MSK Ix Mx

Question 1

Ankle and Foot: Bunions

Question 2

Ankle and Foot: Morton’s neuroma

Question 3

Ankle and Foot: Plantar fasciitis

Plantar fasciitis = the most common cause of heel pain seen in adults

Answer 3

The pain is usually worse around the medial calcaneal tuberosity

Mx = Rest the feet where possible
wear shoes with good arch support and cushioned heels
insoles and heel pads may be helpful

Question 4

Ankylosing spondylitis

Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy

It typically presents in males (sex ratio 3:1) aged 20-30 years old.

back pain worse at night and first thing in the morning

with alternating buttock pain due to SI joint involvement

The pain and stiffness classically improve after exercise.

Answer 4

Ix:
1st = Hip X-Ray + Inflamm markers
2nd = MRI
3rd = Spirometry

Mx: 1st = NSAIDS
2nd = Anti-TNF drugs (etanercept/Adalimumab)

HLA-B27 is of little use in making the diagnosis as it is positive in:
90% of patients with ankylosing spondylitis
10% of normal patients

Radiographs may be normal early in disease, later changes include:
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
chest x-ray: apical fibrosis

If the x-ray is negative for sacroiliac joint involvement in ankylosing spondylitis but suspicion for AS remains high, the next step in the evaluation should be obtaining an MRI. Signs of early inflammation involving sacroiliac joints (bone marrow oedema) confirm the diagnosis of AS and prompt further treatment.

Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints.

encourage regular exercise such as swimming
physiotherapy

the disease-modifying drugs which are used to treat rheumatoid arthritis (such as sulphasalazine) are only really useful if there is peripheral joint involvement

the 2010 EULAR guidelines suggest: ‘Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments’
research is ongoing to see whether anti-TNF therapies such as etanercept and adalimumab should be used earlier in the course of the disease

Question 5

Bursitis

Question 6

Crystal arthropathy: Gout

Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 450 µmol/l)

Answer 6

Ix = Synovial fluid analysis + Uric Acid + X-Ray

Acute mx: 1st = NSAIDs/Colchicine + PPI
2nd = Oral pred 15mg/day (or IV)

REMEMBER: NSAIDS cannot be taken if the pt has CKD or MM!

Long-term mx:
1st = Allopurinol (ULT) 100mg OD + 6months cochicine cover
2nd = Febuxostat

Refractory = Uricase
Persistent = Pegloticase

Synovial Fluid analysis;
needle shaped negatively birefringent monosodium urate crystals under polarised light

Uric acid
should be checked once the acute episode has settled down (typically 2 weeks later) as may be high, normal or low during the acute attack

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

The maximum dose of NSAID should be prescribed until 1-2 days after the symptoms have settled

Colchicine;

Has a slower onset of action
Caution for renal impairment!: Reduce the dose if eGFR is 10-50 ml/min and to avoid if eGFR < 10 ml/min BNF
Main SE = Diarrhoea

If the patient is already taking allopurinol it should be continued

Indications for urate-lowering therapy (ULT)

• After their 1st attack of gout
• > = 2 attacks in 12 months
• Tophi
• Renal disease
• Uric acid renal stones
• Prophylaxis if on cytotoxics or diuretics

Urate-lowering therapy = wait until inlammation is reduced/pt is not in pain to discuss long-term ULT(allopurinol)

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

CKS

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

A lower initial dose of allopurinol should be given if the patient has a reduced eGFR

Re colchicine cover: NSAIDs can be used if colchicine cannot be tolerated. The BSR guidelines suggest this may need to be continued for 6 months

Lifestyle modifications
reduce alcohol intake and avoid during an acute attack
lose weight if obese
avoid food high in purines e.g. Liver, kidneys, seafood, oily fish (mackerel, sardines) and yeast products

Other points;
- Stop precipitating drugs (such as thiazides)
- Losartan has a specific uricosuric action and may be particularly suitable for the many patients who have coexistent hypertension
- Increased vitamin C intake (either supplements or through normal diet) may also decrease serum uric acid levels

Question 7

Elbow: Lateral epicondylitis (tennis elbow)

Answer 7

• Lateral epicondylitis (tennis elbow) = pain and tenderness localised to the lateral epicondyle

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

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

Question 8

Elbow: Medial epicondylitis (golfer’s elbow)

Answer 8

• Medial epicondylitis (golfer’s elbow) = pain and tenderness localised to the medial epicondyle

pain is aggravated by wrist flexion and pronation
symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement

Question 9

Fibromyalgia = stiff muscle pain

Women are around 5 times more likely to be affected
typically presents between 30-50 years old

Chronic pain: at multiple site, sometimes ‘pain all over’
lethargy

Cognitive impairment: ‘fibro fog’
sleep disturbance, headaches, dizziness are common

Answer 9

Ix = Pt is tender all over

Mx = Tailored to the individual patient.

Aerobic exercise: has the strongest evidence base
CBT
Neuropathic drugs = pregabalin, duloxetine, amitriptyline

Question 10

Giant cell arteritis (visual loss mx?)

Answer 10

Ix = ESR + temporal artery biopsy

Mx = high-dose pred (pre Ix!) + bisphos
(for bone protection from long-term steroids)

visual loss = IV methylpred then oral pred + emergency opthal review

Raised inflammatory markers
ESR > 50 mm/hr (note ESR < 30 in 10% of patients)
CRP may also be elevated
temporal artery biopsy
skip lesions may be present
note creatine kinase and EMG normal

There should be a dramatic response to IV methylpred, if not the diagnosis should be reconsidered

visual damage is often irreversible

Question 11

Hip: joint dysfunction (sacroiliac, transient synovitis)

Transient synovitis = irritable hip

Viral infection -> Acute hip pain

It is the commonest cause of hip pain in children. The typical age group is 3-8yo’s

Answer 11

Ix: Important to distinguish from septic arth by looking at high fever(red flag)!

Features
limp/refusal to weight bear
groin or hip pain
a low-grade fever is present in a minority of patients
High fever = septic arthritis

children may be monitored in primary care (with a presumptive diagnosis of transient synovitis) ‘If the child is aged 3–9 years, well, afebrile, mobile but limping, and has had the symptoms for less than 72 hours

Mx = Self-limiting, requiring only rest and analgesia

Question 12

Idiopathic inflammatory myopathies: polymyositis

Features
proximal muscle weakness +/- tenderness
Raynaud’s
respiratory muscle weakness
interstitial lung disease
e.g. fibrosing alveolitis or organising pneumonia
seen in around 20% of patients and indicates a poor prognosis
dysphagia, dysphonia

Answer 12

Ix = Muscle enzymes + EMG + muscle biopsy + anti-synth/jo-1 antibodies

Mx = high-dose corticosteroids + azathioprine

Muscle enzymes (CK, lactate dehydrogenase (LDH), aldolase, AST and ALT) are elevated in 85-95% of patients

corticosteroids are tapered as symptoms improve

Azathioprine = steroid-sparing agent

Question 13

Inherited disorders of connective tissue: Marfan syndrome (AD)

Autosomal recessive conditions are often thought to be ‘metabolic’ as opposed to autosomal dominant conditions being ‘structural’, notable exceptions:

some ‘metabolic’ conditions such as Hunter’s and G6PD are X-linked recessive whilst others such as hyperlipidaemia type II and hypokalaemic periodic paralysis are autosomal dominant

some ‘structural’ conditions such as ataxia telangiectasia and Friedreich’s ataxia are autosomal recessive

Answer 13

Marfan Features;

tall stature with arm span to height ratio > 1.05
high-arched palate
arachnodactyly
pectus excavatum
pes planus
scoliosis of > 20 degrees

heart:
dilation of the aortic sinuses (seen in 90%) which may lead to aortic aneurysm, aortic dissection, aortic regurgitation
mitral valve prolapse (75%),

lungs: repeated pneumothoraces

eyes:
upwards lens dislocation (superotemporal ectopia lentis)
blue sclera
myopia
dural ectasia (ballooning of the dural sac at the lumbosacral level)

The life expectancy of patients used to be around 40-50 years.

With the advent of regular echocardiography monitoring and beta-blocker/ACE-inhibitor therapy this has improved significantly over recent years.

Aortic dissection and other cardiovascular problems remain the leading cause of death however.

Question 14

Joint dislocation (incl. acromio-clavicular, elbow, shoulder, patella)

The shoulder is the most common joint in the body to dislocate, accounting for approximately 50% of all major joint dislocations.

Anterior shoulder dislocations account for > 95% of cases.

Answer 14

Shoulder dislocations occur when the humeral head dislodges from the glenoid cavity of the scapula.

Mx:
Recent = Reduction
Otherwise = analgesia/sedation to relax muscles

Question 15

Knee: Pain syndromes (iliotibial band, patellofemoral syndrome)

Answer 15

Iliotibial band syndrome is a common cause of lateral knee pain in runners, occurring in around 1 in 10 people who run regularly

Ix = tenderness 2-3cm above the lateral joint line

Mx:

1st = Activity modification and iliotibial band stretches
2nd = if not improving then physiotherapy referral

Question 16

Osteoarthritis

• Typically presents acutely with a ‘clunk’, pain and inability to weight bear
• On examination there is internal rotation and shortening of the affected leg
• aseptic loosening (most common reason for revision )
  prosthetic joint infection

Answer 16

Ix = Clinical diagnosis if typical, otherwise X-Ray*

Mx = paracetamol/NSAIDS
OA knee/hand = topical NSAIDS

2nd = Oral NSAIDs/COX-2 inhibitors(+PPI)*, opioids, capsaicin cream and intra-articular corticosteroids. These drugs should be avoided if the patient takes aspirin

3rd = Joint replacement (if conservative measures fail)

Intra-articular injections = short-term benefit
total hip replacement remains the definitive treatment

All patients should be offered help with weight loss, given advice about local muscle strengthening exercises and general aerobic fitness

Non-pharmacological mx = supports and braces, TENS and shock-absorbing insoles or shoes

*WF1 - NSAIDS + COXi are contraindicated in osteoarthritis!!!?

*main findings on X-Ray = reduced joint space, subchondral sclerosis, bone cysts and osteophytes

Can be caused by long-term use of omeprazole

Question 17

Osteomyelitis

Answer 17

Most common = S.aureus
SCD pt = Salmonella

Ix = MRI

Mx = flucloxacillin for 6 weeks

clindamycin if penicillin-allergic

Question 18

Peripheral nerve injuries/palsies

Answer 18

pain ladder?

Question 19

Polymyalgia rheumatica

Features
typically patient > 60 years old
usually rapid onset (e.g. < 1 month)
aching, morning stiffness in proximal limb muscles

weakness is NOT considered a symptom of polymyalgia rheumatica
also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats

Muscle pain without weakness in an elderly person is polymyalgia rather than polymyositis

my-A - A-cheing pain!
my-O - O-ld and weak

Answer 19

Same as GCA

Ix = Inflamm markers

Mx = pred 15mg/od

raised inflammatory markers e.g. ESR > 40 mm/hr
note creatine kinase and EMG normal

patients typically respond dramatically to steroids! failure to do so should prompt consideration of an alternative diagnosis

CK is normal

Question 20

Cutanea tarda Porphyria = photosensitive rash with blistering and skin fragility on the face and dorsal aspect of hands (most common feature)

Features
hypertrichosis (abnormally placed hair growth)
hyperpigmentation

Answer 20

Ix = Urine + serum iron/ferritin

urine = elevated uroporphyrinogen and pink fluorescence of urine under Wood’s lamp

serum iron ferritin level is used to guide therapy

Mx: 1st = chloroquine 2nd = venesection

Venesection is preferred if iron ferritin is above 600 ng/ml

Question 21

Psoriatic arthritis

Answer 21

Ix: X-Ray (pencil-in-cup appearance at DIP joint)

Mx: NSAIDS -> methotrex/sulphasal/anti-TNF

Question 22

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

Answer 22

Reactive arthritis is one of the HLA-B27 associated seronegative spondyloarthropathies.

Classic triad = ‘Can’t see, pee or climb a tree’

Mx:

Symptomatic:

1st = analgesia, NSAIDS, intra-articular steroids
2nd = Sulfasalazine and methotrexate are sometimes used for persistent disease

symptoms rarely last more than 12 months

*as Reiter was a member of the Nazi party the term is no longer used

Question 23

Rheumatoid arthritis

How does it present?

Answer 23

Px = pain is particularly
bad first thing in the morning. On examination, the wrists, metacarpophalangeal
joints and proximal interphalyngeal joints are swollen and warm and stiff

Ix = Anti-cyclic citrullinated peptide antibody + X-Ray (hands+feet)

Mx: Pt with evidence of joint inflammation should start a combination of disease-modifying drugs (DMARD) as soon as possible

Initial:
1st = DMARD(methotrex) + pred(short course)
2nd = Try another DMARD
3rd = TNF-inhibitor (sub-cut etanercept or adalimumab / IV infliximab/rituximab)

Monitoring response to treatment = CRP + DAS28 score

Flares = Corticosteroids - oral/IM

Methotrexate monitoring = FBC(myelosupression) & LFTs(cirrhosis). Other important side-effects include;
pneumonitis
sulfasalazine
leflunomide
hydroxychloroquine

ALWAYS GIVE FOLIC ACID WITH METHOTREXATE

Anti-cyclic citrullinated peptide antibody may be detectable up to 10 years before the development of rheumatoid arthritis. It has a key role in the diagnosis of rheumatoid arthritis, allowing early detection of patients suitable for aggressive anti-TNF therapy. It has a sensitivity similar to rheumatoid factor (around 70%) with a much higher specificity of 90-95%.

NICE recommends that patients with suspected rheumatoid arthritis who are rheumatoid factor negative should be tested for anti-CCP antibodies

TNF-inhibitors

etanercept: recombinant human protein, acts as a decoy receptor for TNF-α, can cause demyelination, risks include reactivation of tuberculosis
infliximab: monoclonal antibody, binds to TNF-α and prevents it from binding with TNF receptors, intravenous administration, risks include reactivation of tuberculosis
adalimumab: monoclonal antibody

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

Question 24

Septic arthritis

acute, swollen joint
restricted movement in 80% of patients
examination findings: warm to touch/fluctuant
fever: present in the majority of patients

Answer 24

Ix = synovial fluid sampling + blood culture + X-Ray/CT?

Joint aspiration is only +ve in 50% of pts with septic arth! so just start fluclox asap if suspected

Blood cultures: the most common cause of septic arthritis is hematogenous spread

Mx: IV fluclox (clinda if pen-allergic) 4-6weeks + joint needle aspiration

Patients are typically switched to oral antibiotics after 2 weeks

arthroscopic lavage may be required

Question 25

Shoulder: Adhesive capsulitis (frozen shoulder)

Question 26

Sjögren’s syndrome

S ensory polyneuropathy
J oint pain (arthralgia)
O ral dryness
G renal tubular acidosis??
R aynaud’s
E ye dryness
N eck inflammation (parotitis)
S ex dryness

Answer 26

Ix: RF anti-Ro/La

Mx = artificial saliva and tears

Rheumatoid factor (RF) positive in nearly 50% of patients
ANA positive in 70%
anti-Ro (SSA) antibodies in 70% of patients with PSS
anti-La (SSB) antibodies in 30% of patients with PSS

Schirmer’s test: filter paper near conjunctival sac to measure tear formation

histology: focal lymphocytic infiltration
also: hypergammaglobulinaemia, low C4

pilocarpine may stimulate saliva production

Question 27

Spine: Discitis - Staphylococcus aureus is the most common cause of discitis

Features
Back pain
General features
pyrexia,
rigors
sepsis
Neurological features
e.g. changing lower limb neurology
if an epidural abscess develops

Causes
Bacterial
Viral
TB
Aseptic

Answer 27

Ix:
1st = MRI
2nd = CT to guide type of antimicrobial treatment
3rd = TOE

Mx: 6-8weeks of IV antibiotics! (vanc)

the patient should be assessed for endocarditis with a TOE - Discitis is usually due to haematogenous seeding of the vertebrae implying that the patient has had a bacteraemia and seeding could have occurred elsewhere!

Question 28

Spine: Radiculopathy

Answer 28

?

Question 29

Spine: Spondylolisthesis

This occurs when one vertebra becomes displaced relative to its immediate inferior vertebral body

May occur as a result of stress fracture or spondylolysis

Answer 29

Ix: X-Ray

Traumatic cases may show the classic ‘Scotty Dog’ appearance on plain films. Cannae see it at all ngl

Mx:
Minor = monitor
Radicular sx = spinal decompression

Treatment depends upon the extent of deformity and associated neurological symptoms, minor cases may be actively monitored.

Individuals with radicular symptoms or signs will usually require spinal decompression and stabilisation

Question 30

Spine: Spondylosis

Congenital or acquired deficiency of the pars-interarticularis of the neural arch of a particular vertebral body, usually affects L4/ L5

May be asymptomatic and affects up to 5% of the population

Answer 30

Spondylolysis is the commonest cause of spondylolisthesis in children

Asymptomatic cases do not require treatment

Question 31

Systemic lupus erythematosus (SLE)

Female
anaemia,
leukopaenia,
thrombocytopaenia
Renal involvement
and arthropathy

Answer 31

Ix = Antibodies (ANA + dsDNA + smith

Monitor = Inflammmarkers

Mx = Hydroxychloroquine

NSAIDs
sun-block

If internal organ involvement e.g. renal, neuro, eye then consider prednisolone, cyclophosphamide

99% are ANA positive
this high sensitivity makes it a useful rule out test, but it has low specificity
20% are rheumatoid factor positive
anti-dsDNA: highly specific (> 99%), but less sensitive (70%)
anti-Smith: highly specific (> 99%), sensitivity (30%)
also: anti-U1 RNP, SS-A (anti-Ro) and SS-B (anti-La)

Monitoring
inflammatory markers
ESR is generally used
during active disease the CRP may be normal - a raised CRP may indicate underlying infection
complement levels (C3, C4) are low during active disease (formation of complexes leads to consumption of complement)
anti-dsDNA titres can be used for disease monitoring (but note not present in all patients)

Question 32

Systemic sclerosis

Diffuse cutaneous systemic sclerosis
scleroderma affects trunk and proximal limbs predominately

the most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)

other complications include renal disease and hypertension

patients with renal disease should be started on an ACE inhibitor

Poor prognosis

Limited = CREST - Scleroderma (without internal organ involvement)
tightening and fibrosis of skin
may be manifest as plaques (morphoea) or linear

Answer 32

Ix = Antibodies (ANA)

diffuse = scl-70
centromere = limited (CREST)

ANA positive in 90%
RF positive in 30%
anti-scl-70 antibodies associated with diffuse cutaneous systemic sclerosis
anti-centromere antibodies associated with limited cutaneous systemic sclerosis

Mx…

Question 33

Vasculitides

Answer 33

?

Question 34

Wrist/Hand: Carpal tunnel syndrome

Causes
idiopathic
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis

Answer 34

Examination = Tinels + Phalens
weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)

Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms

Electrophysiology
motor + sensory: prolongation of the action potential

Mx = 6-week trial of conservative treatments if the symptoms are mild-moderate

corticosteroid injection

wrist splints at night

Severe/persistent = surgical decompression (flexor retinaculum division)

Question 35

Wrist/Hand: Dupuytren’s contracture (fingers contracted due to fibrous connection between tendon and the palmar skin)

It is more common in older male patients and around 60-70% have a positive family history

Specific causes include:
manual labour
phenytoin treatment
alcoholic liver disease
diabetes mellitus
trauma to the hand

Answer 35

Features
the ring finger and little finger are the fingers most commonly affected

Mx: Consider surgical treatment of Dupuytren’s contracture when the metacarpophalangeal joints cannot be straightened and thus the hand cannot be placed flat on the table

Question 36

Wrist/Hand: Ganglion cyst

A ganglion presents as a ‘cyst’ arising from a joint or tendon sheath. They are most commonly seen around the dorsal aspect of the wrist and are 3 times more common in women.

Answer 36

Features
a firm and well-circumscribed mass that transilluminates

Mx = Ganglions often disappear spontaneously after several months

Surgical excision is indicated for cysts associated with severe symptoms or neurovascular manifestations

Question 37

Pseudogout = microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium

Pseudogout is strongly associated with increasing age. Patients who develop pseudogout at a younger age (e.g. < 60 years) usually have some underlying risk factor, such as:

haemochromatosis
hyperparathyroidism
low magnesium, low phosphate
acromegaly, Wilson’s disease

Answer 37

Ix = aspiration + X-ray

Features
knee, wrist and shoulders most commonly affected

joint aspiration: weakly-positively birefringent

rhomboid-shaped crystals

x-ray: chondrocalcinosis in the knee (specific differentiator for pseudogout)! - this can be seen as linear calcifications of the meniscus and articular cartilage

Mx = Aspiration of joint fluid, to exclude septic arthritis

NSAIDs or intra-articular/IM/oral steroids as for gout

Question 38

Dermatomyositis = An inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions

May be idiopathic or associated with connective tissue disorders or underlying malignancy (typically ovarian, breast and lung cancer, found in 20-25% - more if patient older)

Screening for an underlying malignancy is usually performed following a diagnosis of dermatomyositis
polymyositis is a variant of the disease where skin manifestations are not prominent

Answer 38

Skin features
photosensitive
macular rash over back and shoulder
heliotrope rash in the periorbital region
Gottron’s papules - roughened red papules over extensor surfaces of fingers
‘mechanic’s hands’: extremely dry and scaly hands with linear ‘cracks’ on the palmar and lateral aspects of the fingers
nail fold capillary dilatation

Other features
proximal muscle weakness +/- tenderness
Raynaud’s
respiratory muscle weakness
interstitial lung disease: e.g. Fibrosing alveolitis or organising pneumonia
dysphagia, dysphonia

Ix = Antibodies (ANA + jo-1 + mi-2) + screen for cancers!

the majority of patients (around 80%) are ANA positive
around 30% of patients have antibodies to aminoacyl-tRNA synthetases (anti-synthetase antibodies), including:
antibodies against histidine-tRNA ligase (also called Jo-1)
antibodies to signal recognition particle (SRP)
anti-Mi-2 antibodies

Question 39

Knee: Patella fracture

Answer 39

Ix: X-Ray (AP+Lateral)

Plain films are usually sufficient to diagnose patella fractures, with a minimum of two views required, often an AP and lateral. If the diagnosis is still in doubt then skyline views can be taken, but this is uncomfortable and difficult to obtain.

Mx:

Undisplaced fractures(can still extend) = hinged knee brace for 6weeks

Displaced (loss of extension) = operate (wire/screws) + knee brace for 6weeks

Undisplaced fractures, particularly vertical fractures with an intact extensor mechanism can be managed non-operatively in a hinged knee brace for 6 weeks and patients allowed to fully weight bear.

Displaced fractures and those with loss of extensor mechanisms should be considered for operative management with either tension band wire, inter-fragmentary screws or cerclage wires. Again, patients are placed in a hinged knee brace for 4 to 6 weeks and allowed to fully weight bear.

Question 40

Acute intermittent porphyria

Answer 40

Ix:
classically urine turns deep red on standing
raised urinary porphobilinogen (elevated between attacks and to a greater extent during acute attacks)
assay of red cells for porphobilinogen deaminase
raised serum levels of delta aminolaevulinic acid and porphobilinogen

Mx:
avoiding triggers
acute attacks
IV haematin/haem arginate
IV glucose should be used if haematin/haem arginate is not immediately available

Question 41

Suprapinatous tendiopathy

Answer 41

Ix = clinical

There is no deformity, tenderness or reduced range of movement. There is pain on abduction of the right shoulder that is worse with the arm in internal rotation and when abduction is resisted. He is treated with ibuprofen.

Mx = refer for physio/at home exercises

Question 42

Pagets disease of the bone excessive remodelling

specific feature caused due to bone remodelling?

Answer 42

Ix: ALP is super high ! everything else is normal

X-ray shows thickened sclerotic bone

Mx = bisphosphonates

The remodelling of bone can lead to nerve compression. Nerves affected may include CN VIII, resulting in sensorineural deafness.

Question 43

back pain

Answer 43

Ix: X-Ray

MRI if suspicious of;

malignancy,
infection,
fracture,
cauda equina
or ankylosing spondylitis

mx = NSAIDS! (+PPI) if “mechanical” back pain

Question 44

What is feltys syndrome?

and still’s disease?

Answer 44

Felty’s syndrome is splenomegaly and neutropenia in a patient with
rheumatoid arthritis

Still’s disease is
systemic juvenile idiopathic arthritis and is characterized by swinging
pyrexia, rash and arthritis. Juvenile idiopathic arthritis is the most common
form of persistent arthritis in those under 16 years of age. There is a
variable pattern of arthritis including oligoarthritis, polyarthritis and
systemic arthritis

Question 45

Which drug increases the risk of osteonecrosis? and which bones have a high risk of getting osteonecrosis?

Answer 45

Steroids increase the risk of osteonecrosis.

A fracture of the scaphoid carries a high risk of osteonecrosis already, nearly 100% at the proximal pole, and this requires surgery for bone grafting.

Fractures of the talus and neck of femur also carry a high risk of osteonecrosis.

Question 46

How to tell the difference between inflammatory and mechanical back pain?

Answer 46

IBP = improved by activity, morning stiffness + sacroiliitis can radiate to the thigh

Mechanical = worse with activity + more common in old people