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MSK/Rheumatology Flashcards

1
Q

OSTEOARTHRITIS
What is osteoarthritis (OA)?
What causes it?

A
  • Degenerative joint disorder with loss of hyaline cartilage “wear and tear”
  • Primary (no underlying cause) or secondary to joint trauma or obesity
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2
Q

OSTEOARTHRITIS
What joints does OA tend to affect?
What symptoms might a patient complain of?

A
  • Large weight bearing (hip, knee), also carpometocarpal joints, DIP/PIPJs
  • Morning stiffness <30m + stiffness after rest
  • Joint pain which is exacerbated on movement
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3
Q

OSTEOARTHRITIS

What are some examination signs of OA?

A
  • Deformity = squaring of thumb (carpometacarpal joint of thumb), Bouchard nodes (PIPJ swelling) + Heberden nodes (DIPJ swelling)
  • Decreased range of movement
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4
Q

OSTEOARTHRITIS

What investigation would you do in suspected OA and what would you expect to see?

A

Joint x-ray shows LOSS –

  • Loss of joint space
  • Osteophytes
  • Subchondral cysts
  • Subchondral sclerosis
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5
Q

OSTEOARTHRITIS

What is the conservative management of OA?

A
  • Weight loss
  • Aerobic exercises for muscle strengthening (avoid weight-bearing)
  • Physio/OT
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6
Q

OSTEOARTHRITIS

What is the stepwise medical management of OA?

A
  • First line = paracetamol + topical NSAID gel
  • Second line = PO NSAIDs (+ PPI) or weak then stronger opioids
  • Intra-articular steroid injections
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7
Q

OSTEOARTHRITIS

After medical management, how might you manage OA?

A
  • Surgical = arthroplasty (joint replacement), arthroscopy (loose bodies), fusion
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8
Q

RHEUMATOID ARTHRITIS
What is rheumatoid arthritis (RA)?
What is the epidemiology?

A
  • Autoimmune inflammatory synovial joint disease commonly presenting with a symmetrical distal polyarthropathy affecting small joints
  • F>M, peak onset 40–60s
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9
Q

RHEUMATOID ARTHRITIS
What joints does RA tend to affect?
What symptoms might a patient complain of?

A
  • Small joints in hands + feet, almost NEVER DIPJs
  • Early morning stiffness >30m which improves with use
  • Swollen, painful joints in hands + feet
  • Systemically unwell (fatigue, flu-like illness)
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10
Q

RHEUMATOID ARTHRITIS

What are some examination signs of RA?

A
  • Swollen, red, warm + tender joints
  • Ulnar deviation of fingers at the MCPJs
  • Z-shaped deformity of thumb
  • Boutonnière thumb = hyperextended DIPJ, flexed PIPJ
  • Swan-neck deformity = hyperextended PIPJ, flexed DIPJ
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11
Q

RHEUMATOID ARTHRITIS

What are some extra-articular manifestations of RA?

A
  • Eyes = keratoconjunctivitis sicca #1, (epi)scleritis, corneal ulceration
  • Neuro = carpal tunnel syndrome
  • Resp = pulmonary fibrosis, pleural effusion, nodules
  • Cardio = pericardial effusion, IHD
  • Felty syndrome = RA + splenomegaly + low WCC
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12
Q

RHEUMATOID ARTHRITIS

A patient with known RA presents with neck pain, weakness and loss of sensation in the arms. What has happened?

A
  • Atlanto-axial joint subluxation
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13
Q

RHEUMATOID ARTHRITIS

What investigations would you do in RA?

A
  • FBC = anaemia of chronic disease
  • Raised CRP/ESR
  • Serum Ab = rheumatoid factor (IgM) first-line but anti-CCP if negative as more specific
  • XR of hands + feet
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14
Q

RHEUMATOID ARTHRITIS

What does an xray show in RA?

A

LESS –

  • Loss of joint space
  • Erosions (periarticular)
  • Soft tissue swelling
  • Soft bone (periarticular osteoporosis) + Subluxation
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15
Q

RHEUMATOID ARTHRITIS

What are some poor prognostic markers in RA?

A
  • RF
  • Anti-CCP
  • XR showing early erosions
  • Extra-articular signs
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16
Q

RHEUMATOID ARTHRITIS
What is the mainstay of management for RA?
Give some examples

A
  • Disease modifying antirheumatic drugs (DMARDs)

- Methotrexate, leflunomide, sulfasalazine + hydroxychloroquine

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17
Q 
RHEUMATOID ARTHRITIS
How is methotrexate prescribed?
Does it require monitoring?
What drugs should be avoided and why?
What are some side effects?
A
  • Once weekly, 5mg folic acid on separate day
  • Regular FBC, U&E, LFTs baseline, weekly, 3/12
  • Trimethoprim + co-trimoxazole as risk of marrow aplasia
  • Myelosuppression, liver/pulmonary fibrosis, teratogenic (M+F stop 6m prior to conception)
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18
Q

RHEUMATOID ARTHRITIS
What are some side effects of…

i) leflunomide?
ii) sulfasalazine?
iii) hydroxychloroquine?

A

i) HTN, peripheral neuropathy
ii) Rashes, oligospermia
iii) Retinopathy (reduced vision), nightmares

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19
Q

RHEUMATOID ARTHRITIS

What more advanced treatments may be used in RA management and what are some side effects of them?

A
  • TNF-alpha inhibitors (infliximab, adalimumab, etanercept) = severe infections, reactivation of TB
  • Rituximab (monoclonal Ab to CD20) = night sweats + thrombocytopaenia
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20
Q

RHEUMATOID ARTHRITIS

What is the stepwise management of RA?

A
  • 1st = DMARD monotherapy ± short course of bridging prednisolone
  • 2nd = 2 DMARDs in combination
  • 3rd = Methotrexate PLUS TNF-alpha inhibitor
  • 4th = Methotrexate PLUS rituximab
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21
Q

RHEUMATOID ARTHRITIS
How do you manage a flare of RA?
How does NICE recommend you assess response to RA management?
What other options might you consider in RA management?

A
  • PO/IM corticosteroids
  • CRP + disease activity (DAS28 score)
  • Analgesia (NSAIDs), physiotherapy + surgery
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22
Q

GOUT

What is gout?

A
  • Inflammatory arthritis caused by hyperuricaemia (>0.45) + intra-articular deposition of monosodium urate crystals
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23
Q

GOUT

What are the two broad aetiologies of gout and some examples for each?

A
  • Increased uric acid production = myelo- + lymphoproliferative disorders, chemotherapy, severe psoriasis
  • Decreased uric acid excretion = diuretics, renal impairment, alcohol excess
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24
Q

GOUT
What are some potential triggers of a gout episode?
What are some risk factors for gout?

A
  • Seafood/protein binges, chemo, trauma + surgery

- Men, obesity, CKD, DM, medications (diuretics, ACEi)

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25
GOUT What joints are typically affected in gout? What is the clinical presentation of gout?
- Classically 1st metatarsophalangeal joint, also wrists + CMCJ of thumb - Acute hot, swollen, red + painful joint - Reduced ROM - Mild fever
26
GOUT | What are two potential sequelae from gout?
- Chronic tophaceous gout = large smooth white deposits (tophi, urate crystals) in skin + joints (DIPJ, elbows, ears) - Chronic polyarticular gout = painful erythematous swelling
27
GOUT | What investigations would you do in gout and why?
- Serum urate (2w after attack as can be low/falsely normal) - Joint fluid aspiration MC&S to rule out septic arthritis - Joint XR
28
GOUT | What would joint fluid aspiration MC&S show in gout?
- NO bacterial growth = excludes septic arthritis - Needle shaped crystals - Negative birefringence under polarised light
29
GOUT | What would a joint xray show in gout?
- NORMAL joint space - Soft tissue swelling - Periarticular erosions
30
GOUT | What lifestyle advice would you recommend in gout?
- Reduce alcohol + avoid in acute - Lose weight - Avoid purine rich food = liver, kidney, seafood, oily fish
31
GOUT How do you manage an acute flare of gout? What is a side effect to be aware of?
- NSAIDs first line (unless C/I) if not colchicine - Colchicine = slower onset + can cause diarrhoea - Steroids may be considered
32
GOUT What is the prophylaxis for gout and it's mechanism? When is it started? What drug should you be cautious of?
- Allopurinol = xanthine oxidase inhibitor > reduces uric acid levels - After acute attack (2w) + cover with colchicine or NSAID - Azathioprine toxicity due to 6-mercaptopurine build up
33
PSEUDOGOUT What is pseudogout? What are some associations with it?
- Microcrystal synovitis caused by deposition of calcium pyrophosphate crystals on joint surfaces - Hyperparathyroidism, hypothyroidism, haemochromatosis + hypophosphataemia
34
PSEUDOGOUT What joints are typically affected in pseudogout? What is the clinical presentation of pseudogout?
- Knee, wrists + shoulder - Acute hot, swollen, red, painful joint - Reduced ROM
35
PSEUDOGOUT | What investigations would you do in pseudogout and what would you find?
- Joint fluid aspiration MC&S = no bacterial growth (excludes septic arthritis), rhomboid-shaped crystals, Positive birefringence under polarised light - XR = chondrocalcinosis (calcium deposition in cartilage of joints)
36
PSEUDOGOUT | What is the management of pseudogout?
- NSAIDs or colchicine if C/I | - PO/intra-articular corticosteroids if both above C/I
37
ANKYLOSING SPONDYLITIS | What is ankylosing spondylitis?
- Seronegative spondyloarthropathy = HLA B27 associated typically affecting the sacroiliac joints + joints of the vertebral column
38
ANKYLOSING SPONDYLITIS | What is the clinical presentation of ankylosing spondylitis?
- Insidious onset lower back pain + stiffness in a young man - Stiffness worse in the morning + improves with exercise - Night pain which improves with movement
39
ANKYLOSING SPONDYLITIS | What are some examination signs of ankylosing spondylitis
- Reduced lateral + forward flexion (Schober's test <20cm) - Loss of lumbar lordosis + progressive thoracic kyphosis - Reduced chest expansion
40
ANKYLOSING SPONDYLITIS | What are some extra-articular features of ankylosing spondylitis?
- As = Apical fibrosis, Anterior uveitis, Aortic regurg, Achilles tendonitis (enthesitis), AV node block, Amyloidosis
41
ANKYLOSING SPONDYLITIS What investigations may you do in ankylosing spondylitis? What investigation is most useful?
- FBC, CRP/ESR elevated, HLA B27 +ve - CXR = apical fibrosis - Restrictive spirometry - Plain x-ray of sacroiliac joints/spine most useful
42
ANKYLOSING SPONDYLITIS | What features may be present on x-ray in ankylosing spondylitis?
- Sacroiliitis = subchondral erosions, sclerosis - Squaring of lumbar vertebrae - Syndesmophytes = ossification of outer fibres of annulus fibrosus - Bamboo spine (fusion) is late finding
43
ANKYLOSING SPONDYLITIS | What is the management of ankylosing spondylitis?
- Encourage regular exercise, physio input - NSAIDs = first line - DMARDs only useful if peripheral joint involvement - Anti-TNF therapy if persistently high disease activity despite treatments
44
PSORIATIC ARTHRITIS What is psoriatic arthritis? What are the 5 different types?
- Seronegative spondyloarthropathy = HLA-B27 associated - Symmetrical polyarthritis (>5 joints) - Asymmetrical oligoarthritis (<5 joints) - Spondylitic pattern - Distal interphalangeal joint arthritis - Arthritis mutilans
45
PSORIATIC ARTHRITIS What are some features of... i) symmetrical polyarthritis? ii) asymmetrical oligoarthritis? iii) spondylitic pattern? iv) arthritis mutilans?
i) Like RA but DIPJ affected and MCPJ less affected in comparison ii) Mainly affects digits iii) Back stiffness + sacroiliitis, more common in men iv) Severe deformity with destruction of bone in digits > telescoping
46
PSORIATIC ARTHRITIS What is the clinical presentation of psoriatic arthritis? What are some extra-articular findings?
- Joint pain, swelling + stiffness | - Anterior uveitis, aortitis, amyloidosis
47
PSORIATIC ARTHRITIS | What are some clinical signs seen in psoriatic arthritis?
- Psoriatic plaques (check scalp, behind ears, umbilicus, natal cleft) - Nail changes = onycholysis, pitting, subungual hyperkeratosis - Enthesitis = Achilles' tendonitis, plantar fasciitis - Tenosynovitis - Dactylitis
48
PSORIATIC ARTHRITIS | What investigation might you do in psoriatic arthritis and what might you see?
- XR = erosive changes + new bone formation, periostitis, 'pencil-in-cup' appearance
49
PSORIATIC ARTHRITIS | What is the management of psoriatic arthritis?
- Guided by rheumatologist > mild peripheral arthritis = NSAIDs, some may be on monoclonal antibodies
50
REACTIVE ARTHRITIS | What is reactive arthritis?
- Seronegative spondyloarthropathy = HLA-B27 with sterile inflammation of the synovial membrane due to autoimmune reaction to infection elsewhere
51
REACTIVE ARTHRITIS | What causes reactive arthritis?
- Post-dysenteric illness = Shigella, Salmonella, Campylobacter - Post-STI = chlamydia (more common in men)
52
REACTIVE ARTHRITIS | What is the clinical presentation of reactive arthritis?
- 4w post-infection triad of "can't see, can't pee, can't climb a tree" = conjunctivitis, urethritis + arthritis - Usually asymmetrical oligoarthritis of lower limbs - Systemically unwell
53
REACTIVE ARTHRITIS | What are the extra-articular manifestations of reactive arthritis?
- Anterior uveitis - Circinate balanitis (painless vesicles on prepuce) - Keratoderma blenorrhagica = waxy yellow/brown papules on palms/soles
54
REACTIVE ARTHRITIS | What investigations would you do in reactive arthritis?
- Raised CRP/ESR - HLA-B27 +ve - Joint MC&S to exclude septic arthritis = sterile with high neutrophils
55
REACTIVE ARTHRITIS | What is the management of reactive arthritis?
- Analgesia (NSAIDs), ?intra-articular steroids | - DMARDs (methotrexate/sulfasalazine) if Sx >6m
56
SEPTIC ARTHRITIS What is septic arthritis? How does it occur? What can cause it?
- Acute joint infection which can cause damaging inflammation + joint loss <24h - Commonly haematogenous spread - #1 overall = staphylococcus aureus - #1 in young, sexually active = neisseria gonorrhoea - In infants, think about group B strep
57
SEPTIC ARTHRITIS | What are some risk factors for developing septic arthritis?
- Pre-existing joint disease (especially RA) - Prosthetic joints - IVDU - Immunosuppression (DM/HIV)
58
SEPTIC ARTHRITIS What is the clinical presentation of septic arthritis? Additional features in paeds?
- Acute red, hot, swollen joint (commonly knee) - Pain on movement + reduced ROM - Systemically unwell (fever) - Paeds = may present with limb + refusal to weight bear
59
SEPTIC ARTHRITIS | What investigations would you do for septic arthritis?
- Blood cultures, FBC (raised WCC), CRP/ESR raised - Joint aspiration for MC&S crucial - XR joint - Kocher criteria ≥3 = temp>38.5, non-weight bearing, raised ESR + WCC
60
SEPTIC ARTHRITIS | What is the management of septic arthritis?
- IV Abx often flucloxacillin (clindamycin if pen allergic) before sensitivities back - Arthroscopic lavage may be required, analgesia
61
OSTEOMYELITIS What is osteomyelitis? What are the two ways it can occur?
- Infection in the bone + bone marrow, often in metaphysis of long bones - Haematogenous from bacteraemia (#1 paeds) or non-haematogenous from spread from adjacent soft tissues (#1 adults)
62
OSTEOMYELITIS What are some risk factors for haematogenous spread osteomyelitis? What are some risk factors for non-haematogenous spread osteomyelitis?
- Sickle cell anaemia, IVDU, immunosuppression | - PVD, DM + diabetic foot ulcers
63
OSTEOMYELITIS | What are some common organisms that can cause osteomyelitis?
- Staph. aureus #1, H. influenzae | - Most common in sickle cell anaemia = Salmonella
64
OSTEOMYELITIS | What is the clinical presentation of osteomyelitis?
- Local pain, swelling + erythema - Refusal to weight bear + reduced ROM - Systemically unwell (fever)
65
OSTEOMYELITIS | What are some investigations for osteomyelitis?
- FBC (raised WCC), raised ESR/CRP, blood cultures | - XR may be normal so MRI is best diagnostic imaging
66
OSTEOMYELITIS | What is the management of osteomyelitis?
- IV empirical Abx (flucloxacillin or clindamycin if pen allergic) until sensitivities back - Surgical debridement mainstay for chronic
67
SLE What is the pathophysiology of systemic lupus erythematosus (SLE)? What is the epidemiology?
- Multi-system autoimmune disease where immune system dysregulation leads to immune complex formation + deposition (T3HR) - More common in females, Afro-Caribbean + Asian communities + onset 20–40y
68
SLE What are some drugs that may cause SLE? What are some potential triggers of SLE?
- SHIPP = Sulfonamides, Hydralazine, Isoniazid, Phenytoin, Procainamide - Oestrogen containing contraception, sunlight overexposure, infections + stress
69
SLE | What is the clinical presentation of SLE?
DOPAMINE RASH – - Discoid lupus (erythematous raised patches with keratotic scales) - Oral ulcers - Photosensitivity - Arthritis - Malar rash (spares nasolabial folds) - Immunological - Neuro (psychosis, depression, seizures) - ESR raised - Raynaud's/renal involvement (proteinuria, HTN) - ANA +ve - Serositis (pleurisy, pericarditis) - Haem (anaemia of chronic disease, low WCC + plts)
70
SLE | What are some investigations you might do in SLE?
- FBC (anaemia of chronic disease, low WCC + plts) - Antibodies = 99% ANA +ve (not specific), anti-dsDNA (specific) and anti-Smith (specific), anti-histone in drug induced lupus
71
SLE | How would you monitor SLE disease activity?
- ESR as CRP can be normal so raised CRP ?infection - Complement levels (C3/4) LOW in active disease - Urinalysis + urine ACR to monitor for proteinuria
72
SLE What is the leading cause of death in SLE? What are some other complications?
- CVD - Infections, pericarditis, pleurisy - Lupus nephritis > nephrotic syndrome > ESRF - Antiphospholipid syndrome
73
SLE | What is antiphospholipid syndrome?
- Acquired disorder leading to predisposition to venous + arterial thromboses, recurrent foetal loss + thrombocytopaenia
74
SLE | What is the clinical presentation of antiphospholipid syndrome?
CLOTS - Coagulation defect (raised APTT) - Livedo reticularis - Obstetric (Recurrent miscarriage) - Thrombocytopaenia
75
SLE What markers in the blood would you look for in antiphospholipid syndrome? What is the primary thromboprophylaxis of antiphospholipid syndrome?
- Anticardiolipin + lupus anticoagulant antibodies | - Low dose aspirin
76
SLE | How do you manage VTE in antiphospholipid syndrome?
- First = lifelong warfarin with INR target 2–3 | - Subsequent on warfarin = INR target 3–4
77
SLE | What is the management of SLE?
- Conservative = sun block - Mainstay = DMARD hydroxychloroquine + NSAIDs - Consider pred or cyclophosphamide if internal organ involvement
78
GIANT CELL ARTERITIS What is giant cell arteritis (GCA)? What is it associated with?
- Large vessel vasculitis | - PMR, those >60y/o
79
GIANT CELL ARTERITIS | What is the clinical presentation of GCA?
- Severe unilateral temporal headache - Scalp tenderness (brushing hair) - Jaw claudication - Blurred, double vision, amaurosis fugax - Systemic = fever, fatigue, weight loss
80
GIANT CELL ARTERITIS | What signs might be present in GCA?
- Tender, thickened, pulseless temporal artery
81
GIANT CELL ARTERITIS | What initial investigations would you do in GCA?
- FBC = normocytic anaemia + thrombocytosis - LFTs = raised ALP - CRP/ESR (ESR >60mm/h in >60y/o)
82
GIANT CELL ARTERITIS What other investigations would you do in GCA? What investigation is diagnostic?
- Duplex USS temporal artery = hypoechoic halo sign | - Vascular for temporal artery biopsy Dx = multinucleated giant cells, ?skip lesions
83
GIANT CELL ARTERITIS | What are some potential complications of GCA and how are they managed?
- Stroke - Permanent monocular blindness due to anterior ischaemic optic neuropathy - Ophthalmology for emergency same day appt if visual Sx
84
GIANT CELL ARTERITIS | What is the management of GCA?
- Stat high dose corticosteroids before biopsy = IV methyl pred (visual loss), PO pred (no visual loss) + gradually taper - Bisphosphonate + PPI cover whilst on steroids - Aspirin 75mg OD to decrease vision loss + stroke risk
85
POLYMYALGIA RHEUMATICA What is polymyalgia rheumatica? How does it usually present?
- Inflammatory condition strongly associated to GCA causing muscle stiffness - Rapid onset <1m in a white woman >60y/o
86
POLYMYALGIA RHEUMATICA | What is the clinical presentation of polymyalgia rheumatica?
- Bilateral shoulder + pelvic girdle pain - Aching + morning stiffness in proximal limb muscles but NO weakness - Systemic = low-grade fever, fatigue
87
POLYMYALGIA RHEUMATICA What investigations would you do in polymyalgia rheumatica? What is the management?
- ESR/CRP raised, creatinine kinase + EMG normal | - PO prednisolone shows dramatic response (diagnostic)
88
SJOGREN'S SYNDROME | What is the pathophysiology of Sjogren's syndrome?
- Autoimmune lymphocytic infiltration of exocrine glands (type 4 hypersensitivity reaction) > dry mucosal surfaces
89
SJOGREN'S SYNDROME What causes Sjogren's syndrome? What is the epidemiology and what are patients with Sjogren's syndrome at risk of?
- Primary or secondary to RA, SLE or other connective tissue disorders - Much more common in females - Increased risk of lymphoid malignancy
90
SJOGREN'S SYNDROME | What is the clinical presentation of Sjogren's syndrome?
- Reduced tear secretion (keratoconjunctivitis sicca) = dry, gritty eyes - Reduced saliva = dry mouth + dysphagia - Recurrent episodes of parotitis - Vaginal dryness = dyspareunia
91
SJOGREN'S SYNDROME | What are some extra-glandular features of Sjogren's syndrome?
- Raynaud's - Arthritis - Systemic upset (fever, fatigue)
92
SJOGREN'S SYNDROME | What investigations would you do in Sjogren's syndrome?
- Schirmer's test = filter paper near conjunctival sac to measure tear formation - Specific Ab = anti-Ro + anti-La - Non-specific Ab = RF + ANA
93
SJOGREN'S SYNDROME | What is the management of Sjogren's syndrome?
- Artificial saliva + tears | - Pilocarpine may stimulate saliva production
94
RAYNAUD'S What is Raynaud's? What causes it?
- Exaggerated vasoconstrictive response of digital arteries + cutaneous arterioles to the cold or emotional stress - Primary (Raynaud's disease) or secondary (phenomenon) = RA, SLE, Sjogren's
95
RAYNAUD'S What is the classic clinical presentation of Raynaud's? How can you clinically differentiate between Raynaud's disease and phenomenon?
- Colour change of fingertips white > blue > red - Disease = young women, bilateral - Phenomenon = unilateral, rashes, onset after 40y/o
96
RAYNAUD'S | What is the management of Raynaud's
- All referred to secondary care - First line = CCB nifedipine - IV prostacyclin infusion may be used
97
SYSTEMIC SCLEROSIS What is systemic sclerosis? Who does it normally affect? What general antibodies are associated with it?
- Disease characterised by hardened, sclerotic skin + other connective tissues - Females - ANA + RF but not specific
98
SYSTEMIC SCLEROSIS | What are the three subtypes in systemic sclerosis and the antibodies associated?
- Limited cutaneous systemic sclerosis = anti-centromere - Diffuse cutaneous systemic sclerosis = anti-scl-70 - Scleroderma
99
SYSTEMIC SCLEROSIS Where is affected in limited cutaneous systemic sclerosis? What is the clinical presentation?
- Scleroderma affects face + distal limbs mainly | - Subtype CREST syndrome = Calcinosis, Raynaud's, oEsophageal dysmotility, Sclerodactyly, Telangiectasia
100
SYSTEMIC SCLEROSIS Where is affected in diffuse cutaneous systemic sclerosis? What are some complications?
- Diffuse (may affect many internal organs) scleroderma affects trunk + proximal limbs mainly - #1 cause of death resp involvement (ILD, pulmonary HTN), renal disease + HTN
101
SYSTEMIC SCLEROSIS | How does scleroderma present?
- Tightening and fibrosis of skin without internal organ involvement
102
POLYMYOSITIS What is polymyositis? What is a variant? What causes it?
- Autoimmune inflammatory disorder causing symmetrical, proximal myopathy - Dermatomyositis with prominent skin manifestations - Idiopathic or associated with connective tissue disorders or malignancy (lung, ovarian, breast)
103
POLYMYOSITIS | What is the clinical presentation of polymyositis?
- Progressive symmetrical proximal muscle weakness (shoulder + pelvic girdle), F>M - Dysphagia, dysphonia + resp muscle weakness
104
POLYMYOSITIS | How does dermatomyositis present?
- Photosensitive rash - Grotton's papules = rough red papules on finger extensors - Heliotrope (purple) periorbital rash
105
POLYMYOSITIS What are some investigations you might do in polymyositis? What investigation is diagnostic? What antibodies might you find?
- Muscle enzymes raised (CK, LDH), EMG - Muscle biopsy Dx - Anti-Jo-1 (specific), also ANA
106
POLYMYOSITIS | What is the management of polymyositis?
- Screen for malignancy | - Immunosuppression with PO pred
107
OSTEOMALACIA | What is osteomalacia?
- Softening of bones secondary to low vitamin D levels + other minerals > decreased bone mineral content (but normal bone mass density)
108
OSTEOMALACIA | What are some causes of osteomalacia?
- Vitamin D deficiency = malabsorption (IBD/coeliac), lack of sunlight, CKD, cirrhosis - Drugs = anticonvulsants (carbamazepine, phenytoin) - Inherited = hypophosphataemic rickets
109
OSTEOMALACIA | What is the clinical presentation of osteomalacia?
- Bone pain + tenderness - Fractures (especially NOF) - Proximal myopathy > waddling gait
110
OSTEOMALACIA | What would investigations show in osteomalacia?
- Low = vitamin D, calcium + phosphate - Raised = ALP, PTH - XR may show translucent bands (Looser's zones)
111
OSTEOMALACIA | What is the management of osteomalacia?
- Vitamin D (colecalciferol) if 25–50nmol/L (loading dose if <25) - Renal disease = alfacalcidol as needs activated - Calcium supplementation if dietary calcium inadequate
112
COMPARTMENT SYNDROME | What is the pathophysiology of compartment syndrome?
- Oedema within a closed anatomical space leads to increased compartment pressure more than the venous pressure so no venous blood leaves - This leads to further pressure rise + so prevents entry of arterial blood leading to rapid ischaemia, muscle necrosis, rhabdomyolysis + acute renal failure
113
COMPARTMENT SYNDROME | What are some causes of compartment syndrome?
- Tight plaster cast, burns | - # = especially supracondylar + tibial shaft (anterior leg compartment #1)
114
COMPARTMENT SYNDROME | What is the clinical presentation of compartment syndrome?
- Increasing pain + pain on passive flexion - Loss of function + opiate analgesia does not control pain - Pulseless (may be present), paralysis, pallor
115
COMPARTMENT SYNDROME | What investigations would you do in compartment syndrome and what might they show?
- Typically XR normal | - Compartment pressure >20mmHg abnormal, >40mmHg diagnostic
116
COMPARTMENT SYNDROME | What is the management of compartment syndrome?
- Remove all pressure + emergency fasciotomy - May require debridement - Aggressive IV fluids due to myoglobinuria from rhabdomyolysis
117
SHOULDER DISLOCATION What happens in a shoulder dislocation? What is the most common type? What causes it?
- Humeral head dislodges from glenoid cavity of scapula, often 2º to trauma - Anterior 95% = antero-inferior dislocation - Posterior = sustained muscle contraction like epilepsy, electric shocks
118
SHOULDER DISLOCATION What is a key complication of shoulder dislocation? How might it present?
- Axillary nerve damage - Sensory loss in regimental badge area over lateral deltoid - Motor loss in deltoid (shoulder abduction)
119
SHOULDER DISLOCATION How does shoulder dislocation present? How is it diagnosed? How is it managed?
- Pain, reduced ROM + joint deformity - AP + lateral shoulder x-ray - Anterior = manual reduction (without sedation if recent) + sling immobilisation - Posterior = orthopaedic input for closed reduction
120
ADHESIVE CAPSULITIS What is adhesive capsulitis? What is the epidemiology?
- Reactive inflammation within the capsule causing adhesions (frozen shoulder) - Middle aged females + DM
121
ADHESIVE CAPSULITIS | What is the clinical presentation of adhesive capsulitis?
- Gradual onset pain + stiffness - EXTERNAL ROTATION is most affected, also abduction - BOTH active + passive movement affected
122
ADHESIVE CAPSULITIS | What is the management of adhesive capsulitis?
- Conservative = rest + physio | - Medical = NSAIDs or steroid injections
123
ROTATOR CUFF PATHOLOGY | What are the 4 rotator cuff muscles and their action?
SITS – - Supraspinatus = abducts arm (first 20º then deltoids) - Infraspinatus = externally rotates arm - Teres minor = externally rotates arm - Subscapularis = internally rotates arm
124
ROTATOR CUFF PATHOLOGY | What is subacromial impingement?
- Entrapment of supraspinatus tendon + subacromial bursa between humeral head + acromion = subacromial bursitis + supraspinatus tendinitis
125
ROTATOR CUFF PATHOLOGY | What is the clinical presentation of subacromial impingement?
- Painful arc = pain between 60–120º - Passive abduction is painless - Weakness + decreased ROM (especially with overhead)
126
ROTATOR CUFF PATHOLOGY | How would you investigate and manage subacromial impingement?
- XR to evaluate acromiohumeral joint space - Conservative (rest + physio) - Medical (NSAIDs or steroid injection) - Surgical = arthroscopic acromioplasty
127
ROTATOR CUFF PATHOLOGY What causes rotator cuff tears? How do they present?
- Traumatic or secondary to repetitive activity - Supraspinatus = painful arc - Pain on movement - Decreased ROM depending on site of tear
128
ROTATOR CUFF PATHOLOGY | How would you investigate and manage rotator cuff tears?
- USS + MRI for imaging | - Rest + physio, may need open or arthroscopic repair
129
EPICONDYLITIS What are the two types of epicondylitis? How do they present similarly?
- Lateral = Tennis elbow > exTensor mechanism (of wrist) - Medial = Golfer's elbow > flexor mechanism (of wrist) - Hx of elbow related activity
130
EPICONDYLITIS What is the clinical presentation of tennis elbow? What is the clinical presentation of golfer's elbow?
- Pain + tenderness on lateral epicondyle, pain worse on wrist extension - Pain + tenderness on medial epicondyle, pain worse on wrist flexion
131
EPICONDYLITIS What signs may you elicit in tennis elbow? What signs may you elicit in golfer's elbow?
- Pain worse on resisted wrist extension/forearm supination with elbow extended - Medial pain reproduced on resisted wrist flexion
132
EPICONDYLITIS | What is the management of epicondylitis?
- Avoid muscle overload - Simple analgesia (NSAIDs) - Physiotherapy
133
OLECRANON BURSITIS | What is olecranon bursitis?
- Inflammation of the bursa (fluid filled sac of synovial membrane which reduces friction between bones + soft tissues during movement) in the elbow
134
OLECRANON BURSITIS | What can cause olecranon bursitis?
- Repetitive damage like manual workers (e.g., carpet layers) - Associated with RA + gout
135
OLECRANON BURSITIS | What is the clinical presentation of olecranon bursitis?
- Fluctuant swelling around posterior elbow - May be pain, warmth + erythema - Infected = systemically unwell, hot to touch, spreading erythema
136
OLECRANON BURSITIS | What is the management of olecranon bursitis?
- Exclude septic arthritis if unwell > aspirate for joint fluid MC&S + treat empirically - Conservative (ice, NSAIDs), PO flucloxacillin if infected but not too unwell
137
CUBITAL TUNNEL SYNDROME | What is cubital tunnel syndrome
- Compression of ulnar nerve as it passes through the cubital tunnel
138
CUBITAL TUNNEL SYNDROME | What is the clinical presentation of cubital tunnel syndrome?
- Intermittent paraesthesia + numbness in 4/5th digit > constant - Over time weakness + muscle wasting - Pain worse when leaning on affected elbow
139
CUBITAL TUNNEL SYNDROME | What signs may be present in cubital tunnel syndrome?
- Claw hand | - +ve Froment's = thumb bent when holding paper (weak adductor pollicis)
140
CUBITAL TUNNEL SYNDROME | What is the management of cubital tunnel syndrome?
- Avoid aggravating activity - Elbow splint - Physio - Steroid injections
141
DE QUERVAIN'S TENOSYNOVITIS What is De Quervain's tenosynovitis? What's the epidemiology?
- Sheath inflammation containing extensor pollicis brevis + abductor pollicis longus - Females 30–50y
142
DE QUERVAIN'S TENOSYNOVITIS | What is the clinical presentation of De Quervain's tenosynovitis?
- Pain + swelling in anatomical snuffbox - Radial styloid process tenderness - Finkelstein's test = pain reproduced by bending thumb into palm
143
DE QUERVAIN'S TENOSYNOVITIS | What is the management of De Quervain's tenosynovitis?
- Rest, NSAIDs, steroid injections, thumb splint | - Surgical decompression may be required
144
TRIGGER FINGER | What is trigger finger?
- Thickening of flexor tendon or tendon sheath with tendon nodules at entry of tendon sheath > prevents tendon passing through sheath = trapped in flexion
145
TRIGGER FINGER What is the clinical presentation of trigger finger? How is it managed?
- Fixed flexion deformity in thumb, middle + ring finger - Forced extension = painful click - Steroid injection ± finger splint or surgery
146
DUPUYTREN'S CONTRACTURE What is a dupuytren's contracture? What causes it? What is the management?
- Painless fibrotic thickening of palmar fascia, commonly ring + little fingers - Manual labour, phenytoin, alcoholic liver disease, DM - Physio, fasciectomy if MCPJ cannot be straightened (hand can't be flat on table)
147
UPPER LIMB FRACTURES What is a key feature of a proximal humerus fracture? What is a key complication?
- Children = #1 greenstick fracture (breaks on 1 side) through surgical neck - Axillary nerve damage = sensory loss regimental badge area over deltoid, motor loss in deltoid (shoulder abduction
148
UPPER LIMB FRACTURES What causes a supracondylar fracture of the humerus? How does it present?
- Children fall onto outstretched arm | - Elbow in semi-flexed position with tenderness + swelling
149
UPPER LIMB FRACTURES What is a potential consequence of a supracondylar fracture? What is the management?
- Damage to brachial artery, median or radial nerve + compartment syndrome - Non-displaced = collar + cuff, displaced = anaesthetic manipulation
150
UPPER LIMB FRACTURES | What is a Colles' fracture?
- Transverse radial # within 2.5cm of distal end of radius with dorsal (upwards) angulation of distal fragment
151
UPPER LIMB FRACTURES | What are some clinical features of a Colles' fracture?
- Falling onto outstretched hand - Females >50y with osteoporosis - Dinner fork deformity
152
UPPER LIMB FRACTURES | What is the management of a Colles' fracture?
- Manipulation for reduction if not open reduction + internal fixation
153
UPPER LIMB FRACTURES What causes a scaphoid fracture? What are the clinical features?
- Fall onto outstretched hand - Tender, swollen anatomical snuffbox - Pain on wrist movements + thumb compression
154
UPPER LIMB FRACTURES | What is a key complication with scaphoid fractures?
- Retrograde blood supply so complete # = avascular necrosis + non-union
155
UPPER LIMB FRACTURES How are scaphoid fractures diagnosed? What is the management of scaphoid fractures?
- Scaphoid XRs - Treat if high suspicion even if no initial radiological evidence - Wrist in scaphoid plaster
156
UPPER LIMB FRACTURES | What is a smith's fracture?
- Reverse Colles' with anterior (volar) angulation of distal fragment
157
UPPER LIMB FRACTURES What is a boxer's fracture? How does it present?
- # neck of 4th or 5th metacarpal due to punching a hard object - Pain + swelling over MCPJ of 4th/5th fingers
158
UPPER LIMB FRACTURES What is a Bennett's fracture? How does it appear on XR?
- Intra-articular # at base of thumb metacarpal from fist fights - Triangular fragment at base of metacarpal
159
UPPER LIMB FRACTURES | What is a Barton's fracture?
- Colles/Smith's with associated radiocarpal dislocation
160
UPPER LIMB FRACTURES | What is the difference between a Monteggia + Galeazzi fracture?
MUGGER – - MonteggiA = PROXIMAL Ulnar # with dislocation of PROXIMAL radial head - GaleazZi = DISTAL Radial # with dislocation of DISTAL radio-ulnar joint (A is proximal, Z is distal)
161
HIP FRACTURE | What are the two types of hip fracture?
- Intracapsular = break in femoral neck, within the capsule of the hip joint - Extracapsular = trochanteric or subtrochanteric (lesser trochanter divides)
162
HIP FRACTURE | How can intracapsular hip fractures be classified?
Garden system – - Type I = incomplete #, not displaced - Type II = complete #, not displaced - Type III = partial displacement (trabeculae are at an angle) - Type IV = full displacement = (trabeculae are parallel)
163
HIP FRACTURE | What are some risk factors for hip fractures?
- Increasing age - Osteoporosis - Female
164
HIP FRACTURE | What is the clinical presentation of a hip fracture?
- Painful hip with a shortened + externally rotated leg | - Nondisplaced/incomplete NOF # may be able to weight bear
165
HIP FRACTURE What investigations would you do in hip fracture? What would indicate a hip fracture?
- AP and lateral (frog leg) XR = first line (Shenton's line disruption from medial edge of femoral neck + inferior edge of superior pubic ramus) - MRI second line if clinically hip # but normal XR
166
HIP FRACTURE What is a key complication of hip fractures? Explain the process of this
- Avascular necrosis - Branches of medial + lateral circumflex femoral arteries run along surface of femoral neck, within the capsule + only supply femoral head - Intracapsular hip # (especially displaced III/IV) can disrupt supply so femoral head removed + replaced, nondisplaced may have intact blood supply
167
HIP FRACTURE | What is the management of intracapsular hip fractures?
- Not displaced (I/II) = ORIF (open reduction + internal fixation) with cannulated screws OR hemiarthroplasty if unfit - Displaced (III/IV) = arthroplasty to all patients
168
HIP FRACTURE | How do you determine what arthroplasty to do in displaced intracapsular hip fractures?
- THR favoured to hemiarthroplasty (just femoral head replaced, not acetabulum) if pt able to walk independently with no more than stick, not cognitively impaired + med fit for anaesthesia + procedure
169
HIP FRACTURE | What is the management of extracapsular hip fractures?
- Intertrochanteric = ORIF with dynamic hip screws | - Sub-trochanteric = intramedullary device
170
HIP FRACTURE What is a key differential of hip fracture? How would it present? What are the risks?
- Hip dislocation 2º to trauma (posterior dislocation #1) - Affected leg shortened, adducted + INTERNALLY rotated - Risk of sciatic nerve injury + avascular necrosis
171
TROCHANTERIC BURSITIS What is trochanteric bursitis? What are some causes?
- Inflammation of bursa overlying the greater trochanter of the femur - Friction from repetitive movements, trauma, inflammatory RA
172
TROCHANTERIC BURSITIS | How might trochanteric bursitis present?
- Tenderness on palpation of greater trochanter | - Pain over lateral side of hip > worse at night + exacerbated by activity
173
TROCHANTERIC BURSITIS | What signs might you elicit on clinical examination in trochanteric bursitis?
- +ve Trendelenburg (foot falls to side with foot off ground) = weak hip abductors on contralateral side - Pain on resisted abduction, internal + external rotation
174
TROCHANTERIC BURSITIS | What is the management of trochanteric bursitis?
- Analgesia ± steroid injections - Physio - Rarely bursectomy
175
KNEE INJURIES What is the mechanism of an ACL injury? How might it present? What signs may be present?
- High twisting force applied to a bent knee, sport injury - Loud crack, feel it give way + rapid joint swelling (haemoarthrosis) - +ve anterior draw + Lachman's test
176
KNEE INJURIES What investigations would you do in ACL injury? How would you manage an ACL injury?
- MRI | - NSAIDs, physio or arthroscopic surgery
177
KNEE INJURIES What is the mechanism of a PCL injury? How might it present?
- Hyperextension injuries > tibia lies back on the femur | - Paradoxical anterior draw test, +ve posterior sag test
178
KNEE INJURIES What is the mechanism of an MCL injury? How does it present? What is the management?
- Leg forced into valgus via force outside the leg - Knee unstable when put into valgus position - Immobilisation cast + surgical reconstruction
179
KNEE INJURIES | What is the mechanism of a meniscal tear?
- Rotational sporting injury, often minor trauma
180
KNEE INJURIES How might a meniscal tear present? What sign may you elicit?
- Delayed knee swelling, knee locking (medial more common) | - Thessaly's test +ve = weight bearing at 20º knee flexion = pain on twisting
181
KNEE INJURIES How would you investigate a meniscal tear? What is the management of a meniscal tear?
- MRI | - NSAIDs, physio, arthroscopy ± meniscectomy
182
KNEE INJURIES What cause a patella fracture? Who is it commonly seen in? What is the management?
- Fall onto a flexed knee or car crash dashboard injury - Adolescent girls = dislocates laterally - Non-displaced = cast, displaced = ORIF, comminuted = patellectomy
183
KNEE INJURIES | What is a Baker's cyst?
- Popliteal swelling due to herniation from joint synovium often 2º to OA
184
KNEE INJURIES | How might a Baker's cyst present?
- Acute calf pain + swelling | - Foucher's sign = increased tension of cyst on extension of knee (standing)
185
KNEE INJURIES How might you investigate a Baker's cyst? What's the management?
- USS | - NSAIDs, physio, steroid injections, aspiration
186
ACHILLES' TENDINOPATHY | What are some risk factors for Achilles' tendinopathy?
- Quinolone use such as ciprofloxacin | - Hypercholesterolaemia predisposes to tendon xanthomata
187
ACHILLES' TENDINOPATHY | What is Achilles' tendon rupture?
- Loss of connection between calf muscles (gastrocnemius + soleus) + calcaneus
188
ACHILLES' TENDINOPATHY | What is the clinical presentation of Achilles' tendon rupture?
- Often during sport - Audible 'pop' in ankle - Sudden onset significant pain in calf or ankle - Inability to walk or continue sport
189
ACHILLES' TENDINOPATHY | What might examination reveal in Achilles' tendon rupture?
- Greater dorsiflexion of injured foot compared to uninjured - Palpable gap in tendon - Simmonds test = squeeze calf muscles as acute rupture > no plantar flexion response
190
ACHILLES' TENDINOPATHY How would you investigate Achilles' tendon rupture? What is the management of Achilles' tendon rupture?
- USS initial choice | - Acute referral to orthopaedics for either boot immobilisation or surgical reattachment
191
ACHILLES' TENDINOPATHY | How would Achilles' tendinitis present?
- Gradual onset of posterior heel pain that is worse following activity - Morning pain + stiffness
192
ACHILLES' TENDINOPATHY What is the management of Achilles' tendinitis? What would you avoid?
- NSAIDs, reduce precipitating activities, calf muscle exercises (self-directed or physio guided) - Steroid injections as risk of tendon rupture
193
PLANTAR FASCIITIS | What is plantar fasciitis?
- Strain on attachment of plantar fascia to calcaneus
194
PLANTAR FASCIITIS | How does plantar fasciitis present?
- Pain when heel strikes ground on walking | - Tender point on heel
195
PLANTAR FASCIITIS | What is the management of plantar fasciitis?
- Firm pad in shoes - Analgesia - Steroid injections
196
MORTON'S NEUROMA What is Morton's neuroma? Where is commonly affected? Who is commonly affected?
- Dysfunction of a nerve in intermetatarsal space towards top of foot - 3rd/4th metatarsal - F>M, high heels
197
MORTON'S NEUROMA | What is the clinical presentation of Morton's neuroma?
- Pain at front of foot + sensation of lump in shoe - Burning, numbness or paraesthesia in distal toes - Mulder's sign = painful click when metatarsal heads rub neuroma
198
MORTON'S NEUROMA How is Morton's neuroma diagnosed? What is the management of Morton's neuroma?
- Clinical Dx but USS can confirm | - Shoe padding (metatarsal pads) ± steroid injections or neuroma excision
199
BUNION What is a bunion? How does it present?
- Bony lump created by deformity at MTP joint at base of big toe - Big toe = hallux valgus (deviates laterally to other toes), can be painful
200
BUNION How is bunion diagnosed? What is the management of a bunion?
- Weight bearing radiograph - Conservative = comfortable shoes + bunion pads - Surgical = bunionectomy + treat hallux valgus deformity
201
LOWER LIMB FRACTURES | How can fibular fractures in the ankle be classified and subsequently managed?
Weber system - A: # below joint line + syndesmosis = closed reduction - B: # at level of joint line + syndesmosis = ?closed, ?ORIF - C: # above joint line + syndesmosis = very unstable, ORIF
202
LOWER LIMB FRACTURES | When considering whether to order an x-ray in ankle fractures, what must be satisfied?
1 of Ottawa ankle rules – - Bony tenderness at lateral malleolar zone - Bony tenderness at medial malleolar zone - Inability to walk 4 steps directly after injury + in ED
203
LOWER LIMB FRACTURES How are ankle fractures managed? What is a key differential and how does it present?
- Prompt reduction due to pressure on overlying skin > necrosis - Ankle sprain, low more common 2º to inversion injury
204
``` LOWER LIMB FRACTURES What is a tibial plateau fracture? How are they classified? Who does it occur in? How do you manage it? ```
- Tibia # which subsequent breaks the knee joint itself - Schatzker classification - Elderly or young high energy impact - Immobilisation + brace or surgical fixation if displaced/open
205
LOWER LIMB FRACTURES What is a stress fracture? What are the features? What is the management?
- 2nd metatarsal # common in athletes - Gradual pain related to activity, direct palpation causes pain - Rest + analgesia, physio
206
LOWER LIMB FRACTURES What is a type of foot fracture? What causes it? What is the management?
- Avulsion # of 5th metatarsal base - Common due to inversion with plantar flexion - Below knee plaster cast
207
LOWER LIMB FRACTURES What is an open fracture? What fractures are most at risk?
- Bone breaches the skin + communicates directly with external environment - # of tibia + phalanges
208
LOWER LIMB FRACTURES | What is the management of an open fracture?
- Increased infection risk so As = Analgesia, prompt Abx, Assess (neurovascular), Antisepsis (irrigate, cover), Alignment (reduction + fixation)
209
BONE CANCER | What are the most common bone tumours?
- Secondary bone tumours e.g., metastases = Breast, Bronchus, Bidney, Byroid, Brostate
210
BONE CANCER What are some benign bone tumours? What is the most common?
- Osteochondroma (exotosis) #1 = males, | - Osteoma = benign overgrowth of bone, often skull
211
BONE CANCER What is the most common primary bone tumour? Where does it normally present and who in?
- Osteosarcoma | - Knee in adolescent males
212
BONE CANCER | What is the clinical presentation of osteosarcoma?
- Persistent, localised bone pain often worse at night | - Warm painful swelling
213
BONE CANCER | How might an osteosarcoma appear on xray?
- Sunburst appearance | - Codman's triangle = periosteal elevation
214
BONE CANCER What is another type of primary bone cancer? Where does it normally present and who in?
- Ewing's sarcoma | - Long bone diaphysis (e.g., femoral), males <20
215
BONE CANCER How does Ewing's sarcoma present? How might it present on xray?
- Painful, warm, enlarging mass, fever, raised WCC + ESR | - Lytic tumour, onion skin periosteal reaction
216
BONE CANCER What other type of bone cancer is there? Where does it normally present and who in?
- Chondrosarcoma = malignant tumour of cartilage - Axial skeleton - Middle age >40y
217
PAGET'S DISEASE (BONE) What is Paget's disease of the bone? Where is commonly affected?
- Uncontrolled bone turnover with excessive osteoclastic resorption then chaotic bone deposition by osteoblasts - Skull, spine/pelvis + lower extremity long bones
218
PAGET'S DISEASE (BONE) What is the clinical presentation of Paget's disease of the bone? If left untreated, what can happen?
- Older male with bone pain and isolated raised ALP (normal calcium + phopshate) - Bowing of tibia + bossing of skull, hearing loss, OA
219
PAGET'S DISEASE (BONE) What investigation might you do? What is the management of Paget's disease of the bone?
- XR = osteolysis, osteoporosis circumscripta on skull XR (lytic skull lesions) - Bisphosphonate
220
POLYARTERITIS NODOSA What is polyarteritis nodosa? What is the epidemiology?
- Medium-sized vasculitis with necrotising inflammation > aneurysms - Middle-aged men + associated with hepatitis B
221
POLYARTERITIS NODOSA | What are some clinical features of polyarteritis nodosa?
- Systemic = fever, weight loss, arthralgia - Cardio = aneurysms, thrombosis + HTN - Renal = haematuria, renal failure - Does NOT affect pulmonary vessels
222
FIBROMYALGIA What is fibromyalgia? What is the epidemiology?
- Widespread pain throughout the body with tender points at specific anatomical sites - F>M, 30–50y
223
FIBROMYALGIA | What is the clinical presentation of fibromyalgia?
- Chronic pain at multiple sites, sometimes all over - Lethargy, cognitive impairment (fibro fog) - Sleep disturbance, headaches, dizziness
224
FIBROMYALGIA How is fibromyalgia diagnosed? What is the management of fibromyalgia?
- Diagnosis likely = tender in 11/18 tender points (9 pairs) in body - MDT approach = CBT, aerobic exercise, meds (amitriptyline, pregabalin)
225
GANGLION What is a ganglion? What are some features? How are they managed?
- Smooth fluid filled swelling near a joint or tendon - 90% dorsum of wrist, F>M, may limit movement, cause pain or nerve pressure Sx - Resolves spontaneously

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