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Phase 4 - GI, MSK, Infectious Diseases > MSK > Flashcards

MSK Flashcards

1
Q

What are the 3 conditions making up the seronegative spondyloarthropathies?

A

Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis

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2
Q

What joints are mainly affected in ankylosing spondylitis?

A

Vetebral column joints
Sacroiliac joints

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3
Q

What gene is associated with ankylosing spondylitis

A

HLA-B27

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4
Q

What is the typical presentation of ankylosing spondylitis

A

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

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5
Q

What symptoms can one experience other than back and sacroiliac pain in ankylosing spondylitis

A

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)

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6
Q

What conditions are associated with ankylosing spondylitis

A

5A’s
Anterior uveitis
Aortic regurgitation
Atrioventricular block
Apical lung fibrosis
Anaemia of chronic disease

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7
Q

Investigations for anklyosing spondylitis

A

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

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8
Q

What would an X-ray show in anklyosing spondylitis

A

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

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9
Q

What would an MRI of show in ankylosing spondylitis

A

Bone marrow oedema in sacroiliac joints

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10
Q

Management of ankylosing spondylitis

A

Regular exercise
1st line = NSAIDs
Anti-TNF therapy (if high disease activity) - adalimumab, etanercept or infliximab
Physiotherapy

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11
Q

What is the function of bursae

A

They act to reduce the friction between the bones and soft tissues during movement.

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12
Q

What are the causes of bursitis

A

Friction from repetives movement or leaning on the elbow
Trauma
Infection - septic bursitis
Inflammatory conditions - rheumatoid arthritis or gout

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13
Q

What are the symptoms of olecranon bursitis

A

Young/middle-aged man with an elbow that is:
Swollen
Warm
Tender
Fluctuant (fluid filled)

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14
Q

How do you identify that bursitis is caused by infection

A

Hot to touch
More tender on plapation
Erythema spreading to surrounding skin
Fever
Skin abrasion overlying the bursa
Features of sepsis - tachycardia, hypotensions, confusion)

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15
Q

Investigations for olecranon bursitis

A

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

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16
Q

Management of olecranon bursitis

A

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

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17
Q

Treatment of olecranon bursitis due to infective cause

A

Aspiration for microscopy and culture
Antibiotics - flucloxacillin (2nd line = clarithromycin)

IF septic = sepsis 6

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18
Q

Presentation of trochanteric bursitis

A

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

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19
Q

What would be the examination finding in trochanteric bursitis

A

Positive Trendelenburg test
Resisted abduction of the hip
Resisted internal rotation of the hip
Resisted external rotation of the hip

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20
Q

What is the Trendelenburg test

A

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.

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21
Q

Management of trochanteric bursitis

A

Rest
Ice
Analgesia (e.g., ibuprofen or naproxen)
Physiotherapy
Steroid injections

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22
Q

Define compartment syndrome

A

Where the pressure within a fascial compartment is abnormally elevated, cutting off the blood flow to the contents of that compartment

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23
Q

If compartment syndrome is not treated in time what can occur

A

Tissue necrosis

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24
Q

Where does compartment syndrome most commonly affect

A

Leg
Forearm
Feet
Thigh
Buttocks

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25
Q

What is the presentation of compartment syndrome

A

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)

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26
Q

Investigations for compartment syndrome

A

Needle manometry
- Pressures >20mmHg is abnormal and >40mmHg is diagnostic

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27
Q

Management of compartment syndrome

A

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

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28
Q

What are patients undergoing fasciotomy due to compartment syndrome at risk of and what is given to avoid this

A

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

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29
Q

What is chronic compartment syndrome

A

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

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30
Q

What are the two types of crystal arthropathies

A

Gout
Pseudogout

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31
Q

What is gout

A

Chronically high blood uric aci levels with urate crystals deposited in the joints causing them to become inflamed

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32
Q

What are the risk factors for gout

A

Male
Family history
Obesity
High purine diet (meat and seafood)
Alcohol
Diuretics
Cardiovascular disease
Kidney disease

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33
Q

What joints are mostly affected in gout

A

Metatarsophalangeal joint (base of big toe)
Carpometacarpal joint (base of thumb)
Knee
Ankle

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34
Q

What are the symptoms of gout

A

Acute - develop meaximal intesnsity within 12 hours:
Pain of the joint
Swelling of the joint
Erythema of the joint

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35
Q

Investigations for gout

A

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

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36
Q

What can gout show on X-rays

A

Lytic lesions
Punched out erosions
Erosions have sclerotic borders with overhanging edges
Joint effusion

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37
Q

Management of gout

A

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

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38
Q

What is pseudogout caused by

A

Deposition of calcium pyrophosphate dihydrate crystals in the synovium

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39
Q

Presentation of pseudogout

A

Joint is:
Hot
Swollen
Stiff
Painful

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40
Q

What joints does pseudogout affect

A

Knee (most common)
Shoulders
Hips
Wrists

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41
Q

Investigations for pseudogout

A

Joint aspiration shows:
Calcium pyrophoshpate crystals
Rhomboid shaped crytals
Positively birefringent of polarised light

X-ray

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42
Q

What does an x-ray show in pseudogout

A

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)

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43
Q

Management of pseudogout

A

NSAIDs (with PPIs)
Colchicine
Intra-articular steroid injections
Oral steroids

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44
Q

What is fibromyalgia

A

Widespread pain throughout the body with tender points at specific anatomical sites

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45
Q

Typical presentation of fibromyalgia

A

Women between 30 and 50 with:
Chronic pain at multiple sites, sometimes pain all over
Lethargy
Cognitive impairment (fibro fog)
Sleep disturbances
Headaches
Dizziness

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46
Q

Investigations for fibromyalgia

A

History of widespread pain
Pain must be present at 11 of the 18 tender point sites published by American College of Rheumatology
classification criteria

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47
Q

Management of fibromyalgia

A

Aerobic exercise
CBT
Pregabalin
Duloxetine
Amitriptyline

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48
Q

What are the risk factors for osteoarthritis

A

Female
Obese
Age
Occupation
Trauma
Family history

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49
Q

What are the most common sites for osteoarthritis

A

Hips
Knees
Distal interphalangeal joints (DIP) in the hands
Carpometacarpal (CMC) joint at base of thumb
Lumbar spine
Cervial spine (cervial spondylosis)

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50
Q

Pathophysiology of osteoarthritis

A

Imbalance between cartilage damage and the chondrocyte response

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51
Q

Presentation of osteoarthritis in the hands

A

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

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52
Q

Presentation of osteoarthritis in the hip

A

Chronic history of aching groin pain following exercise and relieved by rest

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53
Q

Investigations for osteoarthritis

A

Clinical if typical features
X-ray shows LOSS:
Loss of joint spcae
Osteophytes
Subchondral sclerosis
Subchondral cysts

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54
Q

Management of osteoarthritis

A

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

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55
Q

What are the adverse affects of long term NSAIDs use

A

GI side effects - gastritis, peptic ulcers
Renal - AKI (acute tubular necrosis) and CKD
Cardio - hypertension, heart failure, MI, stroke
Exacerbating asthma

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56
Q

What is osteomalacia

A

Soften bones caused by insufficient Vitamin D

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57
Q

What does Vitamin D help absorb

A

Helps absorb Calcium and Phosphate in the intestines and kindeys

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58
Q

Why may patients with osteomalacia get secondary hyperparathyroidism

A

Decreased Vitamin D = insufficient Calcium and Phosphate absorption = increased PTH released = secondary hyperparathyroidism

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59
Q

Causes of osteomalacia

A

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)

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60
Q

Presentation of osteomalcia

A

Fatigue
Bone pain
Muscle pain
Muscle aches
Pathological or abnormal fractures
Proximal myopathy - waddling gait

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61
Q

Investigations for osteomalacia

A

Serum 25-hydroxyvitamin D (VItamin D) = low
Serum calcium =
Serum phosphate = low
Serum alkaline phosphatase = high
PTH = high (secondary hyperparathyroidism)

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62
Q

What will X-rays show in osteomalacia

A

Translucent bands (Looser’s zones or psuedofractures)

Looser zones are fragility fractures that go partially through the bone

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63
Q

Management of osteomalacia

A

Vitamin D supplementation (loading dose is often needed)
Calcium supplementation if dietary calcium is inadequate

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64
Q

Why does NICE recommend testing serum calcium a month after loading dose of Vitamin D

A

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

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65
Q

What is osteomyelitis

A

Refers to inflammation in a bone and bone marrow

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66
Q

What are the two main ways somoene can acquire osteomyelitis

A

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

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67
Q

What organism most commonly causes osteomyelitis

A

Staphylococcus aureus

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68
Q

Risk factors for osteomyelitis

A

Open fractures
Orthopaedic operations (specifically with prosthetic joints)
Diabetes (particularly with diabetic foot ulcers)
Peripheral arterial disease
IV drug use
Immunosuppression

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69
Q

Presentation of osteomyelitis

A

Fever
Pain and tenderness around site of infection
Erythema around site of infection
Swelling around site of infection
Muscle aches
Lethargy

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70
Q

Investigations for osteomyelitis

A

Bloods:
Raised WCC, ESR, CRP
Blood cultures - identify causative organism
MRI
Bone cultures

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71
Q

Management of osteomyelitis

A

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

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72
Q

Treatment of chronic osteomyelitis

A

3 or more months of antibiotics

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73
Q

What is paget’s disease of bone

A

Excessive bone turnover (reabsorption and formation) due to increased osteoclast and osteoblast activity

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74
Q

Where does paget’s disease most commonly affect

A

Axial skeleton:
Spine
Skull

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75
Q

Risk factors for paget’s disease of bone

A

Male
Increasing age
Family history
Northern latitude

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76
Q

Presentation of paget’s disease of bone

A

Bone pain (e.g. pelvis, lumbar spine, femur)
Bone deformity - bowing of tibia and/or bossing of skull
Fractures
Hearing loss

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77
Q

Investigations for paget’s disease of bone

A

Bloods:
Raised ALP
Normal calcium and phosphate
X-ray
Bone scintigraphy - increased uptake is seen focally at the sites of active bone lesions

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78
Q

What are the X-ray findings in paget’s disease of bone

A

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

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79
Q

What is the management of paget’s disease of bone? What are the aims of treatment?

A

Aims:
- Eliminate bone pain
- Normalise serum alkaline posphatase

Bisphosphanates - oral risendronate
Calcitonin
Analgesia

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80
Q

Complications of paget’s disease of bone

A

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

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81
Q

What are the features of polymyalgia rheumatica

A

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

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82
Q

Investigations for polymyalgia rheumatica

A

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)

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83
Q

Treatment of polymyalgia rehumatica

A

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

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84
Q

What is the additional management for patients on long term steroids? (there is a mnemonic)

A

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)

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85
Q

What are the four bony parts of the ankle?

A

Medial malleolus
Lateral malleolus
Tibial plafond
Talus

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86
Q

What are the main symptoms of an ankle fractue

A

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

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87
Q

What are the investigations for an ankle fracture

A

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

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88
Q

What are the Ottowa ankle rules and what are its components?

A

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.

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89
Q

What is Weber classification of the lateral malleolus

A

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

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90
Q

According to the Ottowa rules, when is a foot x-ray indicated?

A

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.

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91
Q

Treatment for ankle fractures

A

Usually open reduction and internal fixation

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92
Q

What are the two different locations of hip fractures?

A

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.

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93
Q

What is the system called which grades a hip fracture

A

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.

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94
Q

What are the symptoms of a hip fracture

A

Pain
Shortened and externall rotated leg
Patients with non-displaced or incomplete neck of femur fractures may be able to weight bear

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95
Q

Treatment for hip fractures

A

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

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96
Q

What is the most commonly fractured metatarsal

A

The proximal 5th metatarsal

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97
Q

What are the three different types of metatarsal fractures

A

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

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98
Q

What are the symptoms of a metatarsal fracture

A

Pain and bony tenderness
Swelling
Antalgic gait

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99
Q

Investigations for metatarsal fractures

A

X-ray - determines whether stable, displaced or stress fracture
Stress fractures do not show on x-rays hence:
Isotope scan or MRI

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100
Q

Whats the difference between direct and indirect injury to the patella

A

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

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101
Q

Clinical features of a patella fracture

A

Swelling
Bruising
Pain and tenderness around the knee
Palpable gap may be felt

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102
Q

Investigations for a patella fracture

A

AP and lateral x-rays
Skyline vciew if diagnosis is sitll unclear after AP and lateral

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103
Q

Management of a patella fracture

A

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

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104
Q

What are the risk factors for developing achilles tendon disorders

A

Quinolone use - ciprofloxacin
Hypercholesterolaemia (predisposed to tendon xanthomata)

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105
Q

What are the symptoms of achilles tendonopathy (tendonitis)

A

Gradual onset of posterior heel pain that is worse following activity
Morning pain and stiffness

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106
Q

Management for achilles tendonopathy (tendonitis)

A

Supportive
Simple analgesia
Reduction in precipitating activity
Calf muscle eccentric exercises

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107
Q

What may a patient describe if they have ruptured their achilles tendon

A

Audible pop in ankle
Sudden nset significant pain in calf or ankle
Inability to walk or continue playing sports

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108
Q

How to examine if a patient has ruptured their achilles tendon

A

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

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109
Q

Investigation and management for achilles tendon rupture

A

Ultrasound
Refferal to orthopaedics

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110
Q

What is a sprain

A

stretching, partial or complete tear of a ligament

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111
Q

What is a syndesmosis

A

fibrous joint in which two adjacent bones are linked by a strong membrane or ligaments
E.G. syndesmosis beween tibia and fibular

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112
Q

How do patients with a lower ankle sprain present

A

Pain
Swelling
and
Tenderness over affected ligament
Usually able to weight bear unless severe

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113
Q

How do youy classify low ankle sprains

A

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

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114
Q

Investigations for a low ankle sprain

A

X-ray accoridng to Ottowa ankle rules (to check for fracture)
MRI - if persistent pain

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115
Q

Most common mechanism of injury for high ankle sprains

A

External rotation of the foot causing talus to push fibula laterally

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116
Q

Presentation of high ankle sprains

A

Pain
Swelling
Tenderness
Pain when squeezing tibia and fibula together (Hopkin’s squeeze test)

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117
Q

Investigations for high ankle sprains

A

X-ray - widening of tibiofibular joint (diastasis) or ankle mortise
MRI - if suspicious of syndesmosis injury

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118
Q

Treatment for high ankle sprains

A

IF no diastasis - non-weight bearing orthosis or cast until pain subsides
IF diastasis (or failed non-operative management) - operative fixation

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119
Q

What is iliotibial band syndrome

A

Most common cause of lateral knee pain in runners

120
Q

What are the symptoms of iliotibial band syndrome

A

tenderness 2-3cm above the lateral joint line

121
Q

Management of iliotibial band syndrome

A

Activity modification and iliotibial band stretches
IF no improvement then physiotherapy referral

122
Q

Common mechanisms of injry to the anterior cruciate ligament (ACL)

A

Lateral blow to the knee
Sudden twising
Akward landing

123
Q

Presentation of an ACL injury

A

Sudden popping sound
Knee swelling
Instability - feel as if knee is going to give way

124
Q

Investigations for ACL injury

A

Anterior draw test
Lachman’s test

125
Q

Most common mechanism of injury to the meniscus

A

Twisting force to knee

126
Q

Symtpoms of a meniscal tear

A

Pain worse on straightening knee
Knee may give way
May cause knee locking (if displaced)
Tenderness along the joint line

127
Q

What investigation can be done to check for meniscal tears

A

Thessaly’s test -weight bearing at 20 degrees of knee flexion
Positive if pain on twisting

128
Q

What is Chondromalacia patellae

A

Softening of the cartilage of the patella
most commonly seen in teenage girls

129
Q

Features and treatment of Chondromalacia patellae

A

Anterior knee pain on walking up and down stairs and rising from prolonged sitting

Physiotherapy

130
Q

Features of Osgood-Schlatter disease

A

Pain
Tenderness
and
Swelling over the tibial tubercle

131
Q

Features of Osteochondritis dissecans

A

Pain after exercise
Intermittent swelling and locking

132
Q

Features of Patellar subluxation

A

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

133
Q

Features of Patellar tendonitis

A

Most commonly seen in athletic teenage boys
Chronic anterior knee pain that worsens after running
Tender below the patella on examination

134
Q

Symptoms of plantar fasciitis

A

Heel pain
Usually worse around the medial calcaneal tuberosity

135
Q

Management of plantar fasciitis

A

Rest the feet
Wear shoes with good arch support and cushioned heels
Insoles and heel pads may be helpful

136
Q

What is a Boxer’s fracture and what is the most common cause?

A

Minimally displaced fracture of the 5th metacarpal
Patient punching a hard surface

137
Q

What is a Colle’s fracture and what is the most common cause?

A

Dorsally displaced distal radius fracture (DDDr F)
Caused by a fall onto an outstretched hand (FOOSH)
AKA dinner fork type deformity

138
Q

What are the early complications of a Colle’s fracture

A

Median nerve injury -acute carpal tunnel syndrome
Compartment syndrome ,
Vascular compromise
Malunion
Rupture of the extensor pollicis longus tendon

139
Q

What are the late complications of a Colle’s fracture?

A

Osteoarthritis
Complex regional pain syndrome

140
Q

What are the the features of a Colle’s fracture

A

Transverse fracture of the radius
1 inch proximal to the radio-carpal joint
Dorsal displacement and angulation

141
Q

What is a Smith’s fracture and what is the most common cause?

A

Reverse Colle’s fracture
Volar angulation of distal radius fragments
Caused by falling backwards onto the palm or the flexed wrists

142
Q

What is a Bennett’s fracture and what is the most common cause? What is shown on X-rays?

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

143
Q

What is a Monteggia’s fracture and what is the most common cause?

A

Dislocation of the proximal radioulnar joint in association with an ulna fracture
Fall on outstretched hand with forced pronation

144
Q

What is a Galeazzi fracture? What is the most common cause?

A

Radial shaft fracture with associated dislocation of the distal radioulnar joint
Direct blow

145
Q

What is a Pott’s fracture? What is the most common cause?

A

Bimalleolar ankle fracture
Forced foot eversion

146
Q

What is a Barton’s fracture? What is the most common cause?

A

Distal radius fracture (Colles’/Smith’s) with associated radiocarpal dislocation
Fall onto extended and pronated wrist

147
Q

How can humeral fractures be divided?

A

Proximal humeral fracture
Humeral shaft fractures
Distal humeral fractures

148
Q

What is a supracondylar fracture?

A

Distal humerus fracture just above the elbow joint

149
Q

What are the features of a supracondylar fracture?

A

Pain
Swelling over the elbow immediately
Elbow typically in a semi-flexed position

150
Q

What is the management of a supracondylar fracture?

A

Non-displaced - collar and cuff
Displaced - manipulation and fixation under anaesthesia

151
Q

What are the features of a scaphoid fracture?

A

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

152
Q

Causes of a scaphoid fracture

A

Fall on outstretched hand (FOOSH)

153
Q

Investigations for scaphoid fracture

A

X-ray with PA, lateral and oblique views

154
Q

Initial management of scaphoid fracture

A

Immobilisation with a futuro splint or standard below-elbow back slab

155
Q

Orthopaedic management of scaphoid fracture

A

Undisplaced - cast for 6-8 weeks
Displaced - surgical fixation

156
Q

Complications of scaphoid fracture

A

Avascular necrosis

157
Q

Features of a radial head fracture and most common cause

A

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).

158
Q

What is De Quervain’s tenosynovitis

A

Sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed

159
Q

Features of De Quervain’s tensosynovitis

A

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

160
Q

Management of De Quervain’s tensosynovitis

A

Analgesia
Steroid injection
Immobilisation with thumb splint

161
Q

What are 5 causes of elbow pain?

A

Lateral epicondylitis (Tennis elbow)
Medial epicondylitis (Golfer’s elbow)
Radial tunnel syndrome
Cubital tunnel syndrome
Olecranon bursitis

162
Q

Features of lateral epicondylitis

A

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

163
Q

Features of medial epicondylitis

A

pain and tenderness localised to the medial epicondyle
pain is aggravated by wrist flexion and pronation

164
Q

Features of radial tunnel syndrome and nerve involved

A

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.

165
Q

Features of cubital tunnel syndrome

A

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

166
Q

Features of olecranon bursitis

A

Swelling over posterior aspect of elbow
Pain
Warmth
Erythema

167
Q

Management of lateral epicondylitis

A

Advice on avoiding muscle overload
Simple analgesia
Steroid injection
Physiotherapy

168
Q

What is a compound fracture

A

When the skin is broken and the broken bone is exposed to the air. The broken bone can puncture through the skin

169
Q

What is a stable fracture

A

When the fractured bone remains in alignment at the fracture

170
Q

What is a pathological fracture

A

When a bone breaks due to abnormality within bone

171
Q

What fractures most commonly occur in children?

A

Greenstick
Buckle
Salter-Harris (growth plate fractures)

172
Q

What bones are at risk of avascular necrosis if fractured

A

Scaphoid
Femoral head
Humeral head
Talus
Navicular
5th metatarsal

173
Q

What diseases can cause pathological fractures

A

Osteoporosis
Tumour
Paget’s disease of the bone

174
Q

What are the main cancers that metastasis to the bone

A

PoRTaBLe
Prostate
Renal
Thyroid
Breast
Lung

175
Q

What is the FRAX tool

A

Risk of a fragility fracture over the next 10 years

176
Q

What are fragility fractures

A

Fractures caused by weakness of bone (usually due to osteoporosis)

177
Q

How is bone mineral density measured

A

DEXA scan

178
Q

What are the interpretations of the DEXA scan

A

T-scores
More than -1 = Normal
-1 to -2.5 = Osteopenia
Less than -2.5 = Osteoporosis
Less than -2.5 + plus fracture = severe osteoporosis

179
Q

First line treatments for reducing the risk of fragility fractures

A

Calcium and Vitamin D
Bisphosphonates (e.g. alendronic acid)

180
Q

Side effects of bisphosphonates

A

Reflux and oesophageal erosions
Atypical fractures
Osteonecrosis of the jaw
Osteonecrosis of the external auditory canal

181
Q

What is an alternative to bisphosphate in fragility fractures prophylaxis

A

Denosumab - blocks activity of osteoclasts

182
Q

When can a fat embolism occur

A

Following the fracture of long bones
May become lodged in vessels - PE

183
Q

Management of fat embolism

A

Operating early to fix the fracture reduces the risk of fat embolism syndrome

184
Q

What is reactive arthritis

A

Synovitis in one or more joints following an infective trigger

185
Q

What are the common triggers of reactive arthritis

A

Gastroenteritis
STIs

186
Q

What organisms are most commonly associated with reactive arthritis

A

Chlamydia trochamatis
Shigella flexneri
Salmonella
Yersinia enterocolitica
Campylobacter

187
Q

What are the symptoms of reactive arthritis

A

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”

188
Q

Management of reactive arthritis

A

Symptomatic
NSAIDs
Intra-articular steroids
Persistent disease: sulfasalazine and methotrexate

189
Q

What is rheumatoid arthritis

A

Autoimmune condition causing chronic inflammation in the synovial lining of joints, tendon sheaths and bursa

190
Q

What is the disease pattern of rheumatoid arthritis

A

Symmetrical (distal - hands and feet) polyarthritis

191
Q

Risk factors for rheumatoid arthritis

A

Obesity
Smoking
HLADR4
Family history

192
Q

Presentation of rheumatoid arthritis

A

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

193
Q

What are the most commonly affected joints in rheumatoid arthritis

A

MCP joints
PIP joints
Wrist
MTP joints

194
Q

What is palindromic rheumatism and what are its symptoms

A

Self limiting episodes of inflammatory arthritis
Pain, stiffness and swelling typically affecting a few joints

195
Q

What can indicate that palindromic rheumatism may develop into rheumatoid arthritis

A

Positive rheumatoid factor and anti-CCP

196
Q

What are the joint signs in rheumatoid arthritis

A

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

197
Q

What are the extra-articular manifestations of rheumatoid arthritis

A

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

198
Q

What are the ocular manifestations of rheumatoid arthritis

A

Keratoconjunctivitis sicca
Episcleritis
Scleritis
Keratitis
Cataracts (secondary to steroids)
Retinopathy (secondary to hydroxychloroquine)

199
Q

What are the investigations of rheumatoid arthritis

A

Rheumatoid factor
Anti-CCP antibodies
CRP and ESR
X-ray of hands and feet
Ultrasound or MRI if clinical findings are unclear

200
Q

What are the X-ray changes in rheumatoid arthritis

A

LESS
Loss of joint space
Erosions
Soft-tissue swelling
See-through bones (osteopenia)

201
Q

What scoring system measures functional ability in rheumatoid arthritis

A

Health Assessment questionnaire (HAQ)

202
Q

What scoring systems monitors disease activity in rheumatoid arthritis

A

Disease Activity Score 28 Joints (DAS28)
Assigns points for:
Swollen joints
Tender joints
ESR/CRP results

203
Q

What is the management of rheumatoid arthritis

A

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

204
Q

How are flares of rheumatoid arthritis managed

A

Oral or IM corticosteroids

205
Q

How should methotrexate be taken

A

Once a week
Since it interferes with folic acid metabolism:
+ folic acid 5mg (on a different day)

206
Q

Side effects of methotrexate

A

Mouth ulcers and mucositis
Liver toxicity
Bone marrow suppression and leukopenia
Teratogenic

207
Q

Side effects of leflunomide

A

Hypertension
Peripheral neuropathy
Mouth ulcers and mucositis
Liver toxicity
Bone marrow suppression and leukopenia
Teratogenic

208
Q

Side effects of sulfasalazine

A

Orange urine
Reversible male infertility
Bone marrow suppression

209
Q

Side effects of hydroxychloroquine

A

Retinal toxicity - reduces visual acuity
Blue-grey skin pigmentation
Hair lightening (bleaching)

210
Q

Side effects of rituximab

A

Night sweats and thrombocytopenia

211
Q

What medications can cause reactivation of tuberculosis

A

Anti-TNF medications: adalimumab, infliximab and etanercept

212
Q

What rheumatoid arthritis drug is teratogenic

A

methotrexate

213
Q

What are the poor prognostic features fir rheumatoid arthritis

A

RF positive
Anti-CCP antibodies
Poor functional status at presentation
HLADR4
X-ray: early erosions (e.g. after <2 years)
Insidious onset

214
Q

What are the most common causative agents in septic arthritis

A

Staphylococcus aureus
Neisseria gonorrhoea - in young adults that are sexually active
then
Group A strep - streptococcus pyogenes
Haemophilus influenza
E.coli

215
Q

What is the presentation of septic arthritis

A

Acutely hot, red, swollen, painful joint
Stiffness and reduced range of motion
Fever
Lethargy
Sepsis

216
Q

Differential diagnoses of septic arthritis

A

Pseudogout
Gout
Reactive arthritis
Hemarthrosis

217
Q

Investigations for septic arthritis

A

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

218
Q

Management of septic arthritis

A

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

219
Q

What are the seronegative spondyloarthropathies

A

Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Enterohepatic arthritis

220
Q

After how long does psoriatic arthritis develop after having psoriasis?

A

Usually within in 10 years

221
Q

What are the 5 patterns of psoriatic arthritis

A

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)

222
Q

What is a good way of distinguishing between rheumatoid arthritis and psoriatic arthritis

A

PA usually affects the DIP joints whereas RA does not

223
Q

What are the features of psoriatic arthritis

A

Psoriatic skin lesions
Enthesitis
Dactylitis
Nail pitting
Onycholysis
Uveitis
IBD

224
Q

What is the tool used for screening for psoriatic arthritis in patients with psoriasis

A

Psoriasis Epidemiological Screening Tool (PEST)
Involves questions about joint pain, swelling, history of arthritis and nail pitting

225
Q

Investigations for psoriatic arthritis

A

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

226
Q

What is the management of psoriatic arthritis

A

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

227
Q

What is SLE

A

Systemic inflammatory autoimmune connective tissue disorder

228
Q

In who does SLE most commonly occur in

A

Women
Asian, African, Caribbean and Hispanic
Young to middle-aged adults

229
Q

What is the disease pattern of SLE

A

Relapsing-remitting

230
Q

What are the symptoms of SLE

A

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

231
Q

Investigations for SLE

A

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

232
Q

What can occur secondary to SLE

A

antiphospholipid antibodies and antiphospholipid syndrome

233
Q

Management for SLE

A

NSAIDs
Sun block
Hydroxychloroquine

IF internal organ involvement then consider:
prednisolone
cyclophosphamide

More severe SLE
DMARDs - methotrexate
Rituximab
Belimumab

234
Q

What are the complications of SLE

A

Cardiovascular:
Hypertension
Anaemia
Pericarditis
Pleuritis
Pulmonary fibrosis
Lupus nephritis
Optic neuritis
Transverse myelitis
Recurrent miscarriage
VTE

235
Q

What are sarcomas

A

Cancers originating in the muscles, bones or connective tissues

236
Q

What are three types of bone sarcomas

A

Osteosarcoma - most common form of bone cancer
Chondrosarcoma - originating from cartilage
Ewing sarcoma - bone and soft tissue cancer affecting children/young adults

237
Q

What are the different soft tissue sarcomas

A

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

238
Q

What are the key features of sarcomas

A

A soft tissue lump, particularly if growing, painful or large
Bone swelling
Persistent bone pain

239
Q

Investigations for sarcomas

A

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

240
Q

Treatments for sarcomas

A

Surgery - resection
Radiotherapy
Chemotherapy
Palliative care

241
Q

What are the most common sites to be affected in osteosarcoma

A

Femur
Tibia
Humerus

242
Q

Presentation of osteosarcoma

A

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

243
Q

Investigations for osteosarcoma

A

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

244
Q

Management of osteosarcoma

A

Surgical resection of the lesion with limb amputation
Adjuvant chemotherapy

245
Q

What is an osteoma and where does it typically occur

A

Overgrowth of bone
Commonly occurs in the skull

246
Q

What is an osteochondroma

A

Most common benign bone tumour
Cartilage-capped bony projection on external surface of bone

247
Q

What is a giant cell tumour and how is it shown on an x-ray

A

Tumour of multinucleated giant cells withing a fibrous stroma
Occurs most commonly in the epiphyses of long bones

X-ray shows soap bubble appearance

248
Q

Where do chondrosarcomas most commonly occur

A

Axial skeleton

249
Q

Where do Ewing’s sarcoma most commonly occur and what is shown on x-ray

A

Pelvis and long bones
Tends to cause severe pain
X-ray shows ‘onion skin’ appearance

250
Q

Other than bone pain, what are the common features of bone cancer

A

pathological fractures
Hypercalcaemia
Raised ALP

251
Q
A
252
Q

What are the most common sites for bone metastases

A

Spine
Pelvis
Ribs
Skull
Long bones

253
Q

What symptoms are suggestive of spinal metastases

A

Unrelenting lumbar back pain
Any thoracic or cervical back pain
Worse with sneezing, coughing, or straining
Nocturnal
Associated with tenderness

254
Q

What investigation should be done in anyone with suspected spinal metastases

A

MRI

255
Q

What is the Mirel’s scoring system

A

A classification system that evaluates the risk of a pathologic fracture in a lesion

256
Q

What are the causes of mechanical back pain

A

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)

257
Q

What are the causes of neck pain

A

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

258
Q

What are the red flag causes of back pain

A

Spinal fracture
Cauda equina
Spinal stenosis (e.g., intermittent neurogenic claudication)
Ankylosing spondylitis
Spinal infection

259
Q

What spinal nerves join o form the sciatic nerve?

A

L4 - S3

260
Q

What nerves branch off the sciatic nerve once it reaches the knee?

A

Tibial nerve
Common peroneal nerve

261
Q

What are the causes of sciatica

A

Herniated disc
Spondylolisthesis
Spinal stenosis

262
Q

Symptoms of sciatica

A

Unilateral pain from buttocks radiating down back of thigh to below knee or feet
Paraesthesia
Numbness
Motor weakness

263
Q

What is the sciatic stretch test

A

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.

264
Q

What investigations can be done for lower back pain

A

Usually a clinical diagnosis
X-rays and CT scans
MRI - emergency for cauda equina
Inflammatory markers

265
Q

What is the STarT Back Screening Tool

A

Stratifies the risk of a patient presenting with acute back pain developing chronic back pain.

266
Q

How to manage non-specific lower back pain

A

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

267
Q

Management of sciatica

A

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

268
Q

What is spinal stenosis

A

Narrowing of the spinal canal leading to compression of the spinal cord or nerve roots

269
Q

What are the three types of spinal stenosis

A

Central stenosis - narrowing of the central spinal canal
Lateral stenosis - narrowing of the nerve root canals
Foramina stenosis - narrowing of the intervertebral foramina

270
Q

What are the causes of spinal stenosis

A

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

271
Q

Presentation of spinal stenosis

A

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)

272
Q

How to differentiate intermittent neurogenic claudication and PAD?

A

Take ABPI - normal in spinal stenosis
Spinal stenosis patients have back pain, PAD does not

273
Q

Investigations for spinal stenosis

A

MRI
ABPI and CT angiogram to rule out PAD

274
Q

Management of spinal stenosis

A

Exercise and weight loss
Analgesia
Physiotherapy
Decompression surgery (if all else fails) - laminectomy (removal of part of lamina from vertebra)

275
Q

Examples of large vessel vasculitis

A

GCA - temporal arteritis
Takayasu’s arteritis

276
Q

Examples of medium vessel arteritis

A

Polyarteritis nodosa
Kawasaki disease

277
Q

Examples of small vessel vasculitis

A

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)

278
Q

Which vasculitides are p-ANCA and c-ANCA positive?

A

p-ANCA:
Microscopic polyangiitis
Eosinophilic granulomatosis with polyangiitis
c-ANCA:
Granulomatosis with polyangiitis

279
Q

What is Henoch-Schoenlein purpura

A

IgA vasculitis
IgA deposits in the blood vessels

280
Q

Symptoms of Henoch-Schoenlein purpura

A

Purpura
Joint pain
Abdominal pain
Renal involvement (IgA nephritis) - raised creatinine, haematuria and proteinuria

281
Q

Management of Henoch-Schoenlein purpura

A

Supportive:
Analgesia
Rest
Hydration
If using steroids, monitor with:
Urine dipstick - to check for renal involvement
BP - to monitor hypertension

282
Q

Features of microscopic polyangiitis

A

Renal failure due to glomerulonephritis
Diffuse alveolar haemorrhage - haemoptysis

283
Q

Features of granulomatosis with polyangiitis

A

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

284
Q

Eosinophilic granulomatosis with polyangiitis

A

Most commonly affects lungs and skin
Severe asthma
Sinusitis
Allergic rhinitis

285
Q

Characteristic finding on FBC in eosinophilic granulomatosis with polyangiitis

A

Raised eosinophils

286
Q

What infection can polyarteritis nodosa be secondary to

A

Hepatitis B

287
Q

Features of polyarteritis nodosa

A

Renal impairment
Hypertension
Tender, erythematous skin nodules
MI
Stroke
Mesenteric arteritis - GI symptoms

288
Q

Features of Kawasaki’s disease

A

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

289
Q

What vessel does Takayasu’s arteritis most commonly affect

A

Aorta and its branches
+ pulmonary arteries

290
Q

Features of Takayasu’s arteritis

A

Fever
Malaise
Muscle aches
Claudication symptoms in the upper limb

Stenosis or occlusion can reduce pulses and BP in a limb = ‘pulseless disease)

291
Q

Investigations for Takayasu’s arteritis

A

CT or MRI angiography: vessels can swell and form aneurysms or become narrowed and blocked

292
Q

What are the general features of vascultidies

A

Joint and muscle pain
Peripheral neuropathy
Renal impairment
Purpura
GI symptoms
Necrotic skin ulcers
+ SYSTEMIC SYMPTOMS:
Fatigue
Fever
Night sweats
Anorexia
Weight loss
Anaemia

293
Q

Investigations for vasculitis

A

Inflammatory markers - ESR and CRP
p-ANCA
c-ANCA
Urinalysis for haematuria and proteinuria

294
Q

General management of vasculitis

A

Steroids:
oral prednisolone
IV hyrdrocortisone
Nasal for nasal symptoms
Inhaled for lung involvement

immunosuppressants:
Cyclophaosphamide
Rituximab

295
Q
A

Phase 4 - GI, MSK, Infectious Diseases (3 decks)

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