MSK Flashcards
What are the 3 conditions making up the seronegative spondyloarthropathies?
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
What joints are mainly affected in ankylosing spondylitis?
Vetebral column joints
Sacroiliac joints
What gene is associated with ankylosing spondylitis
HLA-B27
What is the typical presentation of ankylosing spondylitis
Young adult male in their 20s with:
Pain and stiffness in the lower back
Sacroiliac pain
Pain and stiffness is worse in the morning and takes around 30 mins to improve, improves with exercise and worsens with rest
What symptoms can one experience other than back and sacroiliac pain in ankylosing spondylitis
Chest pain related to the costovertebral and sternocostal joints
Enthesitis (inflammation of the entheses, where tendons or ligaments insert into bone)
Dactylitis (inflammation of the entire finger)
Vertebral fractures (presenting with sudden-onset new neck or back pain)
Shortness of breath relating to restricted chest wall movement)
What conditions are associated with ankylosing spondylitis
5A’s
Anterior uveitis
Aortic regurgitation
Atrioventricular block
Apical lung fibrosis
Anaemia of chronic disease
Investigations for anklyosing spondylitis
Schober’s test - mark 10cm above and 5cm below L5 vertebrae and ask patient to bend forward –> length of <20cm between points = supportive of anklyosing spondylitis
ESR/CRP
HLA-B27 gene testing
X-ray of spine and sacrum
MRI of spine
What would an X-ray show in anklyosing spondylitis
Sacroiliitis: subchondral erosions, sclerosis
Squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
Syndesmophytes: due to ossification of outer fibers of annulus fibrosus
Apical fibrosis in CXR
What would an MRI of show in ankylosing spondylitis
Bone marrow oedema in sacroiliac joints
Management of ankylosing spondylitis
Regular exercise
1st line = NSAIDs
Anti-TNF therapy (if high disease activity) - adalimumab, etanercept or infliximab
Physiotherapy
What is the function of bursae
They act to reduce the friction between the bones and soft tissues during movement.
What are the causes of bursitis
Friction from repetives movement or leaning on the elbow
Trauma
Infection - septic bursitis
Inflammatory conditions - rheumatoid arthritis or gout
What are the symptoms of olecranon bursitis
Young/middle-aged man with an elbow that is:
Swollen
Warm
Tender
Fluctuant (fluid filled)
How do you identify that bursitis is caused by infection
Hot to touch
More tender on plapation
Erythema spreading to surrounding skin
Fever
Skin abrasion overlying the bursa
Features of sepsis - tachycardia, hypotensions, confusion)
Investigations for olecranon bursitis
Clinical diagnosis
If infection suspected:
Aspiration of bursal fluid and examine fluid:
Pus = infection
Straw-coloured = infection less likely
blood stained = trauma, infection or inflammatory cause
Milky = gout or psuedogout
Microscopy and culture of fluid:
Gram staining for bacteria
Examine for crystals = gout/pseudogout
Management of olecranon bursitis
Rest
Ice
Compression
Analgesia (e.g., paracetamol or NSAIDs)
Protecting the elbow from pressure or trauma
Aspiration of fluid may relieve pressure
Steroid injections may be used in problematic cases where infection has been excluded
Treatment of olecranon bursitis due to infective cause
Aspiration for microscopy and culture
Antibiotics - flucloxacillin (2nd line = clarithromycin)
IF septic = sepsis 6
Presentation of trochanteric bursitis
Middle aged patient with:
Gradual onset hip pain (over greater trochanter) - aching or burning
May radiate down the outer thigh
Worse with activity, standing after sitting and trying to sit cross legged
Tenderness over geeater trochanter
What would be the examination finding in trochanteric bursitis
Positive Trendelenburg test
Resisted abduction of the hip
Resisted internal rotation of the hip
Resisted external rotation of the hip
What is the Trendelenburg test
Involves asking the patient to stand one-legged on the affected leg. Normally, the other side of the pelvis should remain level or tilt upwards slightly. A positive Trendelenburg test is when the other side of the pelvis drops down, suggesting weakness in the affected hip.
Management of trochanteric bursitis
Rest
Ice
Analgesia (e.g., ibuprofen or naproxen)
Physiotherapy
Steroid injections
Define compartment syndrome
Where the pressure within a fascial compartment is abnormally elevated, cutting off the blood flow to the contents of that compartment
If compartment syndrome is not treated in time what can occur
Tissue necrosis
Where does compartment syndrome most commonly affect
Leg
Forearm
Feet
Thigh
Buttocks
What is the presentation of compartment syndrome
Usually after an acute injury like:
Bone fracture
Crush injuries
Presentation: 5 P’s
Pain - disproportionate to underlying injury (not made better with analgesics) and made worse by stretching
Parathesia
Pale
Pressure (high)
Paralysis (a late and worrying feature)
Investigations for compartment syndrome
Needle manometry
- Pressures >20mmHg is abnormal and >40mmHg is diagnostic
Management of compartment syndrome
Initial:
Removing any bandages/dressing
Elevation of leg
Maintaing good BP (avoid hypotension)
Emergency fasciotomy - cutting the fascia to release pressure
- Debridement of any necrotic tissue too
What are patients undergoing fasciotomy due to compartment syndrome at risk of and what is given to avoid this
Myoglobinuria - myoglobin released from dead RBCs and enters blood stream where it reaches kidneys and excreted
Breakdown of myoglobin can damage kidney
Patient given aggressive IV fluids to prevent this
What is chronic compartment syndrome
Usually due to exertion
During exertion, the pressure within the compartment rises, blood flow to the compartment is restricted, and symptoms start. During rest, the pressure falls, and symptoms begin to resolve. It is not an emergency.
Same treatment and symptoms as acute
What are the two types of crystal arthropathies
Gout
Pseudogout
What is gout
Chronically high blood uric aci levels with urate crystals deposited in the joints causing them to become inflamed
What are the risk factors for gout
Male
Family history
Obesity
High purine diet (meat and seafood)
Alcohol
Diuretics
Cardiovascular disease
Kidney disease
What joints are mostly affected in gout
Metatarsophalangeal joint (base of big toe)
Carpometacarpal joint (base of thumb)
Knee
Ankle
What are the symptoms of gout
Acute - develop meaximal intesnsity within 12 hours:
Pain of the joint
Swelling of the joint
Erythema of the joint
Investigations for gout
Uric acid levels:
- Above 360umol/L = gout strongly suspected
Synovial fluid analysis from joint aspiration shows:
Monosodium urate crystals
Needle shaped crystals
Neatively birefringent under polarised light
What can gout show on X-rays
Lytic lesions
Punched out erosions
Erosions have sclerotic borders with overhanging edges
Joint effusion
Management of gout
Acute flares:
1st line = NSAIDs (with PPIs)
2nd line = colchicine
3rd line = steroids (prednisolone)
Prophylaxis:
Allopurinol
Febuxostat
(once allopurinol is started, continue it even during another acute attack as well as taking meds for acute flares)
Lifestyle changes:
No alcohol
Minimising purine diet
What is pseudogout caused by
Deposition of calcium pyrophosphate dihydrate crystals in the synovium
Presentation of pseudogout
Joint is:
Hot
Swollen
Stiff
Painful
What joints does pseudogout affect
Knee (most common)
Shoulders
Hips
Wrists
Investigations for pseudogout
Joint aspiration shows:
Calcium pyrophoshpate crystals
Rhomboid shaped crytals
Positively birefringent of polarised light
X-ray
What does an x-ray show in pseudogout
Chondrocalcinosis - calcium deposits in the joint cartilage show up in a thin white line in the middle of the joint space.
LOSS
Loss of joint space
Osteophytes (bone spurs)
Subarticular sclerosis (increased density of the bone along the joint line)
Subchondral cysts (fluid filled holes in the bones)
Management of pseudogout
NSAIDs (with PPIs)
Colchicine
Intra-articular steroid injections
Oral steroids
What is fibromyalgia
Widespread pain throughout the body with tender points at specific anatomical sites
Typical presentation of fibromyalgia
Women between 30 and 50 with:
Chronic pain at multiple sites, sometimes pain all over
Lethargy
Cognitive impairment (fibro fog)
Sleep disturbances
Headaches
Dizziness
Investigations for fibromyalgia
History of widespread pain
Pain must be present at 11 of the 18 tender point sites published by American College of Rheumatology
classification criteria
Management of fibromyalgia
Aerobic exercise
CBT
Pregabalin
Duloxetine
Amitriptyline
What are the risk factors for osteoarthritis
Female
Obese
Age
Occupation
Trauma
Family history
What are the most common sites for osteoarthritis
Hips
Knees
Distal interphalangeal joints (DIP) in the hands
Carpometacarpal (CMC) joint at base of thumb
Lumbar spine
Cervial spine (cervial spondylosis)
Pathophysiology of osteoarthritis
Imbalance between cartilage damage and the chondrocyte response
Presentation of osteoarthritis in the hands
Usually bilateral
Episodic aching pain provoked by movement and relieved by rest
Stifness
Painless nodes:
Bouchard’s nodes - PIPJs
Heberden’s nodes - DIPJs
Squaring of the base of thumbs
Weak grip
Presentation of osteoarthritis in the hip
Chronic history of aching groin pain following exercise and relieved by rest
Investigations for osteoarthritis
Clinical if typical features
X-ray shows LOSS:
Loss of joint spcae
Osteophytes
Subchondral sclerosis
Subchondral cysts
Management of osteoarthritis
Weight loss advice, local muscle strengthening exercises
1st line = topical NSAIDs
2nd line = oral NSAIDs
(PPI co-prescribed)
IF above do not work then:
Intra-articular injections (last for 2-10 weeks)
If all do not work then:
Joint replacement
What are the adverse affects of long term NSAIDs use
GI side effects - gastritis, peptic ulcers
Renal - AKI (acute tubular necrosis) and CKD
Cardio - hypertension, heart failure, MI, stroke
Exacerbating asthma
What is osteomalacia
Soften bones caused by insufficient Vitamin D
What does Vitamin D help absorb
Helps absorb Calcium and Phosphate in the intestines and kindeys
Why may patients with osteomalacia get secondary hyperparathyroidism
Decreased Vitamin D = insufficient Calcium and Phosphate absorption = increased PTH released = secondary hyperparathyroidism
Causes of osteomalacia
Vitamin d deficiency:
- malabsorption
- lack of sunlight
- diet
CKD
Durg induced - anti-convulsants
Liver disease = cirrhosis
Coeliac disease
Inherited: hypophosphatemic rickets (previously called vitamin D-resistant rickets)
Presentation of osteomalcia
Fatigue
Bone pain
Muscle pain
Muscle aches
Pathological or abnormal fractures
Proximal myopathy - waddling gait
Investigations for osteomalacia
Serum 25-hydroxyvitamin D (VItamin D) = low
Serum calcium =
Serum phosphate = low
Serum alkaline phosphatase = high
PTH = high (secondary hyperparathyroidism)
What will X-rays show in osteomalacia
Translucent bands (Looser’s zones or psuedofractures)
Looser zones are fragility fractures that go partially through the bone
Management of osteomalacia
Vitamin D supplementation (loading dose is often needed)
Calcium supplementation if dietary calcium is inadequate
Why does NICE recommend testing serum calcium a month after loading dose of Vitamin D
NICE CKS (2022) recommend checking the serum calcium within a month of the loading regime. It may be:
Low in calcium deficiency
High in primary hyperparathyroidism (previously masked by the vitamin D deficiency)
High in other conditions that cause hypercalcaemia, such as cancer, sarcoidosis or tuberculosis
What is osteomyelitis
Refers to inflammation in a bone and bone marrow
What are the two main ways somoene can acquire osteomyelitis
Haematogenous osteomyelitis = pathogen is carried through the blood and seeded in the bone
Non-haematogenous spread - due to direct contamination of the bone, for example, at a fracture site or during an orthopaedic operation
What organism most commonly causes osteomyelitis
Staphylococcus aureus
Risk factors for osteomyelitis
Open fractures
Orthopaedic operations (specifically with prosthetic joints)
Diabetes (particularly with diabetic foot ulcers)
Peripheral arterial disease
IV drug use
Immunosuppression
Presentation of osteomyelitis
Fever
Pain and tenderness around site of infection
Erythema around site of infection
Swelling around site of infection
Muscle aches
Lethargy
Investigations for osteomyelitis
Bloods:
Raised WCC, ESR, CRP
Blood cultures - identify causative organism
MRI
Bone cultures
Management of osteomyelitis
6 weeks of flucloxacillin (clindamycin for penicllin allergy)
- possibly with rifampicin or fusidic acid
IF MRSA:
vancomycin or teicoplanin
IF associated with prosthetic joints then:
complete revision surgery to replace prosthesis
Treatment of chronic osteomyelitis
3 or more months of antibiotics
What is paget’s disease of bone
Excessive bone turnover (reabsorption and formation) due to increased osteoclast and osteoblast activity
Where does paget’s disease most commonly affect
Axial skeleton:
Spine
Skull
Risk factors for paget’s disease of bone
Male
Increasing age
Family history
Northern latitude
Presentation of paget’s disease of bone
Bone pain (e.g. pelvis, lumbar spine, femur)
Bone deformity - bowing of tibia and/or bossing of skull
Fractures
Hearing loss
Investigations for paget’s disease of bone
Bloods:
Raised ALP
Normal calcium and phosphate
X-ray
Bone scintigraphy - increased uptake is seen focally at the sites of active bone lesions
What are the X-ray findings in paget’s disease of bone
Bone enlargement and deformity
Osteoporosis circumscripta (well-defined osteolytic lesions that appear less dense compared with normal bone)
Cotton wool appearance of the skull (poorly defined patchy areas of increased and decreased density)
V-shaped osteolytic defects in the long bones
What is the management of paget’s disease of bone? What are the aims of treatment?
Aims:
- Eliminate bone pain
- Normalise serum alkaline posphatase
Bisphosphanates - oral risendronate
Calcitonin
Analgesia
Complications of paget’s disease of bone
Fractures
Hearing loss (affects bones in the ear)
Heart failure (due to hypervascularity of abnormal bone)
Osteosarcoma
Spinal stenosis = spinal canal narrowing = cord compression = nuerological symtpoms
What are the features of polymyalgia rheumatica
Usually rapid onset (< 1 month)
Aching and morning stifness in proximal muscles - neck, shoulders and hips
Worse in the morning, after rest or inactivity
Inteferes with sleep
Improves with activity
Investigations for polymyalgia rheumatica
Clinical diagnosis but can also check inflammatory markers:
ESR/CRP usually raised
Also bloods to exclude differentials:
FBC
Renal profile (U&E)
LFTs
Calcium (abnormal in hyperparathyroidism, cancer and osteomalacia)
Serum protein electrophoresis for myeloma
Thyroid-stimulating hormone for thyroid function
Creatine kinase for myositis
Rheumatoid factor for rheumatoid arthritis
Urine dipstick
Anti-nuclear antibodies (ANA) for systemic lupus erythematosus
Anti-cyclic citrullinated peptide (anti-CCP) for rheumatoid arthritis
Urine Bence Jones protein for myeloma
Chest x-ray for lung and mediastinal abnormalities (e.g., lung cancer or lymphoma)
Treatment of polymyalgia rehumatica
Reducing regime of prednisolone:
15mg until the symptoms are fully controlled, then
12.5mg for 3 weeks, then
10mg for 4-6 weeks, then
Reducing by 1mg every 4-8 weeks
What is the additional management for patients on long term steroids? (there is a mnemonic)
Don’t STOP:
Don’t – steroid dependence occurs after 3 weeks of treatment, and abruptly stopping risks adrenal crisis
S – Sick day rules (steroid doses may need to be increased if the patient becomes unwell)
T – Treatment card – patients should carry a steroid treatment card to alert others that they are steroid-dependent
O – Osteoporosis prevention may be required (e.g., bisphosphonates and calcium and vitamin D)
P – Proton pump inhibitors are considered for gastro-protection (e.g., omeprazole)
What are the four bony parts of the ankle?
Medial malleolus
Lateral malleolus
Tibial plafond
Talus
What are the main symptoms of an ankle fractue
Bony tenderness over the injured area
Inability to walk four weight bearing steps immediately after the injury/in A&E
Soft tissue swelling
Deformity - ankle dislocation
Neurovascular deficity - dislocation can cause nerve injury or compression
What are the investigations for an ankle fracture
X-ray
Full neurovascular assessment:
Dorsalis pedis and posterior tibialis pulse
Capillary refill in toes
Sensation over dorsum of foot, first web spaces, distal sole and heel
Ottowa ankle rules
What are the Ottowa ankle rules and what are its components?
Determine the need for radiographs in acute ankle injuries
An ankle X-ray is only required if:
There is any pain in the malleolar zone; and,
Any one of the following:
Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus, OR
Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus, OR
An inability to bear weight both immediately and in the emergency department for four steps.
What is Weber classification of the lateral malleolus
Type A - below the ankle joint - syndesmosis intact
Type B - at level of ankle joint - syndesmosis intact or partially torn
Type C - above the ankle joint - syndesmosis will be disrupted
According to the Ottowa rules, when is a foot x-ray indicated?
A foot X-ray series is indicated if:
There is any pain in the midfoot zone; and,
Any one of the following:
Bone tenderness at the base of the fifth metatarsal (for foot injuries), OR
Bone tenderness at the navicular bone (for foot injuries), OR
An inability to bear weight both immediately and in the emergency department for four steps.
Treatment for ankle fractures
Usually open reduction and internal fixation
What are the two different locations of hip fractures?
Intracapsular
- Femoral head fractures: These are rare and often associated with dislocations.
- Femoral neck fractures: More common and further classified as subcapital, transcervical, and basicervical.
Extracapsular
- Intertrochanteric fractures: Occur between the greater and lesser trochanters.
- Subtrochanteric fractures: Occur below the lesser trochanter.
What is the system called which grades a hip fracture
Garden system classifications:
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
Blood supply disruption is most common following Types III and IV.
What are the symptoms of a hip fracture
Pain
Shortened and externall rotated leg
Patients with non-displaced or incomplete neck of femur fractures may be able to weight bear
Treatment for hip fractures
Intracapsular:
Undisplaced Fracture:
internal fixation, or hemiarthroplasty if unfit.
Displaced Fracture:
Arthroplasty (total hip replacement or hemiarthroplasty) to all patients with a displaced intracapsular hip fracture
Total hip replacement is favoured to hemiarthroplasty if patients:
- were able to walk independently out of doors with no more than the use of a stick and
- are not cognitively impaired and
- are medically fit for anaesthesia and the procedure.
Extracapsular:
Management
stable intertrochanteric fractures: dynamic hip screw
if reverse oblique, transverse or subtrochanteric fractures: intramedullary device
What is the most commonly fractured metatarsal
The proximal 5th metatarsal
What are the three different types of metatarsal fractures
Proximal avulsion fractures (pseudo-jones) - occurs at proximal tuberosity and is associated with lateral ankle sprain/inversion injuries
Jones fracture - transverse fracture at the metaphyseal-diaphyseal junction
Metatarsal stress fracture - occurs in athletes, most common site is 2nd metatarsal shaft
What are the symptoms of a metatarsal fracture
Pain and bony tenderness
Swelling
Antalgic gait
Investigations for metatarsal fractures
X-ray - determines whether stable, displaced or stress fracture
Stress fractures do not show on x-rays hence:
Isotope scan or MRI
Whats the difference between direct and indirect injury to the patella
Direct - usually follows a direct blow or trauma to the front of the knee
Indirect - happens when the quadriceps forcefully contracts against a block to knee extension
Clinical features of a patella fracture
Swelling
Bruising
Pain and tenderness around the knee
Palpable gap may be felt
Investigations for a patella fracture
AP and lateral x-rays
Skyline vciew if diagnosis is sitll unclear after AP and lateral
Management of a patella fracture
Undisplaced (particularly vertical fractures with intact extensor mechanism) - hinged knee brace for 6 weeks and patients allowed to fully weight bear
Displaced & loss of extensor mechanism - operative management w/ tension band wire, inter-fragmentary screws or cerclarge wires followed by hinged knee brace for 4-6 weeks
What are the risk factors for developing achilles tendon disorders
Quinolone use - ciprofloxacin
Hypercholesterolaemia (predisposed to tendon xanthomata)
What are the symptoms of achilles tendonopathy (tendonitis)
Gradual onset of posterior heel pain that is worse following activity
Morning pain and stiffness
Management for achilles tendonopathy (tendonitis)
Supportive
Simple analgesia
Reduction in precipitating activity
Calf muscle eccentric exercises
What may a patient describe if they have ruptured their achilles tendon
Audible pop in ankle
Sudden nset significant pain in calf or ankle
Inability to walk or continue playing sports
How to examine if a patient has ruptured their achilles tendon
Simmond’s triad:
Ask patient to lie prone with feet hanging off the bed
1) Abnormal angle of declination - injured foot may be more dorsiflexed
2) Squeeze the calf muscle and the foot should plantarflex, injured foot will not mvoe
3) Feel for a gap in the tendon
Investigation and management for achilles tendon rupture
Ultrasound
Refferal to orthopaedics
What is a sprain
stretching, partial or complete tear of a ligament
What is a syndesmosis
fibrous joint in which two adjacent bones are linked by a strong membrane or ligaments
E.G. syndesmosis beween tibia and fibular
How do patients with a lower ankle sprain present
Pain
Swelling
and
Tenderness over affected ligament
Usually able to weight bear unless severe
How do youy classify low ankle sprains
Grade 1 (mild) - stretch or micro tear to ligament, minimal bruising and swelling, no pain on weight bearing
Grade 2 (moderate) - Partial tear to ligament, Moderate brusing and swelling and minimal pain on weight bearing
Grade 3 (severe) - complete tear to ligament, severe bruising and swelling, severe pain on weight bearing
Investigations for a low ankle sprain
X-ray accoridng to Ottowa ankle rules (to check for fracture)
MRI - if persistent pain
Most common mechanism of injury for high ankle sprains
External rotation of the foot causing talus to push fibula laterally
Presentation of high ankle sprains
Pain
Swelling
Tenderness
Pain when squeezing tibia and fibula together (Hopkin’s squeeze test)
Investigations for high ankle sprains
X-ray - widening of tibiofibular joint (diastasis) or ankle mortise
MRI - if suspicious of syndesmosis injury
Treatment for high ankle sprains
IF no diastasis - non-weight bearing orthosis or cast until pain subsides
IF diastasis (or failed non-operative management) - operative fixation
What is iliotibial band syndrome
Most common cause of lateral knee pain in runners
What are the symptoms of iliotibial band syndrome
tenderness 2-3cm above the lateral joint line
Management of iliotibial band syndrome
Activity modification and iliotibial band stretches
IF no improvement then physiotherapy referral
Common mechanisms of injry to the anterior cruciate ligament (ACL)
Lateral blow to the knee
Sudden twising
Akward landing
Presentation of an ACL injury
Sudden popping sound
Knee swelling
Instability - feel as if knee is going to give way
Investigations for ACL injury
Anterior draw test
Lachman’s test
Most common mechanism of injury to the meniscus
Twisting force to knee
Symtpoms of a meniscal tear
Pain worse on straightening knee
Knee may give way
May cause knee locking (if displaced)
Tenderness along the joint line
What investigation can be done to check for meniscal tears
Thessaly’s test -weight bearing at 20 degrees of knee flexion
Positive if pain on twisting
What is Chondromalacia patellae
Softening of the cartilage of the patella
most commonly seen in teenage girls
Features and treatment of Chondromalacia patellae
Anterior knee pain on walking up and down stairs and rising from prolonged sitting
Physiotherapy
Features of Osgood-Schlatter disease
Pain
Tenderness
and
Swelling over the tibial tubercle
Features of Osteochondritis dissecans
Pain after exercise
Intermittent swelling and locking
Features of Patellar subluxation
Medial knee pain due to lateral subluxation of the patella
Knee may give way
Features of Patellar tendonitis
Most commonly seen in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination
Symptoms of plantar fasciitis
Heel pain
Usually worse around the medial calcaneal tuberosity
Management of plantar fasciitis
Rest the feet
Wear shoes with good arch support and cushioned heels
Insoles and heel pads may be helpful
What is a Boxer’s fracture and what is the most common cause?
Minimally displaced fracture of the 5th metacarpal
Patient punching a hard surface
What is a Colle’s fracture and what is the most common cause?
Dorsally displaced distal radius fracture (DDDr F)
Caused by a fall onto an outstretched hand (FOOSH)
AKA dinner fork type deformity
What are the early complications of a Colle’s fracture
Median nerve injury -acute carpal tunnel syndrome
Compartment syndrome ,
Vascular compromise
Malunion
Rupture of the extensor pollicis longus tendon
What are the late complications of a Colle’s fracture?
Osteoarthritis
Complex regional pain syndrome
What are the the features of a Colle’s fracture
Transverse fracture of the radius
1 inch proximal to the radio-carpal joint
Dorsal displacement and angulation
What is a Smith’s fracture and what is the most common cause?
Reverse Colle’s fracture
Volar angulation of distal radius fragments
Caused by falling backwards onto the palm or the flexed wrists
What is a Bennett’s fracture and what is the most common cause? What is shown on X-rays?
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
What is a Monteggia’s fracture and what is the most common cause?
Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation
What is a Galeazzi fracture? What is the most common cause?
Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow
What is a Pott’s fracture? What is the most common cause?
Bimalleolar ankle fracture
Forced foot eversion
What is a Barton’s fracture? What is the most common cause?
Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist
How can humeral fractures be divided?
Proximal humeral fracture
Humeral shaft fractures
Distal humeral fractures
What is a supracondylar fracture?
Distal humerus fracture just above the elbow joint
What are the features of a supracondylar fracture?
Pain
Swelling over the elbow immediately
Elbow typically in a semi-flexed position
What is the management of a supracondylar fracture?
Non-displaced - collar and cuff
Displaced - manipulation and fixation under anaesthesia
What are the features of a scaphoid fracture?
Pain along the radial aspect of the wrist and base of thumb
Maximum tenderness at the anatomical snuffbox
Wrist joint effusions
Pain elicited by telescoping of the thumb
Pain on ulnar deviation of the wrist
Loss of grip/pincer strength
Causes of a scaphoid fracture
Fall on outstretched hand (FOOSH)
Investigations for scaphoid fracture
X-ray with PA, lateral and oblique views
Initial management of scaphoid fracture
Immobilisation with a futuro splint or standard below-elbow back slab
Orthopaedic management of scaphoid fracture
Undisplaced - cast for 6-8 weeks
Displaced - surgical fixation
Complications of scaphoid fracture
Avascular necrosis
Features of a radial head fracture and most common cause
Fall on outstretched hand
Local tenderness over head of radius
Impaired movement at elbow
Sharp pain at the lateral side of the elbow at the extremes of rotation (pronation and supination).
What is De Quervain’s tenosynovitis
Sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed
Features of De Quervain’s tensosynovitis
Pain on radial side of wrist
Tenderness over radial styloid process
Abduction of thumb against resistance is painful
Finkelstein’s test - examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction = pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus
Management of De Quervain’s tensosynovitis
Analgesia
Steroid injection
Immobilisation with thumb splint
What are 5 causes of elbow pain?
Lateral epicondylitis (Tennis elbow)
Medial epicondylitis (Golfer’s elbow)
Radial tunnel syndrome
Cubital tunnel syndrome
Olecranon bursitis
Features of lateral epicondylitis
Pain and tenderness localised to lateral epicondyle
pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
Features of medial epicondylitis
pain and tenderness localised to the medial epicondyle
pain is aggravated by wrist flexion and pronation
Features of radial tunnel syndrome and nerve involved
Similar to lateral epicondylitis
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
compression of the posterior interosseous branch of the radial nerve.
Features of cubital tunnel syndrome
Due to ulnar nerve compression
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
Features of olecranon bursitis
Swelling over posterior aspect of elbow
Pain
Warmth
Erythema
Management of lateral epicondylitis
Advice on avoiding muscle overload
Simple analgesia
Steroid injection
Physiotherapy
What is a compound fracture
When the skin is broken and the broken bone is exposed to the air. The broken bone can puncture through the skin
What is a stable fracture
When the fractured bone remains in alignment at the fracture
What is a pathological fracture
When a bone breaks due to abnormality within bone
What fractures most commonly occur in children?
Greenstick
Buckle
Salter-Harris (growth plate fractures)
What bones are at risk of avascular necrosis if fractured
Scaphoid
Femoral head
Humeral head
Talus
Navicular
5th metatarsal
What diseases can cause pathological fractures
Osteoporosis
Tumour
Paget’s disease of the bone
What are the main cancers that metastasis to the bone
PoRTaBLe
Prostate
Renal
Thyroid
Breast
Lung
What is the FRAX tool
Risk of a fragility fracture over the next 10 years
What are fragility fractures
Fractures caused by weakness of bone (usually due to osteoporosis)
How is bone mineral density measured
DEXA scan
What are the interpretations of the DEXA scan
T-scores
More than -1 = Normal
-1 to -2.5 = Osteopenia
Less than -2.5 = Osteoporosis
Less than -2.5 + plus fracture = severe osteoporosis
First line treatments for reducing the risk of fragility fractures
Calcium and Vitamin D
Bisphosphonates (e.g. alendronic acid)
Side effects of bisphosphonates
Reflux and oesophageal erosions
Atypical fractures
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal
What is an alternative to bisphosphate in fragility fractures prophylaxis
Denosumab - blocks activity of osteoclasts
When can a fat embolism occur
Following the fracture of long bones
May become lodged in vessels - PE
Management of fat embolism
Operating early to fix the fracture reduces the risk of fat embolism syndrome
What is reactive arthritis
Synovitis in one or more joints following an infective trigger
What are the common triggers of reactive arthritis
Gastroenteritis
STIs
What organisms are most commonly associated with reactive arthritis
Chlamydia trochamatis
Shigella flexneri
Salmonella
Yersinia enterocolitica
Campylobacter
What are the symptoms of reactive arthritis
Typically develops within 4 weeks of initial infection - symptoms last around 4-6 months
Asymmetrical oligoarthritis of lower limbs
Warm, swollen and painful joint
Dactylitis
Anterior uveitis
Bilateral conjunctivitis
Urethritis
Circinate balanitis (dermatitis to head of penis)
“Cant see, pee or climb a tree”
Management of reactive arthritis
Symptomatic
NSAIDs
Intra-articular steroids
Persistent disease: sulfasalazine and methotrexate
What is rheumatoid arthritis
Autoimmune condition causing chronic inflammation in the synovial lining of joints, tendon sheaths and bursa
What is the disease pattern of rheumatoid arthritis
Symmetrical (distal - hands and feet) polyarthritis
Risk factors for rheumatoid arthritis
Obesity
Smoking
HLADR4
Family history
Presentation of rheumatoid arthritis
Swollen painful joints in the hands and feet
Stiffness worse in the morning
Gradually gets worse with larger joints becoming involved
Positive ‘squeeze test’
Fatigue
Weight loss
flu like symptoms
What are the most commonly affected joints in rheumatoid arthritis
MCP joints
PIP joints
Wrist
MTP joints
What is palindromic rheumatism and what are its symptoms
Self limiting episodes of inflammatory arthritis
Pain, stiffness and swelling typically affecting a few joints
What can indicate that palindromic rheumatism may develop into rheumatoid arthritis
Positive rheumatoid factor and anti-CCP
What are the joint signs in rheumatoid arthritis
Z-shaped deformity of the thumb
Swan neck deformity (hyperextended PIP and flexed DIP)
Boutonniere deformity (hyperextended DIP and flexed PIP)
Ulnar deviation
Atlantoaxial subluxation - can cause spinal cord compression
What are the extra-articular manifestations of rheumatoid arthritis
Pulmonary fibrosis
Bronchiolitis obliterans
Cardiovascular disease
Sjogren’s syndrome
Felty’s syndrome (triad of rheumatoid arthritis, neutropenia and splenomegaly)
Anaemia of chronic disease
Caplan syndrome (pulmonary nodules in patients with RA exposed to asbestos, silica and coal)
Lymphadenopathy
What are the ocular manifestations of rheumatoid arthritis
Keratoconjunctivitis sicca
Episcleritis
Scleritis
Keratitis
Cataracts (secondary to steroids)
Retinopathy (secondary to hydroxychloroquine)
What are the investigations of rheumatoid arthritis
Rheumatoid factor
Anti-CCP antibodies
CRP and ESR
X-ray of hands and feet
Ultrasound or MRI if clinical findings are unclear
What are the X-ray changes in rheumatoid arthritis
LESS
Loss of joint space
Erosions
Soft-tissue swelling
See-through bones (osteopenia)
What scoring system measures functional ability in rheumatoid arthritis
Health Assessment questionnaire (HAQ)
What scoring systems monitors disease activity in rheumatoid arthritis
Disease Activity Score 28 Joints (DAS28)
Assigns points for:
Swollen joints
Tender joints
ESR/CRP results
What is the management of rheumatoid arthritis
DMARD monotherapy +/- short course of bridging prednisolone
Methotrexate
Leflunomide
Sulfasalazine
Hydroxychloroquine
If not successful with monotherapy then combination treatment with multiple DMARDs
If still not successful then biological therapies (usually alongside methotrexate)
- TNF inhibitors - adalimumab, infliximab and etanercept
- Anti-CD20 on B cells - rituximab
How are flares of rheumatoid arthritis managed
Oral or IM corticosteroids
How should methotrexate be taken
Once a week
Since it interferes with folic acid metabolism:
+ folic acid 5mg (on a different day)
Side effects of methotrexate
Mouth ulcers and mucositis
Liver toxicity
Bone marrow suppression and leukopenia
Teratogenic
Side effects of leflunomide
Hypertension
Peripheral neuropathy
Mouth ulcers and mucositis
Liver toxicity
Bone marrow suppression and leukopenia
Teratogenic
Side effects of sulfasalazine
Orange urine
Reversible male infertility
Bone marrow suppression
Side effects of hydroxychloroquine
Retinal toxicity - reduces visual acuity
Blue-grey skin pigmentation
Hair lightening (bleaching)
Side effects of rituximab
Night sweats and thrombocytopenia
What medications can cause reactivation of tuberculosis
Anti-TNF medications: adalimumab, infliximab and etanercept
What rheumatoid arthritis drug is teratogenic
methotrexate
What are the poor prognostic features fir rheumatoid arthritis
RF positive
Anti-CCP antibodies
Poor functional status at presentation
HLADR4
X-ray: early erosions (e.g. after <2 years)
Insidious onset
What are the most common causative agents in septic arthritis
Staphylococcus aureus
Neisseria gonorrhoea - in young adults that are sexually active
then
Group A strep - streptococcus pyogenes
Haemophilus influenza
E.coli
What is the presentation of septic arthritis
Acutely hot, red, swollen, painful joint
Stiffness and reduced range of motion
Fever
Lethargy
Sepsis
Differential diagnoses of septic arthritis
Pseudogout
Gout
Reactive arthritis
Hemarthrosis
Investigations for septic arthritis
Synovial fluid sampling via joint aspiration
- shows leucocytosis
- gram staining is negative in around 30-50% of cases
- fluid culture is positive in patients with non-gonococcal septic arthritis
Blood cultures
Joint imaging
Management of septic arthritis
IV Flucloxacillin (clindamycin if allergic) for 4-6 weeks
Switches to oral after 2 weeks
Needle aspiration to decompress joint
Arthroscopic lavage may be required
What are the seronegative spondyloarthropathies
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis
After how long does psoriatic arthritis develop after having psoriasis?
Usually within in 10 years
What are the 5 patterns of psoriatic arthritis
Asymmetrical oligoarthritis - affects 1-4 joints of the body on one side
Symmetrical polyarthritis (similar to rheumatoid arthritis) - more than four joints affected (usually hands, wrists and ankles)
Distal interphalangeal joint disease - primarily only affects the DIP joints
Spondylitis - presents with back stiffness and pain (involves axial skeleton - spine and sacroiliac joints)
Arthritis mutilans (most severe form of psoriatic arthritis) - osteolysis of the phalanges around the joints leading to shorter digits resulting in skin folds (telescoping digit)
What is a good way of distinguishing between rheumatoid arthritis and psoriatic arthritis
PA usually affects the DIP joints whereas RA does not
What are the features of psoriatic arthritis
Psoriatic skin lesions
Enthesitis
Dactylitis
Nail pitting
Onycholysis
Uveitis
IBD
What is the tool used for screening for psoriatic arthritis in patients with psoriasis
Psoriasis Epidemiological Screening Tool (PEST)
Involves questions about joint pain, swelling, history of arthritis and nail pitting
Investigations for psoriatic arthritis
X-ray:
Periostitis - inflammation of periosteum around bone = thickening and irregular outline of bone
Ankylosis - fusion of bones at the joint
Osteolysis - destruction of bone
Dactylitis - Inflammation of the whole digit - soft tissue swelling
PENCIL IN CUP appearance - associated with arthritis mutilans
What is the management of psoriatic arthritis
Mild peripheral arthritis/axial disease = NSAIDs
Moderate/severe = DMARDs - methotrexate, leflunomide, sulfasalzine
Can also use:
Ustekinumab and secukinumab (monoclonal antibodies)
Anti-TNF - etanercept, infliximab, adalimumab
Apremilast (phosphodiesterase type-4 (PDE4) inhibitors
What is SLE
Systemic inflammatory autoimmune connective tissue disorder
In who does SLE most commonly occur in
Women
Asian, African, Caribbean and Hispanic
Young to middle-aged adults
What is the disease pattern of SLE
Relapsing-remitting
What are the symptoms of SLE
General:
Fatigue
Fever
Mouth ulcers
Lymphadenopathy
Skin:
Malar rash
Discoid rash - scaly, erythematous, well demarcated rash ins un exposed areas
Photosensitivity
Raynaud’s phenomenon
MSK:
Arthralgia
Non-erosive arthritis
Cardiovascular:
Pericarditis
Myocarditis
Respiratory:
Fibrosing alveolitis
Pleurisy
Renal:
Proteinuria
Glomerulonephritis
Neuropsychiatric:
Anxiety and depression
Psychosis
Seizures
Investigations for SLE
Anti-nuclear antibodies (ANA) - 99% positive (high sensitivity but low specificity)
Anti-dsDNA - highly specific
RF - 20% are positive
ESR and CRP may be raised in active inflammation
Complement (C3 and C4) levels are low
Urinalysis - urine protein:creatinine ratio shows proteinuria
What can occur secondary to SLE
antiphospholipid antibodies and antiphospholipid syndrome
Management for SLE
NSAIDs
Sun block
Hydroxychloroquine
IF internal organ involvement then consider:
prednisolone
cyclophosphamide
More severe SLE
DMARDs - methotrexate
Rituximab
Belimumab
What are the complications of SLE
Cardiovascular:
Hypertension
Anaemia
Pericarditis
Pleuritis
Pulmonary fibrosis
Lupus nephritis
Optic neuritis
Transverse myelitis
Recurrent miscarriage
VTE
What are sarcomas
Cancers originating in the muscles, bones or connective tissues
What are three types of bone sarcomas
Osteosarcoma - most common form of bone cancer
Chondrosarcoma - originating from cartilage
Ewing sarcoma - bone and soft tissue cancer affecting children/young adults
What are the different soft tissue sarcomas
Rhabdomyosarcoma - of skeletal tissue
Leiomyosarcoma - of smooth muscle
Liposarcoma - of adipose tissue
Synovial sarcoma - of soft tissues surrounding joints
Angiosarcoma - of blood and lymph vessels
What are the key features of sarcomas
A soft tissue lump, particularly if growing, painful or large
Bone swelling
Persistent bone pain
Investigations for sarcomas
X-ray - for bony lumps or persistent bone pain
US - if soft tissue lump
CT/MRI - used to look for metastatic spread
Biopsy - histology of cancer
Treatments for sarcomas
Surgery - resection
Radiotherapy
Chemotherapy
Palliative care
What are the most common sites to be affected in osteosarcoma
Femur
Tibia
Humerus
Presentation of osteosarcoma
Seen mainly in children and adolescents
Persistent bone pain
Worse at night and may disturb/wake them up from sleep
Bone swelling
Palpable mass
Restricted joint movement
Investigations for osteosarcoma
Urgent X-ray within 48 hours, shows:
Poorly defined lesion in bone
Destruction of normal bone
Fluffy appearance of bone
Irritation of lining of bone = ‘sunburst’ appearance
Bloods: raised ALP
Staging scans: MRI, CT, Bone scan, PET scan, Biopsy
Management of osteosarcoma
Surgical resection of the lesion with limb amputation
Adjuvant chemotherapy
What is an osteoma and where does it typically occur
Overgrowth of bone
Commonly occurs in the skull
What is an osteochondroma
Most common benign bone tumour
Cartilage-capped bony projection on external surface of bone
What is a giant cell tumour and how is it shown on an x-ray
Tumour of multinucleated giant cells withing a fibrous stroma
Occurs most commonly in the epiphyses of long bones
X-ray shows soap bubble appearance
Where do chondrosarcomas most commonly occur
Axial skeleton
Where do Ewing’s sarcoma most commonly occur and what is shown on x-ray
Pelvis and long bones
Tends to cause severe pain
X-ray shows ‘onion skin’ appearance
Other than bone pain, what are the common features of bone cancer
pathological fractures
Hypercalcaemia
Raised ALP
What are the most common sites for bone metastases
Spine
Pelvis
Ribs
Skull
Long bones
What symptoms are suggestive of spinal metastases
Unrelenting lumbar back pain
Any thoracic or cervical back pain
Worse with sneezing, coughing, or straining
Nocturnal
Associated with tenderness
What investigation should be done in anyone with suspected spinal metastases
MRI
What is the Mirel’s scoring system
A classification system that evaluates the risk of a pathologic fracture in a lesion
What are the causes of mechanical back pain
Muscle or ligament sprain
Facet joint dysfunction
Sacroiliac joint dysfunction
Herniated disk
Spondylolisthesis (anterior displacement of a vertebra out of line with the one below)
Scoliosis
Degenerative changes to discs and facet joints (arthritis)
What are the causes of neck pain
Muscle or ligament sprain
Torticollis (waking up with a unilaterally stiff and painful neck due to muscle spasm)
Whiplash (typically after a road traffic accident)
Cervical spondylosis
What are the red flag causes of back pain
Spinal fracture
Cauda equina
Spinal stenosis (e.g., intermittent neurogenic claudication)
Ankylosing spondylitis
Spinal infection
What spinal nerves join o form the sciatic nerve?
L4 - S3
What nerves branch off the sciatic nerve once it reaches the knee?
Tibial nerve
Common peroneal nerve
What are the causes of sciatica
Herniated disc
Spondylolisthesis
Spinal stenosis
Symptoms of sciatica
Unilateral pain from buttocks radiating down back of thigh to below knee or feet
Paraesthesia
Numbness
Motor weakness
What is the sciatic stretch test
Helps diagnose sciatica
The patient lies on their back with their leg straight. The examiner lifts one leg from the ankle with the knee extended until the limit of hip flexion is reached (usually around 80-90 degrees). Then the examiner dorsiflexes the patient’s ankle. Sciatica-type pain in the buttock/posterior thigh indicates sciatic nerve root irritation. Symptoms improve with flexing the knee.
What investigations can be done for lower back pain
Usually a clinical diagnosis
X-rays and CT scans
MRI - emergency for cauda equina
Inflammatory markers
What is the STarT Back Screening Tool
Stratifies the risk of a patient presenting with acute back pain developing chronic back pain.
How to manage non-specific lower back pain
IF low risk of developing chronic back pain:
Self management
Education
Reassurance
Analgesia - NSAIDs first line, Codeine alternative, Benzodiazepines (diazepam) for muscle spasms (short term only)
Stay active
IF medium or high risk:
Physiotherapy
Group exercise
CBT
SAFETY NET FOR RED FLAGS - CAUDA EQUINA SYMPTOMS
Management of sciatica
Initial management is same as lower back pain management
For analgesia use:
Amitriptyline
Duloxetine
Chronic options:
Epidural corticosteroid injections
Local anaesthetic injections
Radiofrequency denervation
Spinal decompression
What is spinal stenosis
Narrowing of the spinal canal leading to compression of the spinal cord or nerve roots
What are the three types of spinal stenosis
Central stenosis - narrowing of the central spinal canal
Lateral stenosis - narrowing of the nerve root canals
Foramina stenosis - narrowing of the intervertebral foramina
What are the causes of spinal stenosis
Congenital spinal stenosis
Degenerative changes (including facet joint changes, disc disease and bone spurs)
Herniated discs
Thickening of the ligamental flava or posterior longitudinal ligament
Spinal fractures
Spondylolisthesis
Tumours
Presentation of spinal stenosis
Intermittent neurogenic claudication (lumbar spinal stenosis with central stenosis), symptoms include:
Lower back pain
Buttock and leg pain
Leg weakness
Symptoms absent at rest and sitting but arise when walking or standing after sitting
Bending expands spinal canal therefore relieves symptoms (vice versa for standing)
How to differentiate intermittent neurogenic claudication and PAD?
Take ABPI - normal in spinal stenosis
Spinal stenosis patients have back pain, PAD does not
Investigations for spinal stenosis
MRI
ABPI and CT angiogram to rule out PAD
Management of spinal stenosis
Exercise and weight loss
Analgesia
Physiotherapy
Decompression surgery (if all else fails) - laminectomy (removal of part of lamina from vertebra)
Examples of large vessel vasculitis
GCA - temporal arteritis
Takayasu’s arteritis
Examples of medium vessel arteritis
Polyarteritis nodosa
Kawasaki disease
Examples of small vessel vasculitis
ANCA-associated vasculitis:
Granulomatosis with polyangiitis
Eosinophilic granulomatosis with polyangiitis
Microscopic polyangiitis
Immune complex small-vessel vasculitis:
Henoch-Schoenlein purpura
Goodpasture’s syndrome (anti-glomerular basement membrane disease)
Which vasculitides are p-ANCA and c-ANCA positive?
p-ANCA:
Microscopic polyangiitis
Eosinophilic granulomatosis with polyangiitis
c-ANCA:
Granulomatosis with polyangiitis
What is Henoch-Schoenlein purpura
IgA vasculitis
IgA deposits in the blood vessels
Symptoms of Henoch-Schoenlein purpura
Purpura
Joint pain
Abdominal pain
Renal involvement (IgA nephritis) - raised creatinine, haematuria and proteinuria
Management of Henoch-Schoenlein purpura
Supportive:
Analgesia
Rest
Hydration
If using steroids, monitor with:
Urine dipstick - to check for renal involvement
BP - to monitor hypertension
Features of microscopic polyangiitis
Renal failure due to glomerulonephritis
Diffuse alveolar haemorrhage - haemoptysis
Features of granulomatosis with polyangiitis
Most commonly affects respiratory tract and kidneys:
Nose:
Epistaxis
Crusting around nose
Nasal secretions
Saddle shaped nose
Ears:
Hearing loss
Sinuses:
Sinusitis
Lungs:
Cough
Wheeze
Haemoptysis
Kidneys:
Glomerulonephritis
Eosinophilic granulomatosis with polyangiitis
Most commonly affects lungs and skin
Severe asthma
Sinusitis
Allergic rhinitis
Characteristic finding on FBC in eosinophilic granulomatosis with polyangiitis
Raised eosinophils
What infection can polyarteritis nodosa be secondary to
Hepatitis B
Features of polyarteritis nodosa
Renal impairment
Hypertension
Tender, erythematous skin nodules
MI
Stroke
Mesenteric arteritis - GI symptoms
Features of Kawasaki’s disease
CRASH and BURN
Conjunctivitis (Bilateral)
Rash (widespread erythematous maculopapular rash)
Adenopathy
Strawberry tongue
Hands and feet swelling (desquamation)
and
Persistently high fever for more than 5 days
What vessel does Takayasu’s arteritis most commonly affect
Aorta and its branches
+ pulmonary arteries
Features of Takayasu’s arteritis
Fever
Malaise
Muscle aches
Claudication symptoms in the upper limb
Stenosis or occlusion can reduce pulses and BP in a limb = ‘pulseless disease)
Investigations for Takayasu’s arteritis
CT or MRI angiography: vessels can swell and form aneurysms or become narrowed and blocked
What are the general features of vascultidies
Joint and muscle pain
Peripheral neuropathy
Renal impairment
Purpura
GI symptoms
Necrotic skin ulcers
+ SYSTEMIC SYMPTOMS:
Fatigue
Fever
Night sweats
Anorexia
Weight loss
Anaemia
Investigations for vasculitis
Inflammatory markers - ESR and CRP
p-ANCA
c-ANCA
Urinalysis for haematuria and proteinuria
General management of vasculitis
Steroids:
oral prednisolone
IV hyrdrocortisone
Nasal for nasal symptoms
Inhaled for lung involvement
immunosuppressants:
Cyclophaosphamide
Rituximab
