MSK and trauma Flashcards
XR features in septic arthritis
- may be normal initially or show only soft tissue swelling
- later features - bone destruction, subluxation, narrowing of spaces, erosive changes
- wide spaces suggests effusion
Kocher criteria for septic arthritis
- temp >38.5
- increased ERSR
- increased WCC
- non-weight bearing
antibiotic usually given in septic arthritis
flucloxacillin, clindamycin if allergic
given 6-12 weeks
which arteries are inflamed in GCA
posterior ciliary arteries
why can GCA cause visual disturbances
secondary to anterior ischaemic optic neuropathy
when to consider Takayusu’s in GCA
if <55
investigations for GCA
- ESR >50
- temporal artery biopsy (skip lesions?)
retinal appearance in GCA
- pale papilloedema
- ischaemic disc is pale, waxy, elevated
- splinter haemorrhages
at which level is a prolapsed disc most common
L4-5 or L5-S1
what to consider as a differential for spinal cord compression
if on steroids - may have caused some proximal myopathy
will have a normal neurological exam other than some wasting/maybe reduced hip flexion which is symmetrical
neurological signs of spinal cord compression depending on level of lesion
- lesions above L1 = UMN signs in legs
- lesions below L1 = LMN signs in legs and perianal numbness
analgesia to use in osteoarthritis
- topical NSAIDs + paracetamol
- if ineffective - oral NSAIDs + PPI
most common sites of fragility fractures
- vertebrae
- hip (proximal femur)
- wrist (distal radius)
risk assessment to do in those on oral steroids over 3 months
FRAX tool for osteoporosis
first line bisphosphonate to use in osteoporosis
alendronate
review after 5 years (3 years for zolendronic acid)
drug to use for osteoporosis in severe osteoporosis in postmenopausal women and men at high risk of fracture
strontium ranelate - increases MI risk
what is palindromic RA
relapsing/remitting mono arthritis of different large joints
what is a poor prognostic factor in RA
positive rheumatoid factor (positive in 70% but can also be raised in Sjogren’s Felty’s SLE etc)
more specific antibody in RA
anti-CCP antibodies
FBC findings in RA
normocytic, normochromic anaemia and reactive thrombocytosis
ESR and CRP may be increased
DMARDs to use in RA
- monotherapy +/- short course prednisolone
- give methotrexate, or sulfasalazine, hydroxychloroquine, leflunomide
when to give TNF inhibitors in RA
if inadequate response to at least 2 DMARDs including methotrexate
E.g:
- etanercept
- adalimumab
- infliximab
condition associated with GCA
polymyalgia rheumatica
bloods results in PMR
- ESR >40
- raised CRP
- ALP raised in 30%
- CK and EMG NORMAL
histology in PMR
- vasculitis with giant cells
- skip lesions
- muscle bed arteries most affected
dose of prednisolone to give in PMR
15mg/d PO
reduce dose slowly
most need for >2 years (remember GI and bone protection)
2nd line drugs for PMR after prednisolone
- methotrexate
- tocilizumab
drugs which can precipitate gout
diuretics
cytotoxic
what is Lesch Nyhan syndrome
X-linked recessive disorder causing gout, renal failure, neurological deficits
joint aspirate in gout
negatively birefringent crystals
drugs to give in acute gout attack
NSAIDs + colchicine
if contraindicated - prednisolone 15mg/day
what to give for gout remission if allopurinol contraindicated
febuxostat
aim for serum uric acid <300
risk factors for pseudogout
- hyperparathyroidism
- hypothyroidism
- haemochromatosis
- acromegaly
- low magnesium, low phosphate
- Wilson’s disease
joint aspirate in pseudogout
positively birefringent rhomboid shaped crystals
XR finding in pseudogout
chonedrocalcinosis
investigation to diagnose spinal stenosis
MRI
what does a straight leg raise test for
lumbar root irritation
genes associated with ankylosing spondylitis and reactive arthritis
HLA-B27 (only positive in 10%)
seronegative
XR changes in ankylosing spondylitis
- normal in early disease
- sacroiliitis: subchondral erosions, sclerosis
- squaring of lumbar vertebrae
- bamboo spine (late)
- syndesmophytes - due to ossification of outer fibres of annulus fibrosis
what might spirometry show in ankylosing spondylitis
restrictive defect due to:
- pulmonary fibrosis
- kyphosis
- ankylosis of costovertebral joints
6 As of ankylosing spondylitis
- apical fibrosis (CXR)
- anterior uveitis
- aortic regurgitation
- achilles tendonitis
- AV node block
- amyloidosis
first line drugs for ankylosing spondylitis
NSAIDs
when to use DMARDs in ankylosing spondylitis
only if peripheral joint involvement
can’t see, pee or climb a tree
reactive arthritis - urethritis, conjunctivitis, arthritis
asymmetrical oligoarthritis of lower limbs
usual organism causing reactive arthritis
chlamydia (do PCR) - develops within 4 weeks of initial infection
2 fractures commonly causing compartment syndrome
- supracondylar
- tibial shaft fractures
why may arterial pulsation still be felt in compartment syndrome
necrosis occurs due to microvascular compromise
investigations for compartment syndrome
measurement of intra-compartmental pressure:
- > 20mmHg abnormal
- > 40mmHg diagnostic
why can renal failure occur after fasciotomy
myoglobinuria - need aggressive IV fluids
what can cause chronic compartment syndrome
young athletes - excessive training
ligaments involved in high ankle sprain
tibia and fibula syndesmosis (what binds them together)
ligaments involved in low ankle sprain
lateral collateral ligaments
most common ligament affected in low ankle sprain
inversion injury causing tear of ATFL
what is Hopkin’s squeeze test
pain when tibia and fibula squeezed together at mid-calf
shows a high ankle sprain
management of low ankle sprain
RICE
crutches etc.
management of high ankle sprain
non-weight bearing orthosis
if widening of tibiofibular joint (diastasis) then operative fixation needed
how does Colles’ fracture occur
FOOSH - dinner fork deformity
distal radius fracture with dorsal displacement of fragments
nerve which can be damaged in Colles’ fracture
median or ulnar nerve
may experience acute carpal tunnel syndrome
what is a Smith’s fracture
reverse Colles’ - anterior displacement of distal fragments - garden spade deformity
type of hip fracture at risk of avascular necrosis
intracapsular
what is broken in hip fractures
Shenton’s line
classification of hip fractures I-IV
I = stable fracture with impaction in valgus, inferior cortex intact
II = complete fracture but undisplaced
II = displaced
IV = complete bony disruption
management of intracapsular hip fractures
surgery within 24 hours
- undisplayed = internal fixation with screws, hemiarthroplasty if unfit
- displaced = young and fit then reduction and internal fixation, if older and reduced mobility then hemiarthroplasty/total hip replacement
management of extra capsular hip fractures
- dynamic hip screw
- if reverse oblique, transverse or subtrochanteric: intramedullary device
cerebral perfusion pressure equation
CPP = MAP - ICP
why can increased ICP result in ipsilateral pupillary dilatation
increased ICP = herniation of temporal lobe through tentorial hiatus = compresses oculomotor nerve
what is Battle’s sign
bruising over mastoid process - sign of basal skull fracture but takes several days to appear
what NOT to use in a basal skull fracture
nasopharyngeal airway
when to do an immediate CT scan after head injury
o GCS <13 initial assessment o GCS <15 2 hours post injury o Suspected open/depressed skull fracture o Any sign basal skull fracture o Post traumatic seizure o Focal neurological deficit o >1 episode vomiting
when to do a CT scan within 8 hours after head injury
if some LOC/amnesia and ANY of:
- 65+
- history bleeding/clotting problems
- dangerous mechanism of injury - fall >1m, pedestrian struck by car etc.
- > 30 min retrograde amnesia of events immediately before injury
if on warfarin
score 1-4 in Eye on GCS
Eye opening:
- spontaneous = 4
- to speech = 3
- to pain = 2
- none = 1
score 1-5 in verbal on GCS
Verbal response:
- orientated = 5
- confused = 4
- inappropriate words = 3
- sounds = 2
- none = 1
score 1-6 in motor on GCS
Best motor response:
- obeys commands = 6
- localises to pain = 5
- normal flexion = 4
- abnormal flexion = 3
- extension = 2
- none = 1
what is the trauma triad of death
hypothermia
coagulopathy
acidosis
ATOM FC for major thoracic injury
Airway obstruction
Tension pneumothorax
Open chest wound
Massive haemothorax
Flail chest (2+ ribs broken in 2+ places) Cardiac tamponade
type of shoulder dislocation associated with seizures
posterior dislocation (limited external rotation)
but rare type of dislocation
triad of symptoms in reactive arthritis
urethritis
conjunctivitis
arthritis
investigation results in reactive arthritis
- ESR and CRP raised
- HLA-B27 positive in majority of those affected
why do PCR in reactive arthritis
to test for chlamydia (because reactive arthritis is usually caused by chlamydia)
management of reactive arthritis
- analgesia, NSAIDs, intra-articular steroids if unresponsive to NSAIDs
- antibiotics to treat causative organism
- sulfasalazine and methotrexate if persistent disease
extra-articular manifestations of seronegative arthritis
- uveitis
- pulmonary fibrosis (upper zone)
- amyloidosis
- aortic regurgitation
examples of seronegative arthritis
- ankylosing spondylitis
- psoriatic arthritis
- Reiter’s syndrome (reactive arthritis)
- enteropathic arthritis (associated with IBD)
- JIA (rare)
causes of osteomalacia
- vitamin D deficiency
- renal failure
- drugs
- liver disease
what does XR show in osteomalacia
translucent bands
sclerotic bone tumour - likely primary?
prostate
lytic bone tumour - likely primary?
breast, myeloma
treatment of lupus nephritis, vasculitis and cerebral lupus
cyclophosphamide
lung problems associated with scleroderma
ILD
pulmonary artery HTN
CK levels in myositis
> 1000
