develop the condition at some point.

738
Q

most common joints affected in RA?

A

MCP joints
PIP joints
wrist
MTP joints in foot

739
Q

MCP joints

A

Metacarpophalangeal joints (knuckle)

740
Q

PIP joints

A

Proximal interphalangeal

741
Q

MTP joints

A

Metatarsophalangeal joints (in foot- between metatarsal bones and proximal phalanges)

742
Q

Enlarged and painful distal interphalangeal joints

A

? Heberden’s nodes due to osteoarthritis.

743
Q

What large joints may be affected in RA?

A

ankle, knee, hips, shoulders, C spine (not L)

744
Q

Arthritis worse with rest, improve with activity. Worse in morning.

A

RA

745
Q

Morning stiffness >30mins

A

RA

746
Q

Arthritis worse with activity and improve with rest

A

OA

747
Q

Morning stiffness <30mins

A

OA

748
Q

Palindromic rheumatism?

A

self-limiting episodes of inflammatory arthritis, with pain, stiffness and swelling typically affecting only a few joints.

symptoms last days, then completely resolve

Joints appear normal between episodes.

RF or anti-CCP antibodies may indicate that it will progress to rheumatoid arthritis.

749
Q

Same 4 hand signs in RA?

A

Z-shaped deformity

Swan neck deformity

Boutonniere deformity

Ulnar deviation

750
Q

RA hand signs: Z-shaped deformity?

A

to the thumb

751
Q

RA hand signs: swan neck derformity?

A

hyperextended PIP and flexed DIP

752
Q

RA hand signs: boutonniere deformity?

A

hyperextended DIP and flexed PIP

753
Q

RA hand signs: ulnar deviation?

A

ulnar deviation of the fingers at the MCP joints

754
Q

What causes Boutonniere deformity in RA?

A

Tear in the central slip of the extensor components at the PIP joint. The central slip connects to the middle phalanx at the PIP, and the lateral bands go around the PIP and connect to the distal phalanx. When the patient tries to straighten their finger, the lateral bands pull on the distal phalanx, causing the distal interphalangeal (DIP) joint to hyperextend and the PIP joint to flex.

755
Q

What causes swan neck deformity in RA?

A

opposite of Boutonnieres deformity. It is caused by an extensor mechanism imbalance, causing flexion of the DIP joint and extension of the PIP joint.

756
Q

Atlantoaxial Subluxation in RA?

A

Occurs in the C spine.

Synovitis and damage to the ligaments around the odontoid peg of the axis (C2) allow it to shift within the atlas (C1). Subluxation can cause spinal cord compression and is an emergency.

Needs to be considered when a patient is having a general anaesthetic and requires intubation.

MRI can be used to visualise changes in these areas as part of a pre-operative assessment.

757
Q

Name some extra-articular manifestations of RA?

A
  • eye manifestations
  • Pulmonary fibrosis
  • Felty’s syndrome
  • Sjögren’s syndrome (with dry eyes and dry mouth)
  • Anaemia of chronic disease
  • CVD
  • Rheumatoid nodules
  • Lymphadenopathy
  • Carpel tunnel syndrome
  • Amyloidosis
  • Bronchiolitis obliterans
  • Caplan syndrome
758
Q

Felty’s syndrome?

A

extra-articular manifestation of RA

triad= RA, neutropenia and splenomegaly

759
Q

RA, neutropenia and splenomegaly

A

Felty’s syndrome

760
Q

Bronchiolitis obliterans in RA?

A

small airway destruction and airflow obstruction in the lungs

761
Q

Caplan syndrome?

A

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

762
Q

Eye manifestations in RA?

A

Dry eye syndrome (keratoconjunctivitis sicca)

Episcleritis

Scleritis

Keratitis

Cataracts (secondary to steroids)

Retinopathy (secondary to hydroxychloroquine)

763
Q

X-ray changes in RA?

A

Periarticular osteopenia

Joint destruction & deformity (advanced)

L.oss of joint space
E.rosions (boney)
S.oft tissue swelling
S.ubluxation

764
Q

Scoring systems in RA?

A

Health Assessment Questionnaire (HAQ) measures functional ability= response to Tx

Disease Activity Score 28 Joints (DAS28) score is used in monitoring disease activity and response to treatment. It involves assessing 28 joints and assigning points for=
Swollen joints
Tender joints
The ESR or CRP result

765
Q

What is considered the safest cDMARD in RA in pregnancy?

A

Hydroxychloroquine and sulfasalazine

766
Q

Examples of biological therapies that can be used in RA (interact with immune system to reduce inflam)?

A

Tumour necrosis factor (TNF) inhibitors (e.g., adalimumab, infliximab, etanercept, golimumab and certolizumab)

Anti-CD20 on B cells (e.g., rituximab)

Anti-interleukin-6 inhibitors (e.g., sarilumab and tocilizumab)

JAK inhibitors (e.g., upadacitinib, tofacitinib and baricitinib)

T-cell co-stimulation inhibitors (e.g., abatacept)

767
Q

How do TNF inhibitors work in RA?

A

Tumour necrosis factor is a cytokine involved in stimulating inflammation. Blocking TNF reduces inflammation.

768
Q

Main biologics to remember for RA?

A
  • TNF inhibitors= adalimumab, infliximab, entanercept
  • Rituximab ( monoclonal antibody that targets the CD20 proteins on the surface of B cells)
769
Q

Adverse effects of biologics in RA?

A

cause immunosuppression, increasing the risk of infection, certain cancers (e.g., skin) and reactivation of latent TB.

770
Q

Why does folic acid need to be co-prescribed with methotrexate?

A

methotrexate interferes with folate metabolism and suppresses the immune system

771
Q

RA drug side effects= methotrexate?

A

Bone marrow suppression and leukopenia, and highly teratogenic

772
Q

RA drug side effects= leflunomide?

A

Hypertension and peripheral neuropathy

773
Q

RA drug side effects= sulfasalazine?

A

Orange urine and male infertility (reduces sperm count)

774
Q

RA drug side effects= hydroxychloroquine?

A

Retinal toxicity, blue-grey skin pigmentation and hair bleaching

775
Q

RA drug side effects= anti-TNF medications?

A

Reactivation of tuberculosis

775
Q

RA drug side effects= rituximab?

A

Night sweats and thrombocytopenia

776
Q

American College of Rheymatology criteria for RA?

A

need 6/10 to diagnose

A) joint involvement= 2-10 large joints (1 point); 1-3 small (2); 4-10 small (3); 10 joints (5)

B) serology= negative RF and ACPP (0); low positive RF or ACPP (2); high positive (3)

C) acute phase reactants= abnormal CRP or ESR (1)

D) duration= >6 w (1)

777
Q

Acute phase reactants in RA?

A

CRP/ESR

778
Q

How can RF be detected?

A

Rose-Waaler test: sheep red cell agglutination
Latex agglutination test (less specific)

779
Q

Conditions associated with RF other than RA?

A

Felty’s syndrome (around 100%)
Sjogren’s syndrome (around 50%)
infective endocarditis (around 50%)
SLE (= 20-30%)
systemic sclerosis (= 30%)
general population (= 5%)
rarely: TB, HBV, EBV, leprosy

780
Q

What pts with suspected RA should be tested for anti-CCP antibodies?

A

if RF negative

781
Q

How long can anti-CPP antibodies be detected for in RA?

A

may be detectable up to 10 years before the development of rheumatoid arthritis

allows early detection of patients suitable for aggressive anti-TNF therapy

782
Q

What is RF (in RA for example)?

A

circulating antibody (usually IgM) that reacts with the Fc portion of the patients own IgG.

1st line antibody test in suspected RA

783
Q

TNF-inhibitors in RA?

A

indication= inadequate response to at least two DMARDs including methotrexate

etanercept: recombinant human protein, acts as a decoy receptor for TNF-α, subcutaneous administration, can cause demyelination, risks include reactivation of tuberculosis

infliximab: monoclonal antibody, binds to TNF-α and prevents it from binding with TNF receptors, intravenous administration, risks include reactivation of tuberculosis

adalimumab: monoclonal antibody, subcutaneous administration

784
Q

Rituximab for RA?

A

anti-CD20 monoclonal antibody, results in B-cell depletion

two 1g intravenous infusions are given two weeks apart

infusion reactions are common

785
Q

Iatrogenic ocular manifestations in RA?

A

steroid-induced cataracts
chloroquine retinopathy

786
Q

Most common ocular manifestations in RA?

A

keratoconjunctivitis sicca (most common)

episcleritis (erythema)
scleritis (erythema and pain)
corneal ulceration
keratitis

787
Q

Mx of RA in pregnancy?

A

sulfasalazine and hydroxychloroquine

low-dose corticosteroids may be used in pregnancy to control symptoms

NSAIDs may be used until 32 weeks but after this time should be withdrawn due to the risk of early close of the ductus arteriosus

patients should be referred to an obstetric anaesthetist due to the risk of atlanto-axial subluxation

788
Q

When do pts with RA typically get flares if they are pregnant?

A

after delivery

789
Q

positive ‘squeeze test’ - discomfort on squeezing across the metacarpal or metatarsal joints

A

RA

790
Q

Are hand joint deformities an early or late sign in RA?

A

late

791
Q

Poor prognostic features in RA?

A

rheumatoid factor positive
anti-CCP antibodies
poor functional status at presentation
X-ray: early erosions (e.g. after < 2 years)
extra articular features e.g. nodules
HLA DR4
insidious onset

792
Q

Periarticular?

A

area surrounding the joint

793
Q

Most common cause of septic arthritis in adults?

A

staph aureus overall

young adults who are sexually active= N.gonorrhoeae (disseminated gonococcal infection)

794
Q

Most common cause of septic arthritis in adults (how is it spread)?

A

hematogenous spread,
may be from distant bacterial infections eg. abscesses

795
Q

Most common location of septic arthritis in adults?

A

knee

796
Q

Features of septic arthritis in adults?

A
  • acute swollen joint= restricted movement, warm to touch
  • fever in majority
797
Q

Ix for septic arthritis?

A
  • synovial fluid sampling under radiographic guidance
  • blood cultures
  • joint imaging
798
Q

What does synovial fluid sampling show in septic arthritis?

A
  • leucocytosis with neutrophil predominance
  • gram staining is negative in around 30-50% of cases
  • fluid culture is positive in patients with non-gonococcal septic arthritis
799
Q

When is fluid culture positive in septic arthritis (from synovial joint sampling)?

A

pts with non-gonococcal septic arthritis

800
Q

Mx of septic arthritis?

A

IV Abx that cover gram +ve cocci= flucloxacillin or clindamycin if penicillin allergic
- give 4-6w, switched from IV to oral after 2w

  • needle aspiration to decompress joint
  • may need arthroscopic lavage
801
Q

Most common joints affected in septic arthritis in children?

A

hip, knee, ankle

m>f

802
Q

Symptoms and signs of septic arthritis in children?

A

symptoms= joint pain, limp, fever, systemically unwell (lethargy)

signs= swollen red joint, typically only able to minimally move affected joint

803
Q

Ix for septic arthritis in children?

A

joint aspiration: for culture. Will show a raised WBC

raised inflammatory markers
blood cultures

804
Q

Criteria to diagnose septic arthritis in children?

A

Kocher criteria:
1) fever >38.5 degrees C
2) non-weight bearing
3) raised ESR
4) raised WCC

805
Q

How to pts with osteoporotic vertebral fractures typically present?

A
  • asymptomatic= my be incidental finding on x-ray
  • acute back pain
  • breathing difficulties= change in shape may compress organs eg. lungs, heart, intestine
  • GI problems= compression abdo organs
  • minority will have Hx of fall/trauma
806
Q

Signs of osteoporotic vertebral fracture?

A
  • loss of height= compress spinal vertebrae so reduction in length of spine
  • kyphosis (curved spine)
  • localised tenderness on palpation of spinous processess at fracture site
807
Q

Ix for osteoporotic vertebral fracture?

A

x-ray spine= wedging of vertebrae due to compression of bone, may show old fractures (sclerotic appearance)

2nd line= CT spine (extent of fracture) or MRI (differentiate from those caused by another pathology like tumour)

808
Q

Epidemiology of SLE?

A

F:M (9:1)

Afro-Caribbeans and Asian

onset 20-40yrs

809
Q

What does SLE stand for?

A

systemic lupus erythematosus

810
Q

What type of disease is SLE?

A

autoimmune disease= a type 3 hypersensitivity reaction

811
Q

What genes is SLE associated with?

A

HLA B8, DR2, DR3

812
Q

What is SLE thought to be caused by?

A

immune system dysregulation leading to immune complex formation; immune complex deposition can affect any organ eg, skin, joints, kidneys and brain

813
Q

Immune complex deposition (formed by immune system dysregulation) in SLE can affect where?

A

any organ icl. skin, joints, kidney and brain

814
Q

Systemic lupus erythematosus (SLE)?

A

multisystem autoimmune disorder; typically presents in early adulthood and more common in women & Afro-Caribeean

815
Q

General features of SLE?

A
  • fatigue
  • fever
  • mouth ulcers
  • lymphadenopathy
  • skin features= malar rash
  • MSK= arthralgia
  • CVD= pericarditis
  • Resp= pleurisy, fibrosing alveolitis
  • Renal= proteinuria, glomerulonephritis
  • Neuropsychiatric= anxiety, depression, seizures
816
Q

Skin features in SLE (6)?

A

malar (butterfly) rash: spares nasolabial folds

discoid rash

photosensitivity

Raynaud’s phenomenon

livedo reticularis

non-scarring alopecia

817
Q

2 types of rash in SLE?

A

malar (butterfly) rash= spares nasolabial folds

discoid rash= scaly, erythematous, well demarcated rash in sun-exposed areas. Lesions may progress to become pigmented and hyperkeratotic before becoming atrophic

818
Q

MSK features in SLE?

A

arthralgia
non-erosive arthritis

819
Q

Cardiovascular features in SLE?

A

pericarditis (most common)
myocarditis

820
Q

Resp features in SLE?

A

pleurisy
fibrosing aleovlitis

821
Q

Renal features in SLE?

A

proteinuria

glomerulonephritis (diffuse proliferative glomerulonephritis is the most common type)

822
Q

Neuropsychiatric features in SLE?

A

anxiety & depression
psychosis
seizures

823
Q

Ix in SLE?

A
  • ANA positive (90%)
  • RF +ve (20%)
  • anti-dsDNA
  • anti-Smith
  • anti-RO (SS-A), anti-La (SS-B) and anti-U1 RNP
824
Q

Antibodies in SLE?

A
  • ANA positive (90%), high sensitivity so useful rule out test, low specificity
  • RF +ve (20%)
  • anti-dsDNA: very specific but low sensitive
  • anti-Smith: high specific, low sensitive
  • anti-RO (SS-A), anti-La (SS-B) and anti-U1 RNP
825
Q

Monitoring in SLE?

A

1) ESR used; during active disease CRP may be normal, if it is raised may mean infection

2) complement levels (C3,C4) low during active disease

3) anti-dsDNA titres can be used but not present in all pts

826
Q

Why in SLE are complement levels (C3 and C4) low during active disease?

A

formation of immune complexes leads to consumption of complement

827
Q

Mx for SLE?

A

Hydroxychloroquine
+ NSAIDs and sun-block

internal organ involvement (eg. renal, neuro, eye)= consider prednisolone or cyclophosamide

828
Q

Lupus nephritis?

A

severe manifestation of SLE that can result in end-stage renal disease

829
Q

SLE pts should be monitored how to look for renal Cx (eg. lupus nephritis)?

A

urinalysis to rule out proteinuria

830
Q

WHO classification of renal Cx (SLE)?

A

class I: normal kidney

class II: mesangial glomerulonephritis

class III: focal (and segmental) proliferative glomerulonephritis

class IV: diffuse proliferative glomerulonephritis

class V: diffuse membranous glomerulonephritis

class VI: sclerosing glomerulonephritis

831
Q

Most common form of renal Cx in SLE?

A

Class IV (diffuse proliferative glomerulonephritis)

832
Q

What does renal biopsy show in pt with SLE with renal Cx: Class IV (diffuse proliferative glomerulonephritis) ?

A

glomeruli shows endothelial and mesangial proliferation, ‘wire-loop’ appearance

if severe, the capillary wall may be thickened secondary to immune complex deposition

electron microscopy shows subendothelial immune complex deposits

granular appearance on immunofluorescence

833
Q

Mx of renal Cx in SLE?

A

treat HTN

initial therapy for focal (class III) or diffuse (class IV) lupus nephritis=
glucocorticoids with either mycophenolate or cyclophosphamide

subsequent therapy=
mycophenolate is generally preferred to azathioprine to decrease the risk of developing end-stage renal disease

834
Q

Boxer fracture?

A

a minimally displaced fracture of the 5th metacarpal (little finger)

typically following pt punching a hard surface eg. wall

835
Q

Pt punches wall, what fracture?

A

boxer (5th metacarpal)

836
Q

Fall onto outstretched hand- what fracture?

A

Colles’ fracture
Scaphoid fracture

837
Q

When does a Colles’ fracture occur?

A

fall onto outstretched hand (known as a FOOSH)

838
Q

Colles’ fracture?

A

distal radius fracture with dorsal displacement of fragments
described as a dinner fork type deformity

839
Q

3 features of Colles’ fracture?

A

Transverse fracture of the radius

1 inch proximal to the radio-carpal joint

Dorsal displacement and angulation

840
Q

How to remember Colles’ fracture?

A

Dorsally Displaced Distal radius → Dinner fork Deformity

841
Q

Early Cx of Colles’ fracture?

A

median nerve injury: acute carpal tunnel syndrome presenting with weakness or loss of thumb or index finger flexion

compartment syndrome

vascular compromise

malunion

rupture of the extensor

pollicis longus tendon

842
Q

acute carpal tunnel syndrome presenting with weakness or loss of thumb or index finger flexion following fall onto outstretched hand

A

median nerve injury due to colles’ fracture

843
Q

What nerve injury does Colles’ fracture cause?

A

median nerve injury: acute carpal tunnel syndrome presenting with weakness or loss of thumb or index finger flexion

844
Q

Late Cx of Colles’ fracture?

A

osteoarthritis
complex regional pain syndrome

845
Q

Smith’s fracture (reverse colles’ fracture)?

A

Volar angulation of distal radius fragment (Garden spade deformity)

Caused by falling backwards onto the palm of an outstretched hand or falling with wrists flexed

846
Q

falling backwards onto the palm of an outstretched hand or falling with wrists flexed- what fracture?

A

Smith’s

847
Q

Bennetts’ fracture?

A

Intra-articular fracture of the first carpometacarpal joint

Impact on flexed metacarpal, caused by fist fights

X-ray: triangular fragment at ulnar base of metacarpal

848
Q

Impact on flexed metacarpal, caused by fist fights- what fracture?

A

Bennetts

849
Q

Monteggia’s fracture?

A

Dislocation of the proximal radioulnar joint in association with an ulna fracture

Fall on outstretched hand with forced pronation

Needs prompt diagnosis to avoid disability

850
Q

Fall on outstretched hand with forced pronation- what fracture?

A

Monteggia’s fracture

851
Q

Galeazzi fracture?

A

Radial shaft fracture with associated dislocation of the distal radioulnar joint

Direct blow

852
Q

What fracture can be associated with a direct blow?

A

Galeazzi fracture

853
Q

Pott’s fracture?

A

Bimalleolar ankle fracture
Forced foot eversion

854
Q

Forced foot eversion- what fracture?

A

Pott’s

855
Q

Barton’s fracture?

A

Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation

Fall onto extended and pronated wrist

856
Q

Fall onto extended and pronated wrist- what fracture?

A

Barton’s fracture

857
Q

Fractures of the humerus can be divided into what?

A

proximal humeral fractures

humeral shaft fractures

distal humeral fractures

858
Q

proximal humeral fractures?

A

typically seen in elderly

859
Q

distal humeral fractures?

A

typically seen in children

includes supracondylar fractures

860
Q

Examples of Eponymous fractures?

A

Colles’
Smith’s
Bennett’s
Monteggia’s
Galeazzi
Pott’s
Barton’s

861
Q

Supracondylar fractures?

A

fractures of the distal humerus just above elbow joint

typically seen in children and most common type of elbow fracture in children

862
Q

Features of Supracondylar fractures (fractures of the distal humerus just above elbow joint)?

A

typically result from a fall onto an outstretched hand
pain

swelling over the elbow immediately

the elbow will typically be in a semi-flexed position

complications due to neurovascular involvement:
median nerve
radial nerve
brachial artery
ulnar nerve

863
Q

child falls onto outstretched hand and the elbow is now in semi-flexed postition?

A

Supracondylar fracture (fractures of the distal humerus just above elbow joint)

864
Q

Mx of Supracondylar fractures (fractures of the distal humerus just above elbow joint)?

A

non-displaced fractures=
collar and cuff

displaced fractures=
manipulation under anaesthesia with fixation

865
Q

Types of paediatric fractures?

A
  • complete fracture
  • toddlers fracture
  • plastic deformity
  • Greenstick fracture
  • Buckle (‘torus’) fracture
  • Growth plate fractures
  • Pathological fractures
866
Q

Paediatric fractures: injury pattern in a complete fracture?

A

both sides of cortex are breached

867
Q

Paediatric fractures: injury pattern in a toddlers fracture?

A

oblique tibial fracture in infants

868
Q

Paediatric fractures: injury pattern in a plastic deformity?

A

stress on bone resulting in deformity without cortical disruption

869
Q

Paediatric fractures: injury pattern in a Greenstick fracture?

A

unilateral cortical breach only

870
Q

Paediatric fractures: injury pattern in a buckle (‘torus’) fracture?

A

incomplete cortical disruption resulting in periosteal haematoma only

871
Q

Paediatric fractures: injury pattern in a growth plate fracture?

A

fractures that involve growth plates

872
Q

How are growth plate fractures in paeds classified?

A

Salter-Harris system:

I= Fracture through the physis only (x-ray often normal)

II= Fracture through the physis and metaphysis

III= Fracture through the physis and epiphysis to include the joint

IV= Fracture involving the physis, metaphysis and epiphysis

V= Crush injury involving the physis (x-ray may resemble type I, and appear normal)

873
Q

What indicates a growth plate fracture in children?

A

growth plate tenderness even if x-ray is normal

874
Q

Mx of growth plate fractures in children?

A

Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.

875
Q

Signs of non-accidental injury in children?

A

Delayed presentation

Delay in attaining milestones

Lack of concordance between proposed and actual mechanism of injury

Multiple injuries

Injuries at sites not commonly exposed to trauma

Children on the at risk register

Bruising of different ages

876
Q

What conditions may cause pathological fractures in children?

A

genetic:
- osteogenesis imperfecta
- osteopetrosis

877
Q

Pathological fractures in children: osteogenesis imperfecta?

A

Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.

Failure of maturation of collagen in all the connective tissues.

Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.

878
Q

Pathological fractures in children: subtypes of osteogenesis imperfecta?

A

Type I - The collagen is normal quality but insufficient quantity.

Type II - Poor collagen quantity and quality.

Type III - Collagen poorly formed. Normal quantity.

Type IV - Sufficient collagen quantity but poor quality.

879
Q

Pathological fractures in children: osteopetrosis?

A

Bones become harder and more dense.

Autosomal recessive condition.

It is commonest in young adults.

Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone.

880
Q

Scaphoid fracture?

A

type of wrist fracture

typically arises as a result of a fall onto an outstretched hand (FOOSH); contact sports (rugby, football) or road traffic accident when pt holding wheel

881
Q

Result of a scaphoid fracture?

A

axial compression of the scaphoid, with the wrist hyperextended, and radially deviated

882
Q

axial compression of the scaphoid, with the wrist hyperextended, and radially deviated

A

scaphoid fracture

883
Q

What is it important to examine for in anyone presenting with acutely painful wrist for medico-legal reasons?

A

scaphoid fracture

884
Q

Blood supply to scaphoid bone?

A

Around 80% of the blood supply is derived from the dorsal carpal branch (branch of the radial artery), in a retrograde manner.

885
Q

Why is it so important to recognise scaphoid fractures?

A

given the unusual blood supply of the scaphoid bone; Interruption of the blood supply risks avascular necrosis of the scaphoid, with this most commonly complicating proximal injuries.

886
Q

What do pts with scaphoid fracture present with?

A

Pain along the radial aspect of the wrist, at the base of the thumb

Loss of grip / pinch strength

887
Q

Name 5 signs of a scaphoid fracture?

A
  1. Point of maximal tenderness over the anatomical snuffbox
  2. Wrist joint effusion`;
    Hyperacute injuries (<4hrs old), and delayed presentations (>4days old) may not present with joint effusions.
  3. Pain elicited by telescoping of the thumb (pain on longitudinal compression)
  4. Tenderness of the scaphoid tubercle (on the volar aspect of the wrist)
  5. Pain on ulnar deviation of the wrist
888
Q

Ix for scaphoid fractures?

A
  • clinical: look for signs, esp 1,3 and 4
  • Plain film radiographs of the wrist in the anterior-posterior view, and lateral view
  • CT if uncertain or planning operative Mx
  • MRI definitive to confirm (use 2nd line when x-ray inconclusive)
889
Q

X-ray in scaphoid fracture?

A

‘Scaphoid views’: posterioranterior (PA), lateral, oblique (with wrist pronated at 45º) and Ziter view (PA view with the wrist in ulnar deviation and beam angulated at 20º)

The sensitivity in the first week of injury is only 80%

890
Q

Mx of scaphoid fracture?

A
  • initial= immobilisation with a Futuro splint or standard below-elbow backslab
  • referral to orthopaedics
    clinical review with further imaging should be arranged for 7-10 days later when initial radiographs are inconclusive
  • may need ortho Mx
891
Q

Ortho Mx of scaphoid fracture?

A

dependent on the patient and type of fracture

undisplaced fractures of the scaphoid waist=
cast for 6-8 weeks;
union is achieved in > 95%;
certain groups e.g. professional sports people may benefit from early surgical intervention

displaced scaphoid waist fractures=
requires surgical fixation

proximal scaphoid pole fractures=
require surgical fixation

892
Q

Cx of scaphoid fractures?

A

non-union → pain and early osteoarthritis

avascular necrosis

893
Q

Commonest carpal fractures?

A

scaphoid

894
Q

Why does fracture of scaphoid risk blood supply?

A

Surface of scaphoid is covered by articular cartilage with small area available for blood vessels

895
Q

What forms floor of anatomical snuffbox?

A

scaphoid

896
Q

Summarise features of scaphoid fracture?

A

The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb.

Ulnar deviation AP needed for visualization of scaphoid

Immobilization of scaphoid fractures difficult

897
Q

Radial head fracture?

A

Fracture of the radial head is common in young adults.

It is usually caused by a fall on the outstretched hand.

marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).

898
Q

marked local tenderness over the head of the radius, impaired movements at the elbow, and a sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination)

A

radial head fracture

899
Q

De Quervain’s tenosynovitis?

A

common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed

900
Q

De Quervain’s tenosynovitis typically affects who?

A

females 30-50yrs

901
Q

Features of De Quervain’s tenosynovitis?

A

pain on the radial side of the wrist

tenderness over the radial styloid process

abduction of the thumb against resistance is painful

Finkelstein’s test

902
Q

Finekelstein’s test in De Quervain’s tenosynovitis?

A

examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus

903
Q

Mx for De Quervain’s tenosynovitis?

A

analgesia

steroid injection

immobilisation with a thumb splint (spica) may be effective

surgical treatment is sometimes required

904
Q

Lateral epicodylitits aka

A

tennis elbow

905
Q

Lateral epicodylitits (tennis elbow) features?

A

pain and tenderness localised to the lateral epicondyle

pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended

episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks

906
Q

Medial epicondylitis aka

A

golfer’s elbow

907
Q

Medial epicondylitis (golfer’s elbow) features?

A

pain and tenderness localised to the medial epicondyle

pain is aggravated by wrist flexion and pronation

symptoms may be
accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement

908
Q

pain is aggravated by wrist flexion and pronation

symptoms may be
accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement

A

Medial epicondylitis (golfer’s elbow)

909
Q

pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended

A

Lateral epicondylitis (tennis elbow)

910
Q

Radial tunnel syndrome most commonly due to what?

A

compression of the posterior interosseous branch of the radial nerve. It is thought to be a result of overuse.

911
Q

Radial tunnel syndrome features?

A

symptoms are similar to lateral epicondylitis making it difficult to diagnose

however, the pain tends to be around 4-5 cm distal to the lateral epicondyle

symptoms may be worsened by extending the elbow and pronating the forearm

912
Q

symptoms are similar to lateral epicondylitis making it difficult to diagnose
however, the pain tends to be around 4-5 cm distal to the lateral epicondyle
symptoms may be worsened by extending the elbow and pronating the forearm

A

radial tunnel syndrome (compression of the posterior interosseous branch of the radial nerve/overuse)

913
Q

Cubital tunnel syndrome due to?

A

compression of ulnar nerve

914
Q

Cubital tunnel syndrome features?

A

initially intermittent tingling in the 4th and 5th finger

may be worse when the elbow is resting on a firm surface or flexed for extended periods

later numbness in the 4th and 5th finger with associated weakness

915
Q

initially intermittent tingling in the 4th and 5th finger

may be worse when the elbow is resting on a firm surface or flexed for extended periods

later numbness in the 4th and 5th finger with associated weakness

A

cubital tunnel syndrome (ulnar nerve compression)

916
Q

Olecranon bursitis summary?

A

Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.

917
Q

Swelling over the posterior aspect of the elbow. There may be associated pain, warmth and erythema. It typically affects middle-aged male patients.

A

Olecranon bursitis

918
Q

Olecranon bursa?

A

verlying the olecranon process of the elbow beneath the skin. It reduces friction on movement between the skin, tendons, ligaments, and bone, and allows them to glide smoothly over one another.

919
Q

When does bursitis occur?

A

when the bursa is irritated and inflamed and is generally classified as:

Non-septic (most common) — sterile inflammation resulting from various causes including trauma or overuse.

Septic — infection resulting from seeding of the bursal sac with micro-organisms, usually bacteria.

920
Q

Who is olecranon bursitis more common in?

A

Young or middle-aged men.

People in jobs which involve risk of regular elbow trauma or pressure on the bursa.
For example gardeners and mechanics.

Athletes who play sports which involve repetitive overhead throwing or elbow flexion and extension.

921
Q

Mx of olecranon bursitis?

A

conservative measures (such as rest, compression bandaging, avoidance of trauma to the elbows, and analgesia) until symptoms improve.

most resolve without complications; however, recurrent episodes may occur especially after recurrent minor trauma.

922
Q

CP of olecranon bursitis?

A
  • swelling over the elbow that appears over several hours to several days, may be tender or warm (but may be painless), and is fluctuant.
  • Movement at the elbow joint is painless except at full flexion when the swollen bursa is compressed.
  • Hx of preceding trauma or bursal disease.
  • local skin abrasion.
923
Q

Non-septic bursitis Mx?

A

reassurance that most people will respond to conservative treatment.

Considering aspiration, particularly if the effusion is large.

Considering corticosteroid injection into the bursa.

Referral if there is no response to available treatments in primary care after 2 months.

924
Q

Septic bursitis Mx?

A

Aspiration and Tx empirically with Abx until culture results are known.

Urgent referral or specialist advice sought if there is no response, or an inadequate response to an antibiotic in septic bursitis, or complications are suspected.

Considering repeated aspiration if swelling, tenderness, and erythema recur.

Mx any associated conditions, such as gout, rheumatoid arthritis, or cellulitis.

925
Q

Admission to hospital with bursitis?

A

if…
suspected septic joint (which presents with a limited range of movement of the elbow joint, unlike septic bursitis).

Septic bursitis and severe infection or systemic toxicity.

A pointing abscess requiring incision and drainage, if the expertise to perform this procedure is not available.

Extensive cellulitis.

926
Q

Recurrent septic bursitis?

A

urgent referral

or consider referral in non-septic bursitis (in whom septic bursitis has been excluded) does not respond after 2 months of conservative measures

927
Q

Lateral epicondylitis (tennis elbow)?

A

typically follows unaccustomed activity such as house painting or playing tennis (‘tennis elbow’). It is most common in people aged 45-55 years and typically affects the dominant arm.

928
Q

Pain in Lateral epicondylitis (tennis elbow)?

A

pain and tenderness localised to the lateral epicondyle

pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended

929
Q

Lateral epicondylitis (tennis elbow) episodes?

A

episodes typically last between 6 months and 2 years. Patients tend to have acute pain for 6-12 weeks

930
Q

Mx options for Lateral epicondylitis (tennis elbow)?

A

advice on avoiding muscle overload for 6w but maintain activity

heat and ice

simple analgesia

consider orthosis eg. forearm strap

steroid injection if severe but only short term relief

physiotherapy

if uncertain, refractory pain, severe impairment or persist 6-12m then refer to ortho surgeon

931
Q

Definition of Lateral epicondylitis (tennis elbow)?

A

tendinosis (chronic symptomatic degeneration of the tendon) that affects the common attachment of the tendons of the extensor muscles of the forearm to the lateral epicondyle of the humerus.

932
Q

Pt with Lateral epicondylitis (tennis elbow) may describe what?

A

pain around lateral epicondyle with radiation down extensor aspect of forearm

difficulty with common activities= raising cup, shaking hands, shaving, lifting bags

exacerbated by XS and repetitive use of extensor muscles of forearm eg. gripping and repetitive wrist movements; occupational activities eg. vibrating tools, typing, playing piano, tennis, construction work

933
Q

What is Lateral epicondylitis (tennis elbow) also known as?

A

lateral elbow pain, ‘rowing elbow’, tendonitis of the common extensor origin, and peri-tendinitis of the elbow.

934
Q

Lateral epicondylitis (tennis elbow) pathophysiology?

A

Occurs after minor or unrecognized trauma of the forearm extensor muscles.

Repetitive overuse causes micro-tears near the origin of the common extensor tendon at the lateral epicondyle of the humerus, which initiates a degenerative process.

935
Q

Examination findings in Lateral epicondylitis (tennis elbow)?

A

Localized point tenderness on palpation over and/or distal to the lateral epicondyle and along the common extensor tendon.

Pain on resisted middle finger extension.

Pain on resisted wrist extension.

Reduced grip strength due to pain.

Preserved full range of active and passive movement at the elbow and wrist joints.

936
Q

Ottawa ankle rules state that x-rays are only needed to assess for ankle fracture if…

A

pain in the malleolar zone and:
1. Inability to weight bear for 4 steps
2. Tenderness over the distal tibia
3. Bone tenderness over the distal fibula

937
Q

Weber classification for ankle fracture?

A

Related to the level of the fibular fracture.

Type A is below the syndesmosis

Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis

Type C is above the syndesmosis which may itself be damaged

938
Q

Weber classification for ankle fracture- subtype?

A

Maisonneuve fracture may occur with spiral fibular fracture that leads to disruption of the syndesmosis with widening of the ankle joint, surgery is required.

939
Q

Mx of ankle injuries?

A

All ankle fractures should be promptly reduced to remove pressure on the overlying skin and subsequent necrosis

Young patients, with unstable, high velocity or proximal injuries will usually require surgical repair. Often using a compression plate.

Elderly patients, even with potentially unstable injuries usually fare better with attempts at conservative management as their thin bone does not hold metalwork well.

940
Q

Discitis?

A

infection of the intervertebral disc space; can lead to serious Cx eg. sepsis or epidural abscess

941
Q

Features of discitis?

A
  • back pain
  • general= pyrexia, rigors, sepsis
  • neuro= eg. changes in lower limb neurology, if epidural abscess develops
942
Q

Causes of discitis?

A
  • bacterial= staph aureus most common cause of discitis
  • viral
  • TB
  • aseptic
943
Q

Diagnosis of discitis?

A

MRI

  • CT guided biopsy may be needed to guide antimicrobial Tx
944
Q

Tx for discitis?

A

6-8w IV Abx

Choice of antibiotic is dependent on a variety of factors. The most important factor is to identify the organism with a positive culture (e.g. blood culture, or CT-guided biopsy)

the patient should be assessed for endocarditis e.g. with transthoracic echo or transesophageal echo. Discitis is usually due to haematogenous seeding of the vertebrae implying that the patient has had a bacteraemia and seeding could have occurred elsewhere

945
Q

Cx of discitis?

A

sepsis
epidural abscess

946
Q

Red flags for lower back pain?

A

age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever

947
Q

name 4 specific causes of lower back pain?

A
  • facet joint
  • spinal stenosis
  • ankylosing spondylitis
  • PAD
948
Q

Causes of lower back pain (LBP): facet joint?

A

May be acute or chronic

Pain worse in the morning and on standing

On examination there may be pain over the facets. The pain is typically worse on extension of the back

949
Q

Causes of lower back pain (LBP): spinal stenosis?

A

Usually gradual onset

Unilateral or bilateral leg pain (with or without back pain), numbness, and weakness which is worse on walking. Resolves when sits down. Pain may be described as ‘aching’, ‘crawling’.

Relieved by sitting down, leaning forwards and crouching down

Clinical examination is often normal

Requires MRI to confirm diagnosis

950
Q

Causes of lower back pain (LBP): ankylosing spondylitis?

A

Typically a young man who presents with lower back pain and stiffness

Stiffness is usually worse in morning and improves with activity

Peripheral arthritis (25%, more common if female)

951
Q

Causes of lower back pain (LBP): peripheral arterial disease?

A

Pain on walking, relieved by rest

Absent or weak foot pulses and other signs of limb ischaemia

Past history may include smoking and other vascular diseases

952
Q

What does low back pain refer to?

A

pain in the lumbosacral area, from the 12th ribs to the iliac crest, and sometimes the buttocks and gluteal folds.

953
Q

Non-specific low back pain?

A

pain not attributable to an underlying cause. It is also referred to as ‘mechanical’, ‘musculoskeletal’, or ‘simple’ low back pain

90-95% cases in primary care

954
Q

Acute vs chronic low back pain?

A

A= <3m
C= 3m+

955
Q

RFs for low back pain?

A

obesity, physical inactivity, heavy lifting, and stress or depression.

956
Q

prognosis of low back pain?

A

self-limiting normally and usually resolves within few w

957
Q

Cx of low back pain?

A

impact on daily activities including work, study, leisures, and sleep; depression and anxiety; increased risk of falls and chronic pain.

958
Q

Assessment for pt with low back pain?

A

onset, type, site, and pattern of pain; any pain radiation; duration of symptoms; associated symptoms and red flags; impact on daily functioning; drug treatments.

Examine: gait, posture, spine for localized tenderness and range of movement; red flags; and neuro examination.

Using a risk stratification screening tool to assess risk factors for a prolonged or complex recovery if non-specific low back pain is suspected.

959
Q

Mx of non-specific low back pain?

A

keep active, normal activities when able, local heat for symptom relief

NSAIDs; 2nd line- short term codeine +/- para

exercise programmes

occy health assessment

review if persist or worsen after 3-4w

?refer to chronic pain

960
Q

Lumbar spinal stenosis?

A

central canal is narrowed by tumour, disc prolapse or other similar degenrative changes

961
Q

Lumbar spinal stenosis presentation?

A

combination of back pain, neuropathic pain and symptoms mimicking claudication

Sitting is better than standing and patients may find it easier to walk uphill

962
Q

How to differentiate lumbar spinal stenosis from true claudication?

A

Sitting is better than standing and patients may find it easier to walk uphill rather than downhill. Makes lumbar spinal stenosis a likely underlying diagnosis, the absence of such symptoms makes it far less likely.

963
Q

Pathophysiology of lumbar spinal stenosis?

A

degenerative disease commonest cause

Degeneration begins in intervertebral disk where biochemical changes (cell death and loss of proteoglycan and water content) lead to progressive disk bulging and collapse.

Leads to increased stress transfer to the posterior facet joints, which accelerates cartilaginous degeneration, hypertrophy, and osteophyte formation; this is associated with thickening and distortion of the ligamentum flavum.

The combination of the ventral disk bulging, osteophyte formation at the dorsal facet, and ligamentum flavum hyptertrophy combine to circumferentially narrow the spinal canal and the space available for the neural elements.

The compression of the nerve roots of the cauda equina leads to the characteristic clinical signs and symptoms of lumbar spinal stenosis.

964
Q

Diagnosis of lumbar spinal stenosis?

A

MRI= canal narrowing

Historically a bicycle test was used as true vascular claudicants could not complete the test.

965
Q

Tx for lumbar spinal stenosis?

A

laminectomy

966
Q

Paget’s disease of the bone?

A

disease of increased but uncontrolled bone turnover. It is thought to be primarily a disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity.

967
Q

How common is Paget’s?

A

5% UK but only 1 in 20 have symptoms

968
Q

What is most commonly affected in Paget’s?

A

skull, spine/pelvis, and long bones of the lower extremities

969
Q

Paget’s predisposing factors?

A

increasing age
male sex
northern latitude
family history

970
Q

Clinical features of Paget’s?

A
  • only 5% symptomatic
  • bone pain (e.g. pelvis, lumbar spine, femur)

-classical, untreated features: bowing of tibia, bossing of skull

  • typically: older male with bone pain and an isolated raised ALP
971
Q

older male with bone pain and an isolated raised ALP

A

?Paget’s

972
Q

Bowing of tibia and bossing of the skull?

A

classic untreated features of Paget’s

973
Q

Ix for Paget’s?

A
  • Bloods= raised ALP, normal Ca and phosphate; hypercalcaemia may occur with prolonged immobilisation
  • other markers of bone turnover= PINP, CTx, NTx, urinary hydroxyproline
  • x-rays
  • bone scintigraphy
974
Q

Markers of bone turnover results in Pagets?

A

raised alkaline phosphatase (ALP)

calcium and phosphate are typically normal.

Hypercalcaemia may occasionally occur with prolonged immobilisation

other markers of bone turnover includeL
procollagen type I N-terminal propeptide (PINP)
serum C-telopeptide (CTx)
urinary N-telopeptide (NTx)
urinary hydroxyproline

975
Q

X-ray findings in Paget’s?

A

osteolysis in early disease → mixed lytic/sclerotic lesions later

skull x-ray: thickened vault, osteoporosis circumscripta

976
Q

Bone scintigraphy in Paget’s?

A

increased uptake is seen focally at the sites of active bone lesions

977
Q

Indications for Tx in Paget’s?

A

bone pain
skull or long bone deformity
fracture
periarticular Paget’s

978
Q

Mx of Paget’s?

A

if indicated= bisphosphonate (oral risedronate or IV zoledronate)

979
Q

Cx of Paget’s?

A

deafness (cranial nerve entrapment)

bone sarcoma (1% if affected for > 10 years)

fractures
skull thickening
high-output cardiac failure

980
Q

Polyarthritis?

A

inflammation of 5+joints simultaneously, within the first 6 weeks of symptom onset.

981
Q

Features of polyarthritis?

A

pain, swelling, and stiffness in multiple joints

the pattern of joint involvement may be symmetrical, as seen in rheumatoid arthritis, or asymmetrical, as noted in psoriatic arthritis

systemic symptoms= fever, weight loss, and fatigue may also be present, reflecting the underlying systemic inflammatory process.

982
Q

Differential diagnosis of polyarthritis?

A

inflammatory arthritis= RA,
psoriatic arthritis, SLE, seronegative spondyloarthropathies

infective= viral : EBV, HIV, hepatitis, mumps, rubella; TB; disseminated gonococcal infection

pseudogout

Henoch-Schonlein purpura

sarcoidosis

983
Q

Psoriatic arthropathy (arthritis)?

A

inflammatory arthritis associated with psoriasis and is classed as one of the seronegative spondyloarthropathies

984
Q

Link between psoriasis and arthritis in psoriatic arthritis?

A

often precedes the development of skin lesions

Around 10-20% of patients with skin lesions develop an arthropathy with males and females being equally affected.

985
Q

Presentation patterns in psoriatic arthritis?

A

symmetric polyarthritis= very similar to rheumatoid arthritis; most common type

asymmetrical oligoarthritis: typically affects hands and feet (20-30%)

sacroiliitis

DIP joint disease (10%)

arthritis mutilans (severe deformity fingers/hand, ‘telescoping fingers’)

986
Q

Signs in psoriatic arthritis other than the disease patterns?

A

psoriatic skin lesions

periarticular disease - tenosynovitis and soft tissue inflammation resulting in:
- enthesitis: inflammation at the site of tendon and ligament insertion e.g. Achilles tendonitis, plantar fascitis
- tenosynovitis: typically of the flexor tendons of the hands
- dactylitis: diffuse swelling of a finger or toe

Nail changes

987
Q

Nail changes in psoriatic arthritis?

A

pitting and onycholysis

988
Q

Ix in psoriatic arthritis?

A

x-ray= ‘penicl-in-cup’ appearance; periostitis; often unusual combination of coexistence of erosive changes and new bone formation

989
Q

Mx of psoriatic arthritis?

A
  • Mx by rheumatology

Tx similar to RA but:
- mild= NSAID not DMARD
- moderate/severe= methotrexate

  • use of monoclonal antibodies such as ustekinumab (targets both IL-12 and IL-23) and secukinumab (targets IL-17)
  • apremilast: phosphodiesterase type-4 (PDE4) inhibitor

better prognosis than RA

990
Q

apremilast: phosphodiesterase type-4 (PDE4) inhibitor MOA in psoriatic arthritis?

A

→ suppression of pro-inflammatory mediator synthesis

991
Q

Causes of limping child?

A

1) transient synovitis
2) septic arthritis/osteomyelitis
3) Juvenile idiopathic arthritis
4) trauma
5) developmental dysplasia of hip
6) perthes disease
7) slipped upper femoral epiphysis

992
Q

Cervical spondylosis?

A

degenerative condition affecting the cervical spine, essentially osteoarthritis of the cervical vertebral bodies.

993
Q

If spinal canal is narrowed due to cervical sponylosis then that can happen?

A

C vertebral bodies can press on spinal cord resulting in neuro dysfunction

994
Q

Link between cervical spondylosis and cervical spondylitic myelopathy?

A

myelopathy occurs in 5-10% pts with C spondylosis

995
Q

Features of cervical spondylitic myelopathy?

A

a variety of motor weakness, sensory loss and
bladder/bowel dysfunction may be seen

neck pain

wide-based, ataxic or spastic gait

UMN weakness in the lower legs - increased reflexes, increased tone and upgoing plantars

bladder dysfunction e.g. urgency, retention

996
Q

Definition of cervical spondylosis?

A

degenerative condition affecting the cervical spine, particularly the intervertebral discs, vertebral bodies, and facet joints.

997
Q

Causes of cervical spondylosis?

A

primarily an age-related process, often referred to as ‘cervical osteoarthritis,’ and is characterised by the progressive deterioration of the spinal structures in the neck region.

998
Q

Is cervical spondylosis common?

A

common, esp in >50yrs

by 60yrs radiographic evidence is present in >85% of individuals, although many remain asymptomatic.

999
Q

4 stages of the pathogenesis of cervical spondylosis (sequence of degenerative changes)?

A

1) intervertebral disc degeneration
2) osteophyte formation
3) facet joint arthropathy
4) ligamentous hypertrophy

1000
Q

4 stages of the pathogenesis of cervical spondylosis (sequence of degenerative changes): 1) intervertebral disc degeneration?

A

process begins with the dehydration and shrinkage of the nucleus pulposus within the intervertebral discs, leading to reduced disc height and loss of elasticity.

1001
Q

4 stages of the pathogenesis of cervical spondylosis (sequence of degenerative changes): 2) osteophyte formation?

A

In response to disc degeneration, the body attempts to stabilise the spine by forming osteophytes, or bone spurs, at the margins of the vertebral bodies and facet joints. These osteophytes can encroach upon the spinal canal and intervertebral foramina.

1002
Q

4 stages of the pathogenesis of cervical spondylosis (sequence of degenerative changes): 3) facet joint arthropathy?

A

Degenerative changes in the facet joints contribute to instability, inflammation, and further osteophyte formation. This can result in nerve root compression (radiculopathy) or, less commonly, spinal cord compression (myelopathy).

1003
Q

4 stages of the pathogenesis of cervical spondylosis (sequence of degenerative changes): 4) ligamentous hypertrophy?

A

The ligamentum flavum and other supporting ligaments may thicken and lose elasticity, contributing to spinal canal stenosis and potential neurological complications.

1004
Q

Clinical features of cervical spondylosis?

A
  • neck pain= chronic, stiffness, limited ROM, may radiate to shoulder & upper back
  • radiculopathy= compression C nerve roots- radicular pain, paraesthesia, weakness in upper limbs (follows dermatomal pattern)
  • myelopathy= severe manifestation due to spinal cord compression; clumisness in hands, gait disturbance, limb weakness, bowel or bladder dysfunction in advanced
  • headaches= occipital due to irritation of C nerve roots or muscles in upper C region
1005
Q

Examination findings in cervical spondylosis?

A

reduced range of motion in the neck, tenderness over the cervical spine, and signs of radiculopathy or myelopathy (e.g., positive Spurling’s test, hyperreflexia, or gait instability).

1006
Q

Ix (imaging) for cervical spondylosis?

A
  • plain x-rays of C spine= disc space narrowing, osteophytes and facet joint arthropathy
  • MRI= GOLD; images soft tissue eg. spinal cord, nerve roots and intervertebral discs
  • electrophyisological studies= nerve conduction and electromyography to differentiate C radiculopaty from peripheral neuropathy & other conditions
1007
Q

Mx for cervical spondylosis can be what?

A

conservative or interventional procedures

1008
Q

Mx for cervical spondylosis: conservative?

A
  • NSAIDs
  • physio= improve neck strength, postural training
  • cervical collar= temp in acute flares but long term use discouraged due to risk of muscle weakness
1009
Q

Mx for cervical spondylosis: interventional procedures?

A
  • cervical epidural steroid injections= if radicular symptoms, temp relief by reducing inflam around affected nerve root
  • facet joint injections or radiofrequency ablation= pts with chronic facet-mediated pain
1010
Q

Radiculopathy

A

neurological state in which conduction is limited or blocked along a spinal nerve or its roots — it is differentiated from radicular pain, although they commonly occur together.

1011
Q

Radicular pain?

A

usually caused by compression of the nerve root due to cervical disc herniation or degenerative spondylotic changes, but radicular symptoms can also occur without evident compression (for example, due to inflammation of the nerve).

1012
Q

Cervical radiculopathy?

A

pain and weakness and/or numbness in one or both of the upper extremities, which corresponds to the dermatome of the involved cervical nerve root.

  • neck pain secondary to compression or irritation of nerve roots in C spine
  • pain may radiate to shoulders, upper back and chest
1013
Q

The most common causes of cervical radiculopathy are

A

degenerative changes, including cervical disc herniation and spondylosis.

1014
Q

Prognosis of cervical radiculopathy?

A

most will improve regardless of Tx

88% of people improve within four weeks with non-operative management.

1015
Q

Tests to identify cervical radiculopathy?

A

The Spurling test.

Arm squeeze test.

Axial traction — a combination of a positive Spurling’s test, axial traction test, and arm squeeze test increases the likelihood of cervical radiculopathy.

Upper limb neurodynamic tests — a combination of four neurodynamic tests and an arm squeeze test can rule out cervical radiculopathy.

1016
Q

Ix for cervical radiculopathy?

A

not normally needed, usually clinical

1017
Q

For people who have neck pain for less than 4–6 weeks and no objective neurological signs, management should include:

A

Providing reassurance, information, and advice.
Offering oral analgesia to relieve symptoms.
Considering offering amitriptyline, duloxetine, pregabalin, or gabapentin.
Considering a referral for physiotherapy.

1018
Q

People with cervical radiculopathy that has been present for 4–6 weeks or more, or objective neurological signs?

A

refer for MRI and for invasive procedures to be considered. These may include interlaminar cervical epidural injections, transforaminal injections, or spinal surgery.

1019
Q

Cervical radiculopathy: Spurling test?

A

flex the neck laterally, rotate and then press on top of the person’s head. The test is positive if this pressure causes the typical radicular arm pain.

Note: This test should not be performed in people with rheumatoid arthritis, cancer, infection, or possible neck injury.

1020
Q

Cervical radiculopathy: arm squeeze test?

A

squeeze the middle third of the upper arm with simultaneous thumb and fingers compression (the thumb from posterior on the triceps muscle and the fingers from anterior on the biceps muscle). The test is positive when the pain score (on a 0-10 visual analogue scale) is 3 points or higher during pressure on the middle third of the upper arm compared with two other areas.

1021
Q

How are fractures classified?

A

based on…
1) bone alignment
2) fracture line
3) cause
4) bone location
5) stability
6) special types
7) pt age
8) special patterns

1022
Q

Types of fracture: based on bone alignment?

A
  • closed (simple) fracture
  • open (compound fracture)
1023
Q

Types of fracture: based on bone alignment= closed (simple) fracture?

A

bone breaks but does not pierce skin

1024
Q

Types of fracture: based on bone alignment= open (compound) fracture?

A

bone breaks and pierces skin, increases risk of infection

1025
Q

Types of fracture: based on fracture line?

A
  • transverse fracture
  • oblique
  • spiral
  • longitudinal
  • comminuted
  • segmental
  • greenstick
1026
Q

Types of fracture: based on fracture line= transverse fracture?

A

straight horizontal break across the bone

1027
Q

Types of fracture: based on fracture line= oblique fracture?

A

angled break across bone

1028
Q

Types of fracture: based on fracture line= spiral fracture?

A

twisting break resembling a spiral, often caused by rotational force

1029
Q

Types of fracture: based on fracture line= longitudinal fracture?

A

break that runs along the bone’s length

1030
Q

Types of fracture: based on fracture line= comminuted fracture?

A

bone shatters into 3 of more fragments

1031
Q

Types of fracture: based on fracture line= segmental fracture?

A

2 fractures create an isolated segment of bone

1032
Q

Types of fracture: based on fracture line= greenstick fracture?

A

incomplete break in which one side of the bone bends, common in children

1033
Q

Types of fracture: based on cause?

A
  • traumatic
  • pathologic
  • stress
1034
Q

Types of fracture: based on cause= traumatic fracture?

A

caused by direct trauma or force

1035
Q

Types of fracture: based on cause= pathologic fracture?

A

occurs in weakend bone due to disease eg. tumours or osteoporosis

1036
Q

Types of fracture: based on cause= stress fracture?

A

small hairline crack caused by repetitive stress or overuse

1037
Q

Types of fracture: based on bone location?

A

intra-articular
extra-articular
epiphyseal
diaphyseal
metaphyseal

1038
Q

Types of fracture: based on bone location= intra-articular fracture?

A

break extends into a joint surface

1039
Q

Types of fracture: based on bone location= extra-articular fracture?

A

break does not involve a joint surface

1040
Q

Types of fracture: based on bone location= epiphyseal fracture?

A

break at the growth plate in children

1041
Q

Types of fracture: based on bone location= diaphyseal fracture?

A

break in shaft of a long bone

1042
Q

Types of fracture: based on bone location= metaphyseal fracture?

A

break in widened part of the bone near the joint

1043
Q

Types of fracture: based on stability?

A

stable
unstable

1044
Q

Types of fracture: based on stability= stable fracture?

A

broken ends of the bone are aligned and minimally displaced

1045
Q

Types of fracture: based on stability= unstable fracture?

A

broken ends are misaligned or move easily

1046
Q

Types of fracture: special types?

A
  • impacted
  • compression
  • avulsion
  • hairline
  • buckle (torus)
1047
Q

Types of fracture: special types= impacted fracture?

A

broken ends of the bone are driven into eachother

1048
Q

Types of fracture: special types= compression fracture?

A

bone collapses, often seen in vertebrae

1049
Q

Types of fracture: special types= avulsion fracture?

A

a fragment of bone is pulled away by a tendon or ligament

1050
Q

Types of fracture: special types= hairline fracture?

A

very thin crack in bone

1051
Q

Types of fracture: special types= buckle (torus) fracture?

A

an incomplete fracture where one side of the bone buckles under pressure, common in children

1052
Q

Types of fracture: based on pt age?

A

paediatric
adult

1053
Q

Types of fracture: based on pt age= paediatric fractures?

A

greenstick, buckle and epiphyseal fractures more common in children due to softer bones

1054
Q

Types of fracture: based on pt age= adult fractures?

A

complete and comminuted fractures are more typical in adults due to denser brittle bones

1055
Q

Types of fracture: special types?

A

Colles’
Smiths’
Pott’s
Le Fort

1056
Q

Types of fracture: special types= Colles’ fracture?

A

distal radius fracture, typically from falling on outstretched hand

1057
Q

Types of fracture: special types= Smith’s fracture?

A

distal radius fracture with the broken segment displaced toward the palm

1058
Q

Types of fracture: special types= Pott’s fracture?

A

fracture affecting one or both malleoli (ankle)

1059
Q

Types of fracture: special types= Le Fort fractures?

A

fractures of the maxilla (face), classified into 3 types based on severity

1060
Q

Mx of stable vs unstable/open fractures?

A

stable= may only need immobilisation

unstable or open= often need surgery

1061
Q

epiphyseal vs diaphyseal vs metaphyseal

A

The epiphysis is the rounded end of a long bone that includes the growth plate (in children) and contributes to joint formation; fractures here can affect growth.

The diaphysis is the long, tubular shaft made of dense compact bone and houses the marrow, commonly fractured by trauma.

The metaphysis is the flared region between the diaphysis and epiphysis, consisting of spongy bone and absorbing stress; fractures here are common in children and adults.

1062
Q

Acetabular labral tear?

A

may occur following trauma (most commonly in younger adults) or as a result of degenerative change (typically in older adults).

1063
Q

Acetabular labral tear features?

A

hip/groin pain

snapping sensation around hip

there may occasionally be the sensation of locking

1064
Q

Acromioclavicular joint injury?

A

Injury to the AC joint is relatively common and typically occurs during collision sports such as rugby following a fall on to the shoulder or a FOOSH (falls on outstretched hand).

1065
Q

How are Acromioclavicular joint injuries graded?

A

graded I to VI depending on the degree of separation.

Grade I and II injuries are very common and are typically managed conservatively including resting the joint using a sling.

Grade IV, V and VI are rare and require surgical intervention.

Mx of grade III injuries is a matter of debate and often depends on individual circumstances.

1066
Q

Avascular necrosis?

A

death of bone tissue secondary to loss of the blood supply. This leads to bone destruction and loss of joint function.

1067
Q

Avascular necrosis most commonly affects what?

A

the epiphysis of long bones such as the femur

1068
Q

Causes of avascular necrosis of the hip?

A

long term steroid use
chemo
alcohol XS
trauma

1069
Q

Features of avascular necrosis of the hip?

A

initially asymptomatic
pain in affected joint

1070
Q

Ix for avascular necrosis of the hip?

A

MRI Ix of choice

plain x-ray may be normal initially:
- osteopenia and microfractures may be seen early on
- collapse of the articular surface may result in the crescent sign

1071
Q

Mx for avascular necrosis of the hip?

A

May need joint replacement

1072
Q

Baker’s cysts (a popliteal cyst)?

A

not true cysts but rather a distension of the gastrocnemius-semimembranosus bursa. They may be primary or secondary

1073
Q

Primary vs secondary Baker’s cysts (a popliteal cyst)?

A

Primary: no underlying pathology, typically seen in children

Secondary: underlying condition such as osteoarthritis, typically seen in adults

1074
Q

CP of Baker’s cysts (a popliteal cyst)?

A

swellings in the popliteal fossa behind the knee

1075
Q

Rupture of Baker’s cysts (a popliteal cyst)?

A

may occur resulting in similar symptoms to a deep vein thrombosis, i.e. pain, redness and swelling in the calf. However, the majority of ruptures are asymptomatic.

1076
Q

Mx of Baker’s cysts (a popliteal cyst)?

A

children= usually resolve and don’t require Tx

adults= treat underlying cause

1077
Q

Biceps muscle tendons?

A

has 2 tendons:
- long tendon attaches to glenoid
- short attaches to coracoid proceps

It inserts distally via another tendon onto the radial tuberosity.

1078
Q

Biceps rupture?

A

biceps tendon rupture is when one of the tendons (long or short) separates from its attachment site or is torn across it’s full width. This most frequently occurs at the long tendon (90%), but rarely can occur in the distal tendon (10%).

1079
Q

Epidemiology of biceps tendon rupture?

A

M>F

Proximal tendon rupture= >60yrs, long tendon, most common (90%)

distal= less common, mean age is 40; mainly men

1080
Q

RFs for biceps rupture?

A

Heavy overhead activities
Shoulder overuse or underlying shoulder injuries which may stress the biceps tendon
Smoking
Corticosteroids; these weaken tendons

1081
Q

Biceps rupture: mechanism of injury?

A

Proximal biceps long tendon ruptures: typically occurs when the biceps are lengthened and contracted and a load is applied. e.g. the descent phase of a pull-up.

Distal biceps tendon ruptures: Usually when a flexed elbow is suddenly and forcefully extended whilst the biceps muscle is contracted. already

1082
Q

CP of biceps rupture?

A

sudden pop or tear at shoulder (long tendon) or anticubital fossa (distal tendon) followed by pain, bruising, swelling

Popeye deformity= buscle bulk results in bulge in middle upper arm

distal tendon rupture= reverse popeye deformity

weakness in shoulder & elbow follows eg. difficulty supination

may have chronic shoulder pain prior to rupture then notice improvement in pain

1083
Q

Popeye deformity

A

rupture of proximal tendon of biceps muscle

1084
Q

Ix for biceps rupture?

A
  • palpate
  • biceps squeeze test= if intact then squeeze will cause supination
  • 1st Ix= MSK USS
  • long head biceps rupture= conservative Mx
  • distal biceps= then do urgent MRI as requires surgical intervention
1085
Q

Blood results in Pagets?

A

ALP high
others normal

1086
Q

Blood results in osteoporosis?

A

ALP normal
Ca ect all normal

1087
Q

Blood results in secondary bone tumours?

A

high Ca
high ALP

1088
Q

Buckle (torus) fractures?

A

incomplete fractures of the shaft of a long bone that is characterised by bulging of the cortex. They typically occur in children aged 5-10 years.

1089
Q

Mx of Buckle (torus) fractures?

A

typically self-limiting they do not usually require operative intervention and can sometimes be managed with splinting and immobilisation rather than a cast.

1090
Q

Cauda equina syndrome (CES)?

A

rare
lumbosacral nerve roots that extend below the spinal cord are compressed

1091
Q

What to always consider in pts who present with new/worsening lower back pain and why?

A

cauda equina

late diagnosis may lead to permanent nerve damage resulting in long term leg weakness and urinary/bowel incontinence

1092
Q

Causes of cauda equina syndrome?

A

most common= central disc prolapse
this typically occurs at L4/5 or L5/S1

  • tumours: primary or metastatic
  • infection: abscess, discitis
  • trauma
  • haematoma
1093
Q

Central disc prolapse causing cauda equina typically occurs at what spinal level?

A

L4/5 or L5/S1

1094
Q

Possible features of cauda equina (variety of presentations and not one symptom or sign that can diagnose or exclude CES)?

A
  • low back pain
  • bilateral sciatica
  • reduced sensation/paraesthesia in perianal area
  • decreased anal tone (check in pts with new onset back pain)
  • uriniary dysfunction eg. reduced awareness of bladder filling, loss of urge to void; incontinence is late sign
1095
Q

Incontinence in cauda equina?

A

late sign and may indicate irreversible damage

1096
Q

Bilateral sciatica

A

think cauda equina as 50% present with this

1097
Q

Ix for cauda equina?

A

urgent MRI

1098
Q

Mx of cauda equina?

A

surgical decompression

1099
Q

Charcot joint?

A

(neuropathic joint)

a joint which has become badly disrupted and damaged secondary to a loss of sensation.

most commonly seen in diabetics or caused by neuropathy secondary to syphilis (tabes dorsalis)

1100
Q

Features of charcot joints?

A
  • lot less painful than would be expected given the degree of joint disruption due to the sensory neuropathy
  • swollen red and warm joint
  • as progresses= affected joint becomes unstable -> abnormal movements and increased risk of fractures & dislocations
  • progressive joint destruction can cause significant deformities
    common deformities include a collapsed arch in the foot (commonly referred to as ‘rocker-bottom’ foot) or severe joint misalignment
  • secondary Cx such as skin ulceration and infection can occur due to repeated trauma and poor wound healing
1101
Q

Dupuytren’s contracture?

A

an abnormal thickening of the skin in the palm of the hand. The skin may develop into a hard lump. Over time, it can cause one or more fingers to curl (contract) or pull in toward the palm.

the ring finger and little finger are the fingers most commonly affected

1102
Q

Epidemiology of Dupuytren’s contacture?

A

5% prevalence

older male pts

60-70% FHx

1103
Q

Specific causes of Dupuytren’s contracture?

A

manual labour
phenytoin Tx
DM
alcoholic liver disease
trauma to hand

1104
Q

Mx of Dupuytren’s contracture?

A

consider surgical treatment of Dupuytren’s contracture when the metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table

1105
Q

Features of fat embolism?

A

Resp= early persistent tachycardia; tachypnoea, dyspnoea, hypoxia 72hrs following injury; pyrexia

Derm= red/browm impalpable petechial rash (25-50%); subconjunctival and oral haemorrhage/petechiae

CNS= confusion, agitation; Retinal haemorrhages and intra-arterial fat globules on fundoscopy

1106
Q

Fat embolism?

A

when one or more droplet-like particles of fat enter your bloodstream and block circulation through some of your blood vessels.

caused following trauma eg. long bone and pelvic fractures

1107
Q

Ix for fat embolism?

A

imaging may be normal

fat emboli tend to lodge distally so CTPA may not show vascular occlusion; may see ground glass appearance at the periphery

1108
Q

Fat embolism Mx?

A

Prompt fixation of long bone fractures

Some debate regarding benefit Vs. risk of medullary reaming in femoral shaft/ tibial fractures in terms of increasing risk (probably does not).

DVT prophylaxis

General supportive care

1109
Q

Fracture diagnosis?

A

clinical + x-rays of proximal and distal joints= assess for changes in length of the bone, the angulation of the distal bone, rotational effects, presence of material such as glass

1110
Q

Oblique fracture?

A

fracture lies obliquely to long axis of bone

1111
Q

Comminuted fracture?

A

> 2 fragments

1112
Q

Segmental fracture?

A

more than 1 fracture along a bone

1113
Q

Transverse fracture?

A

perpendicular to long axis of bone

1114
Q

Spiral fracture?

A

severe oblique fracture with rotation along long axis of bone

1115
Q

Gustilo and Anderson classification system for open fractures?

A

1 Low energy wound <1cm

2 Greater than 1cm wound with moderate soft tissue damage

3 High energy wound > 1cm with extensive soft tissue damage

3 A (sub group of 3) Adequate soft tissue coverage

3 B (sub group of 3) Inadequate soft tissue coverage

3 C (sub group of 3) Associated arterial injury

1116
Q

Key points in the Mx of fractures?

A

Immobilise the fracture including the proximal and distal joints

Carefully monitor and document neurovascular status, particularly following reduction and immobilisation

Manage infection including tetanus prophylaxis

IV broad spectrum antibiotics for open injuries

All open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution)

Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury

1117
Q

Ganglion?

A

‘cyst’ arising from a joint or tendon sheath. They are most commonly seen around the dorsal aspect of the wrist

W>M

1118
Q

a firm and well-circumscribed mass that transilluminates

A

ganglion

1119
Q

Mx of ganglion?

A

often disappear spontaneously after several months

surgical excision is indicated for cysts associated with severe symptoms or neurovascular manifestations

1120
Q

Osler’s nodes?

A

Osler’s nodes are painful, red, raised lesions found on the hands and feet. They are the result of the deposition of immune complexes.

1121
Q

Bouchard’s nodes?

A

Hard, bony outgrowths or gelatinous cysts on the proximal interphalangeal joints (the middle joints of fingers or toes.) They are a sign of osteoarthritis, and are caused by formation of calcific spurs of the articular cartilage.

1122
Q

Herberden’s nodes?

A

Typically develop in middle age, beginning either with a chronic swelling of the affected joints or the sudden painful onset of redness, numbness, and loss of manual dexterity. This initial inflammation and pain eventually subsides, and the patient is left with a permanent bony outgrowth that often skews the fingertip sideways.

1123
Q

Summary of ganglion?

A

Swelling in association with a tendon sheath commonly near a joint. They are common lesions in the wrist and hand. Usually they are asymptomatic and cause little in the way of functional compromise. They are fluid filled although the fluid is similar to synovial fluid it is slightly more viscous. When the cysts are troublesome they may be excised.

1124
Q

name 4 types of hand lumps?

A
  • osler’s nodes
  • bouchard’s nodea
  • heberden’s nodes
  • ganglion
1125
Q

Hip dislocation?

A

extremely painful

mostly caused by direct trauma eg. fall from height or RTA

may be associated with other fractures and life-threatening injuries due to the large force required to cause

1126
Q

What is it important to do if ?hip dislocation?

A

prompt diagnosis and Mx to reduce morbidity

1127
Q

Types of hip dislocation?

A

Posterior dislocation: (90%) The affected leg is shortened, adducted, and internally rotated.

Anterior dislocation: The affected leg is usually abducted and externally
rotated. No leg shortening.

Central dislocation

1128
Q

Mx of hip dislocation?

A

ABCDE approach.

Analgesia

A reduction under general anaesthetic within 4 hours to reduce the risk of avascular necrosis.

Long-term management: Physiotherapy to strengthen the surrounding muscles.

1129
Q

Cx of hip dislocation?

A

Sciatic or femoral nerve injury

Avascular necrosis

Osteoarthritis: more common in older patients.

Recurrent dislocation: due to damage of supporting ligaments

1130
Q

Prognosis of hip dislocation?

A

It takes about 2 to 3 months for the hip to heal after a traumatic dislocation

the prognosis is best when the hip is reduced less than 12 hours post-injury and when there is less damage to the joint.

1131
Q

iliopsoas abscess?

A

collection of pus in iliopsoas compartment (iliopsoas and iliacus).

1132
Q

Causes of primary iliopsoas abscess?

A

Haematogenous spread of bacteria
Staphylococcus aureus: most common

1133
Q

Causes of secondary iliopsoas abscess?

A

Crohn’s (commonest cause in this category)
Diverticulitis, colorectal cancer
UTI, GU cancers
Vertebral osteomyelitis
Femoral catheter, lithotripsy
Endocarditis
intravenous drug use

1134
Q

Mortality rate in primary iliopsoas abscess vs secondary?

A

secondary 20%

primary 2.4%

1135
Q

Features of iliopsoas abscess?

A

fever
back/flank pain
limp
weight loss

1136
Q

Clinical exam of iliopsoas abscess?

A

Patient in the supine position with the knee flexed and the hip mildly externally rotated

Specific tests to diagnose iliopsoas inflammation:
- Place hand proximal to the patient’s ipsilateral knee and ask patient to lift thigh against your hand. This will cause pain due to contraction of the psoas muscle.
- Lie the patient on the normal side and hyperextend the affected hip. This should elicit pain as the psoas muscle is stretched.

1137
Q

Ix for iliopsoas abscess?

A

CT abdo

1138
Q

Mx of iliopsoas abscess?

A

Antibiotics

Percutaneous drainage is the initial approach and successful in around 90% of cases

Surgery is indicated if:
1. Failure of percutaneous drainage
2. Presence of an another intra-abdominal pathology which requires surgery

1139
Q

What is commonly seen following a lateral blow to the knee?

A

Unhappy triad (damage to):
1) anterior cruciate ligament
2) medial collateral ligament
3) meniscus (lateral meniscus is more commonly injured)

1140
Q

What knee injury may result from twisting injuries and
Anterior drawer test and Lachman test may be positive if damaged

A

ACL

1141
Q

What knee injury may occur following dashboard injuries?

A

posterior cruciate ligament

1142
Q

What knee injury may commonly result from skiing and following valgus stress;
damage typically causes abnormal passive abduction of the knee

A

medial collateral ligament

1143
Q

Isolated injury to what structure in the knee is uncommon?

A

lateral collateral ligament

1144
Q

What knee injury may result from twisting injuries;
Locking and giving way are common symptoms?

A

menisci

1145
Q

Ruptured ACL?

A

Sport injury
Mechanism: high twisting force applied to a bent knee
Typically presents with: loud crack, pain and RAPID joint swelling (haemoarthrosis)
Poor healing
Management: intense physiotherapy or surgery

1146
Q

Ruptured PCL?

A

Mechanism: hyperextension injuries
Tibia lies back on the femur
Paradoxical anterior draw test

1147
Q

Rupture of medial collateral ligament?

A

Mechanism: leg forced into valgus via force outside the leg
Knee unstable when put into valgus position

1148
Q

Menisceal tear?

A

Rotational sporting injuries
Delayed knee swelling
Joint locking (Patient may develop skills to ‘unlock’ the knee
Recurrent episodes of pain and effusions are common, often following minor trauma

1149
Q

Chondromalacia patellae?

A

Teenage girls, following an injury to knee e.g. Dislocation patella
Typical history of pain on going downstairs or at rest
Tenderness, quadriceps wasting

1150
Q

Dislocation of the patella?

A

Most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation
Genu valgum, tibial torsion and high riding patella are risk factors
Skyline x-ray views of patella are required, although displaced patella may be clinically obvious
An osteochondral fracture is present in 5%
The condition has a 20% recurrence rate

1151
Q

Fractured patella?

A

2 types:
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture

1152
Q

Tibial plateau fracture?

A

Occur in the elderly (or following significant trauma in young)
Mechanism: knee forced into valgus or varus, but the knee fractures before the ligaments rupture
Varus injury affects medial plateau and if valgus injury, lateral plateau depressed fracture occurs
Classified using the Schatzker system (see below)

1153
Q

Schatzker Classification system for tibial plateau fractures?

A

1) Vertical split of lateral condyle
2) Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle
3) Depression of the articular surface with intact condylar rim
4) Fragment of the medial tibial condyle
5) Fracture of both condyles
6) Combined condylar and subcondylar fractures

1154
Q

Schatzker Classification system for tibial plateau fractures: 1) Vertical split of lateral condyle?

A

Fracture through dense bone, usually in the young. It may be virtually undisplaced, or the condylar fragment may be pushed inferiorly and tilted

1155
Q

Schatzker Classification system for tibial plateau fractures: 2) Vertical split of the lateral condyle combined with an adjacent load bearing part of the condyle?

A

The wedge fragment (which may be of variable size), is displaced laterally; the joint is widened. Untreated, a valgus deformity may develop

1156
Q

Schatzker Classification system for tibial plateau fractures: 3) Depression of the articular surface with intact condylar rim?

A

The split does not extend to the edge of the plateau. Depressed fragments may be firmly embedded in subchondral bone, the joint is stable

1157
Q

Schatzker Classification system for tibial plateau fractures: 4) Fragment of the medial tibial condyle?

A

Two injuries are seen in this category; (1) a depressed fracture of osteoporotic bone in the elderly. (2) a high energy fracture resulting in a condylar split that runs from the intercondylar eminence to the medial cortex. Associated ligamentous injury may be severe

1158
Q

Schatzker Classification system for tibial plateau fractures: 5) Fracture of both condyles?

A

Both condyles fractured but the column of the metaphysis remains in continuity with the tibial shaft.

1159
Q

Schatzker Classification system for tibial plateau fractures: 6) Combined condylar and subcondylar fractures?

A

High energy fracture with marked comminution.

1160
Q

Features of meniscal tear?

A

pain worse on straightening the knee
knee may ‘give way’
displaced meniscal tears may cause knee locking
tenderness along the joint line
Thessaly’s test - weight bearing at 20 degrees of knee flexion, patient supported by doctor, postive if pain on twisting knee

1161
Q

Anterior draw test (test for ACL injury)?

A

the patient lies supine with the knee at 90 degrees
the examiner should place one hand behind the tibia and the other grasping the patient’s thigh. It is important that the examiner’s thumb be on the tibial tuberosity
the tibia is pulled forward to assess the amount of anterior motion of the tibia in comparison to the femur
an intact ACL should prevent forward translational movement

1162
Q

Lachman’s test (test for ACL injury)?

A

variant of anterior draw test, but the knee is at 20-30 degrees
evaluate the anterior translation of the tibia in relation to the femur and is considered a variant
more reliable than anterior draw test

1163
Q

Knee injurys in older pts: Infrapatellar bursitis
(Clergyman’s knee) vs Prepatellar bursitis
(Housemaid’s knee)?

A

Infrapatellar bursitis
(Clergyman’s knee)= associated with kneeling

Prepatellar bursitis
(Housemaid’s knee)= Associated with more upright kneeling

1164
Q

Leriche syndrome?

A

Atheromatous disease involving the iliac vessels. Blood flow to the pelvic viscera is compromised. Patients may present with buttock claudication and impotence (in this particular syndrome). Diagnostic work up will include angiography, where feasible, iliac occlusions are usually treated with endovascular angioplasty and stent insertion.

1165
Q

Femoral nerve= motor?

A

knee extension, thigh flexion

1166
Q

Femoral nerve= sensory?

A

anterior & medial aspect of thigh and lower leg

1167
Q

Femoral nerve= typical mechanism of injury?

A

hip and pelvic fractures

stab/gunshot wounds

1168
Q

Obturator nerve= motor?

A

thigh adduction

1169
Q

Obturator nerve= sensory?

A

medial thigh

1170
Q

Obturator nerve= typical mechanism of injury?

A

anterior hip dislocation

1171
Q

Lateral cutaneous nerve of thigh= motor?

A

none

1172
Q

Lateral cutaneous nerve of thigh= sensory?

A

lateral and posterior surfaces of thigh

1173
Q

Lateral cutaneous nerve of thigh= typical mechanism of injury?

A

Compression of the nerve near the ASIS → meralgia paraesthetica, a condition characterised by pain, tingling and numbness in the distribution of the lateral cutaneous nerve

1174
Q

Tibial nerve= motor?

A

foot plantarflexion and inversion

1175
Q

Tibial nerve= sensory?

A

sole of foot

1176
Q

Tibial nerve= mechanism of injury?

A

Not commonly injured as deep and well protected.
Popliteral lacerations, posterior knee dislocation

1177
Q

Common peroneal nerve= motor?

A

foot dorsiflexion and eversion

extensor hallucis longus

1178
Q

Common peroneal nerve= sensory?

A

Dorsum of the foot and the lower lateral part of the leg

1179
Q

Common peroneal nerve= mechanism of injury?

A

often occurs at neck of fibula

tightly applied lower limb plaster cast

injury causes foot drop

1180
Q

Injury to what nerve causes foot drop?

A

common peroneal nerve

1181
Q

Superior gluteal nerve= motor?

A

hip abduction

1182
Q

Superior gluteal nerve= sensory?

A

none

1183
Q

Superior gluteal nerve= mechanism of injury?

A

Misplaced intramuscular injection
Hip surgery
Pelvic fracture
Posterior hip dislocation

Injury results in a positive Trendelenburg sign

1184
Q

Injury to what nerve results in +ve Trendelenburg sign?

A

Superior gluteal nerve

1185
Q

Inferior gluteal nerve= motor?

A

hip extension and lateral rotation

1186
Q

Inferior gluteal nerve= sensory?

A

none

1187
Q

Inferior gluteal nerve= mechanism of injury?

A

Generally injured in association with the sciatic nerve

Injury results in difficulty rising from seated position. Can’t jump, can’t climb stairs

1188
Q

Injury to what nerve causes difficulty rising from seated position; can’t jump and can’t climb stairs?

A

inferior gluteal nerve

1189
Q

What muscles are in the anterior compartment of the lower limb?

A

tibialis anterior

extensor digitorum longus

peroneus tertius

extensor hallucis longus

1190
Q

What nerve is in the anterior compartment of the lower limb?

A

deep peroneal (aka fibular) nerve

1191
Q

Muscular compartments of the lower limb? (4)

A
  • anterior
  • peroneal
  • superficial posterior
  • deep posterior
1192
Q

Anterior compartment of lower limb muscles= Tibialis anterior:
- action?
- nerve?

A

dorsiflexes ankle joint, inverts foot

deep peroneal (aka fibular) nerve

1193
Q

Anterior compartment of lower limb muscles= extensor digitorum longus:
- action?
- nerve?

A

extends lateral four toes, dorsiflexes ankle joint

deep peroneal (aka fibular) nerve

1194
Q

Anterior compartment of lower limb muscles= peroneus tertius:
- action?
- nerve?

A

dorsiflexes ankle, everts foot

deep peroneal (aka fibular) nerve

1195
Q

Anterior compartment of lower limb muscles= extensor hallucis longus:
- action?
- nerve?

A

dorsiflexes ankle joint, extends big toe

deep peroneal (aka fibular) nerve

1196
Q

Muscles in the peroneal compartment of the lower limb?

A

peroneus longus

peroneus brevis

1197
Q

Nerve in the peroneal compartment of the lower limb?

A

superficial peroneal (aka fibular) nerve

1198
Q

Peroneal compartment of lower limb muscles= Peroneus longus:
- action?
- nerve?

A

everts foot, assists in plantar flexion

superficial peroneal (aka fibular) nerve

1199
Q

Peroneal compartment of lower limb muscles= Peroneus brevis:
- action?
- nerve?

A

plantar flexes the ankle joint

superficial peroneal (fibular) nerve

1200
Q

Muscles in the superficial posterior compartment of the lower limb?

A

Gastrocnemius

Soleus

1201
Q

Nerve in the superficial posterior compartment of the lower limb?

A

tibial nerve

1202
Q

2 main terminal branches of the sciatic nerve?

A

tibial nerve
fibular (peroneal) nerve

1203
Q

Superficial posterior compartment of lower limb muscles= Gastrocnemius:
- action?
- nerve?

A

plantar flexes the foot, may also flex the knee

tibial nerve

1204
Q

Superficial posterior compartment of lower limb muscles= Soleus:
- action?
- nerve?

A

plantar flexor

tibial nerve

1205
Q

Muscles in the deep posterior compartment of the lower limb?

A

flexor digitorum longus

flexor hallucis longus

tibialis posterior

1206
Q

Nerve in the deep posterior compartment in the lower limb?

A

tibial nerve

1207
Q

Deep posterior compartment of lower limb muscles= Flexor digitorum longus:
- action?
- nerve?

A

flexes the lateral 4 toes

tibial

1208
Q

Deep posterior compartment of lower limb muscles= Flexor hallucis longus:
- action?
- nerve?

A

flexes the great toe

tibial

1209
Q

Deep posterior compartment of lower limb muscles= Tibialis posterior:
- action?
- nerve?

A

plantar flexor, inverts the foot

tibial

1210
Q

Meralgia paraesthetica?

A

syndrome of paraesthesia or anaesthesia in distribution of lateral femoral cutaneous nerve (LFCN)

meros=high

algos=pain

1211
Q

Cause of Meralgia paraesthetica?

A

entrapment mononeuropathy of the LFCN, but can also be iatrogenic after a surgical procedure, or result from a neuroma. Although uncommon, meralgia paraesthetica is not rare and is hence probably underdiagnosed.

1212
Q

Anatomy in Meralgia paraesthetica syndrome?

A

The LFCN is primarily a sensory nerve, carrying no motor fibres.

It most commonly originates from the L2/3 segments.

After passing behind the psoas muscle, it runs beneath the iliac fascia as it crosses the surface of the iliac muscle and eventually exits through or under the lateral aspect of the inguinal ligament.

As the nerve curves medially and inferiorly around the anterior superior iliac spine (ASIS), it may be subject to repetitive trauma or pressure.

Compression of this nerve anywhere along its course can lead to the development of meralgia paraesthetica.

1213
Q

Epidemiology of meralgia paraesthetica?

A

30-40yrs
In some, both legs may be affected.
It is more common in men than women.
Occurs more commonly in those with diabetes than in the general population.

1214
Q

RFs for meralgia paraesthetica?

A

Obesity
Pregnancy
Tense ascites
Trauma
Iatrogenic, such as pelvic osteotomy, spinal surgeries, laparoscopic hernia repair and bariatric surgery. In some cases, may result from abduction splints used in the management of Perthe’s disease.
Various sports have been implicated, including gymnastics, football, bodybuilding and strenuous exercise.
Some cases are idiopathic.

1215
Q

Symptoms in meralgia paraesthetica?

A

Burning, tingling, coldness, or shooting pain
Numbness
Deep muscle ache
Symptoms are usually aggravated by standing, and relieved by sitting
They can be mild and resolve spontaneously or may severely restrict the patient for many years.

1216
Q

Signs in meralgia paraesthetica?

A

Symptoms may be reproduced by deep palpation just below the ASIS (pelvic compression) and also by extension of the hip.
There is altered sensation over the upper lateral aspect of the thigh.
There is no motor weakness.

1217
Q

Ix for meralgia paraesthetica?

A

pelvic compression test is highly sensitive, and often, can be diagnosed based on this test alone

Injection of the nerve with local anaesthetic will abolish the pain. Using ultrasound is effective both for diagnosis and guiding injection therapy in meralgia paraesthetica

Nerve conduction studies may be useful.

1218
Q

Mx of meralgia paraesthetica?

A

Physical therapy to strengthen the muscles of the legs and buttocks, and reduce injury to the hips.
Wearing less restrictive clothing.
Weight loss management.
Corticosteroid injection to reduce swelling.

1219
Q

Froment’s sign?

A

Assess for ulnar nerve palsy

Adductor pollicis muscle function tested

Hold a piece of paper between their thumb and index finger. The object is then pulled away. If ulnar nerve palsy, unable to hold the paper and will flex the flexor pollicis longus to compensate (flexion of thumb at interphalangeal joint).

1220
Q

Phalen’s test?

A

Assess carpal tunnel syndrome

More sensitive than Tinel’s sign

Hold wrist in maximum flexion and the test is positive if there is numbness in the median nerve distribution.

1221
Q

Tinel’s sign (test)?

A

Assess for carpal tunnel syndrome

Tap the median nerve at the wrist and the test is positive if there is tingling/electric-like sensations over the distribution of the median nerve.

1222
Q

open fracture

A

disruption of the bony cortex associated with a breach in the overlying skin. Any wound that is present in the same limb as a fracture should be suspected as being representative of an open fracture

1223
Q

One of the main problems with open fractures is

A

associated injuries to the surrounding soft tissues. Whilst the skin is usually relatively resistant to trauma, underlying muscle can be damaged or devitalised, nerves, blood vessels and periosteum may all be disrupted the degree to which this occurs correlates with the severity of the injury and the outcome. These can be graded using the Gustilo and Anderson system

1224
Q

Open fractures: Gustilo and Anderson system?

A

1 Low energy wound <1cm

2 Greater than 1cm wound with moderate soft tissue damage

3 High energy wound > 1cm with extensive soft tissue damage

3 A (sub group of 3) Adequate soft tissue coverage

3 B (sub group of 3) Inadequate soft tissue coverage

3 C (sub group of 3) Associated arterial injury

1225
Q

Open fractures: In Type IIIc injuries, the mangled extremity scoring system (MESS) can help to predict the need for?

A

primary amputation

1226
Q

Mx for open fractures?

A
  • check for associated injuries, control haemorrhage and extent of injury
  • area should be carefully imaged, distal neurovascular status established the wound covered with a dressing and antibiotics administered.
  • Early debridement. The aim of the debridement is to remove foreign material and devitalised tissue. In most cases the wound is left open. The wound should be irrigated, generally, 6 litres of saline is used.
  • The fracture should be stabilised and an external fixator is often used in the first instance
1227
Q

Most effective Tx for osteoarthritis in pts who experience signif pain?

A

joint replacement (arthroplasty)

1228
Q

Selection criteria for Osteoarthritis joint replacement?

A

25% <60yrs

whilst obesity is often thought to be a barrier to joint replacement there is only a slight increase in short-term complications. There is no difference in long-term joint replacement survival

1229
Q

Surgical techniques for joint replacement in osteoarthritis?

A

hips= cemented hip replacement: metal femoral component is cemented into the femoral shaft. This is accompanied by a cemented acetabular polyethylene cup

uncementened hip replacements more popular in active and younger pts but more expensive

hip resurfacing sometimes used where a metal cap is attached over the femoral head. Younger pts; femoral neck is preserved which may be useful if conventional arthroplasty is needed later in life

1230
Q

Joint replacement in osteoarthritis: post-op recovery?

A

physio and home exercises

walking sticks or crutches are usually used for up to 6 weeks after hip or knee replacement surgery

1231
Q

Patients who have had a hip replacement operation (eg. due to osteoarthritis) should receive basic advice to minimise the risk of dislocation:

A

avoiding flexing the hip > 90 degrees
avoid low chairs
do not cross your legs
sleep on your back for the first 6 weeks

1232
Q

Cx of joint replacement in osteoarthritis?

A

wound and joint infection

VTE so LMWH for 4w after

dislocation

1233
Q

Osteochondritis dissecans (OCD)?

A

pathological process affecting the subchondral bone (most often in the knee joint) with secondary effects on the joint cartilage, including pain, oedema, free bodies and mechanical dysfunctions.

children and young adults

OCD may progress to degenerative changes if untreated.

1234
Q

Presentation of Osteochondritis dissecans (OCD)?

A

subacute onset

Knee pain and swelling, typically after exercise

Knee catching, locking and/or giving way: more constant and severe symptoms are associated with the presence of loose bodies

Feeling a painful ‘clunk’ when flexing or extending the knee - indicating the involvement of the lateral femoral condyle

1235
Q

Signs of Osteochondritis dissecans (OCD)?

A

Joint effusion

Tenderness on palpation of the articular cartilage of the medial femoral condyle, when the knee is flexed

Wilson’s sign for detecting medial condyle lesion

1236
Q

Wilson’s sign in Osteochondritis dissecans (OCD)?

A

for detecting medial condyle lesion - with the knee at 90° flexion and tibia internally rotated, the gradual extension of the joint leads to pain at about 30°, external rotation of the tibia at this point relieves the pain

1237
Q

Ix for Osteochondritis dissecans (OCD)?

A

x-ray (AP, lateral and tunnel views)= subchondral cresent sign or loose bodies

MRI= to evaluate cartilage, visualise loose bodies, stage and assess stability of the lesion

1238
Q

Mx of Osteochondritis dissecans (OCD)?

A

Early diagnosis is important

Clinical signs may be subtle in the early stages hence there should be a low threshold for imaging and/or orthopaedic opinion.

rest, NSAIDs, avoid intense activity 2-4m, physio, may need brace or crutches

1239
Q

Rib fracture?

A

break in the bony segment of any rib and is most often the consequence of blunt trauma to the chest wall but can be due to underlying diseases which weaken the bone structure of the ribs.

They can occur singly or in multiple places along the length of a rib and may be associated with soft tissue injuries to the surrounding muscles or the underlying lung.

1240
Q

RFs for rib fractures?

A
  • blunt trauma to chest wall
  • polytrauma (chest injuries present in 25% major trauma)
  • spontaneous= coughing, sneezing eg. if PMH osteoporosis, steroid use, COPD
  • pathological= ca mets eg. prostate in men and breast in women
1241
Q

Features of rib fracture?

A
  • severe, sharp chest wall pain worse with deep breaths or coughing
  • chest wall tenderness over site of fracture & bruising
  • crackles or reduced breath sounds if lung injury
  • reduction in ventilation & so drop in O2 sats due to pain/underlying lung injury
  • pneumothorax
1242
Q

Serious Cx of rib fractures?

A

Pneumothorax= reduced chest expansion, reduced breath sounds and hyper-resonant percussion on the affected side

1243
Q

Serious Cx of multiple rib fractures eg. following trauma?

A

Flail chest- caused by two or more rib fractures along three or more consecutive ribs, usually anteriorly

1244
Q

Flail chest (follows multiple rib fractures)?

A

caused by two or more rib fractures along three or more consecutive ribs, usually anteriorly

the flail segment moves paradoxically during respiration and impairs ventilation of the lung on the side of injury

the segment can cause serious contusional injury to the underlying lung if left untreated

often requires treatment with invasive ventilation and surgical fixation to prevent complications

1245
Q

Ix of rib fractures?

A

CT scan GOLD

CXR= A or P fracrures but suboptimal views and non info on soft tissue injury

1246
Q

Mx of rib fractures?

A
  • most cases= conservative + analgesia to ensure breathing not affected by pain. Pain not controlled= can consider nerve blocks
  • Surgical fixation if pain still not managed and fractures failed to heal after 12w
  • flail chest segments= urgent consideration for cardiothoracic surgery as they can impair ventilation and result in signif lung trauma
1247
Q

Lung Cx of rib fractures?

A

pneumothorax or haemothorax

1248
Q

What type of rib fractures need to be discussed urgently with cardiothoracic surgery as they can impair ventilation?

A

flail chest

1249
Q

Most common cause of shoulder pain?

A

rotator cuff injuries

1250
Q

Rotator cuff injuries include what?

A

spectrum of:
1. Subacromial impingement (also known as impingement syndrome, painful arc syndrome)
2. Calcific tendonitis
3. Rotator cuff tears
4. Rotator cuff arthropathy

1251
Q

Shoulder pain worse on abduction?

A

rotator cuff injuries

1252
Q

Signs of rotator cuff injuries?

A

painful arc of abduction. With subacromial impingement, this is typically between 60 and 120 degrees. With rotator cuff tears the pain may be in the first 60 degrees.

tenderness over anterior acromion

1253
Q

Scaphoid bone?

A

concave articular surface for the head of the capitate and at the edge of this is a crescentic surface for the corresponding area on the lunate.

Proximally= wide convex articular surface with the radius. It has a distally sited tubercle that can be palpated. The remaining articular surface is to the lateral side of the tubercle. It faces laterally and is associated with the trapezium and trapezoid bones.

The narrow strip between the radial and trapezial surfaces and the tubercle gives rise to the radial collateral carpal ligament. The tubercle receives part of the flexor retinaculum. This area is the only part of the scaphoid that is available for the entry of blood vessels. It is commonly fractured and avascular necrosis may result.

1254
Q

Shoulder dislocation?

A

occurs when the humeral head dislodges from the glenoid cavity of the scapula.

The shoulder is the most common joint in the body to dislocate, accounting for approximately 50% of all major joint dislocations.

1255
Q

Most common type of shoulder dislocations?

A

Anterior shoulder dislocations account for > 95% of cases.

1256
Q

Mx for shoulder dislocation?

A

reduction

If the dislocation is recent then reduction may be attempted without any analgesia/sedation. However, other patients may require analgesia +/- sedation to ensure the rotator cuff muscles are relaxed.

1257
Q

Common shoulder problems?

A

Adhesive capsulitis
(frozen shoulder)

Supraspinatus tendonitis
(Subacromial impingement,
painful arc)

1258
Q

Shoulder problems: Adhesive capsulitis
(frozen shoulder)?

A

Common in middle-age and diabetics

Characterised by painful, stiff movement

Limited movement in all directions, with loss of external rotation and abduction in about 50% of patients

1259
Q

Shoulder problems:
Supraspinatus tendonitis
(Subacromial impingement,
painful arc)?

A

Rotator cuff injury

Painful arc of abduction between 60 and 120 degrees

Tenderness over anterior acromion

1260
Q

Dorsal column lesion

A

loss of vibration and proprioception

tabes dorsalis, SACD

1261
Q

Spinothalamic tract lesion?

A

loss of pain, sensation and temp

1262
Q

Central cord lesion?

A

flaccid paralysis of the upper limbs

1263
Q

Osteomyelitis of the spine?

A

Normally progressive

Staph aureus in IVDU, normally cervical region affected

Fungal infections in immunocompromised

Thoracic region affected in TB

1264
Q

Infarction to spinal cord?

A

dorsal column signs (loss of proprioception and fine discrimination)

1265
Q

Cord compression?

A

UMN signs
malignancy
haematoma
fracture

1266
Q

Brown-sequard syndrome?

A

Hemisection of the spinal cord

Ipsilateral paralysis

Ipsilateral loss of proprioception and fine discrimination

Contralateral loss of pain and temperature

1267
Q

Signs/symptoms of Brown-sequard syndrome?

A

Ipsilateral paralysis

Ipsilateral loss of proprioception and fine discrimination

Contralateral loss of pain and temperature

1268
Q

Ipsilateral paralysis

Ipsilateral loss of proprioception and fine discrimination

Contralateral loss of pain and temperature

A

Brown-sequard syndrome

1269
Q

Dermatomes C2-C4

A

C2 dermatome covers the occiput and the top part of the neck. C3 covers the lower part of the neck to the clavicle. C4 covers the area just below the clavicle.

1270
Q

Dermatomes C5 to T1?

A

Situated in the arms. C5 covers the lateral arm at and above the elbow. C6 covers the forearm and the radial (thumb) side of the hand. C7 is the middle finger, C8 is the medial aspect of the hand, and T1 covers the medial side of the forearm.

1271
Q

Dermatomes T2-T12?

A

The thoracic covers the axillary and chest region. T3 to T12 covers the chest and back to the hip girdle. The nipples are situated in the middle of T4. T10 is situated at the umbilicus. T12 ends just above the hip girdle.

1272
Q

Dermatomes L1 to L5?

A

The cutaneous dermatome representing the hip girdle and groin area is innervated by L1 spinal cord. L2 and 3 cover the front part of the thighs. L4 and L5 cover medial and lateral aspects of the lower leg.

1273
Q

Dermatomes S1 to S5?

A

S1 covers the heel and the middle back of the leg. S2 covers the back of the thighs. S3 cover the medial side of the buttocks and S4-5 covers the perineal region. S5 is of course the lowest dermatome and represents the skin immediately at and adjacent to the anus.

1274
Q

Upper limb myotomes?

A

C5-T1

1275
Q

Lower limb myotomes?

A

L1 to S1

1276
Q

Anal sphincter myotomes?

A

S2-S4

1277
Q

What myotome= elbow flexors/biceps?

A

C5

1278
Q

What myotome= wrist extensors?

A

C6

1279
Q

What myotome= elbow extensors/triceps?

A

C7

1280
Q

What myotome= long finger flexors?

A

C8

1281
Q

What myotome= small finger abductors?

A

T1

1282
Q

What myotome= hip flexors (psoas)?

A

L1 and L2

1283
Q

What myotome= knee extensors (quads)?

A

L3

1284
Q

What myotome= ankle dorsiflexors (tibialis anterior)?

A

L4 and L5

1285
Q

What myotome= toe extensors (hallucis longus)?

A

L5

1286
Q

What myotome= ankle plantar flexors (gastrocnemius)?

A

S1

1287
Q

What myotome= anal sphinceter?

A

S2,3,4

1288
Q

Stress fractures?

A

Repetitive activity and loading of normal bone may result in small hairline fractures. Whilst these may be painful they are seldom displaced. Surrounding soft tissue injury is unusual.

1289
Q

Stress fractures- presentation/magament?

A

may present late following the injury, in which case callus formation may be identified on radiographs. Such cases may not require formal immobilisation, injuries associated with severe pain and presenting at an earlier stage may benefit from immobilisation tailored to the site of injury.

1290
Q

Most common upper limb injury in children <6yrs?

A

subluxation of the radial head (pulled elbow)

due to the fact that the distal attachment of the annular ligament covering the radial head is weaker in children at this age group.

1291
Q

Signs of subluxation of the radial head (pulled elbow)?

A

elbow pain and limited supination and extension of the elbow. The child usually refuses examination on the affected elbow due to the pain

1292
Q

Mx of subluxation of the radial head (pulled elbow)?

A

analgesia and passively supination of the elbow joint whilst the elbow is flexed to 90 degrees

1293
Q

Subluxation?

A

partial dislocation

1294
Q

Talipes equinovarus (club foot)?

A

describes an inverted (inward turning) and plantar flexed foot. It is usually diagnosed on the newborn exam.

M>F

50% bilateral

1295
Q

Talipes equinovarus (club foot) assocaitions?

A

idiopathic
spina bifida
cerebral palsy
Edward’s syndrome (trisomy 18)
oligohydramnios
arthrogryposis

1296
Q

Diagnosis of talipes equinovarus (club foot)?

A

clinical (the deformity is not passively correctable) and imaging is not normally needed.

1297
Q

Mx of talipes equinovarus (club foot)?

A

Ponseti method= manipulation and progressive casting which starts soon after birth. The deformity is usually corrected after 6-10 weeks.

An Achilles tenotomy is required in around 85% of cases but this can usually be done under local anaesthetic

night-time braces should be applied until the child is aged 4 years. The relapse rate is 15%

1298
Q

Trigger finger?

A

common condition associated with abnormal flexion of the digits. It is thought to be caused by a disparity between the size of the tendon and pulleys through which they pass. In simple terms the tendon becomes ‘stuck’ and cannot pass smoothly through the pulley.

1299
Q

Trigger finger associations?

A

idiopathic
F>M
RA
DM

1300
Q

Features of trigger finger?

A

more common in the thumb, middle, or ring finger

initially stiffness and snapping (‘trigger’) when extending a flexed digit

a nodule may be felt at the base of the affected finger

1301
Q

Mx of trigger finger?

A
  • steroid injections + finger splint after
  • surgery if not responded
1302
Q

Musculocutaneous nerve (C5-C7)= motor?

A

elbow flexion (supplies biceps brachii) and supination

1303
Q

Musculocutaneous nerve (C5-C7)= sensory?

A

lateral part of forearm

1304
Q

Musculocutaneous nerve (C5-C7)= typical mechanism of injury?

A

Isolated injury rare - usually injured as part of brachial plexus injury

1305
Q

Axillary nerve (C5,C6)= motor?

A

shoulder abduction (deltoid muscle)

1306
Q

Axillary nerve (C5,C6)= sensory?

A

inferior region of the deltoid muscle

1307
Q

Axillary nerve (C5,C6)= mechanism of injury?

A

humeral neck fracture/dislocation

results in flattened deltoid

1308
Q

Humeral neck fracture/dislocation resulting in flattened deltoid- injury to what nerve?

A

Axillary nerve (C5,C6)

1309
Q

Radial nerve (C5-C8)= motor?

A

extension (forearm, wrist, fingers, thumb)

1310
Q

Radial nerve (C5-C8)= sensory?

A

small area between the dorsal aspect of the 1st and 2nd metacarpals

1311
Q

Radial nerve (C5-C8)= mechanism of injury?

A

humeral midshaft fracture

palsy results in wrist drop

1312
Q

Humeral midshaft fracture resulting in wrist drop- injury to what nerve?

A

Radial nerve (C5-C8)

1313
Q

Median nerve (C6, C8, T1)= motor?

A

LOAF muscles

Features depend on the site of the lesion:
wrist: paralysis of thenar muscles, opponens pollicis
elbow: loss of pronation of forearm and weak wrist flexion

1314
Q

Median nerve (C6, C8, T1)= sensory?

A

Palmar aspect of lateral 3½ fingers

1315
Q

Median nerve (C6, C8, T1)= mechanism of injury?

A

wrist lesion -> carpal tunnel syndrome

1316
Q

wrist lesion causing carpal tunnel syndrome- injury to what nerve?

A

Median nerve (C6, C8, T1)

1317
Q

Ulnar nerve (C8, T1)= motor?

A

intrinsic hand muscles except LOAF

wrist flexion

1318
Q

Ulnar nerve (C8, T1)= sensory?

A

Medial 1½ fingers

1319
Q

Ulnar nerve (C8, T1)= mechanism of injury?

A

Medial epicondyle fracture

Damage may result in a ‘claw hand’

1320
Q

Medial epicondyle fracture resulting in ‘claw hand’- injury to what nerve?

A

Ulnar nerve (C8, T1)

1321
Q

Long thoracic nerve (C5-C7)= motor?

A

serratus anterior

1322
Q

Long thoracic nerve (C5-C7)= sensory?

A

N/A

1323
Q

Long thoracic nerve (C5-C7)= mechanism of injury?

A

Often during sport e.g. following a blow to the ribs. Also possible complication of mastectomy

Damage results in a winged scapula

1324
Q

Often during sport e.g. following a blow to the ribs. Also possible complication of mastectomy

Damage results in a winged scapula

Injury to what nerve?

A

Long thoracic nerve (C5-C7)

1325
Q

Erb-Duchenne palsy (‘waiter’s tip’)?

A

due to damage of the upper trunk of the brachial plexus (C5,C6)

may be secondary to shoulder dystocia during birth

the arm hangs by the side and is internally rotated, elbow extended

1326
Q

Klumpke injury?

A

due to damage of the lower trunk of the brachial plexus (C8, T1)

as above, may be secondary to shoulder dystocia during birth. Also may be caused by a sudden upward jerk of the hand

associated with Horner’s syndrome

1327
Q

LOAF muscles (in hand)?

A

Lateral two lumbricals

Opponens pollis

Abductor pollis brevis

Flexor pollis brevis

1328
Q

ANCA antibodies stands for what?

A

Anti-neutrophil cytoplasmic antibodies

1329
Q

ANCA (antibodies) are associated with what?

A

number of small-vessel vasculitides, including:

granulomatosis with polyangiitis

eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

microscopic polyangiitis

1330
Q

ANCA associated vasculitis more common with….

A

increasing age

1331
Q

ANCA associated vasculitis: whilst each condition has its own distinct features, there are a number of common findings…

A

renal impairment
caused by immune complex glomerulonephritis → raised creatinine, haematuria and proteinuria

respiratory symptoms:
dyspnoea, haemoptysiis

systemic symptoms: fatigue,
weight loss, fever

vasculitic rash: present only in a minority of patients

ENT symptoms: sinusitis

1332
Q

ANCA associated vasculitis: first line Ix?

A

urinalysis for haematuria and proteinuria

bloods:
- urea and creatinine for renal impairment
- full blood count: normocytic anaemia and thrombocytosis may be seen
- CRP: raised
- ANCA testing (see below)

chest x-ray: nodular, fibrotic or infiltrative lesions may be seen

1333
Q

ANCA types?

A

cytoplasmic (cANCA) and perinuclear (pANCA)

1334
Q

ANCA types- cANCA and pANCA= There is considerable overlap between which antibodies are found in which condition, but as a rule of thumb…

A

cANCA - granulomatosis with polyangiitis

pANCA - eosinophilic granulomatosis with polyangiitis + others

1335
Q

cANCA?

A
  • serine proteinase 3 (PR3)
  • Granulomatosis with polyangiitis= 90%
  • Eosinophilic granulomatosis with polyangiitis= Low
  • Microscopic polyangiitis= 40%
  • other associated conditions= N/A
  • Use for monitoring= Some correlation between cANCA levels and disease activity
1336
Q

pANCA?

A
  • myeloperoxidase (MPO)
  • Granulomatosis with polyangiitis= 25%
  • Eosinophilic granulomatosis with polyangiitis= 50%
  • Microscopic polyangiitis= 75%
  • other associated conditions= Ulcerative colitis (70%); Primary sclerosing cholangitis (70%); Anti-GBM disease (25%); Crohn’s disease (20%)
  • Use for monitoring= Cannot use level of pANCA to monitor disease activity
1337
Q

ANCA associated vasculitis: general approach to Mx?

A

once suspected, should be managed by specialist teams (e.g. renal, rheumatology, respiratory) to allow an exact diagnosis to be made. Kidney or lung biopsies may be taken to aid the diagnosis.

The mainstay of management is immunosuppressive therapy.

1338
Q

Antisynthetase syndrome?

A

autoimmune condition caused by the presence of autoantibodies against aminoacyl-tRNA synthetase enzymes.

These autoantibodies play a critical role in the pathogenesis of the disease by targeting and interfering with these essential enzymes, which are responsible for protein synthesis in cells.

1339
Q

Antisynthetase syndrome most common autoantibody associated with this condition?

A

anti-Jo-1

1340
Q

Clinical features of Antisynthetase syndrome?

A
  • myositis= muscle weakness, primarily affecting the proximal muscles so difficulties in performing everyday activities, such as climbing stairs or lifting objects. Elevated muscle enzymes, such as creatine kinase (CK), are often observed.
  • interstitial lung disease= chronic dry cough, SOB, reduced exercise tolerance. High-resolution CT for diagnosis
  • mechanic’s hands
  • Raynaud’s phenomenon= episodic vasospasm of the small blood vessels, usually in response to cold or stress, leading to pallor, cyanosis, and erythema of the fingers and toes
1341
Q

Antisynthetase syndrome= mechanic’s hands?

A

hyperkeratotic, thickened, and cracked skin on the sides of their fingers and palms, resembling the hands of a manual labourer. This distinctive feature, known as ‘mechanic’s hands,’ is a key clinical sign of the syndrome.

1342
Q

Additional features of Antisynthetase syndrome?

A
  • inflam arthritis
  • fever
  • fatigue, weight loss, malaise
1343
Q

Diagnosis of Antisynthetase syndrome?

A

based on clinical features, serological tests for specific autoantibodies (like anti-Jo-1), and imaging studies to assess lung involvement. Muscle biopsies and electromyography (EMG) may be used to confirm myositis.

1344
Q

Mx of Antisynthetase syndrome?

A

immunosuppressive therapy, such as corticosteroids and other immunomodulatory drugs, to control inflammation and prevent disease progression. Patients with significant lung involvement may require additional treatments, including antifibrotic agents and supplemental oxygen.

1345
Q

Behcet’s syndrome?

A

complex multisystem disorder associated with presumed autoimmune-mediated inflammation of the arteries and veins.

Cause uncertain.

1346
Q

Behcet’s syndrome triad?

A

oral ulcers, genital ulcers and anterior uveitis

1347
Q

oral ulcers, genital ulcers and anterior uveitis

A

Behcet’s syndrome

1348
Q

Epidemiology of Behcet’s syndrome?

A

M>F (more common & more severe)

more common in eastern Mediterranean eg. Turkey

20-40yrs

associated with HLA B51

30% have +ve FHx

1349
Q

Features of Behcet’s syndrome?

A

1) oral ulcers 2) genital ulcers 3) anterior uveitis

thrombophlebitis and deep vein thrombosis
arthritis
neurological involvement (e.g. aseptic meningitis)
GI: abdo pain, diarrhoea, colitis
erythema nodosum

1350
Q

Diagnosis of Behcet’s syndrome?

A

no definitive test

diagnosis based
on clinical findings

positive pathergy test is suggestive (puncture site following needle prick becomes inflamed with small pustule forming)

1351
Q

Ca, Phosphate, ALP and PTH in osteoporosis?

A

Ca= normal
Phosphate= normal
ALP= normal
PTH= normal

1352
Q

Ca, Phosphate, ALP and PTH in osteomalacia?

A

Ca= decreased
Phosphate= decreased
ALP= increased
PTH= increased

1353
Q

Ca, Phosphate, ALP and PTH in primary hyperparathyroidism (-> osteitis fibrosa cystica)?

A

Ca= increased
Phosphate= decreased
ALP= increased
PTH= increased

1354
Q

Ca, Phosphate, ALP and PTH in CKD (-> secondary hyperparathyroidism)?

A

Ca= decreased
Phosphate= increased
ALP= increased
PTH= increased

1355
Q

Ca, Phosphate, ALP and PTH in Paget’s disease?

A

Ca= normal
Phosphate= normal
ALP= increased
PTH= normal

1356
Q

Ca, Phosphate, ALP and PTH in osteopetrosis?

A

Ca= normal
Phosphate= normal
ALP= normal
PTH= normal

1357
Q

Osteopetrosis?

A

group of a rare disorders that cause bones to grow abnormally and become overly dense

1358
Q

Benign bone tumours?

A

osteoma

osteochondroma (exotosis)

giant cell tumour

1359
Q

Benign bone tumours: osteoma?

A

benign ‘overgrowth’ of bone, most typically occuring on the skull

associated with Gardner’s syndrome (a variant of familial adenomatous polyposis, FAP)

1360
Q

Benign bone tumours: osteochondroma (exotosis)?

A

most common benign bone tumour

more in males, usually diagnosed in patients aged < 20 years

cartilage-capped bony projection on the external surface of a bone

1361
Q

Benign bone tumours: giant cell tumour?

A

tumour of multinucleated giant cells within a fibrous stroma
peak incidence: 20-40 years
occurs most frequently in the epiphyses of long bones
X-ray shows a ‘double bubble’ or ‘soap bubble’ appearance

1362
Q

Malignant bone tumours?

A

osteosarcoma

Ewing’s sarcoma

chondrosarcoma

1363
Q

Malignant bone tumours: osteosarcoma?

A

most common primary malignant bone tumour

seen mainly in children and adolescents

occurs most frequently in the metaphyseal region of long bones prior to epiphyseal closure, with 40% occuring in the femur, 20% in the tibia, and 10% in the humerus

x-ray= Codman triangle (from periosteal elevation) and ‘sunburst’ pattern

mutation of the Rb gene increases risk (hence association with retinoblastoma)

other predisposing factors include Paget’s disease of the bone and radiotherapy

1364
Q

Malignant bone tumours: Ewing’s sarcoma?

A

small round blue cell tumour
seen mainly in children and adolescents
occurs most frequently in the pelvis and long bones. Tends to cause severe pain
associated with t(11;22) translocation which results in an EWS-FLI1 gene product
x-ray shows ‘onion skin’ appearance

1365
Q

Malignant bone tumours: chondrosarcoma?

A

malignant tumour of cartilage
most commonly affects the axial skeleton
more common in middle-age

1366
Q

Dactylitis?

A

inflammation of a digit (finger or toe)

1367
Q

Causes of dactylitis?

A

spondyloarthritis: e.g. Psoriatic and reactive arthritis

sickle-cell disease

other rare causes include tuberculosis, sarcoidosis and syphilis

1368
Q

Discoid lupus erythematosus?

A

benign disorder generally seen in younger females. It very rarely progresses to systemic lupus erythematosus (in less than 5% of cases). Discoid lupus erythematosus is characterised by follicular keratin plugs and is thought to be autoimmune in aetiology

1369
Q

Features of Discoid lupus erythematosus?

A

erythematous, raised rash, sometimes scaly
may be photosensitive
more common on face, neck, ears and scalp
lesions heal with atrophy, scarring (may cause scarring alopecia), and pigmentation

1370
Q

Mx of of Discoid lupus erythematosus?

A

topical steroid cream
oral antimalarials may be used second-line e.g. hydroxychloroquine
avoid sun exposure

1371
Q

Drug-induced lupus?

A

not all the typical features of systemic lupus erythematosus are seen, with renal and nervous system involvement being unusual. It usually resolves on stopping the drug.

1372
Q

Features of drug-induced lupus?

A

arthralgia
myalgia
skin (e.g. malar rash) and pulmonary involvement (e.g. pleurisy) are common
ANA positive in 100%, dsDNA negative
anti-histone antibodies are found in 80-90%
anti-Ro, anti-Smith positive in around 5%

1373
Q

Causes of drug-induced lupus?

A

Most common causes:
procainamide
hydralazine

Less common causes:
isoniazid
minocycline
phenytoin

1374
Q

Ehler-Danlos syndrome?

A

autosomal dominant connective tissue disorder that mostly affects type III collagen. This results in the tissue being more elastic than normal leading to joint hypermobility and increased elasticity of the skin.

1375
Q

Features and Cx of Ehler-Danlos syndrome?

A

elastic, fragile skin

joint hypermobility: recurrent joint dislocation

easy bruising

aortic regurgitation, mitral valve prolapse and aortic dissection

subarachnoid haemorrhage

angioid retinal streaks

1376
Q

Referred lumbar spine pain?

A

Femoral nerve compression may cause referred pain in the hip

Femoral nerve stretch test may be positive - lie the patient prone. Extend the hip joint with a straight leg then bend the knee. This stretches the femoral nerve and will cause pain if it is trapped

1377
Q

Summary of Meralgia paraesthetica?

A

Caused by compression of lateral cutaneous nerve of thigh
Typically burning sensation over antero-lateral aspect of thigh

1378
Q

Pubic symphysis dysfunction?

A

Common in pregnancy

Ligament laxity increases in response to hormonal changes of pregnancy

Pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen

1379
Q

Pregnant pt with pain over the pubic symphysis with radiation to the groins and the medial aspects of the thighs. A waddling gait may be seen

A

pubic symphysis dysfunction

1380
Q

Transient idiopathic osteoporosis

A

An uncommon condition sometimes seen in the third trimester of pregnancy
Groin pain associated with a limited range of movement in the hip
Patients may be unable to weight bear
ESR may be elevated

1381
Q
A
1382
Q

An uncommon condition sometimes seen in the third trimester of pregnancy
Groin pain associated with a limited range of movement in the hip
Patients may be unable to weight bear
ESR may be elevated

A

transient idiopathic osteoporosis

1383
Q

Causes of hip pain in adults?

A

OA

inflam arthritis

referred L spine pain

Greater trochanteric pain syndrome

Meralgia paraesthetica

Avascular necrosis

Pubic symphysis dysfunction

Transient idiopathic osteoarthritis

1384
Q

HLA antigens are encoded for by genes on chromosome

A

6

1385
Q

HLA A, B and C are what? DP, DQ and DR?

A

class I antigens

class II antigens

1386
Q

HLA associations- what one for:
- haemochromatosis?

A

HLA-A3

1387
Q

HLA associations- what one for:
- Behcet’s disease?

A

HLA-B51

1388
Q

HLA associations- what one for:
- ankylosing spondylitis
- reactive arthritis
- acute anterior uveitis
- psoriatic arthritis

A

HLA-B27

1389
Q

HLA associations- what one for:
- coeliac disease?

A

HLA-DQ2/DQ8

1390
Q

HLA associations- what one for:
- narcolepsy
- Goodpasture’s

A

HLA-DR2

1391
Q

HLA associations- what one for:
- dermatitis herpetiformis
- Sjogren’s syndrome
- primary biliary cirrhosis

(sometimes DM but not strongly)

A

HLA-DR3

1392
Q

HLA associations- what one for:
- DMT1
- RA

A

HLA-DR4

RA= in particular the DRB1 gene (DRB104:01 and DRB104:04 hence the association with DR4)

1393
Q

Hydroxychloroquine

A

used in Mx of RA and systemic/discoid lupus erythematosus

pharmacologically similar to chloroquine used to treat malaria

1394
Q

Can hydroxychloroquine be used in pregnancy?

A

yes

1395
Q

Monitoring of hydroxychloroquine?

A

‘Ask patient about visual symptoms and monitor visual acuity annually using the standard reading chart’

1396
Q

Adverse effects of hydroxychloroquine?

A

bull’s eye retinopathy - may result in severe and permanent visual loss

baseline ophthalmological examination and annual screening is generally recommened

colour retinal photography and spectral domain optical coherence tomography scanning of the macula

1397
Q

Langerhans cell histiocytosis?

A

are disorder characterised by the proliferation of Langerhans cells, which are specialised dendritic cells that normally function to present antigen to T lymphocytes. The disease can affect multiple organs, including the bones, skin, lungs, and endocrine system. It is notable for its variable clinical presentation, ranging from isolated bone lesions to multisystem disease.

1398
Q

Features of Langerhans cell histiocytosis?

A

bone pain, typically in the skull or proximal femur

cutaneous nodules

pituitary involvement: leads to diabetes insipidus due to pituitary stalk involvement

pulmonary involvement: More common in adults, presenting with dyspnoea, cough, and chest pain

recurrent otitis media/mastoiditis

tennis racket-shaped Birbeck granules on electromicroscopy

1399
Q

Diagnosis of Langerhans cell histiocytosis?

A

biopsy: confirmation is through biopsy showing Langerhans cells with characteristic grooved nuclei and positive staining for CD1a and S100 protein

imaging: radiographs and MRI for bone lesions; CT may be used for chest and abdominal involvement

1400
Q

Tx of Langerhans cell histiocytosis?

A

localized disease: surgical resection or limited radiotherapy for isolated lesions.

multisystem disease: systemic therapy including steroids, chemotherapy (e.g., vinblastine, cytarabine), and targeted therapies for refractory cases.

supportive care: management of diabetes insipidus, pain control, and treatment of secondary infections.

1401
Q

Young girl with multiple well defined ‘punched out’ osteolytic lesions with scalloped edges (geographic skull) are seen in the bilateral parietal regions. The lesions have a characteristic bevelled edge.

A

Langerhans cell histiocytosis

1402
Q

Marfan’s syndrome?

A

autosomal dominant connective tissue disorder

1403
Q

Cause of Marfan’s syndrome?

A

defect in the FBN1 gene on chromosome 15 that codes for the protein fibrillin-1.

1404
Q

Features of Marfan’s syndrome?

A

tall stature with arm span to height ratio > 1.05

high-arched palate

arachnodactyly (long curved slender fingers)

pectus excavatum (caved chest)

pes planus (flat foot)

scoliosis of > 20 degrees

dural ectasia (ballooning of the dural sac at the lumbosacral level)

heart, lung and eye symptoms

1405
Q

tall stature with arm span to height ratio > 1.05

high-arched palate

arachnodactyly (long curved slender fingers)

pectus excavatum (caved chest)

pes planus (flat foot)

scoliosis of > 20 degrees

blue sclera

A

Marfan’s syndrome

1406
Q

Marfan’s syndrome: heart features?

A

dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation

mitral valve prolapse (75%),

1407
Q

Marfan’s syndrome: lung features?

A

repeated pneumothoraces

1408
Q

Marfan’s syndrome: eye features?

A

upwards lens dislocation (superotemporal ectopia lentis)

blue sclera

myopia

1409
Q

Life expectancy of Marfan’s syndrome/Mx?

A

used to be around 40-50 years.

But with regular echocardiography monitoring and beta-blocker/ACE-inhibitor therapy this has improved significantly over recent years.

Aortic dissection and other cardiovascular problems remain the leading cause of death however.

1410
Q

McArdle’s disease?

A

autosomal recessive type V glycogen storage disease
caused by myophosphorylase deficiency
this causes decreased muscle glycogenolysis

1411
Q

Features of McArdle’s disease?

A

muscle pain and stiffness following exercise

muscle cramps

second wind phenomenon

rhabdomyolysis & myoglobinuria

low lactate levels during exercise

1412
Q

Second wind phenomenon in McArdle’s disease?

A

occurs when patients experience an improvement in exercise tolerance after a brief rest or reduction in intensity

due to the body’s switch from glycogen-dependent energy metabolism to increased reliance on circulating glucose and fatty acids

this adaptation allows for better energy utilisation during prolonged activity despite the underlying myophosphorylase deficiency.

1413
Q

Myopathies: features?

A

symmetrical muscle weakness (proximal > distal)

common problems are rising from chair or getting out of bath

sensation normal, reflexes normal, no fasciculation

1414
Q

Myopathies: causes?

A

inflammatory: polymyositis

inherited: Duchenne/Becker muscular dystrophy, myotonic dystrophy

endocrine: Cushing’s, thyrotoxicosis

alcohol

1415
Q

OA vs RA: aetiology?

A

OA=
Mechanical - wear & tear
- localised loss of cartilage
- remodelling of adjacent bone
- associated inflammation

RA=
Autoimmune

1416
Q

OA vs RA: gender?

A

OA= slightly more in W

RA= signif more in W

1417
Q

OA vs RA: age?

A

OA= elderly

RA= adults of all ages

1418
Q

OA vs RA: typical joints affected?

A

OA= Large weight-bearing joints (hip, knee); Carpometacarpal joint; DIP, PIP joints

RA= MCP, PIP joints

1419
Q

OA vs RA: typical symptoms?

A

OA= Pain following use, no morning stiffness or <30mins; improves with rest; Unilateral symptoms; No systemic upset

RA= Morning stiffness, improves with use; Bilateral symptoms; Systemic upset

1420
Q

OA vs RA: x-ray findings?

A

OA=
Loss of joint space
Subchondral sclerosis
Subchondral cysts
Osteophytes forming at joint margins

RA=
Loss of joint space
Juxta-articular osteoporosis
Periarticular erosions
Subluxation

1421
Q

Osteogenesis imperfecta (brittle bone disease)?

A

group of disorders of collagen metabolism resulting in bone fragility and fractures.

The most common, and milder, form of osteogenesis imperfecta is type 1

1422
Q

Osteogenesis imperfecta overview?

A

autosomal dominant

abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides

1423
Q

Osteogenesis imperfecta features?

A

presents in childhood

fractures following minor trauma

blue sclera

deafness secondary to otosclerosis

dental imperfections are common

1424
Q

presents in childhood
fractures following minor trauma
blue sclera
deafness secondary to otosclerosis
dental imperfections are common

A

Osteogenesis imperfecta

1425
Q

Osteogenesis imperfecta Ix?

A

adjusted calcium, phosphate, parathyroid hormone and ALP results are

1426
Q

Polymyositis?

A

inflammatory disorder causing symmetrical, proximal muscle weakness

thought to be a T-cell mediated cytotoxic process directed against muscle fibres

may be idiopathic or associated with connective tissue disorders

associated with malignancy

dermatomyositis is a variant of the disease where skin manifestations are prominent, for example a purple (heliotrope) rash on the cheeks and eyelids

typically affects middle-aged, female:male 3:1

1427
Q

Features of Polymyositis?

A

proximal muscle weakness +/- tenderness

Raynaud’s

respiratory muscle weakness

interstitial lung disease
e.g. fibrosing alveolitis or organising pneumonia
seen in around 20% of patients and indicates a poor prognosis

dysphagia, dysphonia

1428
Q

Ix for polymyositis?

A

elevated creatine kinase

other muscle enzymes (lactate dehydrogenase (LDH), aldolase, AST and ALT) are also elevated in 85-95% of patients

EMG

muscle biopsy

anti-synthetase antibodies: anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud’s and fever

1429
Q

Mx for polymyositis?

A

high-dose corticosteroids tapered as symptoms improve

azathioprine may be used as a steroid-sparing agent

1430
Q

Raynaud’s phenomenon?

A

an exaggerated vasoconstrictive response of the digital arteries and cutaneous arteriole to the cold or emotional stress. It may be primary (Raynaud’s disease) or secondary (Raynaud’s phenomenon).

1431
Q

How does raynaud’s disease typically present?

A

young women (e.g. 30 years old) with bilateral symptoms.

1432
Q

Secondary causes of Raynaud’s phenomenon?

A

connective tissue disorders:
- scleroderma (most common)
- rheumatoid arthritis
- systemic lupus erythematosus

leukaemia

type I cryoglobulinaemia, cold agglutinins

use of vibrating tools

drugs: oral contraceptive pill, ergot

cervical rib

1433
Q

Factors suggesting underlying connective tissue disease in Raynaud’s phenomenon?

A

onset after 40 years

unilateral symptoms

rashes

presence of autoantibodies
features which may suggest rheumatoid arthritis or SLE, for example arthritis or recurrent miscarriages

digital ulcers, calcinosis

very rarely: chilblains

1434
Q

Mx for Raynaud’s phenomenon?

A

all patients with suspected secondary Raynaud’s phenomenon should be referred to secondary care

first-line: calcium channel blockers e.g. nifedipine

IV prostacyclin (epoprostenol) infusions: effects may last several weeks/months

1435
Q

Rotator cuff muscles?

A

SItS

Supraspinatus
Infraspinatus
teres minor
Subscapularis

1436
Q

Rotator cuff muscles: Supraspinatus?

A

aBDucts arm before deltoid

Most commonly injured

1437
Q

Rotator cuff muscles: Infraspinatus?

A

Rotates arm laterally

1438
Q

Rotator cuff muscles: teres minor?

A

aDDucts & rotates arm laterally

1439
Q

Rotator cuff muscles: Suprascapularis?

A

aDDuct & rotates arm medially

1440
Q

Common features of Seronegative spondyloarthropathies?

A

associated with HLA-B27

rheumatoid factor negative - hence ‘seronegative’

peripheral arthritis, usually asymmetrical

sacroiliitis

enthesopathy: e.g. Achilles tendonitis, plantar fasciitis

extra-articular
manifestations: uveitis, pulmonary fibrosis (upper zone), amyloidosis, aortic regurgitation

1441
Q

Spondyloarthropathies?

A

ankylosing spondylitis

psoriatic arthritis

reactive arthritis

enteropathic arthritis (associated with IBD)

1442
Q

Sjogren’s syndrome?

A

autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces.

1443
Q

Sjogren’s syndrome can be…

A

primary (PSS) or secondary to rheumatoid arthritis or other connective tissue disorders, where it usually develops around 10 years after the initial onset.

1444
Q

Sjogren’s syndrome more common in who?

A

females (9:1)

1445
Q

There is a marked increased risk of what in Sjogren’s syndrome?

A

lymphoid malignancy (40-60 fold).

1446
Q

Sjogren’s syndrome features?

A

dry eyes: keratoconjunctivitis sicca

dry mouth

vaginal dryness

arthralgia

Raynaud’s, myalgia

sensory polyneuropathy

recurrent episodes of parotitis

renal tubular acidosis (usually subclinical)

Raynaud’s, myalgia

sensory polyneuropathy

recurrent episodes of parotitis

renal tubular acidosis (usually subclinical)

1447
Q

dry eyes: keratoconjunctivitis sicca

dry mouth

vaginal dryness

arthralgia

Raynaud’s, myalgia

sensory polyneuropathy

recurrent episodes of parotitis

renal tubular acidosis (usually subclinical)

Raynaud’s, myalgia

sensory polyneuropathy

recurrent episodes of parotitis

renal tubular acidosis (usually subclinical)

A

Sjogren’s syndrome

1448
Q

Sjogren’s syndrome Ix?

A

rheumatoid factor (RF) positive in nearly 50% of patients

ANA positive in 70%

anti-Ro (SSA) antibodies in 70% of patients with PSS

anti-La (SSB) antibodies in 30% of patients with PSS

Schirmer’s test: filter paper near conjunctival sac to measure tear formation

histology: focal lymphocytic infiltration

also: hypergammaglobulinaemia, low C4

1449
Q

Sjogren’s syndrome histology?

A

focal lymphocytic infiltration

1450
Q

Clinical test for Sjogren’s syndrome?

A

Schirmer’s test: filter paper near conjunctival sac to measure tear formation

1451
Q

Mx of Sjogren’s syndrome?

A

artificial saliva and tears

pilocarpine may be helpful to stimulate saliva production

1452
Q

Still’s disease in adults?

A

rare type of inflam arthritis

1453
Q

Still’s disease in adults epidemiology?

A

bimodal age distribution - 15-25 yrs and 35-46 yrs

1454
Q

Still’s disease in adults features?

A

arthralgia

elevated serum ferritin

rash: salmon-pink, maculopapular

pyrexia= typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash

lymphadenopathy

rheumatoid factor (RF) and anti-nuclear antibody (ANA) negative

1455
Q

arthralgia

elevated serum ferritin

rash: salmon-pink, maculopapular

pyrexia= typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash

A

Still’s disease in adults

1456
Q

Diagnosis of Still’s disease in adults?

A

challenging

The Yamaguchi criteria is the most widely used criteria and has a sensitivity of 93.5%.

1457
Q

Mx of Still’s disease in adults?

A

NSAIDs= should be used first-line to manage fever, joint pain and serositis; they should be trialled for at least a week before steroids are added.

steroids= may control symptoms but won’t improve prognosis

if symptoms persist, the use of methotrexate, IL-1 or anti-TNF therapy can be considered

1458
Q

Systemic sclerosis?

A

condition of unknown aetiology characterised by hardened, sclerotic skin and other connective tissues. It is four times more common in females

1459
Q

Systemic sclerosis: 3 patterns of disease?

A

Limited cutaneous systemic sclerosis

Diffuse cutaneous systemic sclerosis

Scleroderma (without internal organ involvement)

1460
Q

Systemic sclerosis: 3 patterns of disease= Limited cutaneous systemic sclerosis?

A

Raynaud’s may be the first sign

scleroderma affects face and distal limbs predominately

associated with anti-centromere antibodies

a subtype of limited systemic sclerosis is CREST syndrome: Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia

1461
Q

Systemic sclerosis: 3 patterns of disease= Diffuse cutaneous systemic sclerosis?

A

scleroderma affects trunk and proximal limbs predominately

associated with anti scl-70 antibodies

the most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)

other complications include renal disease and hypertension= patients with renal disease should be started on an ACE inhibitor

poor prognosis

1462
Q

Systemic sclerosis: 3 patterns of disease= Scleroderma (without internal organ involvement)?

A

tightening and fibrosis of skin

may be manifest as plaques (morphoea) or linear

1463
Q

Systemic sclerosis antibodies?

A

ANA positive in 90%

RF positive in 30%

anti-scl-70 antibodies associated with diffuse cutaneous systemic sclerosis
- associated with a higher risk of severe interstitial lung disease

anti-centromere antibodies associated with limited cutaneous systemic sclerosis

1464
Q

The following groups should be advised to take vitamin D supplementation:

A

all pregnant and breastfeeding women should take a daily supplement containing 10µg of vitamin D

all children aged 6 months - 5 years. Babies fed with formula milk do not need to take a supplement if they are taking more than 500ml of milk a day, as formula milk is fortified with vitamin D

adults > 65 years

‘people who are not exposed to much sun should also take a daily supplement’ e.g. housebound patients

(People who are at higher risk of vitamin D deficiency (see above) should be treated anyway so again testing is not necessary)

1465
Q

When to test for vit D def?

A

patients with bone diseases that may be improved with vitamin D treatment e.g. known osteomalacia or Paget’s disease

patients with bone diseases, prior to specific treatment where correcting vitamin deficiency is appropriate e,g, prior to intravenous zolendronate or denosumab

patients with musculoskeletal symptoms that could be attributed to vitamin D deficiency e.g. bone pain ?osteomalacia

1466
Q

Why is vit D not tested in pt with osteoporosis?

A

Patients with osteoporosis should always be given calcium/vitamin D supplements so testing is not considered necessary.

1467
Q
A

FINALS (36 decks)

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