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MSK Flashcards

Rheumatology and Orthopeadics

1
Q

NSAID drug interactions

A

Lithium (toxicity)
Warfarin ( risk of bleeding)
Methotrexate (marrow toxicity)
Diuretics (reduces effect in renal toxicity)

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2
Q

X-ray features of osteoarthritis

A
  • Loss of joint space
  • Osteophytes
  • Subarticular sclerosis
  • Subchondral cysts
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3
Q

X- ray changes in rheumatoid arthritis

A
  • Soft tissue swelling
  • Juxta articular osteopenia
  • Reduced joint space
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4
Q

Risk factors for septic arthritis

A
  • Diabetes
  • Joint disease (RA, gout)
  • Immunodeficiency
  • Joint prosthesis (hip or knee)
  • Joint surgery
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5
Q

Differentials for septic arthritis

A
  • reactive arthritis
  • gout
  • RA
  • OA
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6
Q

Common causative organisms for septic arthritis

A
  • s.aureus
  • streptococci
  • n. gonococcus
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7
Q

Gout precipitants

A
  • starvation
  • diuretics
  • infection
  • surgery
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8
Q

Gout risk factors and associations

A

Reduced urate excretion: Renal failure, diuretics, hypertension

Excess urate production: Alcohol, tumour lysis syndrome

Associations: Diabetes, CVD, hypertension, chronic renal failure

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9
Q

Treatment of acute gout

A

High dose NSAID or if CI colchicine

Rest and elevate joint

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10
Q

Gout prophylaxis

A
  • Lose weight, avoid fasts or alcohol excess, reduce intake of purine rich meats
  • Start prophylactic medication if more than 1 attack in 12months
  • Allopurinol (titrate while checking urate levels) or febuxostat
  • All patients who are due to commence allopurinol or febuxostat should be prescribed either colchicine (500micrograms) or low dose NSAID and this should be given for 6 months
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11
Q

Allopurinol side effects and when to use

A

Can trigger an attack so wait 3 weeks after an acute episode

Avoid stopping in acute attacks if already established medication. All patients who are due to commence allopurinol or febuxostat should be prescribed either colchicine (500micrograms) or low dose NSAID and this should be given for 6 months

SE: Rash, fever, reduced white cells

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12
Q

Treatment of newly diagnosed Churg Strauss syndrome

A
  • Induction of remission with steroid + cyclophosphamide or rituximab

-Maintenance with azathioprine or methotrexate if on cyclophosphamide
OR
- Maintenance: continue with rituximab

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13
Q

Features of spondyloarthropathies

A
  • HLA B27 associated
  • Seronegative
  • Axial arthritis (spine and sacroiliac joint)
  • Asymmetrical large- joint oligoarthritis or monoarthritis
  • Enthesitis (plantar fascitis, achilles tendonitis, costochondritis)
  • Dactylitis
  • Extra articular manifestations
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14
Q

Extra articular manifestations of spondyloarthropathis

A
  • Anterior uveitis
  • Psoriasis
  • Oral ulcers
  • Aortic valve incompetence
  • IBD
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15
Q

Risk factors for osteoarthritis

A
  • Age
  • bmi
  • female
  • previous joint injury
  • genetic
  • alignment
  • quadriceps strength
  • secondary OA
  • professional athletes
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16
Q

Clinical features of RA on examination

A
  • Swan neck deformity
  • Boutonniere deformity
  • ## Muscle wasting
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17
Q

What is Felty’s syndrome

A
  • Neutropenia
  • Anaemia
  • Splenomegaly
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18
Q

Extra articular manifestations of RA

A
  • Lung: Nodules, pleural effusion
  • Cardiac: Pericarditis, pericardial effusion
  • Felty’s syndrome
  • Small vessel vasculitis
  • Eyes: episcleritis, scleritis, dry eyes
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19
Q

Vasculitic Screen

A

fbc, lfts, u&es, tfts, plasma viscosity, crp, ANA, ANCA, CXR, urine dip

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20
Q

Symptoms of SLE (as part of criteria)

A
  • Butterfly rash (acute)
  • Discoid rash (chronic)
  • Photosensitivity
  • Oral ulcers
  • Arthritis
  • Hair loss
  • Pleuritis or pericarditis
  • Renal: Proteinuria or casts
  • Neuro: Seizures or psychosis
  • Blood - Haemolytic anaemia, or leukopenia, or thrombocytopaenia
  • Immunologic disorder Anti DNA OR Anti- Sm OR Antiphospholipid antibodies
  • Positive ANA
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21
Q

Diagnosis of APLS

A

-Anticardiolipin & lupus anticoagulant on two or more occasions at least 12 weeks apart

AND either

Vascular thrombosis or obstetric event

22
Q

Laboratory criteria for SLE

A
  • Positive ANA
  • Anti- dsDNA
  • Anti- Smith antibodies present
  • Antiphospholipid Abs present
  • Low complement
  • Positive direct Coombs test
23
Q

Two most common causes of drug induced lupus

A
  • Procainamide

- Hydralazine

24
Q

Screening required before starting methotrexate

A
  • Baseline bloods
  • Viral screening (HIV, hepatitis)
  • Respiratory assessment
25
Q

Common side effects of methotrexate

A
  • Nausea
  • Vomiting
  • Diarrhoea
  • Mouth ulcers
  • Hair loss
  • Skin rashes
26
Q

Safety netting for methotrexate

A
  • Blood disorders (e.g. sore throat, bleeding, bruising)
  • Liver toxicity (e.g. nausea, vomiting, abdominal discomfort, dark urine)
  • Shortness of breath
27
Q

Contraception advice w/ methotrexate

A
  • Stop methotrexate 3 months before pregnancy

- Not recommended in breastfeeding

28
Q

Drug interactions with methotrexate

A
  • Trimethoprim
  • Co trimoxazole
  • Acitretin
  • Cloxapine
  • Levetiracetam
  • Do not buy NSAIDS over the counter
29
Q

How to take methotrexate

A

ONCE WEEKLY, swallowed whole

Folic acid 3 days after methotrexate

30
Q

What to do if missed a dose of methotrexate

A
  • Take as soon as remembered if within two days of when it should have been taken
  • If more than that wait until next dose.
31
Q

Monitoring required on methotrexate

A
  • Bloods every two weeks until stable for 6 weeks, then monthly
32
Q

Key points in methotrexate counselling

A
  • Does not start working straight away, takes 3-12 weeks
  • Risk of malignancy (lymphoma/skin cancer)
  • Alcohol kept to less than 7 units
  • Avoid live vaccines (MMR, yellow fever, smallpox, rotavirus)
33
Q

Risk factors for poor fracture healing

A
  • Old age
  • Smoker
  • Local complications to fracture
  • Diabetes
  • Steroids
  • Osteoporosis
  • NSAIDs
34
Q

Management of fractures

A
  • Reduction (realignment)
  • Stabilisation (fixation or splinting in a cast)
  • Maintain neurovascular supply
  • Early rehabilitation
35
Q

Indications for ORIF

A
  • Failed conservative management
  • 2 fractures in 1 limb
  • Bilateral identical fractures
  • Intra articular fractures
  • Open fractures
  • Displaced unstable fracture
36
Q

Management of an open fracture

A
  • ABCDE
  • Gross contamination removed
  • Photograph taken
  • IV antibiotics asap and every 8 hours until debridement
  • Theatre for washout and debridement
  • Stabilisation of the fracture within 24 hours on daytime trauma list
37
Q

What is a pathological fracture

A
  • A fracture through abnormal bone, not caused by high energy injury
38
Q

Causes of a pathological fracture

A
  • Osteoporosis
  • Osteomalacia
  • Osteopenia
  • Tumours - primary or secondary
  • Infection
  • Metabolic bone disease (vitamin D deficiency, rickets)
  • Medications
39
Q

Complications of fractures

A

Immediate

  • Internal bleeding
  • organ injury
  • nerve or skin injury
  • limb ischaemia

Later

  • skin necrosis
  • pressure sores
  • infection
  • non/delayed union
  • pulmonary embolism
  • pneumonia
  • arthritis
40
Q

Steroid injection counselling points

A
  • Done to reduce inflammation and subsequently pain the joint
  • Steroid and local anaesthetic
  • Side effects: Pain at injection site, may not work, bruising, skin dimpling
  • Cannot have surgery within three months of steroid injection
  • More than two steroid injections (6 weeks apart) not recommended
41
Q

Causes of hip pain in a child

A
  • Fracture
  • Perthe’s disease
  • Septic arthritis
  • Transient synovitis
  • Malignancy
  • Slipped upper femoral epiphysis
  • Non accidental injury
42
Q

How does a NOF fracture make the leg look on examination?

A
  • Shortened and externally rotated
43
Q

Joint pain history

A
  • Duration
  • Which joints
  • Morning stiffness and for how long?
  • Effect of exercise/activity?
  • Have they tried painkiller?
  • Stiffness or swelling?
  • Severity of pain?
  • Extraarticular features: Painful or red eyes, Recent infections, Rashes, Diarrhoea, Mouth ulcers, Dry mouth, Cold hand that change colour, Back pain?
44
Q

Joint pain differentials

A

Inflammatory

  • RA
  • Spondyloarhtropahies
  • Connective tissue disease (SLE)

Non inflammatory

  • OA
  • Gout
  • Septic arhtirtis
  • Fibromyalgia
45
Q

Back pain differentials

A
  • Mechanical back pain
  • Prolapsed disc
  • Cord compression (tumour, central disc prolapse)
  • Cauda equina syndrome (caused by malignancy or central disc prolapse)
  • Osteoporotic fracture
  • Infection
  • Spondyloarthropathy
46
Q

Serious causes of back pain

A
  • Infection
  • Fracture
  • Cord compression
  • Malignant metasteses
  • Cauda equina
47
Q

Back pain history

A
  • SOCRATES
  • Morning stiffness?
  • Weight loss?
  • Fever?
  • Night sweats?
  • Recent trauma?
  • Neurological symptoms ( Leg weakness, incontinence, saddle aneasthesia
48
Q

Back pain red flags

A
  • Age <20 or >50
  • Night pain
  • Worsening pain not relieved by rest
  • History of malignancy
  • Weight loss or fever
  • Urinary/faecal incontinence
  • Leg weakness
  • Saddle anaesthesia
  • Severe trauma or minor trauma in the presence of osteoporosis
49
Q

Rheumatoid arthritis counselling

A
  • Inflammation of the joints
  • Hands, wrist, feet, and ankles on both sides of the body
  • Worse in the morning
  • Develops gradually
  • It is a long term condition with periods of worsening symptoms called flare ups
  • Flare ups can cause damage to the joint which can lead to deformities
    Diagnosis: symptoms, blood test, X ray of hands or feet
    -Treatment started as early as possible to minimise or prevent permanent damage to the joint (DMARDS, NSAIDS, pain killers, steroids, regular exercise, lifestyle factors to prevent CVD)
50
Q

Osteoarthritis

A
  • Inflammation of the joints
  • Joint cartilage becomes damaged and worn
  • Pain, stiffness, swelling, larger than normal
  • Hips, Knees, fingers, and lower spine
  • Occurs with increasing age
  • No cure but treatment helps ease pain and stiffness and improve mobility
  • Treatment includes exercse, weight control, walking aids, physiotherapy, occupational therapy,
  • Medicatins include pain killers, topical antiinflammatories (diclofenac), steroid injections,
  • Surgery for severe OA affecting quality of life
  • Symptoms can fluctuate and the severity of the condition varies from person to person

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