MSK- orthopaedics and rheumatology Flashcards
What are the seronegative spondyloarthropathies
Ankylosing spondylitis
Psoriatic arthritis
IBD related arthritis
Reactive arthritis
Most common primary malignant bone tumour
Osteosarcoma
Seen mostly in children and adolescents
Sunburst pattern on xray
Ewing’s sarcoma sign on xray
Onion skin appearance
Severe long bone pain
Differentials for polyarteritis
Rheumatoid arthritis SLE Seronegative spondyloarthropathies Henoch-Schonlein purpura Sarcoidosis Tuberculosis Pseudogout Viral infection: EBV, HIV, hepatitis, mumps, rubella
Classical Colle’s fracture
Fall onto an extended outstretched hand
Transverse fracture of the radius
1 inch proximal to the radio-carpal joint
Dorsal displacement and angulation
Bennett’s fracture
Intra-articular fracture of the first carpometocarpal joint
Caused by fist fights
Pott’s fracture
Bimalleolar ankle fracture
Blood results in PMR
Raised ESR and CRP
Normal CK and anti-CCP
Typical features of PMR
Usually patient >60 Association with GCA Usually rapid onset Aching, morning stiffness in proximal limb muscles (which may present as weakness but is not true weakness) Mild polyarthralgia Lethargy and depression Low grade fever Anorexia Night sweats
Schober’s test
A line is drawn at the level of the ASIS
10cm above and 5cm below
Gap should increase on lumbar flexion by more than 5cm
Management of De Quervain’s tenosynovitis
Analgesia
Steroid injection
Immobilisation with a thumb splint
Surgical treatment may be required
Signs of ank spon on Xray
Sacroilitis- subchondral erosions and sclerosis (most useful in establishing diagnosis)
Squaring of lumbar vertebrae
Syndesmophytes due to ossification of the annulus fibrosus
Bamboo spine (late stages)
‘Shiny corners’ on MRI
Felty’s syndrome
RA
Splenomegaly
Low WCC
Sulfasalazine
5-ASA- decreases neutrophil chemotaxis and suppresses lymphocytic prophylaxis
Allergy to sulphonamides
S/E: oligospermia, Stevens-Johnson, pneumonitis/ fibrosis, myelosuppression, anaemia
Considered safe in pregnancy and breast-feeding
Anterior compartment of the lower leg
Innervated by
Tibialis anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis longus
Deep peroneal nerve
Superficial posterior compartment of the lower leg
Innervated by
Gastrocnemius
Soleus
Tibial nerve
Deep posterior compartment of the lower leg
Innervated by
Flexor digitorum longus
Flexor hallucis longus
Tibialis posterior
Still’s disease in adults
Arthralgia Elevated serum ferritin Salmon-pink, maculopapular rash Pyrexia in a daily pattern- rises in the late afternoon Lymphadenopathy RF and ANA negative
Most common cause of mitral stenosis
Rheumatic fever
Erythema marginatum
Pathognomonic for rheumatic fever
Annular erythematous rash that commonly affects the trunk and inner surfaces of arms and legs and can persist for several months
Non-pruritic rings that are barely raised
Generally spares the face
Clinical features of ankylosing spondylitis
Young caucasian man in teens or 20s
Sacroiliitis- MRI can show early oedema
Back pain in the night or early morning, especially on inactivity
Unilateral buttock pain that radiates to the groin
Complications of ankylosing spon
Enphysitis- inflammation between tendon and bone
Costochondritis
Rarely jaw pain
Apical interstitial fibrosis
Fusing of syndesmophytes late stage causes bamboo spine
Treatment of ankylosing spondiliitis
NSAIDs- ibuprofen and/or naproxen
Exercise
Physiotherapy
If this isn’t successful then biologics can be used- infliximab
Management of OA
Exercise to improve muscle strength and general aerobic fitness
MDT approach, PT and OT
Heat or cold packs, walking aids and TENS
Analgesia- regular paracetamol and topical NSAIDs, can use codeine or oral NSAIDs if ineffective
Intra-articular steroid injections temporarily relieve pain in severe cases
Surgical- Joint replacement
Management of septic arthritis
Which organisms and how did they get there? immunosuppression, CKD, recent surgery, STI, IV drug abuse
2 weeks broad spectrum antibiotics IV until sensitivities are known and then more specific by local guidelines
4 weeks oral
Orthopaedic review for athrocentesis, washout and debridement
Extra-articular manifestations of rheumatoid arthritis
Nodules- elbow, lungs, cardiac, CNS, lymphadenopathy, vasculitis
Lungs- pleural disease, interstitial fibrosis, bronchiolitis obliterans
Cardiac- IHD, pericarditis, pericardial effusion
Carpal tunnel syndrome
Peripheral neuropathy
Felty’s syndrome
Eye- episcleritis, scleritis, scleromalacia, keratoconjunctivitis sicca
Osteoporosis
Amyloidosis
Investigating ?RA
Anti-rheumatoid factor- positive in 70%
Anti- citric citrullinated peptide- highly specific (90-95%)
FBC- anaemia of chronic disease, raised platelets
ESR raised
Raised CRP
Xrays- loss of joint space, erosions, soft tissue swelling, juxta-articular osteoporosis
Management of RA
Disease activity monitoring via DAS28
DMARDs and biological agents (after trialling at least 2 DMARDs)
Steroids to bridge, reducing symptoms and inflammation
NSAIDs
PT and OT
Crystals in gout
Monosodium urate
Limited systemic sclerosis
Anti-centromere antibodies
Involves the hands, face and feet, pulmonary hypertension is often subclinical
What should be screened for in any myositis?
Malignancy- lung, pancreatic, ovarian or bowel
Can often present as a paraneoplastic phenomenon, even before the disease takes hold
Clinical features of dermatomyositis
Myositis- symmetrical, proximal muscle weakness
Macular rash- heliotrope rash on eyelids often with oedema
Nailfold erythema
Gottron’s papules- pathognomic if raised CK and weakness
Differentials for myositis
Dermatomyositis Polymyositis Inclusion body myositis Carcinomatous myopathy Muscular dystrophy (Becker's if older) PMR Endocrine/metabolic myopathy Rhabdomyolysis Infection Drugs- penicillamine, colchicine, statins, chloroquine
Tests for myositis
CK and other muscle enzymes- ALT, AST, LDH, aldolase
EMG
Muscle biopsy
Anti-Mi2 or anti-Jo1
Clinical features of systemic lupus erythematosus
Malaise, fatigue, myalgia, fever
Lymphadenopathy, weight loss, alopeecia, nail-fold infarcts, Raynaud’s
Malar rash- flat or raised, sparing of the nasolabial folds, can be photosensitive
Oral nasal uclers
Synovitis
Serositis- pleura or pericardium
Haemolytic anaemia- positive direct Coombs test
Antibodies in drug induced lupus
Anti-histone
Laboratory features of SLE
\+ANA Anti-dsDNA Anti-smith Low complement C3 and C4 \+direct Coombs test Antiphospholipid antibodies in 20-30%
Management of SLE
MDT, specialist team/ nephritis clinic
General measures- high factor sunblock, hydroxychloroquine, screen for co-morbidities and medication toxicity
Maintenance- NSAIDs and hydroxychloroquine
Also can use methotrexate, azathioprine, mycophenolate or biologics
Mild flares- hydroxychloroquine or low dose steroids
Moderate may require DMARDs
Severe flares- urgent high dose steroids, mycophenolate, rituximab, cyclophosphamide
MDT for neuropsychiatric SLE
Antiphospholipid syndrome manifestations
HINT: CLOT
Coagulation defect with paradoxical raised APTT
Livedo reticularis
Obstetric complications- recurrent miscarriage
Thrombocytopenia
Antiphospholipid antibodies
Anti-cardiolipin
Anti glycoprotein
Lupus anticoagulant
