MSK (orthopaedics & rheumatology) Flashcards
What investigation would you do to determine the cause of someone that has presented with a hot, red, swollen joint?
~ what processing/investigations do you want this specimen to undergo? (4)
Whilst awaiting the results of the above, how would you manage the patient?
Joint aspirate → send for gram staining, crystal microscopy, culture & antibiotic sensitivities
Start empirical IV antibiotics - treat as septic arthritis until proven otherwise
What is Perthes disease? (Legg-Calve-Perthes)
Avascular necrosis of the femoral head in children which is caused by disruption to the blood flow of the femoral head
What is the 1st line investigation in SUFE?
What is the management of SUFE?
Xray of hip
Surgery: correction of femoral head positon PLUS screw fixation
~ Prophylactic fixation of contralateral hip may be done
A 37-year-old man presents to A&E C/O a painful, swollen right knee. The pain came on earlier this morning and he says that the knee feels stiffer than usual.
O/E the right knee is hot, red and swollen however the left knee appears normal. There is a reduced ROM in the right knee compared to the left.
What is the most likely diagnosis?
What is the commonest organism to cause this condition?
If the patient was sexually active with multiple sexual partners, what underlying organism would you be most suspicious of instead?
If the patient was an IVDU, what underlying organism would you be most suspicious of instead?
Septic arthritis
Staph aureus
Neisseria gonorrhoea (gonococcus)
Pseudomonas
The crystals causing the inflammation in gout are composed of what?
URIC ACID
What clinical finding is seen when the scaphoid bone is fractured?
Pain on palpation of the anatomical snuffbox
Compartment syndrome usually presents with the 5P’s. Name them:
Pain - disproportionate to the underlying injury
Paraesthesia
Pale skin over affected area
Pressure (high pressure felt within affected area)
Paralysis of affected limb (late and worrying sign)
Name a complication if a scaphoid # is left untreated.
Avascular necrosis of the scaphoid bone.
What investigation can be done to measure the pressure within a compartment if acute compartment syndrome is suspected?
What pressures indicate acute compartment syndrome:
~ Diastolic pressure:
~ Absolute compartment pressure:
Needle manometry
- Diastolic pressure minus compartment pressure = greater than 30mmHg
- Absolute compartment pressure value of 40mmHg + (normal = less than 12mmHg)
Hydroxychloroquine is an example of a drug in what class?
What conditions may hydroxychloroquine be used to treat? (2 main ones)
DMARD
Rheumatoid arthritis, SLE
After what period of time is ischaemic damage (eg in acute compartment syndrome) generally considered irreversible?
6 hours
A 33y man has increasing lower back pain and neck pain for 7 months. The pain is worse in the morning and improves when he plays basketball.
O/E: tenderness over the sacroiliac joints and loss of lumbar lordosis.
A spinal xray shows symmetrical erosions and sclerosis of the sacroiliac joints.
What is the most likely diagnosis?
What typical feature (sign) will you see on an xray of this patient?
~ why do you see this sign?
Ankylosing spondylitis
Bamboo spine
~ vertebral body fusion
A 77-year-old man attends A&E after a fall onto an outstretched hand. On examination he is tender on the radial aspect of his wrist, as well as at the base of the thumb. When asked to grip your finger, he shows an obvious loss of grip strength.
What is the most likely diagnosis?
If this condition isn’t treated appropriately, what complication can occur?
What initial investigation should be done if this condition is suspected?
Scaphoid fracture
Avascular necrosis of the scaphoid
Xray - AP and lateral
What is SUFE?
What age group & sex is it most common in?
What is the biggest RF for SUFE?
List some features seen in someone with SUFE: (3)
It’s when the head of femur is displaced along the growth plate (it looks like it has slipped off)
Teenage boys
Obesity
~ Hip/ groin/ knee pain with insidious onset
~ Restricted ROM of hip
~ Painful limp
LOSS
What xray findings would you see in a patient with osteoarthritis?
L - loss of joint space
O - osteophyte formation
S - subchondral sclerosis
S - subchondral cysts
Name a serious complication of a neck of femur #.
Avascular necrosis of the femoral head.
What imaging is used to measure someones bone mineral density?
DEXA scan
An 83-year-old female is BIBA after having a fall at home. She is complaining of R hip pain that is radiating to her knee.
On examination you notice that her R leg is shorter than the L. It is also abducted and externally rotated.
What is the diagnosis?
What would your initial investigation be? (after simple bedside investigations)
In regards to shenton’s line, what would you expect to see in the xray of this lady?
Hip fracture
Xray of the hip in 2 views: AP and lateral view
Shenton’s line would be disrupted due to the fractured neck of femur (hip fracture)
A 53-year-old woman presents to A&E with a swollen, painful wrist after having tripped and fallen onto her outstretched hand earlier this morning. She notes no pain on palpation of the anatomical snuffbox.
What type of fracture has this woman likely sustained?
In which bone has the fracture occured?
Colles fracture
Distal radius fracture (transverse fracture) with dorsal displacement
What is sarcoidosis?
Which type of people is sarcoidosis commonest in?
State the ‘buzzword’ features of sarcoidosis: (6)
What results would be seen on:
a) blood tests (3)
b) chest xray
Sarcoidosis: a granulatomas inflammatory condition that can affect the whole body
~ commonest in young, black females
Features:
• SOB
• Dry cough
• Erythmema nodosum (nodules on shins)
• Mediastinal lymphadenopathy
• Fatigue & weightloss
Bloods:
• Raised serum ACE (screening tool)
• Hypercalcaemia
• Raised CRP
Imaging:
• Chest xray: hilar lymphadenopathy
Which antibodies are usually always positive in SLE?
What other antibodies may also be positive?
Anti-dsDNA antibodies
~ ANA (anti-nuclear antibodies)
~ Anti-smith antibodies
An 85-year-old male is admitted to the acute medical ward with a deep ulcer over the inferior aspect of his heel which reaches the bone. He had not noticed it and seems unconcerned. His daughter, who brought him into hospital, says that he has poor sensation in his feet and rarely takes off his socks and shoes. His past medical history includes type 2 diabetes, for which he is on a biphasic insulin regime.
His temperature is 37.9ºC, and his heart rate is 101/min.
What is the most likely diagnosis?
What is the treatment of this condition? (be specific, name the medication used & timeframe of treatment)
Osteomyelitis
Antibiotics: Flucloxacillin for 6 weeks
List some risk factors for septic arthritis. (6)
IV drug users
Unprotected sex
Diabetes Mellitus
Underlying joint disease (OA/RA)
Immunosuppression
Older age
What is an important differential to rule out if you suspect someone has presented with gout?
Septic arthritis !!!
If a # is displaced, what 2 things are required in the management of it?
Reduction of the # (to put it back into the correct place)
Immobilisation of the bone (for healing)
List some drugs that are associated with causing gout: (4)
- Furosemide
- Alcohol
- Chemotherapy
- Thiazides
List the main clinical features of septic arthritis. (4)
Hot, painful, swollen joint
Usually only a single joint affected
Restricted movement in affected joint
Systemic features: fever & fatigue
Is the blood supply disrupted or intact in a displaced intra-capsular femoral head fracture?
Bearing the above in mind, what are the 2 ways that displaced intra-capsular fractures are managed?
~ what type of patients would be offered each management option?
Disrupted blood supply! - high risk of avascular necrosis of the femoral head!
Hemiarthroplasty - replacing the head of the femur but leaving the acetabulum in place
~ offered to patients with limited mobility
Total hip replacement - replacing both the head of the femur & the acetabulum (socket)
~ offered to patients who are independent with mobility
List some common side effects of alendronic acid that you need to council patients about before they start it: (3)
- Osteonecrosis of the jaw
- Oesophagitis
- Atypical femur fractures
Joint’s that are stiff for >30mins in the morning & joint pain that improves with exercise indicates what type of joint pain? (degenerative/inflammatory)
Inflammatory joint pain
A 51y woman presents with a 6 month history of fatigue and lower back pain. She also has a persistent pain in her arms and shoulders that worsens after exercise.
O/E: muscle power is normal in both arms. Her joints are not swollen. Palpation of her mid trapezius and medial knee aspects elicits tenderness.
Blood tests are normal.
What is the most likely diagnosis?
Fibromyalgia
What is the main blood vessel that supplies the femoral head?
Femoral circumflex artery
Fat embolisms can occur following the fracture of what types of bone?
Long bones - commonly the femur
What’s the commonest joint affected in gout?
Big toe! (1st MTP joint)
“Tennis elbow” affects what part of the elbow?
Lateral epicondyle
Falls onto an outstretched hand commonly # which carpal bone?
Scaphoid bone
What imaging is used to measure someones bone mineral density?
DEXA scan
Is the blood supply disrupted or intact in a non-displaced intra-capsular femoral head fracture?
Bearing the above in mind, how can non-displaced intra-capsular fractures be managed? - why?
Intact blood supply!
- Internal fixation** (eg, using screws*) to hold the femoral head in place whilst the fracture heals
- the intact blood supply means that the femoral head can be preserved without avascular necrosis occurring*
Which antibodies are tested for in SLE? (3)
List some common symptoms seen in SLE: (6)
What is the 1st line treatment of SLE?
What is used to treat an SLE flare?
- Anti-nuclear antibodies (ANA)
- Anti-double stranded DNA (anti-dsDNA)
- Anti-smith
- Fatigue
- Weight loss
- Photosensitive malar rash
- Joint & muscle pain
- Mouth ulcers
- Hair loss
- *Treatment:** NSAIDs & hydroxychloroquine
- Flares:* steroids (commonly prednisolone)
What is the typical presentation of someone with Legg-Calve-Perthes disease?
Gradual* onset limb & hip pain
Referred pain to the knee
Pain persists for >4 weeks
* Gradual due to the femoral head becoming increasingly ischaemic
What is the name given when a joint is infected?
What is the commonest joint that this condition occurs in?
Septic arthritis
Knee joint
What would you expect to see under a microscope in the joint fluid of a patient with pseudogout?
Rhomboid-shaped positively birefringent crystals
Methotrexate is commonly used to treat what conditon?
Rheumatoid arthritis
What examination findings would be seen in a neck of femur #? (5)
Affected leg is shorter
Affected leg is externally rotated
Palpation of hip is painful
Patient cannot perform a straight leg raise
Bruising/soft tissue swelling in/around the hip area
What is the definition/pathophysiology of compartment syndrome?
Compartment syndrome: pressure within a fascial compartment is abnormally elevated, cutting off the blood flow to the contents of that compartment.
Name the rotator cuff muscles.
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
A 16y boy presents with central abdominal pain & haematuria for 1 week. He also complains of pain in both knees. Examination reveals a non-blanching purpuric rash on his legs & buttocks. Urine dip shows blood ++ & protein +, kidney function is abnormal.
What is the most likely diagnosis? - what is this?
List the 4 common presenting features of this condition:
What is the management of this condition?
What monitoring needs to be done? (2)
Henoch-Schonlein Purpura - A type of IgA vasculitis
- Purpura (rash on legs → buttocks)
- Joint pain (commonly knee’s & ankles)
- Abdominal pain
- Renal impairment
Management: supportive (analgesia, rest, hydration)
~ most usually resolve within 4-6 weeks.
Monitoring: needed whilst the disease is still active:
• urine dipstick (to monitor renal impairment)
• blood pressure (to monitor for hypertension)
What classification is used for intra-capsular neck of femur fractures?
Describe each ‘grade’ within this classification:
~ grade I
~ grade II
~ grade III
~ grade IV
The garden classification
Grade I ~ incomplete fracture & non-displaced
Grade II ~ complete fracture & non-displaced
Grade III ~ partial displacement
Grade IV ~ full displacement
A 75-year-old man presents with lower back pain and weakness in his L leg, that comes on when he walks. The pain is relieved by sitting down, crouching and leaning forwards.
He denies any shooting pains down his legs as well as denying any paraesthesia. He has not experienced any urinary or faecal incontinence and his neuro examination is normal.
What is the likely diagnosis?
After prescribing analgesia, what is the next most appropriate next step for a diagnosis?
Spinal stenosis
MRI is needed for diagnosis!
A 76y lade presents with knee pain. The pain is worse with prolonged standing or climbing stairs. She has also had brief stiffness (<10 mins) when she first rises from bed in the morning. There is minimal rest pain and no nocturnal pain. There are no clicking or locking symptoms.
O/E: Slightly reduced flexion at the left knee compared to the right. No laxity with traction on any direction on the proximal tibia.
What is the most likely diagnosis?
If the patient had complained of nocturnal bone pain, what is the most important differential to rule out?
Osteoarthritis
Bone cancer
What is Osteoarthritis - what does it usually present with?
~ what makes it worse/ better?
List the 4 commonest joints affected:
List 2 common signs that are seen in the hands:
What things are used in the management?
Mechanical wear & tear - presents with joint pain & stiffness
~ worse at night & upon activity, better with rest
- Hips
- Knee
- DIPs (of hands)
- MCP joint at base of thumb
- Haberdens nodes (DIP joints)
- Bouchards nodes (PIP joints)
- Physiotherapy (mobilising joint)
- Weight loss
- Paracetemol & topical NSAIDs ⇒ oral NSAIDs
- Intra-articular steroid injections
Joint pain/ stiffness that is worse in the morning & improves with exercise indicates:
a) mechanical cause
b) inflammatory cause
Inflammatory cause
What is the pathophysiology of Sjogren’s syndrome?
It’s an autoimmune condition affecting the exocrine glands
(There is lymphatic infiltration and fibrosis of lacrimal and salivary glands!)
What is SUFE?
What age group & sex is it most common in?
What is the biggest RF for SUFE?
List some features seen in someone with SUFE: (3)
It’s when the head of femur is displaced along the growth plate (it looks like it has slipped off)
Teenage boys
Obesity
~ Hip/ groin/ knee pain with insidious onset
~ Restricted ROM of hip
~ Painful limp
What is the definitive management of acute compartment syndrome?
In what time frame should this be done before irreversible damage may occur?
Emergency fasciotomy (to restore the blood flow) & debridement of necrotic tissue- wound is left open until the swelling improves.
Within 6hours
Name the 4 main types of # & describe what they would look like.
1. Transverse # # is straight across the bone
2. Oblique # # is diagonally across the bone
3. Spiral # # that winds around the bone in a spiral manner
4. Complex/comminuted # # into lots of fragments of bone
What causes the increased pressure within the fascial compartment in compartment syndrome?
What is the definitive management of compartment syndrome and what is the timeframe which this should be completed within?
When there is a # or crush injury, there is either bleeding into the compartment or tissue oedema which increases the pressure within the compartment.
Emergency fasciotomy (to relieve the pressure within the compartment)
~ within 6 hours
“Golfers elbow” affects what part of the elbow?
Medial epicondyle
List some of the main clinical features seen in sjogren’s syndrome: (5)
- Dry eyes
- Dry mouth (xerostomia)
- Parotid swelling
- Vaginal dryness
- Arthralgia (joint stiffness)
A 32y man presents with a history of early morning back pain, stiffness and a painful red right eye. The pain in the eye started last night.
O/E: his right pupil is seen to be distorted but his visual acuity is unaffected.
What is the most likely diagnosis regarding his eye?
What is the underlying diagnosis that this complication is associated with?
Anterior uveitis
Ankylosing spondylitis
What age group is Perthes disease most common in?
Children aged 4-10y
Erb’s palsy results in damage to what nerves of the brachial plexus?
What obstetric emergency can result in Erb’s palsy?
C5 & C6
Shoulder dystocia
What condition is methotrexate predominantly used to treat?
What birth defects are associated with methotrexate use? (2)
Rheumatoid arthritis
Cleft palate
Hydrocephalus
List some differentials for a hot, red, swollen joint: (5)
Which differential is an emergency and would need to be considered the cause until proven otherwise?
- Septic arthritis
- Gout
- Psuedogout
- Reactive arthritis
- Haemarthrosis (bleeding into a joint)
Septic arthritis!
Which nerve is compressed in cubital tunnel syndrome?
Patients with cubital tunnel syndrome will complain of tingling in which fingers?
Ulnar nerve
4th and 5th fingers
What is the commonest causative organism of septic arthritis?
Staphylococcus aureus
Which antibody is highly specific for rheumatoid arthritis? (eg, if this antibody is present then the patient likely has RA)
What other antibody may also be positive?
Anti-CCP (anti-cyclic citrullinated peptide antibodies)
Rheumatoid factor
Which 6 key bones have vulnerable blood supplies in which a fracture can lead to avascular necrosis, impaired healing and non-union?
- Scaphoid
- Humeral head
- Femoral head
- Talus
- Navicular
- 5th metatarsal (in the foot)
Which STI is associated with septic arthritis?
Which bacteria is the commonest cause of septic arthritis in IVDU’s?
Neisseria gonorrhoeae
Pseudomonas
PEAR
Name the 4 main spondyloarthropathies:
What gene are these conditions all associated with?
- Psoriatic arthritis
- Enteropathic arthritis (associated with IBD)
- Ankylosing spondylitis
- Reactive arthritis
HLA B27
Joint pain that is worse in the evenings and has early morning stiffness for <30mins suggests what type of joint pain? (degenerative/inflammatory)
Degenerative joint pain
What is the management of an:
- undisplaced scaphoid fracture
- displaced scaphoid fracture
- Undisplaced: cast for 6-8 weeks
- Displaced: surgical fixation (to avoid AVN)
What is the 1st line investigation of a red, hot, swollen joint? (Suspicion of septic arthritis)
Aspiration of synovial fluid for cell count, gram stain & culture
What type of hip fracture can lead to avascular necrosis of the femoral head?
What blood vessels supply the femoral head?
Intra-capsular fractures
Medial & lateral circumflex femoral arteries
What medication is commonly used to treat a flare of SLE?
Which 2 medications are used to maintain remission of SLE?
Steroids
NSAIDs & hydroxychloroquine
List 4 common causes of pathological #’s.
- Osteoporosis
- Tumours (within the bone)
- Hyperparathyroidism (causes bone thinning = weak bone)
- Paget’s disease (abnormal bone turnover = weak bone)
What is the management of RA? (2)
DMARDS (eg, methotrexate)
+
Short-term glucocorticoids
What is a pathological #?
A # that didn’t require force/impact as the bone was diseased and thus weaker.
What important disease do patients need to be screened for before being started on a biologic?
What disease is a 100% contraindication to starting a biologic?
TB
Active cancer
Anti-CCP is specific for what condition?
Rheumatoid arthritis
A 40-year-old woman presents with new onset dull lower back pain since moving home. She is normally fit and well. She has a normal examination with no neurology or concerning features.
What would be the first-line treatment for her pain?
Naproxen ~ NSAIDs are 1st line for the treatment of lower back pain!
What condition should you be thinking of if a patient presents with disproportionate pain following a # or a crush injury?
What investigation can be done to confirm this?
Compartment syndrome
Needle manometry
~ a device measures the resistance to injecting saline through a needle into the affected compartment
What are the 2 main joints affected in ankylosing spondylitis?
What gene is associated with the condition?
What is the main presenting symptom?
~ Describe this
List 2 common xray findings seen in ankylosing spondylitis:
What is the 1st line medical treatment? - what is used in acute flares?
- Sacroiliac joint
- vertebrae
HLA B27
Lower back pain & stiffness
~ gradual onset (months)
~ worse at rest & in the morning/ night
~ improves with movement
Bamboo spine, squaring of the vertebral bodies
1st line treatment: NSAIDs (no known drugs modify disease course!)
• flares: steroids
What is the name given for ‘an infection of the bone’?
If this condition is suspected, what is the imaging of choice to confirm the diagnosis?
What is the most common causative organism?
~ in patients with sickle cell, what is the most common causative organism?
Osteomyelitis
MRI
Staph aureus
~ salmonella
A 5y old boy complains of difficulty in hearing. He has had several fractures following minor falls. O/E his legs appear short & deformed and his sclera have a blue tinge.
What is the likely diagnosis?
Osteogenesis imperfecta (brittle bone disease)
What would you expect to see under a microscope in the joint fluid of a patient with gout?
Needle-shaped negatively birefringent crystals
What is the initial management of an open #?
- Tetanus & antibiotic prophylaxis
- Photograph the wound, cover it and stabilise the limb (photo so that the wound isn’t uncovered every time a new clinician assesses the patient)
- Operate within 24h*
* If there is neurovascular compromise, operate within 6h!
What is an open #?
When there is direct communication between the external environment and the #
Which is the most common compartment (in the leg) to be affected in acute compartment syndrome?
If this compartment is affected, which motor deficit would you expect to see?
Anterior compartment
Foot drop ~ the deep fibular nerve is in the anterior compartment and this acts on the muscles that usually dorsiflex the foot
How long post surgery is someone in a pro-thrombotic state for?
6 weeks
Name the condition shown below:
List 5 clinical signs associated with this condition:
Chronic venous insufficiency
- Pain in calves
- Venous ulcers (commonest on medial aspect of lower limb)
- Discolouration of lower leg
- Swelling
- Calf resembles an inverted champagne bottle
A positive trendelenberg’s test suggests weakness of which group of muscles?
What does a positive trendelenberg’s test look like?
Hip abductors
The pelvis drops towards the leg that is being flexed.
What is the difference between tendon’s and ligaments?
Tendon: connects muscle to bone
Ligament: connects bone to bone
Which collateral ligament is attached to one of the meniscus? - Name the meniscus that it’s attached to:
Medial collateral ligament → attached to the medial meniscus
Describe what a colles fracture is (including angulation/displacement):
What is the mechanism of injury for this type of fracture?
Distal radial fracture with dorsal angulation & dorsal displacement
Fall onto an outstretched hand when they have fallen forwards
Describe what a smiths fracture is (including angulation/displacement):
What is the mechanism of injury for this type of fracture?
Is this a stable or unstable fracture? - As a result, what is the management?
Distal radial fracture with volar angulation +/- volar displacement
Fall onto an outstretched hand when they have fallen backwards
ALWAYS unstable, so always needs surgical correction
What shoulder condition usually presents with a painful arc between 60 - 120 degrees on examination of abduction?
Subacromial impingement
What shoulder condition usually presents with a painful first 60 degrees of abduction on examination?
Rotator cuff tears
What is the name of the condition in which there is infection within the intervertebral disc space?
What is the commonest causative organism of this condition?
What investigation should be performed on someone with a confirmed diagnosis of this condition? - why?
Discitis
Staph aureus
ECHO to assess for endocarditis
~ Discitis is usually due to haematogenous seeding of the vertebrae
A 27-year-old woman presents to the GP with a burning sensation across the outside of her left thigh. It is causing her pain when she moves, especially whilst standing at work. The pain does not radiate anywhere else and is relieved by sitting down.
She has never experienced this previously. She has no PMH. There is little information in her records except for a recent blood pressure, recorded as 128/92mmHg, and a BMI of 41kg/m².
What is the most likely diagnosis?
This condition is caused by compression of what nerve?
Meralgia parasthetica
Lateral femoral cutaneous nerve
An eight-year-old boy presents to the emergency department with his mother, having fallen onto his outstretched left hand earlier that afternoon during school sports day. He is complaining of pain and swelling around his left elbow and forearm.
X-rays of the patient’s left elbow and forearm are carried out which show a proximal fracture of the ulna in association with a dislocation of the proximal radial head.
What is the name is given to this type of fracture?
Monteggia fracture
What pathology does a positive Lachman test indicate?
ACL injury (usually rupture)
A 32y/o mother of three-month-old infant presents to the OP clinic with a complaint of pain on her right wrist for one week. The pain is on the radial side of the wrist, and there is tenderness over the radial styloid process.
What is the most likely diagnosis?
De Quervain’s tenosynovitis
aka, texters thumb!
A 44-year-old man is diagnosed with lower back pain and is asking you for analgesia to ‘get him through the day’.
What class of drugs are prescribed 1st line for back pain?
~ what is the commonest medication from this class that is prescribed for back pain?
NSAIDs
~ naproxen
A 73y/o man presents with pain in the right leg. It is most uncomfortable when walking.
O/E he has a deformity of his right femur, which on x-ray is thickened and sclerotic. His serum alkaline phosphatase is elevated, but calcium is within normal limits.
What is the most likely diagnosis?
Pagets disease
If you see an isolated elevated ALP, what condition should you be thinking of?
What is the treatment of this condition?
PAGETS DISEASE
Bisphosphonates
