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MSK & Rheum Flashcards

1
Q

Give general fracture and open fracture tx

A

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
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2
Q

Tx for displaced and undisplaced NOF fracture. Extracapsular?

A

Pt v unwell intracapsular - hemiarthroplasty
Undisplaced - internal fixation
Displaced - below 70 internal fixation. Above 70 total hip
Extracapsular - dynamic hip screw

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3
Q

S&S of femur fracture?

A
  • Pain

* Shortened and externally rotated leg

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4
Q

Early S&S of compartment syndrome?

A 
• EXTREME Pain or tenderness
		○ Worse on passive movement
		○ Worsening despite analgesia
	• Swelling
Parasthesia
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5
Q

Investigation for compartment syndrome. results?

A

• Measure intracompartmental pressure. >20mmHg is abnormal. >40mmHg is diagnostic.

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6
Q

RFs of compartment syndrome?

A

• Occurs following fractures. Typically suprachondylar and tibial shaft injuries.
Be wary also of tight casts or splints or DVTs

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7
Q

Tx for displaced and non displaced humeral fracture?

A

• Significantly displaced - ORIF
• Non displaced - Collar and cuff for 3 wks followed by physio
Assess neurovascular status

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8
Q

RFs for slipped upper femoral epiphysis?

A

• Obesity
• Age 11-15 most common
M 2:1 F

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9
Q

tx for slipped upper femoral epiphysis

A

• 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

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10
Q

Name the types of salter harris fractures

A 
S - Slip 
A - Above physis
L - Lower. Below physis in the epiphysis
TE - Through everything.
R - Rammed (crushed)
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11
Q

Perthes xray?

A

Flattened femoral head

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12
Q

S&S of perthes?

A

• Hip, knee or groin pain exacerbated by internal rotation
• Limp
Leg length disparity

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13
Q

Tx of perthes

A
  • Minimising damage while disease runs course

* Traction of leg using brace, physiotherapy.

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14
Q

Investigation of congenital hip dysplasia?

A

• 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.

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15
Q

Tx of Congenital hip dysplasia

A

pavlik harness

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16
Q

Osteomyelitis investigation

A

Bloods - WCC
CT - cortical destruction with lytic centre
MRI - edema
Bone biopsy

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17
Q

ADR of methotrexate

A

• Myelosuppression
• Hepatotoxic
PULMONARY FIBROSIS

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18
Q

ADR of sulfasalazine

A

• Rashes
• Oligospermia
ILD

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19
Q

ADR of leflunomide

A

• ILD
• HTN
Hepatotoxic

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20
Q

ADR of infliximab

A

Reactivation of TB

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21
Q

Bisphosphonate ADRs

A

• Oeseophageal ulcers

Osteonecrosis of jaw

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22
Q

OA S&S on hands

A

Bouchons nodes - proximal IPJ

Heberdens nodes - distal IPJ

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23
Q

OA investigations

A 
Xray - LOSS
	• L - Loss of joint space
	• O - Osteophytes forming at joint margins
	• S - Subchondral sclerosis
S - Subchondral cysts
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24
Q

OA tx analgesics

A

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

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25
Q

OA tx post operative

A
  • LMWH for 4 weeks after hip
    • Pts need physio and home exercises
    • Crutches and walking sticks used for up to 6 wks
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26
Q

OA general advice

A

• Weight loss

Muscle strengthening + aerobic fitness

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27
Q

How to avoid dislocation in hip replacement?

A

• Avoid flexing hip >90 degrees
• Avoid low chairs
• Don’t cross legs
Sleep on back for first 6 wks

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28
Q

Indications for hip replacement in OA?

A

Conservative tried, pt still in pain.

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29
Q

RA S&S

A

• 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

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30
Q

RA blood tests

A

• Rheumatoid Factor (RF) detected by Rose-Waaler test. RF not specific to RA.
Anti-CCP antibody

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31
Q

RA xray findings

A

• L - Loss of joint space
• E - Erosions periarticular
• S - Soft tissue swelling
S - Soft bones, osteopenia

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32
Q

Tx of RA

A

1st line Methotrexate + 1 other DMARD
+ Prednisolone
2nd line - If 2 DMARDs don’t work + TNF inhibitor eg infliximab

DMARDs - sulfasalazine, leflunomide

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33
Q

RA and pregnancy Tx

A

Use sulfasalazine. Other drugs not safe

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34
Q

Give lung, ocular, heart problems of RA

A

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

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35
Q

Give 3 spondylarthropathies

A

• Psoriatic arthritis
• Reactive arthritis
Ankylosing spondylitis

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36
Q

Patho of ankylosing spondylitis?

A

• HLA-B27
• Rheumatic arthritis affecting joints of spine
• Occasionally affects shoulder or hips
Affects males aged 20-30 typically.

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37
Q

investigation of ankylosing spondylitis

A

• Xray of sacroiliac joints:
○ Syndesmophytes - ossification of outer fibers of annulus fibrosis
○ Squaring of lumbar vertebrae
Sacroiliitis - Sclerosis, subchondral erosions

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38
Q

Tx of ankylosing sponylitis?

A

• Regular exercise
• Physio
• NSAIDs
Last line - TNF inhibitor eg infliximab

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39
Q

S&S of ankylosing spondylitis?

A

• 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

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40
Q

Patho of reactive arthritis

A

• 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

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41
Q

What is Reiters syndrome

A

Part of Reiter’s syndrome - triad of urethritis, conjunctivitis, and arthritis:
○ “Reiter cant see, pee, or climb a tree”

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42
Q

Organisms of reactive arthritis

A

• Post-dysentry - Shigella flexneri, Salmonella enteritidis

Post-STI - Chlamydia trachomatis

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43
Q

Tx of reactive arthritis

A
  • Symptomatic - Analgesia, NSAIDs, Intra articular steroids

* Persistent - sulfasalazine and methotrexate

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44
Q

Patho of soriatic arthropathy

A

• HLA-B27 associated

Arthritis developing in people with psoriasis

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45
Q

Tx of psoriatic arthropathy

A

• Treat as RA

Better prognosis

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46
Q

S&S of psoriatic artrhopathy

A

• Pain, swelling, stiff joint(s)
• Typically symmetrical polyarthritis OR asymmetrical oligoarthritis
• Can affect fingers, nails (pitting or separation), and skin
Psoriasis over extensor regions

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47
Q

Poly vs oligoarthritis?

A

• Oligo arthritis - 2-4 joints

Polyarthritis - 5+ joints

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48
Q

S&S septic arthritis

A

• Acutely inflamed joint

Extremely Painful to move

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49
Q

RFs of septic arthritis

A

• Pre-existing joint disease esp RA
• DM
• Immunosuppression
IVDU

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50
Q

Important thing to remember with septic arthritis?

A

ASK YOURSELF HOW DID THE ORGANISM GET IN??

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51
Q

Investigations for septic arthritis?

A

• Urgent joint fluid aspirate + culture and microscopy

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52
Q

S&S of SLE

A

• Fatigue
• Fevers
• Mouth ulcers
Lymphadenopathy

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53
Q

Skin signs of SLE?

A

• Malar rash sparing nasolabial folds
• Photosensitivity
Raynauds

54
Q

Blood tests for SLE?

A

• ANA,
• anti-dsDNA,
anti-Smith

55
Q

Renal complications and tx of SLE?

A

• Diffuse proliferative glomerulonephritis

Tx - treat HTN, prednisolone, immunosuppressants (azathiopine)

56
Q

Patho of Systemic sclerosis?

A

• 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

57
Q

Blood for systemic sclerosis?

A

• ANA positive
• RF positive
Anti-centromere antibody

58
Q

What is CREST syndrome?

A

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

59
Q

Tx of raynauds?

A

• 1st line - CCB eg nifedipine

IV prostacyclin infusions - effects last several weeks

60
Q

Patho of raynauds?

A

• May be primary or secondary
• Typically young women with symmetrical attacks
Fingers have reduced blood flow due to spasm of arteries

61
Q

Fibromyalgia patho and epidemiology?

A

• Widespread pain throughout body
• Women 10x more likely
30-50 yo

62
Q

S&S of fibromyalgia?

A

• Lethargy
• Chronic pain
Sleep disturbance, headaches, dizziness

63
Q

Tx of fibromyalgia?

A

• Explanation
• Aerobic exercise
• CBT
Medication - pregabalin, duloxetine, amitryptiline

64
Q

Gout patho?

A
  • Comes as episodes
    • Form of inflammatory arthritis
    • Results from elevated serum uric acid which crystallises
65
Q

Xray features of gout?

A

• Joint effusion

Punched out erosion

66
Q

RFs of gout?

A

• Decreased uric acid excretion - diuretics, CKD
• Increase uric acid production - chemo, severe psoriasis
Alcohol

67
Q

S&S of gout?

A

• Pain at max within 12 hrs
• Swelling
• Erythema
Usually affects 1st MTPJ. Also commonly affects ankle, Wrist, knee

68
Q

Tx of acute gout?

A

• NSAIDs
• Intra articular steroid
Colchicine

69
Q

Indications of allopurinol prophylaxis for gout

A

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

70
Q

Lifestyle modifications for gout?

A

• Reduce alcohol and purin intake

Lose weight

71
Q

Gout v pseudogout?

A

Pseudo affects knee mostly. CCP crystals in pseudogout. Chrondocalcinosis on xray in pseudo.

72
Q

Investigations of pseudogout?

A

• Joint aspiration - Crystals of CCP

Xray - Chondrocalcinosis (calcification of cartilage). Pathognomonic.

73
Q

Tx of pseudogout?

A

• Aspiration of joint fluid to exclude septic arthritis

NSAIDs or intraarticular steroids.

74
Q

Red flags for lower back pain?

A 
• <20yo or >50yo new case
	• History of previous malignancy
	• Night pain
	• History of trauma
Systemically unwell
75
Q

Symptoms of lower back pain for facet joint, spinal stenosis, ankylosing spondylitis, peripheral arterieal disease?

A

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

76
Q

S&S of disc prolapse?

A

• Leg pain worse than back

Pain worse when sitting (more pressure on spine)

77
Q

Tx of disc prolapsE?

A

• Analgesia, physio, exercises

Consider MRI and referral if symptoms persist

78
Q

L3 disc prolapse S&S?

A

• Anterior knee sensory loss
• Weak quads
+ve femoral stretch test

79
Q

L4 disc prolapse S&S?

A

• Medial leg sensory loss
• Weak quads
+ve femoral stretch test

80
Q

L5 disc prolapse S&S?

A

Sensory loss of lateral leg
• Weak foot and hallucis dorsiflexion
+ve sciatic nerve stretch test

81
Q

S1 disc prolapse S&S?

A

• Sensory loss lateral foot
• Weak planterflexion of foot
+ve sciatic nerve stretch test

82
Q

Dermatomes of lower limb?

A

Look up

83
Q

Cauda equina syndrome S&S?

A

• Severe back pain
• Saddle anasthesia
• Fecal and urinary incontinence
Sexual dysfunction

84
Q

Tx of cauda equina syndrome?

A

• URGENT referral for surgical decompression

85
Q

Investigationf for cauda equina syndrome?

A

MRI

86
Q

Marfans Patho

A

• Auto dominant

Fibrillin-1 defect

87
Q

S&S of marfans

A 
• Tall stature with arm span to height ratio >1.05
	• Pectus excavatum
	• Scoliosis
	• Heart problems
Repeated pneumothoraces
88
Q

Causes of AVN

A

• LT steroid use
• Chemo
• Alcohol excess
Trauma

89
Q

Polymyalgia rheumatica patho

A

• Muscle bed arteries affected
Histology shows vasculitis with giant cells, skips certain sections of affected artery whilst damaging others (skip lesions)

90
Q

Investigations for polymyalgia rheumatica

A

• ESR >40mm/hr
○ Statin myopathies have normal ESR
Reduced CD8+ T cells

91
Q

Tx for polymyalgia rheumatica

A

Prednisolone

92
Q

S&S of polymyalgia rheumatica

A

• Pt >60yo
• Rapid onset - <1mth
• Aching, morning stiffness in proximal limb muscles
Mild polyarthralgia, lethargy, depression, low grade fever, anorexia, night sweats

93
Q

Epidemiology of MS

A

• 3x F to M

20-40 yrs old

94
Q

Types of MS

A

• 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

95
Q

Acute tx of MS

A

• Acute relapse - high dose steroids for 5 days to shorten relapse. Does not alter degree of recovery

96
Q

Osteomalacia patho

A

• Normal bone but decreased mineral content
• Normal density bone but bones soft and weak
Osteomalacia if occurs after epiphysis fuse

97
Q

S&S of osteomalacia

A

• Bone pain
• Fractures
Muscle tenderness

98
Q

Causes of osteomalacia

A

• Renal failure
• Vit D deficiency
• Liver disease
Drug induced

99
Q

Investigations for osteomalacia

A

• Bloods - Low Serum calcium, phosphate, vit D

Xray - translucent bands

100
Q

Tx of osteomalacia

A

Calcium with Vit D tablets - Adcal

101
Q

Investigations for rickets

A

• Bloods - Low Serum calcium, phosphate, vit D

Xray - cupped, ragged metaphyseal surfaces

102
Q

Osteoporosis RFs and scoring tool RFs

A 
• Female
	• Age
	• FRAX scoring tool:
		○ Steroid use history
		○ RA
		○ Alcohol excess
		○ History of parental hip fracture
		○ Low BMI
Smoker
103
Q

Investigations for osteoporosis causes?

A 
• FBCs
	• U&amp;Es
	• LFTs
	• Bone profile - calcium, phosphate, vit d
	• CRP
TFTs
104
Q

When to offer protection for bone protection in steroid users?

A

• 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

105
Q

DEXA scan results interpret

A

• T score >-1.0 - normal
• T score -1.0 to -2.5 - osteopaenia
T score

106
Q

Tx of osteoporosis

A

• 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)

107
Q

Pagets patho

A

• Increased but uncontrolled bone turnover

Abnormally shaped bones

108
Q

RFs of pagets

A

• Age
• Male
FHx

109
Q

Complications of pagets

A

• Bone sarcoma
• Fractures
• Deafness
Cardiac failure

110
Q

S&S of pagets

A

• Bone pain

Untreated features - bowing of tibia, bossing of skull

111
Q

Investigations of pagets

A

• Bloods - Raised ALP

Skull xray - Thickened, osteoporosis circumscripta

112
Q

Tx of pagets

A

Bisphosphonate - risedronate

113
Q

Give primary benign bone cancer

A 
○ Osteoid osteoma
		○ Osteoblastoma
		○ Osteochondroma
		○ Endochondroma
Giant cell tumour
114
Q

Give metastatic primary bone cancers

A

○ Osteosarcoma

Rhabdomyosarcoma

115
Q

Investigations for bone cancers?

A

• Inflammatory markers - CRP, ESR
• Bone profile - calcium, ALP
Prostate specific antigen

Xray
• Mets lesions
Pathological fractures

Radioisotope scan:
Increased uptake in active bone areas

116
Q

Tx of bone cancers?

A

Bone pain:
• Analgesics - Pain ladder
Radiotherapy

Primary - surgery

Secondary - radiochemo

117
Q

Features and tx of osteochondroma?

A

• Can become malignant

Tx - Excision

118
Q

Features and tx of endochondromata

A

• Bones of hands and feet
• Can become malignant
Tx - Curettage and graft deficit

119
Q

Features and tx of giant cell tumour

A

• Lesion in epiphysis of long bones around knee and wrist
• Can become malignant
Tx - curettage

120
Q

Osteosarcoma featuers andf tx

A

• Knee and proximal humerus is commonest
• Mets to lung
Tx - chemo and surgery with joint replacements

121
Q

Pathogen in dog bites

A

pasteurella multocida

122
Q

MOs in osteomyelitis

A

Staph aureus

123
Q

S&S of acute osteomyelitis

A

• Sudden high fever
• Severe bone pain
• Swelling, redness, warmth, tender at site
ROM restricted

124
Q

S&S of chronic osteomyelitis

A 
• Flaring up of symptoms
	• Bone pain
	• Lethargy
	• Local swelling
Skin changes
125
Q

Rfs for osteomyelitis

A 
• DM
	• Sickle cell
	• IVDU
	• Immunosuppressed
	• Alcohol excess
BROKEN BONES
126
Q

Investigations for osteomyelitits

A

MRI

127
Q

Tx of osteomyelitits

A

• Fluclox

Clindamycin - penicillin allergic

128
Q

Juvenile knee problems

A

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

129
Q

Patho and epi of de querains

A

• Extensor pollicis brevis and abductor pollicis longus sheath inflamed
Females 30-50 yrs

130
Q

S&S of de quervains

A

• Pain on radial side of wrist
• Abduction of thumb against resistance is painful
Finkelsteins test - Thumb flexed, pain reproduced by wrist flexing

131
Q

Tx of de quervains

A

• Analgesia

Steroid injection

132
Q

Elbow pain

A

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

Z IPE (15 decks)

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