MSK/ Rheumatology/ Orthopaedic Surgery Flashcards

Question

Explain the pathogenesis of rheumatoid arthritis.

Answer 1

Combination of genetic and environmental factors. Genetic - family history increases risk, many loci identified including PTPN22 and PADI genes. Environment - Smoking --> expression of peptidylarginine deiminase by alveolar macrophages --> citrullination of proteins --> novel antigens stimulate immune response --> PLUS gingivitis --> P. gingivalis also expresses peptidylarginine deiminase --> novel antigen --> immune response --> (1) production of anti-citrullinated protein antibodies (2) activation of T cells --> stimulates of synovial macrophages --> inflammatory cytokines produced --> joint inflammation, activation of MMPs (destroy ECM), stimulates of osteoclasts (bone destruction). (3) activation of synovium with angiogenesis, hyperplasia --> forms pannus and destroys joint.

Answer 2

SYMPTOMS - Chronicity: greater than 6 wks of symptoms - Prolonged early morning stiffness > 30 min - Loss of function - Joint pain - Swelling - Systemic symptoms: weight loss, fatigue, fever ``` SIGNS: LOOK - - Symmetrical polyarthritis - Involves typical joints: MCP and PIP (not DIP!), MTP, elbow, shoulder, ankle, knee, c spine - Swelling - Erythema - Joint deformities: Swan neck, Boutonniere, ulnar deviation of fingers, volar subluxation, Z thumb FEEL - - Tender - Warm - Feels 'boggy' from effusion (not bony) MOVE - - Limited ROM ```

Answer 3

- Fatigue - Weight loss - Fever Muscles, Bones and Joints --> - Osteopenia and osteoporosis - Muscle wasting and weakness - Rheumatoid nodules - commonly on olecranon - Carpal tunnel Neurological --> - Mononeuritis multiplex - asymmetrical sensory and motor neuropathy in at least 2 separate areas (commonly foot drop and wrist drop) Cardiovascular --> - Vasculitis --> rash (palpable purpura, ulceration, splinter haemorrhages) - Coronary artery disease risk - Pericarditis Respiratory --> - Interstitial lung disease - Pleuritis Haem --> - Felty's syndrome: triad of RA, splenomegaly and neutropenia - Anaemia of chronic disease Eyes --> - Scleritis - Episcleritis - Uveitis

Answer 4

History and examination Lab tests - - RF: antibody (IgM) against IgG - NOT SPECIFIC (found in up to 10% of healthy people), but when pre-test probability is high has a high PPV - i.e. if a patient with inflammatory arthritis has RF --> they likely have RA. RF also gives prognostic information - if +, more aggressive disease and more likely extra-articular manifestations. - Anti-CCP antibodies: more specific than RF, also useful prognostically - FBC often abnormal: anaemia, thrombocytosis - ESR and CRP typically elevated Can consider: - ANA, anti-dsDNA and anti-Smith for SLE - Uric acid for gout ``` IMAGING: Obtain XR - diagnostic and for baseline and monitoring - SYMMETRICAL NARROWING - SUBCHONDRAL EROSIONS - PERIARTICULAR OSTEOPENIA - SOFT TISSUE SWELLING ``` Consider synovial fluid analysis.

Answer 5

SUPPORTIVE CARE - MODERATE EXERCISE improves joint function and ROM (not intensive - can worsen large joint disease), can be combined with PHYSIOTHERAPY to provide a regimen of ROM exercises - OT: assistive devices - PSYCHOLOGIST - SUPPORT GROUP - HEALTHY DIET: Mediterranean diet, certain spices (e.g. ginger), antioxidants and probiotics can reduce disease activity PHARMACOTHERAPY Initial treatment = Begin DMARD ASAP - Usually methotrexate (if CI, consider sulfasalazine or leflunomide) used +/- short course of low-dose corticosteroid (used for rapid symptom control - because DMARDs have a delayed effect) +/- NSAIDs for analgesia - no disease-modifying properties If insufficient response --> - Add second DMARD or - Add biologic - usually TNF-a inhibitor SURGERY - May be required if severe joint disease and uncontrolled pain - Joint replacement REGULAR FOLLOW-UP/ MONITORING - Refer to rheumatologist - Use a validated scoring system to rate disease activity at regular intervals MANAGE COMORBIDITIES: - CVD risk --> because increased risk of CAD ensure risk factors are controlled - Osteoporosis risk - can occur as part of RA, or due to steroid treatment - MOOD disorders - ask about mood, psychology/psychiatry

Answer 6

``` EARLY, LOCAL - Vascular injury, haemorrhage, shock - Nerve injury - Infection - Compartment syndrome - Avascular necrosis EARLY, GENERAL - Fat embolism - Immobilisation --> DVT, PE ``` ``` LATE, LOCAL - Non-union - Malunion - OA - Complex regional pain syndrome LATE, GENERAL - Atelectasis --> pneumonia - Immobilisation --> deconditioning, loss of independence, nursing home ```

Answer 7

1. Clinical assessment HX - AMPLE: allergies, medications, PMH, last meal, events surrounding injury (mechanism) EXAM - Inspection, gentle palpation, neurovascular exam (neuro: motor, sensation; vascular: warmth, pulses, capillary refill) 2. Imaging 2 views at 90 degrees 2 limbs (compare both sides) 2 joints (above and below the suspected break) 2 time points (for bones susceptible to avascular necrosis) 3. Analgesia 4. Definitive treatment Reduction --> fixation --> immobilisation May involve surgery - Orthopaedic consult - Prepare for surgery: NBM, IV cannula, bloods, consent Before casting, need to splint until soft tissue swelling resolves Be sure to check fit of splint/cast -- do NOT compromise neurovascular status (e.g. too tight), do NOT compromise soft tissues (adequate padding, not rubbing) XR again once reduced to ensure correct positioning 5. + for open fractures - Antibiotics - Tetanus prophylaxis - Prompt irrigation and debridement 6. Immobilised? = DVT prophylaxis 7. Patient education - - Safety netting - when to return to ED 8. Arrange follow-up - If more imaging is needed, to remove cast, for physiotherapy/ rehabilitation etc.

Answer 8

The supply is mainly from the medial and lateral circumflex arteries, branches of the femoral a. A small amount of blood is supplied in the artery that accompanies the ligament of the head of the femur (branch of the obturator a.) - this is INADEQUATE to supply the femoral head if the circumflex arteries are damaged --> avascular necrosis

Answer 9

Scaphoid fracture | Distal radial fracture (Colles)

Answer 10

- Pain - Unable to weight bear - Shortened and externally rotated leg - Possible soft tissue injury/ bruising

Answer 11

- Hx of fall onto outstretched hand - On examination --> Pain on palpation of the anatomical snuffbox Pain when compressing in the axial direction through the first MCP (push thumb into wrist)

Answer 12

XR - best initial test But 25% of scaphoid fracture are initially undetectable on XR. If initial XR is negative, but clinical suspicion remains --> either: 1. Immobilise with a cast and repeat XR in 2 weeks 2. Wrist MRI

MSK/ Rheumatology/ Orthopaedic Surgery Flashcards

(36 cards)