MSK & Rheum Flashcards
Give general fracture and open fracture tx
General:
1. Immobilise fracture including proximal and distal joints
2. Document neurovascular status before and after reduction and immobilisation
Ensure tetanus prophylaxis
Open:
1. IV broad spectrum abx 2. Tetanus prophylaxis 3. Thorough debridement and lavage
Tx for displaced and undisplaced NOF fracture. Extracapsular?
Pt v unwell intracapsular - hemiarthroplasty
Undisplaced - internal fixation
Displaced - below 70 internal fixation. Above 70 total hip
Extracapsular - dynamic hip screw
S&S of femur fracture?
- Pain
* Shortened and externally rotated leg
Early S&S of compartment syndrome?
• EXTREME Pain or tenderness ○ Worse on passive movement ○ Worsening despite analgesia • Swelling Parasthesia
Investigation for compartment syndrome. results?
• Measure intracompartmental pressure. >20mmHg is abnormal. >40mmHg is diagnostic.
RFs of compartment syndrome?
• Occurs following fractures. Typically suprachondylar and tibial shaft injuries.
Be wary also of tight casts or splints or DVTs
Tx for displaced and non displaced humeral fracture?
• Significantly displaced - ORIF
• Non displaced - Collar and cuff for 3 wks followed by physio
Assess neurovascular status
RFs for slipped upper femoral epiphysis?
• Obesity
• Age 11-15 most common
M 2:1 F
tx for slipped upper femoral epiphysis
• External fixation or Open reduction and pinning AS IS. Attempts to move it back could cause further damage.
Emergency as could lead to avascular necrosis of head of femur
Name the types of salter harris fractures
S - Slip A - Above physis L - Lower. Below physis in the epiphysis TE - Through everything. R - Rammed (crushed)
Perthes xray?
Flattened femoral head
S&S of perthes?
• Hip, knee or groin pain exacerbated by internal rotation
• Limp
Leg length disparity
Tx of perthes
- Minimising damage while disease runs course
* Traction of leg using brace, physiotherapy.
Investigation of congenital hip dysplasia?
• Barlow maneuver (adduct hip and push knee) and Ortolani maneuver (abduct hip and push knee) - barlow dislocates and Ortolani relocates. Will hear clunking
Limb length inequality in 1 sided hip dysplasia.
Tx of Congenital hip dysplasia
pavlik harness
Osteomyelitis investigation
Bloods - WCC
CT - cortical destruction with lytic centre
MRI - edema
Bone biopsy
ADR of methotrexate
• Myelosuppression
• Hepatotoxic
PULMONARY FIBROSIS
ADR of sulfasalazine
• Rashes
• Oligospermia
ILD
ADR of leflunomide
• ILD
• HTN
Hepatotoxic
ADR of infliximab
Reactivation of TB
Bisphosphonate ADRs
• Oeseophageal ulcers
Osteonecrosis of jaw
OA S&S on hands
Bouchons nodes - proximal IPJ
Heberdens nodes - distal IPJ
OA investigations
Xray - LOSS • L - Loss of joint space • O - Osteophytes forming at joint margins • S - Subchondral sclerosis S - Subchondral cysts
OA tx analgesics
1st line Paracetemol + topical NSAIDs NSAIDs for Hand and knee OA only
2nd line Oral NSAIDs, opioids, capsaicin cream, intra-articular corticosteroids PPI co-prescribed with NSAIDs
3rd line Supports and braces, shock absorbing insoles
4th line Joint replacement
OA tx post operative
- LMWH for 4 weeks after hip
- Pts need physio and home exercises
- Crutches and walking sticks used for up to 6 wks
OA general advice
• Weight loss
Muscle strengthening + aerobic fitness
How to avoid dislocation in hip replacement?
• Avoid flexing hip >90 degrees
• Avoid low chairs
• Don’t cross legs
Sleep on back for first 6 wks
Indications for hip replacement in OA?
Conservative tried, pt still in pain.
RA S&S
• Swollen painful joints in hands and feet
• Morning stiffness improves with use
• Bilateral symptoms over a few months
• Systemic upset
Positive squeeze test - discomfort on squeezing across joint
RA blood tests
• Rheumatoid Factor (RF) detected by Rose-Waaler test. RF not specific to RA.
Anti-CCP antibody
RA xray findings
• L - Loss of joint space
• E - Erosions periarticular
• S - Soft tissue swelling
S - Soft bones, osteopenia
Tx of RA
1st line Methotrexate + 1 other DMARD
+ Prednisolone
2nd line - If 2 DMARDs don’t work + TNF inhibitor eg infliximab
DMARDs - sulfasalazine, leflunomide
RA and pregnancy Tx
Use sulfasalazine. Other drugs not safe
Give lung, ocular, heart problems of RA
Occular:
• Keratoconjunctivitis sicca (conjunctiva dryness)
• Episcleritis (erythema)
Scleritis (erythema and pain)
Lung problems: • PULMONARY FIBROSIS • Pleural effusion • Pleurisy INFECTION DUE TO IMMUNOSUPPRESSION
Heart problems:
IHD
Give 3 spondylarthropathies
• Psoriatic arthritis
• Reactive arthritis
Ankylosing spondylitis
Patho of ankylosing spondylitis?
• HLA-B27
• Rheumatic arthritis affecting joints of spine
• Occasionally affects shoulder or hips
Affects males aged 20-30 typically.
investigation of ankylosing spondylitis
• Xray of sacroiliac joints:
○ Syndesmophytes - ossification of outer fibers of annulus fibrosis
○ Squaring of lumbar vertebrae
Sacroiliitis - Sclerosis, subchondral erosions
Tx of ankylosing sponylitis?
• Regular exercise
• Physio
• NSAIDs
Last line - TNF inhibitor eg infliximab
S&S of ankylosing spondylitis?
• Lower back pain and stiffness with insidious onset
• Worse in morning and improves with exercise
• Pain at night improves on getting up
• Reduced lateral and forward flexion (Schobers test)
Reduced chest expansion
Patho of reactive arthritis
• HLA-B27
• Arthritis that develops in response to an infection in another part of the body
• Part of Reiter’s syndrome - triad of urethritis, conjunctivitis, and arthritis:
○ “Reiter cant see, pee, or climb a tree”
• Can be post-dysenteric (gastroenteritis resulting in diarrhoea with blood) or post STI
What is Reiters syndrome
Part of Reiter’s syndrome - triad of urethritis, conjunctivitis, and arthritis:
○ “Reiter cant see, pee, or climb a tree”
Organisms of reactive arthritis
• Post-dysentry - Shigella flexneri, Salmonella enteritidis
Post-STI - Chlamydia trachomatis
Tx of reactive arthritis
- Symptomatic - Analgesia, NSAIDs, Intra articular steroids
* Persistent - sulfasalazine and methotrexate
Patho of soriatic arthropathy
• HLA-B27 associated
Arthritis developing in people with psoriasis
Tx of psoriatic arthropathy
• Treat as RA
Better prognosis
S&S of psoriatic artrhopathy
• Pain, swelling, stiff joint(s)
• Typically symmetrical polyarthritis OR asymmetrical oligoarthritis
• Can affect fingers, nails (pitting or separation), and skin
Psoriasis over extensor regions
Poly vs oligoarthritis?
• Oligo arthritis - 2-4 joints
Polyarthritis - 5+ joints
S&S septic arthritis
• Acutely inflamed joint
Extremely Painful to move
RFs of septic arthritis
• Pre-existing joint disease esp RA
• DM
• Immunosuppression
IVDU
Important thing to remember with septic arthritis?
ASK YOURSELF HOW DID THE ORGANISM GET IN??
Investigations for septic arthritis?
• Urgent joint fluid aspirate + culture and microscopy
S&S of SLE
• Fatigue
• Fevers
• Mouth ulcers
Lymphadenopathy
Skin signs of SLE?
• Malar rash sparing nasolabial folds
• Photosensitivity
Raynauds
Blood tests for SLE?
• ANA,
• anti-dsDNA,
anti-Smith
Renal complications and tx of SLE?
• Diffuse proliferative glomerulonephritis
Tx - treat HTN, prednisolone, immunosuppressants (azathiopine)
Patho of Systemic sclerosis?
• Hardened, sclerotic skin and other connective tissues
• 3 types:
○ Limited cutaneous - affects face and distal limbs predominantly. AKA CREST syndrome
○ Diffuse cutaneous - Affects trunk, limbs. Involves HTN, lung fibrosis, kidneys
Scleroderma - Tightening and fibrosis of skin. No organ involvement
Blood for systemic sclerosis?
• ANA positive
• RF positive
Anti-centromere antibody
What is CREST syndrome?
Limited cutaneous systemic sclerosis
Calcinosis - thickening + tightening of skin with calcific nodules
• Raynauds
• Esophageal dysmotility - Food stuck in mid or lower esophagous
• Sclerodactyly - Tightening of finger joints
Telangiectasias
Tx of raynauds?
• 1st line - CCB eg nifedipine
IV prostacyclin infusions - effects last several weeks
Patho of raynauds?
• May be primary or secondary
• Typically young women with symmetrical attacks
Fingers have reduced blood flow due to spasm of arteries
Fibromyalgia patho and epidemiology?
• Widespread pain throughout body
• Women 10x more likely
30-50 yo
S&S of fibromyalgia?
• Lethargy
• Chronic pain
Sleep disturbance, headaches, dizziness
Tx of fibromyalgia?
• Explanation
• Aerobic exercise
• CBT
Medication - pregabalin, duloxetine, amitryptiline
Gout patho?
- Comes as episodes
- Form of inflammatory arthritis
- Results from elevated serum uric acid which crystallises
Xray features of gout?
• Joint effusion
Punched out erosion
RFs of gout?
• Decreased uric acid excretion - diuretics, CKD
• Increase uric acid production - chemo, severe psoriasis
Alcohol
S&S of gout?
• Pain at max within 12 hrs
• Swelling
• Erythema
Usually affects 1st MTPJ. Also commonly affects ankle, Wrist, knee
Tx of acute gout?
• NSAIDs
• Intra articular steroid
Colchicine
Indications of allopurinol prophylaxis for gout
dications:
○ Recurrent attacks - 2+ in 1 year
○ Tophi
○ Renal disease
○ Uric acid kidney stones
• Start 2 weeks after acute attack settles or may precipitate another attack
Use NSAID or colchicine cover when starting
Lifestyle modifications for gout?
• Reduce alcohol and purin intake
Lose weight
Gout v pseudogout?
Pseudo affects knee mostly. CCP crystals in pseudogout. Chrondocalcinosis on xray in pseudo.
Investigations of pseudogout?
• Joint aspiration - Crystals of CCP
Xray - Chondrocalcinosis (calcification of cartilage). Pathognomonic.
Tx of pseudogout?
• Aspiration of joint fluid to exclude septic arthritis
NSAIDs or intraarticular steroids.
Red flags for lower back pain?
• <20yo or >50yo new case • History of previous malignancy • Night pain • History of trauma Systemically unwell
Symptoms of lower back pain for facet joint, spinal stenosis, ankylosing spondylitis, peripheral arterieal disease?
Facet Joint • Acute or chronic
• Worse in morning and on standing
• Pain over facts and on extension
Spinal Stenosis • Gradual onset
• Leg pain and/or back pain, numbness, weakness worse on walking
• Aching pain resolved when sitting, leaning forwards
• Investigate with MRI
Ankylosing Spondylitis • Young man with lower back pain + stiffness
• Worse in morning and improves with activity
Peripheral Arterial Disease • Pain on walking, relieved by rest
• Absent foot pulses
• RFs - smoking, vascular diseases
S&S of disc prolapse?
• Leg pain worse than back
Pain worse when sitting (more pressure on spine)
Tx of disc prolapsE?
• Analgesia, physio, exercises
Consider MRI and referral if symptoms persist
L3 disc prolapse S&S?
• Anterior knee sensory loss
• Weak quads
+ve femoral stretch test
L4 disc prolapse S&S?
• Medial leg sensory loss
• Weak quads
+ve femoral stretch test
L5 disc prolapse S&S?
Sensory loss of lateral leg
• Weak foot and hallucis dorsiflexion
+ve sciatic nerve stretch test
S1 disc prolapse S&S?
• Sensory loss lateral foot
• Weak planterflexion of foot
+ve sciatic nerve stretch test
Dermatomes of lower limb?
Look up
Cauda equina syndrome S&S?
• Severe back pain
• Saddle anasthesia
• Fecal and urinary incontinence
Sexual dysfunction
Tx of cauda equina syndrome?
• URGENT referral for surgical decompression
Investigationf for cauda equina syndrome?
MRI
Marfans Patho
• Auto dominant
Fibrillin-1 defect
S&S of marfans
• Tall stature with arm span to height ratio >1.05 • Pectus excavatum • Scoliosis • Heart problems Repeated pneumothoraces
Causes of AVN
• LT steroid use
• Chemo
• Alcohol excess
Trauma
Polymyalgia rheumatica patho
• Muscle bed arteries affected
Histology shows vasculitis with giant cells, skips certain sections of affected artery whilst damaging others (skip lesions)
Investigations for polymyalgia rheumatica
• ESR >40mm/hr
○ Statin myopathies have normal ESR
Reduced CD8+ T cells
Tx for polymyalgia rheumatica
Prednisolone
S&S of polymyalgia rheumatica
• Pt >60yo
• Rapid onset - <1mth
• Aching, morning stiffness in proximal limb muscles
Mild polyarthralgia, lethargy, depression, low grade fever, anorexia, night sweats
Epidemiology of MS
• 3x F to M
20-40 yrs old
Types of MS
• Relapsing-remitting - Most common. Acute attacks lasting 1-2 months and then remission
• Secondary progressive:
○ Relapsing remitting pts who have deteriorated and developed neuro signs and symptoms between relapses
○ Gait and bladder disorders seen
• Primary progressive:
○ Progressive deterioration from onset
Common in older people
Acute tx of MS
• Acute relapse - high dose steroids for 5 days to shorten relapse. Does not alter degree of recovery
Osteomalacia patho
• Normal bone but decreased mineral content
• Normal density bone but bones soft and weak
Osteomalacia if occurs after epiphysis fuse
S&S of osteomalacia
• Bone pain
• Fractures
Muscle tenderness
Causes of osteomalacia
• Renal failure
• Vit D deficiency
• Liver disease
Drug induced
Investigations for osteomalacia
• Bloods - Low Serum calcium, phosphate, vit D
Xray - translucent bands
Tx of osteomalacia
Calcium with Vit D tablets - Adcal
Investigations for rickets
• Bloods - Low Serum calcium, phosphate, vit D
Xray - cupped, ragged metaphyseal surfaces
Osteoporosis RFs and scoring tool RFs
• Female • Age • FRAX scoring tool: ○ Steroid use history ○ RA ○ Alcohol excess ○ History of parental hip fracture ○ Low BMI Smoker
Investigations for osteoporosis causes?
• FBCs • U&Es • LFTs • Bone profile - calcium, phosphate, vit d • CRP TFTs
When to offer protection for bone protection in steroid users?
• If a pt has or will have to be on steroids for 3+ months then consider treatment as below:
○ If pt over 65 or has had previous osteoporotic fracture - Offer bone protection
If pt under 65 give bone density scan - T score of less than -1.5 offer bone protection
DEXA scan results interpret
• T score >-1.0 - normal
• T score -1.0 to -2.5 - osteopaenia
T score
Tx of osteoporosis
• 1st line - Alendronate (bisphosphanate), adcal, exercise
• If aldendronate not tolerated due to GI upset, use risedronate (another bisphos)
If bisphos not tolerated use raloxifene (selective estrogen receptor modulator SERM)
Pagets patho
• Increased but uncontrolled bone turnover
Abnormally shaped bones
RFs of pagets
• Age
• Male
FHx
Complications of pagets
• Bone sarcoma
• Fractures
• Deafness
Cardiac failure
S&S of pagets
• Bone pain
Untreated features - bowing of tibia, bossing of skull
Investigations of pagets
• Bloods - Raised ALP
Skull xray - Thickened, osteoporosis circumscripta
Tx of pagets
Bisphosphonate - risedronate
Give primary benign bone cancer
○ Osteoid osteoma ○ Osteoblastoma ○ Osteochondroma ○ Endochondroma Giant cell tumour
Give metastatic primary bone cancers
○ Osteosarcoma
Rhabdomyosarcoma
Investigations for bone cancers?
• Inflammatory markers - CRP, ESR
• Bone profile - calcium, ALP
Prostate specific antigen
Xray
• Mets lesions
Pathological fractures
Radioisotope scan:
Increased uptake in active bone areas
Tx of bone cancers?
Bone pain:
• Analgesics - Pain ladder
Radiotherapy
Primary - surgery
Secondary - radiochemo
Features and tx of osteochondroma?
• Can become malignant
Tx - Excision
Features and tx of endochondromata
• Bones of hands and feet
• Can become malignant
Tx - Curettage and graft deficit
Features and tx of giant cell tumour
• Lesion in epiphysis of long bones around knee and wrist
• Can become malignant
Tx - curettage
Osteosarcoma featuers andf tx
• Knee and proximal humerus is commonest
• Mets to lung
Tx - chemo and surgery with joint replacements
Pathogen in dog bites
pasteurella multocida
MOs in osteomyelitis
Staph aureus
S&S of acute osteomyelitis
• Sudden high fever
• Severe bone pain
• Swelling, redness, warmth, tender at site
ROM restricted
S&S of chronic osteomyelitis
• Flaring up of symptoms • Bone pain • Lethargy • Local swelling Skin changes
Rfs for osteomyelitis
• DM • Sickle cell • IVDU • Immunosuppressed • Alcohol excess BROKEN BONES
Investigations for osteomyelitits
MRI
Tx of osteomyelitits
• Fluclox
Clindamycin - penicillin allergic
Juvenile knee problems
Chrondomalacia patellae • Softening of patella cartilage
• Common in teenage girls
• Anterior knee pain on climbing stairs
Osgood-Schlatter disease • Sporty teens
• Pain and swelling over tibial tubercle
Osteochrondritis dissecans • Pain after exercise
• Swelling and locking
Patellar subluxation • Medial knee pain due to lateral subluxation of patella
• Knee may give way
Patellar tendonitis • Athletic boys
• Anterior knee pain worse after running
• Tender below patella on exam
Patho and epi of de querains
• Extensor pollicis brevis and abductor pollicis longus sheath inflamed
Females 30-50 yrs
S&S of de quervains
• Pain on radial side of wrist
• Abduction of thumb against resistance is painful
Finkelsteins test - Thumb flexed, pain reproduced by wrist flexing
Tx of de quervains
• Analgesia
Steroid injection
Elbow pain
Lateral epicondylitis • Pain and tenderness over lateral epicondyle
• Worse on resisted wrist extension or supination
Medial epicondylitis • Pain and tenderness over medial epicondyle
• Worse on wrist flexion or pronation
Radial tunnel syndrome • Compression of posterior interosseous branch of radial nerve
• Symptoms similar to lateral epicondylitis but pain is 5cm distal to lateral epicondyle
Cubital tunnel syndrome • Compression of ulnar nerve
• Intermittent tingling in 4th and 5th finger
• Worse when elbow resting on firm surface or flexed for extended periods
Olecranon bursitis • Swelling on posterior aspect of elbow
• Middle aged males
