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Year 4 > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

1
Q

Rheumatoid arthritis (RA)

A

a chronic systemic inflammatory autoimmune disorder that primarily affect the joints but may also manifest with extra articular features e.g. rheumatoid nodules or pulmonary fibrosis

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2
Q

Epidemiology of rheumatoid arthritis (RA)

A

affects ~1% of the population

more commonly seen in women (2-4x)

peak age of onset 30-50 yrs

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3
Q

Risk factors for rheumatoid arthritis (RA)

A

smoking*
genetic predisposition (HLA-DR4, HLA-DR1)
obesity
Family history of RA

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4
Q

Arthritic presentation of rheumatoid arthritis (RA)

A

Polyarthritis:
symmetrical pain, swelling, heat, stiffness (stiffness worse in morning lasting >30min) of affected joint
usually affects metacarpopahryngeal (MCP) / proximal interphalangeal (PIP) / metatarsopharyngeal (MTP) joints, later progressing to affect larger joints

Joint deformities (later in disease):
swan neck deformity (PIP hyperextension, DIP flexion)
boutonniere ferocity (PIP flexion, DIP hyperextension)
Z deformity of thumb (hyperextension of interphalangeal joint, fixed flexion of MCP)
ulnar deviation of fingers
atlantoaxial subluxation
piano key sign (dorsal subluxation of ulna)

NB Distal interphalangeal joints (DIP) are really affected, DIP involvement usually indicates psoriatic arthritis

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5
Q

extra articular manifestations of rheumatoid arthritis (RA)

A

Rheumatoid nodules:
skin (non tender firm swellings)
lungs (bilateral & peripheral)

Lungs:
pleuritic chest pain, fibrosis

Eyes:
keratoconjunctivitis sicca (most common)
episcleritis, scleritis

anaemia
carpal tunnel syndrome 
purpura 
vasculitic ulcers
Raynauds phenomenon (recurrent vasospasm of fingers & toes)
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6
Q

Examination findings for rheumatoid arthritis (RA)

A

compression test (Gaenslen squeeze test) = painful compression of MCP joint

may present as painful handshake

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7
Q

Investigation findings for rheumatoid arthritis (RA)

A

ESR/CRP (↑)
FBC (normochromic normocytic anaemia + thrombocytosis)
LFTs (↑ALP, ↑ gamma GT)
Rheumatoid factor (+ve in 70% of pts)
Antinuclear antibody - ANA (+ve in 30% of pts)
anti-cyclic citrullinated peptide (anti-CCP) antibody (+ve in 70% of pts)

synovial fluid analysis (cloudy, yellow appearance, leucocytosis (WBC = 5000-50,000) ↑proteins)

X-rays (early = loss of joint space, juxta-articular osteoporosis, soft tissue swelling, late= periarticular erosions, subluxation, bon/cartilage erosion, suchondral cysts)

USS (synovitis)

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8
Q

Imagine findings for rheumatoid arthritis (RA)

A

X-rays:
early = loss of joint space, juxta-articular osteoporosis, soft tissue swelling
late= periarticular erosions, subluxation, bon/cartilage erosion, suchondral cysts

USS; synovitis

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9
Q

Disease severity score for rheumatoid arthritis (RA)

A

DAS28

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10
Q

Diagnostic criteria for rheumatoid arthritis (RA)

A

≥6 points is considered RA

Joint distribution:
1 large joint = 0 points
2-10 large joints = 1 point
1-3 small joints = 2 points
4-10 small joints = 3 points
>10 joints (at least 1 small) = 5 points

Serology:
negative RF & anti-CCP = 0 points
low positive RF or anti-CCP = 2 points
high positive RF or anti-CCP = 3 points

Duration:
< 6 weeks = 0 points
> 6 weeks - 1 point

Acute phase reactants:
normal CRP/ESR = 0 points
↑ CRP/ESR = 1 point

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11
Q

Antibodies for rheumatoid arthritis (RA)

A

Rheumatoid factor (+ve in 70% of pts)

Antinuclear antibody - ANA (+ve in 30% of pts)

anti-cyclic citrullinated peptide (anti-CCP) antibody (+ve in 70% of pts)

anti-CCP is most specific

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12
Q

Non drug management of rheumatoid arthritis (RA)

A

MDT approach
exercise
pain clinics

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13
Q

Pharmacological management rheumatoid arthritis (RA)

A

Symptomatic treatment:
NSAIDs (e.g. ibuprofen, naproxen) or COX-2 inhibitors (e.g. celecoxib) + a PPI (e.g. lansoprazole)

Corticosteroids:
for short-term flare up management and short term bridging treatment when starting DMARDs

DMARDs:
1st line: Methotrexate + corticosteroids to bridge treatment
other options: hydroxychloroquine, sulfalazine, leflunomide

Biologicals:
if moderate/severe disease after >3 months of DMARDs
e.g. rituximab, TNF-inhibitors (e.g. adalimumab, etanercept)

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14
Q

Methotrexate

A

given once a week orally, usually co-precribed with folic acid

monitoring: FBC / LFTs / renal function

Side effects: myelosuppresion, liver cirrhosis, pneumonitis, teratogenic (i.e. do not get pregnant )

NB avoid NSAIDs on day of methotrexate dose

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15
Q

Hydroxychloroquine

A

no regular blood test required

considered safe in pregnancy

side effects: retinopathy (bullseye retinopathy), corneal deposits

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16
Q

Sulfalazine

A

safe in pregnancy

monitoring: FBC / LFTs / renal function

side effects: interstitial lung disease, oligospermia, Heinz body anaemia, rash

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17
Q

Leflunomide

A

monitoring: FBC / LFTs / renal function / BP&weight

side effects: cushingoid features, osteoporosis, impaired glucose tolerance, HTN

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18
Q

Felty’s syndrome

A

complication of rheumatoid arthritis

triad of RA, splenomegaly, neutropenia
only seen in seropositive RA

treat firstling with methotrexate

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19
Q

Caplan syndrome

A

complication of rheumatoid arthritis in combination with pneumoconiosis (e.g. asbestosis/silicosis)

rapid development of basilar nodules & obstruction of ventilation

usually seen with coal dust exposure

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20
Q

Occular complications of rheumatoid arthritis

A

dry eye syndrome (keratoconjunctivitis sicca)
episcleritis
scleritis
steroid induced cataracts

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21
Q

Other complications of rheumatoid arthritis

A 
osteoporosis 
respiratory (bronchiolitis, pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis)
raynauds phenomenon 
depression
amyloidosis
carpal tunnel syndrome 
vasculitis & vasculitic ulcers
atlanta axial subluxation (due to inflammatory destruction of ligaments )
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22
Q

Raynaud phenomenon

A

characterised by paroxysmal vasospasm & subsequent vasodilatory chain of events affecting peripheral arterioles usually in the hands & feet

typically presents in young women

triggers: cold, emotional stress

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23
Q

Aetiology of raynauds

A

primary = raynauds disease:
onset usually <30y/o

secondary = raynauds phenomenon
may be related to RA, SLE, scleroderma, meds (COCP)
usually later onset in RA/SLE, >40 y/o

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24
Q

Presentation of Raynauds

A 
usually symmetrical
ischaemic phase (white) = vasoconstriction → hypoxic phase (blue) → hyperaemic phase (red) = vasodilation 
affects fingers & toes
lasts 15-30 min after removing trigger
no tissue damage / ulceration in primary
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25
Q

Management of Raynauds

A

avoid triggers

1st line: Nifedipine
2nd line: IV prostacyclin (lasts weeks to months)

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26
Q

Polymyalgia rheumatica (PMR)

A

inflammatory condition of unknown cause

generally affects people ~70y/o, more common in women

usually seen in pts of northern european descent

associated with HLA-DR4 & giant cell arteritis (10% of PMR pts have GCA)

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27
Q

Presentation of polymyalgia rheumatica (PMR)

A

usually rapid onset (,1 month)
fatigue, malaise, weight, polyarthralgia
morning stiffness (>45min)
symmetric pain/aches of shoulders/pelvic girdle/neck
no weakness

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28
Q

Investigating polymyalgia rheumatica (PMR)

A

ESR & CRP (↑) (ESR >50mm/h)
negative Rheumatoid factor
no autoantibodies
USS (bursitis of affected joint)

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29
Q

Management of polymyalgia rheumatica (PMR)

A

low dose corticosteroids e.g. 15mg prednisolone (typically dramatic response to steroids)

NB if no response to steroid consider alternative diagnosis

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30
Q

Giant cell arteritis (GCA) / temporal arteritis

A

Type of large vessel vasculitis

granulomatous vasculitis of large & medium sized arteries primarily affecting branches of the external carotid arteries, most commonly the temporal artery

most common form of systemic vasculitis in adults

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31
Q

Epidemiology of giant cell arteritis (GCA)

A

most commonly seen in northern european populations

typical onset >50y/o
more common in women (2-3x)

commonly associated with polymyalgia rheumatica (up to 50% of GCA pts have PMR)

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32
Q

Presentation of giant cell arteritis (GCA)

A 
usually rapid onset (<1 month)
headache (temporal/occipital)
scalp tenderness 
unexplained facial pain
jaw claudication 
vision loss/abnormality, diplopia, amaurosis fugax
abnormal temporal artery on palpation
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33
Q

Investigations for giant cell arteritis (GCA)

A

ESR & CRP (↑)
FBC (normochromic normocytic anaemia)
Temporal artery biopsy (gold standard)
temporal artery USS (halo sign, wall thickening, stenosis)

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34
Q

Management of giant cell arteritis (GCA)

A

1st line: glucocorticoids e.g, prednisolone (give even if negative biopsy but GCA suspected)
+prophylaxis against side effects of long term steroid use e.g. bone protection

NB if no response to steroids, reconsider diagnosis

urgent ophthalmological review (visual loss often irreversible)

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35
Q

Sjogren syndrome

A

systemic autoimmune condition with lymphocytic infiltration of exocrine glands

Types:
primary = idiopathic, associated with HLA-DR52
secondary (~60% of cases) = associated with RA, SLE, systemic sclerosis, primary biliary cirrhosis

onset usually age 30-40 yrs
~10x more common in women

↑ risk of lymphocytic malignancy (MALT lymphoma)

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36
Q

Sjogren syndrome presentation

A 
Xerostomia (dry mouth)
xerophthalmia (dry eyes)
keratoconjunctivitis sicca 
vaginal dryness & dyspareunia
dental carries
faitgue
arthrlagia
recurrent parotitis
nasal dryness
raynauds
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37
Q

Sjogren syndrome investigations

A 
ESR (↑)
Rheumatoid factor - RF (+ve in 50%)
Antinuclear antibody - ANA (+ve in 70%)
anti La - SSB (+ve in 30%)
anti Ro - SSA (+ve in 70%)

Schirmers test (quantitatively measures tears) = +ve (<5mm of paper in 5 min)

salivary gland biopsy (focal lymphocytic infiltration)

USS of parotid glands

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38
Q

Sjogren syndrome antibodies

A

Rheumatoid factor - RF (+ve in 50%)
Antinuclear antibody - ANA (+ve in 70%)
anti La - SSB (+ve in 30%)
anti Ro - SSA (+ve in 70%)

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39
Q

Sjogren syndrome management

A

Symptomatic treatment:
artificial tears, artificial saliva, regular dental hygiene
pilocarpine (muscarinic agonist) = ↑ saliva & tear production

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40
Q

Antiphospholipid syndrome

A

autoimmune disorder with ↑ risk of thrombosis as a result of procoagulatory antibodies causing a hypercoaguable state

may be:
primary = idiopathic, associated with HLA-DR7
secondary = associated with SLE, RA, neoplasms

more common in females, usually seen young, fertile women

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41
Q

Antiphospholipid syndrome presentation

A

recurrent thrombotic events (DVT/PE/livido reticular/sinus thrombosis/stroke/TIA/MI)
recurrent miscarriages/premature birth/IUGR/pre-eclampsia
pulmonary hypertension
thrombocytopenia
arthralgia
splinter haemorrhages

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42
Q

Antiphospholipid syndrome investigations

A

antiphospholipid antibodies (aPL) / Lupus anticoagulant / anticardiolipin antibodies (on 2 occasions ≥12 weeks apart)
FBC (thrombocytopenia, haemolytic anemia)
clotting (↑APTT)
USS for DVT
MRI/CT (for CVD & PEG)

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43
Q

Antiphospholipid syndrome management

A

lifestyle modifications

acute management: LMWH/UFH

thromboprophylaxis: low dose aspirin (primary), or warfarin (secondary)

low dose LMWH in pregnancy if ≥pregnancy losses

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44
Q

Ankylosing spondylitis

A

a type of seronegative spondyloarthropathy, a chronic inflammatory disease of the axial skeleton leading to partial / complete fusion & rigidity of the spine

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45
Q

Epidemiology of Ankylosing spondylitis

A

peak onset 20-30yrs
3:1 male:female ratio

NB women tend to have milder, subclinical disease

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46
Q

Genetics of Ankylosing spondylitis

A

strong family tendency (~90% of disease inherited genetically)

associated with HLA-B27

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47
Q

Presentation of Ankylosing spondylitis

A

back & neck pain (gradual onset, dull pain, slowly progressive)
morning stiffness (improves with activity)
tender sacroiliac joints & buttock pain
↓ mobility of spine (↓ lateral & forward flexion)
↓ chest expansion
enthesitis (especially of achilles tendon)
unilateral anterior uveitis
fatigue
↓ lumbar lordosis

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48
Q

Investigations for Ankylosing spondylitis

A

pelvic X-ray (sacroilitis = subchondral erosions, sclerosis)

CRP/ESR (↑)

HLA-B27 (+ve)

Spine X-ray (bamboo spine, single central radio dense line (dagger sign), squared vertebral bodies, bony bridges between adjacent vertebrae, syndesmophytes)

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49
Q

Imaging findings for Ankylosing spondylitis

A

Spine X-ray (bamboo spine, single central radio dense line (dagger sign), squared vertebral bodies, bony bridges between adjacent vertebrae, syndesmophytes)

pelvic X-ray (sacroilitis = subchondral erosions, sclerosis)

Chest X-ray (apical fibrosis)

MRI/CT

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50
Q

Management of Ankylosing spondylitis

A

1st line: physiotherapy & NSAIDs

2nd line: TNF-alpha inhibitors or DMARDs e.g. sulfalazine if peripheral arthritis

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51
Q

complications of Ankylosing spondylitis

A

osteoporosis
cardiac problems e.g. aortic regurg
lung problems e.g. apical fibrosis, restrictive pulmonary disease

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52
Q

Psoriatic arthritis / psoriatic arthropathy

A

chronic inflammatory joint disease associated with psoriasis, its a seronegative inflammatory arthritis

~80% of its have preceding arthritis

most common in middle age, 35-55 yrs

associated with HLA-B27/B17/DR4/DR7

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53
Q

Presentation of psoriatic arthritis

A

most common presents as asymmetric oligoarthritis mainly affecting DIP & PIP joint with possible spinal involvement (sacroilitis)
enthesitis (mainly achilles tendon & plantar fascia)
tenosynovitis
dactylics (single digits, inflammation & swelling)
nail changes (pitting, yellowing, onycholysis)
history of scalp/nail problems
psoriasis

NB DIP involvement is indicative of psoriatic arthritis

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54
Q

Investigating psoriatic arthritis

A

X-rays of hands & feet (asymmetrical bony erosions, DIP/PIP involvement)

ESR/CRP (↑)

synovial fluid aspirate (no crystals, ↑ WCC)

CASPAR criteria (to diagnose psoriatic arhtirits)

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55
Q

Management of psoriatic arthritis

A

NSAIDs (if mild)
local corticosteroid injection

1st line: DMARDs (consider early in disease e.g. methotrexate (if significant cutaneous psoriasis) or leflunomide, sulfalazine)

2nd line: TNF-alpha inhibitors (inadequate control by DMARDs)

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56
Q

Gout

A

an inflammatory crystal arthropathy caused by the precipitation & deposition of uric acid crystals (monosodium rate crystals) synovial fluid & tissues

more common in men & older people (especially men aged 30-60yrs)

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57
Q

Risk factors for gout

A 
male gender
obesity
HTN
CHD
CKD
HF
diabetes
drugs (e.g. diuretics, chemo, cytotoxic drugs)
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58
Q

Presentation of gout

A

acute onset joint pain with a swollen/tender/erythematous joint (70% of first attacks/50% of all attacks affect 1st metatarsophalangeal (MTP) joint)

other joints affected include knee, wrist, ankles, elbows, small hand joints

tophi may be present (asymmetrical, chalky nodule under skin)

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59
Q

Investigations for gout

A

May be clinical diagnosis if typical presentation in 1st MTP

synovial fluid analysis (strongly negatively bifringent needle-shaped crystals under polarised light)

serum uric acid (>420 micro mol/L in men / >360micromol/L in women)

X-ray (periarticular erosions, punched out lesions, no periarticular osteopenia)

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60
Q

Synovial fluid analysis results for gout

A

strongly negatively bifringent needle-shaped crystals under polarised light

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61
Q

Management of gout

A

Acute attack:
1st line: colchicine & NSAIDs
2nd line: oral prednisolone (if colchicine & NSAIDs contraindicated e.g. Renal problems)

Chronic:
1st line: allopurinol (xanthine oxidase inhibitor)
2nd: febuxostat

Lifestyle modifications:
limit alcohol intake, lose weight

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62
Q

Indications for offering urate lowering therapy

A

Indications for urate-lowering therapy (ULT):

Offer urate-lowering therapy to all patients after their first attack of gout

ULT is particularly recommended if:
>= 2 attacks in 12 months
tophi
renal disease
uric acid renal stones
prophylaxis if on cytotoxics or diuretics
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63
Q

Pseudogout / calcium pyrophosphate deposition disease (CPPD)

A

a crystalline inflammatory arthritis caused by the deposition of calcium pyrophosphate crystals intro articular & periarticular tissues

common in elderly people aged >60 yrs

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64
Q

Causes of pseudogout in younger people

A

in people <60y/o

precipitating factors include haemochromatosis, hyperparathyroidism, ↓Mg2+, ↓Phosphate, acromegaly, Wilson’s disease

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65
Q

Presentation of pseudogout

A

often asymptotic

acute monoarticular/oligoarticular arthritis most often affecting the knees
other joints include wrists, shoulders, ankles, hands, feet
usually older than gout but also painful, swollen, erythematous joints

NB may present as a sudden worsening of osteoarthritis

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66
Q

Investigations for pseudogout

A

synovial fluid analysis (positively bifringent rhomboid shaped crystals under polarised light)

serum Ca/PTH (normal or ↑)

USS

X-ray (chonedrocalcinosis i.e. joint carriage calcificatioN)

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67
Q

Synovial fluid analysis results for pseudogout

A

positively bifringent rhomboid shaped crystals under polarised light

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68
Q

Management of pseudogout

A

1st line: NSAIDs
2nd line: intrarticular steroids
3rd line: systemic steroids / colchicine

NB colchicine used if NSAIDS/Steroid contraindicated

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69
Q

Systemic lupus erythematous (SLE)

A

chronic multisystem autoimmune disease of unknown cause, Type II hypersensitivity reaction

most common in women of childbearing age
onset usually age 20-40 yrs
more common in afro-caribbeans/asians

associated with HLA-B8/DR2/DR3

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70
Q

Presentation of Systemic lupus erythematous (SLE)

A

malar (butterfly) rash (over cheeks & bridge of nose)
fever, fatigue, weight loss
arthritis in 90% of cases (mainly PIP/MCP joints, generally symmetrical)
Rayanuds
photosensitive rash (rash after sun exposure)
discoid lupus (discoid rash in sun exposed area, scaly erythematous plaques)
mouth ulcers
non-scarring alopecia
myalgia

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71
Q

Systemic features of Systemic lupus erythematous (SLE)

A

Cardiac:
pericarditis (most common), endocarditis (Libman-Sacks endocarditis), CAD, aortic valve disease

Pulmonary:
pleurisy, pulmonary fibrosis, interstitial lung disease)

nephritis:
Most dangerous organ complication and a common cause of death in SLE, affects >30% of SLE pts

depression/anxiety
vasculitis

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72
Q

Investigations for Systemic lupus erythematous (SLE)

A

Anti nuclear (ANA) antibody (+ve)
Rheumatoid factor (usually -ve)
anti-dsDNA (+ve)
anti-smith antibodies (+ve)

ESR (↑)

FBC (normochromic normocytic anaemia)

CRP (normal)

antiphospholipid antibodies (may be +ve)

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73
Q

Antibodies for Systemic lupus erythematous (SLE)

A

Anti nuclear (ANA) antibody (+ve)
Rheumatoid factor (usually -ve)
anti-dsDNA (+ve)
anti-smith antibodies (+ve)

NB anti-dsDNA & anti-smith antibodies =most specific

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74
Q

Management of Systemic lupus erythematous (SLE)

A

Simple analgesia & NSAIDs (use with care due to GI/cardiac/renal risks) for pain control
avoid sun exposure
corticosteroids (usually as induction therapy)

1st line: Hydroxychloroquine
2nd line: add methotrexate or azathioprine

Cyclophosphamide (for life threatening disease e..g nephritis)

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75
Q

Exacerbating factors for Systemic lupus erythematous (SLE)

A

oestrogen hormones can exacerbate SLE

consider hormonal contraception carefully

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76
Q

Associated conditions for Systemic lupus erythematous (SLE)

A

antiphospholipid syndrome

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77
Q

Drug induced lupus

A

95% of cases are positive for anti-histone antibodies

implicated drugs include chlorpromazine, methyldopa, hydralazine, isoniazid, d-penicillamine and minocycline

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78
Q

Systemic sclerosis/scleroderma

A

auto-immune mediated tissue disease characterised by production of auto-antibodies and overproduction of collagen due to ↑fibroblast activity leading to abnormal connective tissue growth & fibrosis of skin/organs & vasculopathy

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79
Q

Types of systemic sclerosis

A

limited cutaneous systemic sclerosis (lcSSc):
more common mainly affects distal limbs & face
may present with CREST syndrome (Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia)
associated with anti-centromere antibodies

diffuse cutaneous systemic sclerosis (dcSSc):
less common, affects proximal limbs & trunk as well as face & distal limbs
↑ risk of mortality (mainly pulmonary involvement)
associated with anti-scl-70 antibodies / anti topoisomerase

Scleroderma:
no internal organ involvement, tightening & fibrosis of skin only

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80
Q

Epidemiology of systemic sclerosis

A

5:1 female:male ratio

presentation usually 30-50 yrs

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81
Q

Presentation of limited cutaneous systemic sclerosis

A

a subtype is CREST syndrome

  • Calcinosis
  • Raynaud’s phenomenon
  • oEsophageal dysmotility
  • Sclerodactyly
  • Telangiectasia

scleroderma affects face and distal limbs predominately

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82
Q

Presentation of systemic sclerosis

A

thickening & hardening of skin (skin appears smooth/shiny/puffy)
sclerodactyly (fibrotic thickening & tightening of skin of fingers & hands)
Raynauds
multiple painful ischaemic digital ulcers
joint stiffness & pain
mask like facies
microstomia
salt & pepper appearance of skin (dyspigmentation)
myalgia

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83
Q

Antibodies for systemic sclerosis

A

Anti-nuclear (ANA) antibody (+ve)
anti-scl-70 antibodies / anti topoisomerase associated with diffuse cutaneous systemic sclerosis
anti-centromere antibodies associated with limited cutaneous systemic sclerosis

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84
Q

Myositis

A

systemic inflammatory muscle wasting disease characterised by weakness due to chronic inflammation of skeletal muscle

PM & DM = 2x more common in women

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85
Q

Types of myositis

A

Polymyositis (PM):
inflammatory myopathy affecting proximal skeletal muscle

Dermatomyositis (DM):
similar to polymyositis but with skin involvement

Inclusion body myositis (IBM):
inflammatory myositis affecting proximal & distal skeletal muscle

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86
Q

Polymyositis

A

usually presents age 30-60

symmetrical proximal muscle weakness e..g of pelvic & shoulder girdle, dysphagia, muscle tenderness

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87
Q

Dermatomyositis

A

2 peaks: 5-15yrs & 40-60yrs

symmetrical proximal muscle weakness e..g of pelvic & shoulder girdle, dysphagia, muscle tenderness
gottrons papules (prominent erythematous papules)
heliotrope rash (erythematous rash on upper eyelids)
mechanics hands (hyperpigmentation & thickening of skin on hands)
photosensitive poikiloderma
V-sign erythema (upper chest & neck)

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88
Q

Inclusion body myositis

A

usually presents >60y/o

slowly progressive (over years), weakness of proximal & distal muscles

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89
Q

Investigating myositis

A

often a clinical diagnosis

CK (↑)
ESR/CRP (↑)
LDH (↑)
adolase (↑)
muscle biopsy (gold standard)
EMG
ANA (+ve)
myositis specific antibodies
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90
Q

Management of myositis

A

corticosteroids e.g. prednisolone
UV light protection for DM
physiotherapy

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91
Q

Osteoarthritis (OA)

A

disabling join disease characterised by a non-inflammatory degeneration of the joint complex (articular cartilage, subchondral bone, synovium)

one of the most common chronic diseases

generally age related, ↑ incidence with age

more common in females

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92
Q

Osteoarthritis (OA) risk factors

A 
obesity
family history
female sex
↑ age
history of joint injury/trauma
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93
Q

Osteoarthritis (OA) risk factors

A 
obesity
family history
female sex
↑ age
history of joint injury/trauma
mechanical loading/recreational stress on joint
physically demanding occupation/sports
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94
Q

Osteoarthritis (OA) presentation

A

generally affects hips, knees, CMC, DIP, PIP joints & spine

pain (usually associated with activity, relieved by rest, pain at rest is unusual)
generally unilateral 
joint stiffness
↓ROM
joint swelling
crepitus
morning stiffness (<30min)

usually asymmetrical joint involvement

NB in hands
Painless nodes (bony swellings):
Heberden’s nodes at the DIPJs
Bouchard’s Nodes at the PIPJs.
Squaring of the thumbs: Deformity of the CMC joint = fixed adduction of the thumb.
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95
Q

Osteoarthritis (OA) investigations

A

X-ray (loss of joint space, subchondral sclerosis, subchondral cysts, osteophytes of joint margins)

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96
Q

Osteoarthritis (OA) X-ray findings

A

loss of joint space
subchondral sclerosis
subchondral cysts
osteophytes of joint margins

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97
Q

Osteoarthritis (OA) investigations

A

X-ray (loss of joint space, subchondral sclerosis, subchondral cysts, osteophytes of joint margins)

synovial fluid analysis (non inflammatory, yellow/clear, normal WCC)

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98
Q

Osteoarthritis (OA) management

A

General:
weight loss
physio

Symptomatic:
1st line: paracetamol & topical NSAIDs
2nd line: COX-2 inhibtors, oral NSAIDs, intra-articular steroids

Surgical:
joint replacement

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99
Q

Reactive arthritis

A

an inflammatory arthritis that occurs after expiosure to certain gastrointestinal & genitourinary infections, its a type of seronegative spondyloarthritis

strong association with HLA-B27

usually seen in young adults especially men after STI

Used to be know as Reiters syndrome

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100
Q

Causes of reactive arthritis

A

Post enteric: Campylobacter*, salmonella, shigella

Post-venereal: chlamydia trachomatis*

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101
Q

Presentation of reactive arthritis

A

usually presents 2-4 weeks post infection

classic triad:

  • urethritis (can’t pee)
  • conjunctivitis (can’t see)
  • arthritis (can’t climb trees)

acute onset nausea, fatigue, fever, diarrhoea, urogenital symptoms (dysuria, pelvic pain)

asymmetrical predominantly lower extremity oligoarthritis lower back pain common

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102
Q

Investigations for reactive arthritis

A 
ESR/CRP (↑)
Anti nuclear (ANA) antibody (-ve)
Rheumatoid factor (-ve)
test for HLA-B27 (often +ve)
synovial fluid analysis (↑WCC)
stool/urogenital/throat cultures 
X-rays (normal)
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103
Q

Management of reactive arthritis

A

Symptomatic:
NSAIDs & intraarticular steroids

treat cause:
Abx (to treat organism identified)

persistent disease:
sulfalazine / methotrexate

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104
Q

Septic arthritis

A

infection producing inflammation in a native or prosthetic joint, most commonly due to haematogenous spread of infection

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105
Q

Septic arthritis aetiology

A

stap aureus = most common overall

in young sexual active adults Neisseria gonorrhoea is the most common cause

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106
Q

Risk factors for Septic arthritis

A 
↑ age
diabetes
prosthetic joint
immunosuppression 
underlying joint disease e.g. RA
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107
Q

Presentation of Septic arthritis

A 
knee = most commonly affected joint in adults
knee/hip/ankle = most commonly affected joint in children

acute onset of fever, joint pain, restricted ROM
monarticular swollen, erythematous, warm, tender joint

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108
Q

Investigating Septic arthritis

A

synovial fluid sampling* (↑ WCC, positive culture, yellowish/green colour, turbid)

CRP/ESR (↑)

FBC (↑ WCC)

USS (effusion)

blood cultures

X-ray (unremarkable)

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109
Q

Management of Septic arthritis

A

IV Abx:
e.g. flucloxacillin (clindamycin/erythromycin if penicillin allergy)
give for 6-12 weeks

joint drainage & aspiration

arthroscopic lavage

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110
Q

Prosthetic joint septic arthritis

A

often due to skin pathogens eg. staph epidermis or staph aureus if early, i.e. within 12 weeks of implantation

later onset usually doe to haematogenous spread e.g. E. coli, staph aureus, pseudomonas aeruginosa

often managed surgically with irrigation & debridement or exchange of arthroplasty

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111
Q

Synovial fluid analysis in septic arthritis

A

↑ WCC
positive culture
yellowish/green colour
turbid

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112
Q

Paget’s disease

A

slowly progressive disease of ↑ bone turnover causing lamellar bone to be replaced with woven bone, due to disorder of osteoclasts with ↑ osteoclastic bone resorption

onset usually age >55, slight male predominance

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113
Q

Risk factors for Paget’s disease

A

Family history of pagets
male gender
↑ age

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114
Q

Presentation of Paget’s disease

A

commonly asymptomatic (only ~5% of pts symptomatic)

bone pain e.g. pelvis/lumbar spine/femur
if untreated leads to bossing of skull, bowed tibia
pathological fractures
↑ skin temp in areas of disease
usually only affects 1 bone
impaired hearing (due to cranial nerve entrapment)

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115
Q

Investigations for Paget’s disease

A

PTH/phosphate/calcium (normal)

ALP - Alkaline phosphatase (↑↑↑)

X-ray (advancing V-shaped lytic lesions, pathological fractures, cotton wool, osteolysis↑ & bone formation↑)

bone scan (areas of dense uptake in pagetoid bone)

Markers of bone turnover e.g. PINP/CTx/NTx (↑)

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116
Q

Management of Paget’s disease

A

Symptomatic treatment:
NSAIDs/paracetamol for pain
Vit D & Calcium supplements

1st line: Bisphosphonates e.g. zolendronate
2nd line: Calcitonin

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117
Q

Complications of Paget’s disease

A

bone sarcoma

high output cardiac failure

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118
Q

Osteoporosis

A

a complex skeletal disease characterised by low bone density and micro-architectural defects in bone tissue resulting in ↑ bone frailty & ↑ susceptibility to fractures

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119
Q

Osteoporosis

A

a complex skeletal disease characterised by low bone density and micro-architectural defects in bone tissue resulting in ↑ bone frailty & ↑ susceptibility to fractures

more common in women
age of onset usually 50-70yrs

very common overall (1/3 women & 1/5 men in their lifetime)

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120
Q

T-score

A

based on bone mass of young reference population

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121
Q

Z-score

A

bone mass adjusted for age, gender, ethnicity

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122
Q

Bone density measurements

A

normal:
T-score ≥-1

Osteopenia:
T-score -2.5

Osteoporosis:
T-score ≤-2.5

Severe Osteoporosis:
T-score ≤-2.5 + a fracture

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123
Q

Risk factors for osteoporosis

A 
female sex
↑ age
white ethnicity
psot menopausal
corticosteroid use
smoking 
low BMI
family history 
excessive alcohol intake
Chronic disease (CKD, RA, UC, Crohns, coeliac, cushing etc)
drugs (e.g. PPIs, anticonvulsants)
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124
Q

Investigating osteoporosis

A

DEXA scan (T-score ≤-2.5)

Fracture risk assessment tool (FRAX) / QFracture (to asses 10 year risk of frailty fracture)

investigate for underlying cause

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125
Q

Management of osteoporosis

A

For everyone: Vit D supplementation ± calcium supplementation (depending on dietary intake)

1st line: bisphosphonates e.g. alendronate (1st line) or risendronate

2nd line: denosumab (if bisphosphonates contraindicated / special instructions can’t be adhered to)

3rd line: Raloxifene or Strontium ranelate

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126
Q

Bisphophonates

A

Bisphosphonates are analogues of pyrophosphate, they inhibit osteoclasts by reducing recruitment and promoting apoptosis.

Examples:
alendronate, risendronate

Side effects:
oesophagitis/oesophageal ulcers
osteonecrosis of the jaw

How to take:
Tablets should be swallowed whole with plenty of water while sitting or standing; to be given on an empty stomach at least 30 minutes before breakfast (or another oral medication); patient should stand or sit upright for at least 30 minutes after taking tablet’

Hypocalcemia/vitamin D deficiency should be corrected before giving bisphosphonates.

Contraindications include inability to follow special instructions for administration & history of peptic ulcers

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127
Q

Stopping Bisphophonates

A

The duration of bisphosphonate treatment varies according to the level of risk. Some authorities recommend stopping bisphosphonates at 5 years if the following apply:
patient is < 75-years-old
femoral neck T-score of > -2.5
low risk according to FRAX/NOGG

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128
Q

Osteomalacia

A

is a metabolic bone disease characterised by incomplete mineralisation of the underlying mature bone matrix following growth plate closure in adults

the primary cause is Vit D deficiency

NB if its before growth plate closure = rickets

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129
Q

Risk factors for osteomalacia

A 
dark skin
↑ age
obesity
pregnancy 
housebound/institutionalised 
liver disease e..g cirrhosis 
CKD
limited sun exposure
anticonvulsant therapy
malabsorption syndromes 
diet (e.g. vegan)
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130
Q

Presentation of osteomalacia

A

bone pain & tenderness
pathological fractures
waddling gait & difficulty walking
muscle weakness/spasms/cramps

NB in rickets: knock knees, bow legs, features of hypocalcaemia

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131
Q

Investigations for osteomalacia

A 
serum 25-hydrovitamin D (↓)
Ca2+ (↓/normal)
Phosphate (↓)
urea & creatinine (↑ ratio)
alkaline phosphatase (↑)
24h urine calcium (↓)
PTH (↑)

X-rays (translucent bands/↓ bone mineral density, pseudo fracture - linear areas of low bone density sourounded by sclerotic borders)

DEXA scan (↓ bone density)

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132
Q

Management of osteomalacia

A

dietary advice

Vit D & calcium supplementation (nb high dose for 8-12 weeks to replenish stores, then lower dose as maintenance)

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133
Q

Osteomyelitis

A

an infection of the bone marrow which may spread to the bone cortex & periosteum via haversian canals, generally involving a single bone

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134
Q

Types of Osteomyelitis

A

Haematogenous:
due to haematological bacterial seeding from a remote site, usually monomicrobial
more common in children & adolescents

Direct (contiguous):
direct contact of infected tissue with bone, usually more localised clinical signs
more common in adults

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135
Q

Aetiology of Osteomyelitis

A

staph aureus most common

in sickle cell pt most common = salmonella

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136
Q

Presentation of Osteomyelitis

A 
limp
reluctance to weight bear
non specific pain at site of infection
malaise, fatigue, fever
local inflammation, tenderness, erythema, swelling

vertebral involvement very common in adults

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137
Q

Investigating Osteomyelitis

A

may be a clinical diagnosis

CRP/ESR (↑)
FBC (↑WCC)
blod cultures
X-ray of affected area
MRI* (Imaging modality of choice)
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138
Q

Management of Osteomyelitis

A

Abx
e.g. flucloxacillin (or erythromycin/clarithromycin if penicillin allergy)

surgical:
bone debridement, abscess drainage, remove infected prosthesis

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139
Q

Risk factors for Osteomyelitis

A 
trauma
prosthetic orthopaedic device
diabetes
PAD
IVDU
alcoholism
immunosuppression
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140
Q

Compartment syndrome

A

a condition of ↑ pressure within a muscular compartment leading to impaired tissue perfusion due to the ↑ pressure in a closed anatomical space compromising circulation and leading to temporary/permanent muscle & nerve injury

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141
Q

Types of Compartment syndrome

A

acute:
usually due to trauma, requires prompt diagnosis & treatment

chronic:
usually caused by exercise, present wit recurrent pains & disability which subsides when exercise is stopped

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142
Q

Sites for Compartment syndrome

A

upper & lower limb compartments

most commonly anterior & deep posterior compartment of leg & the solar compartment of the forearm

i.e. supracondylar fractures and tibial shaft injuries

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143
Q

Aetiology of Compartment syndrome

A

Acute:
trauma, burns, casts/constrictive bandages, fractures, haematomas

Chronic:
usually in lower legs, exercise induced

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144
Q

Presentation of Compartment syndrome

A

pain, pallor, paraesthesia, pulselessness, paralysis, poikilothermia
soft tissue sweeling
cold peripheries
abesnt/weak pulses
pain (often out of proportion of extent of injury

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145
Q

Investigating Compartment syndrome

A

usually clinical diagnosis

compartment pressure measurement (↑, <40mmHg)

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146
Q

Management for Compartment syndrome

A

prompt & extensive fasciotomy (surgical emergency)
in burns escharotomy

IV fluid resuscitation (to prevent renal failure from myoglobinuria)

if muscle is necrosed may need debridement or amputation

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147
Q

Developmental dysplasia of the hip (DDH)

A

refers to hip instability, subluxation/dislocation of the femoral head and/or acetabular dysplasia in the developing hip joint

~20% are bilateral

~80% of all cases are female

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148
Q

Risk factors for Developmental dysplasia of the hip (DDH)

A 
female sex
breech presentation 
family history of DDH
first born child
oligohydramnios
multiple pregnacy
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149
Q

Routine screening for Developmental dysplasia of the hip (DDH)

A

routine part of NIPE & new-born examination at 6-8 weeks
Barlow test: attempts to dislocate articulated femoral head
Ortolani test: attempts to relocated dislocated femoral head

also look at leg length symmetry, asymmetrical gluteal/thigh folds, Galeazi sign (level of knees with hips & knees flexed)

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150
Q

Presentation of Developmental dysplasia of the hip (DDH)

A

generally asymptomatic in early life

later:
hip pain abnormal leg positing
delayed crawling/walking
toe walking

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151
Q

Investigating Developmental dysplasia of the hip (DDH)

A

USS (subluxation on provocation test, abnormal relationship between femoral head & acetabulum)

X-ray (abnormal relationship of femoral head & acetabulum)

NB use X-ray first line if infant >4.5 months

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152
Q

Managing Developmental dysplasia of the hip (DDH)

A

generally spontaneously stables by 3-6 weeks of age

pavlik harness in children aged <4-5 months

surgery:
if response to splint or harness or if late diagnosis

153
Q

ultrasound screening for Developmental dysplasia of the hip (DDH)

A

Performed at 6 weeks

used if first degree family history of hip problems in early life
breech presentation at/after 36 weeks irrespective of mode of birth & presentation at delivery
multiple pregnancy
breech presentation at delivery before 36 weeks

154
Q

Perthes disease

A

degenerative self limiting disease of the femoral head compromising of necrosis, collapse, repair & remodelling, due to avascular necrosis of the femoral epiphysis

usually presents age 3-10 yrs
5x more common in boys

155
Q

Presentation of perthes disease

A

onset over weeks with no history of trauma
limp
limited ROM of hip
hip pain
stiffness
short statue common
some muscle wasting of gluteals & quadriceps

156
Q

Investigating perthes disease

A

Bilateral AP & frog leg lateral hip X-rays (show femoral head collapse & fragmentation, subchondral fractures, joint space widening)

Bone scinitgraphy (technetium bone scan)

157
Q

Managing perthes disease

A

children <6y/o
conservative (NSAIDs, physio, restriction of activities)

children >6y/o / extensive damage
surgical management with femoral osteotomy

158
Q

Catterall staging

A

For perthes disease

Stage 1 Clinical and histological features only
Stage 2 Sclerosis with or without cystic changes and
preservation of the articular surface
Stage 3 Loss of structural integrity of the femoral head
Stage 4 Loss of acetabular integrity

159
Q

Slipped upper femoral epiphysis (SUFE)

A

weakness of the proximal femoral growth plate allows displacement of the capital femoral epiphysis

more common in boys
usually age 10-16yrs

160
Q

Slipped upper femoral epiphysis (SUFE) risk factors

A 
obesity
family history
endocrine disorders
trauma
puberty
161
Q

Slipped upper femoral epiphysis (SUFE) presentation

A

often seen in obese boys usually aged 10-16yrs (especially during growth spurts)

20-40% are bilateral

dull pain in medial thigh/knee/groin/hip
limping
↓ ROM
affected leg is externally rooted
loss of internal rotation in flexion
162
Q

Slipped upper femoral epiphysis (SUFE) investigations

A

Bilateral AP & frog leg lateral hip X-rays (Klein’s line does not intersect the femoral head, femoral head is displaced posterior-inferioir in relation to femoral neck, widening of growth plate)

163
Q

Slipped upper femoral epiphysis (SUFE) mangement

A

immediate orthopaedic referral

surgery: usually single crew placed in centre of epiphysis

164
Q

Slipped upper femoral epiphysis (SUFE) compilations

A

early hip OA

chondrolysis of hip (degeneration of articular cartilage)

165
Q

Osgood-Schlatter disease

A

Tibial osteochondritis thought to arise from overuse if the quadriceps muscles during periods of growth

one of the most common causes of knee pain in active adolescents who play sport

more common in boys (often age 12-15)

166
Q

Presentation of Osgood-Schlatter disease

A 
progressive anterior knee pain that is worse with activity & reproducible by extension against resistance 
proximal tibial swelling
pain usually gradual onset
pain relived by rest
tenderness over tibial tuberosity
167
Q

Investigating Osgood-Schlatter disease

A

clinical diagnosis

Knee X-ray (enlarge tibial tuberosity)

168
Q

Mangament of Osgood-Schlatter disease

A

usually self limiting so manage conservatively (RICE)

physiotherapy (strengthening & stretching quads)

169
Q

Transient synovitis

A

selflimitng inflammatory disorder of a joint, usually preceded by URTI commonly affecting hip joint

most common cause of hip pain in children aged 3-10 yrs

NB must exclude septic arthritis

170
Q

Presentation of transient synovitis

A

usually younger children (4-10y/o) with preceding viral infection e.g. URTI

unilateral hip/groin pain (not severe)
limp
refusal to weight bear
↓ ROM
Child systemically well (if high grade fever should raise concern of septic arthritis)
171
Q

Investigating transient synovitis

A

X-rays
FBC
ESR/CRP

NB generally all normal

172
Q

Management of transient synovitis

A

self limiting

analgesia

173
Q

congenital talipes equinovarus (CTEV) i.e. club foot

A

congenital orthopaedic condition describing an inverted (upward turning) & plantar flexed foot (i.e. sole of foot pointing medially), usually diagnosed on NIPE

most often idiopathic, ~50% bilateral

associated with spina bifida, cerebral palsy, trisomy 18, oligohydramnios

Management
1st line: serial progressive casting & manipulation (ponseti method)
2nd line: surgery

174
Q

Flat foot (pes planus)

A

flat/convex plantar surface

treated with orthotics, manipulation, surgery

175
Q

Equinus deformity

A

presents as toe walking, leg length discrepancy, impaired stability

inability to dorsiflex foot above plantigrade

treated with surgical correction or manipulation surgeyr

176
Q

Pes cavus (high arch)

A

high longitudinal arch & hind foot virus

treated with orthotics or surgery

177
Q

Myeloma / Multiple myeloma

A

malignant plasma cell dyscrasia characterised by uncontrolled proliferation & diffuse infiltration of monoclonal plasma cells in the bone marrow

arises due to genetic mutation which occur as B-lymphocytes differentiate to mature plasma cells

15-20% of haematological malignancies (2nd most common)

generally affects people aged >70yrs

178
Q

Myeloma presentation

A 
often asymptomatic 
bone pain (especially back pain)
mild fever
night sweats
weakness, weight loss
symptoms of hypercalcaemia (constipation, nausea, anorexia, constipation, thirst)
spontaneous/pathological fractures (due to lytic bone lesions)
lethargy (due to anaemia)
recurrent infections 
foamy urine (Bence-Jones proteinuria)
renal impairment 
bruising / bleeding
179
Q

Investigations for myeloma

A

serum electrophoresis (↑ monoclonal IgG/IgA protein)
urine electrophoresis (↑ Bence-jones protein = immunoglobulin light chain)
serum free light chain assay (↑ levels)
bone marrow biopsy (monoclonal plasma cell infiltration)
FBC (anaemia)
U&Es (↑, renal impairment)
Ca (↑)
whole body MRI/CT (osteoltyic lesions)

180
Q

Management of myeloma

A

If symptomatic + suitable for stem cell transplant:
induction with Bortezomib + Dexamethasone

If symptomatic + not suitable for stem cell transplant:
induction with Thalidomide + an Alkylating agent + Dexamethasone

Relapses:
bortezomib monotherapy

Symptomatic:
VTE prophylaxis
zolendronic acid (to help bone strength)

181
Q

Classifying myeloma

A

depending on what antibody is produced

IgG myeloma most common
followed by IgA

182
Q

Monitoring for myeloma patients

A

FBC
U&Es
Ca2+

183
Q

Osteoma

A

benign overgrowth of bone most typically of skull

associated with gardeners syndrome (variant of familia adenomatous polyposis)

184
Q

Ostechondroma

A

most common benign bone tumour*

bony outgrowth (exostosis) with cartilaginous cap usually occurring on surfaces of long bone adjacent to growth plates

usually seen in males <20y/o

x-ray = pedunculated/sessile lession of long bones

185
Q

Ostechondroma bones affected

A

bony outgrowth (exostosis) with cartilaginous cap usually occurring on surfaces of long bone adjacent to growth plates

186
Q

Osteoclastoma (giant cell tumour of bone)

A

tumours of multinucleate giant cells within a fibrous stroma, usually found on long bone epiphysis

seen in people aged 20-40 yrs

X-ray = asymmetric rarefied area at the end of long bone (soap bubble sign)

187
Q

Osteosarcoma

A

most common primary bone malignancy occurring in metaphysic of long bones (most common site = ~75% around knee & proximal humerus)

mainly seen in children & adolescence

presents as relatively painless tumour mainly with swelling

X-Ray = Codman triangle (form periosteal elevation) + sunburst pattern (soft tissue calcification)

188
Q

Most common primary bone malignancy

A

osteosarcoma

189
Q

Osteosarcoma

A

most common primary bone malignancy occurring in metaphysic of long bones (most common site = ~75% around knee & proximal humerus)

mainly seen in children & adolescence

presents as relatively painless tumour mainly with swelling, usually metastasises to lungs

X-Ray = Codman triangle (form periosteal elevation) + sunburst pattern (soft tissue calcification)

190
Q

Common site of metastases for osteosarcoma

191
Q

Most common site of osteosarcoma

A

~75% around knee & proximal humerus

192
Q

Common site of metastases for osteosarcoma & Ewing’s sarcoma

193
Q

Ewings sarcoma

A

primitive neuroectodermal tumour arising from mesenchymal stem cells, very aggressive (early metastasises to lungs)

usually presents as mass/swelling, most commonly in long bones of arms & legs / pelivs / chest

usually diagnosed around age 15

X-ray: onion skin appearance (multiple layers of new bone)

194
Q

Ewings sarcoma X-ray findings

A

onion skin appearance (multiple layers of new bone)

195
Q

Chondrosarcoma

A

malignant tumour of the cartilage, presents as deep & dull pain + local swelling

usually seen in middle age

196
Q

Fibromyalgia

A

a neurosensory disorder of unknown aetiology characterised by chronic musculocutaneous pain

5-10x more common in women

presents between 20-50y/o

197
Q

Presentation of fibromyalgia

A 
chronic widespread pain primarily at point where muscles & tendon attach to bones (tender points) 
diffuse tenderness on examination
fatigue unrelieved by rest
unrefreshing sleep
headache, morning stiffness, dizziness
cognitive impairment (fibro fog)
198
Q

Investigations for fibromyalgia

A

clinical diagnosis:
symptoms >3 months
presence of ≥11/18 tender points amongst 9 pairs of specced sites

199
Q

Management of fibromyalgia

A

pt education
lifestyle changes
Medication (low dose TCAs/SNRIs)
MDT management

200
Q

Associated conditions with fibromyalgia

A

functional somatic syndromes (e.g. IBS, chronic fatigue syndrome)
depression
GAD
sleep disorders

201
Q

Parts of the bone

A

Diaphysis = shaft of long bone

Metaphysis = between diaphysis & epiphysis

physis = growth plate between epiphysis & metaphysis

epiphysis = end of long bone

202
Q

Salter-Harris fracture classification

A

used for paediatric fractures

I Fracture through the physis only (x-ray often normal)
II Fracture through the physis and metaphysis
III Fracture through the physis and epiphyisis to
include the joint
IV Fracture involving the physis, metaphysis and
epiphysis
V Crush injury involving the physis (x-ray may
resemble type I, and appear normal)

203
Q

Type I Salter-Harris fracture

A

transverse fracture through growth plate (physis), i.e. separating epiphysis & metaphysis

204
Q

Type II Salter-Harris fracture

A

Most common type

transverse fracture of physis (growth plate) & metaphysis i.e. fracture through growth plate and toward middle of bone

205
Q

Type III Salter-Harris fracture

A

transverse fracture of physis (growth plate) & epiphysis (end of bone) which includes the joint

i.e. fracture through growth plate and towards end of bone

206
Q

Type IV Salter-Harris fracture

A

fractures of physis (growth plate) + metaphysis + epiphysis

207
Q

Type V Salter-Harris fracture

A

fracture with impaction & disruption of physis (growth plate)

i.e. crush fracture of growth plate

may look normal on X-ray or like Type I

208
Q

Hip fractures (NOF)

A

any fracture of the femur distal to the femoral head & proximal to the level ~5cm below the lesser trochanter

209
Q

Types of hip fractures

A

Intracapsular (subcapital):
involve femoral neck between the edge of the femoral head & insertion of the capsule of the hip joint
~50% of hip fractures
may disrupt blood supply to femoral head leading to avascular necrosis

Extracapsular:
fracture distal to the insertion of the capsule, involving/between the trochanters, can be trochanteric or subtrochanteric

210
Q

Classification for intracapsular hip fractures

A

Garden classification:
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and
angulated, but still has boney contact
Type IV: Complete boney disruption

NB Type III & IV cause disruption to blood supply

211
Q

Garden classification

A

used to classify intracapsular hip fractures

212
Q

Risk factors for hip fractures

A 
↑ age
osteoporosis
falls
low BMI
female sex
high energy trauma (in younger pts)
213
Q

Epidemiology of hip fractures

A

relatively common

usually seen in those aged >65 yrs often after low energy trauma e.g. falls from standing height

more common in females

214
Q

Presentation of hip fractures

A 
Pain in affected hip/thigh/groin (usually upper outer thigh or groin)
inability to weight bear
↓ ROM
bruising
shortened & externally rotated leg
215
Q

Investigating hip fractures

A

AP pelvic & lateral hip X-ray (interruption of shelton’s line, fracture is visible)

MRI (if fracture suspected but not visible on X-ray)

216
Q

Management of intracapsular hip fractures

A

undiscplaced = internal fixation e.g. cannulated hip screw or hemiarthroplasty

displaced = arthroplasty (total or hemiarthroplasty)

total hip replacement is favoured to hemiarthroplasty if patients:
were able to walk independently out of doors with no more than the use of a stick and
are not cognitively impaired and
are medically fit for anaesthesia and the procedure.

217
Q

Management of extracapsular hip fractures

A

generally dynamic hip screw (i.e. internal fixation) if intratrochanteric

intramedullary nail if subtrochanteric

218
Q

When to perform total hip replacement or hemiarthroplasty in displaced intracapsular hip fractures

A

total hip replacement is favoured to hemiarthroplasty if patients:
were able to walk independently out of doors with no more than the use of a stick and
are not cognitively impaired and
are medically fit for anaesthesia and the procedure.

219
Q

Fractured femur

A

fractures of the femoral shaft & supracondylar fractures

generally secondary to violent trauma / high energy mechanisms of injury in young adults & adolescence

may be due to low energy trauma in older people for example with bone metastases

220
Q

Presentation of femoral fractures

A 
painful swollen tense thigh
inability to weight bear 
↓ ROM
deformity % shortening of affected side
distal neuromuscular deficits

NB be aware of signs of fat embolism

221
Q

Investigating femoral fractures

A

AP & lateral X-rays of femur + ipsilateral hip & knee X-ray (to rule out co-exisitng NOF)

Consider CT

222
Q

Management of femoral fractures

A

splint / traction fracture (e.g. Thomas splint, KTD)

Surgery:
open/closed reduction, most commonly intramedullary nail used

4-6 months healing time

223
Q

Supracondylar femur fractures

A

fracture of the distal 1/3 of the femur, usually due to direct trauma, often comminuted & intra-articular involvement with associated damage to knee joint

presents with pain of distal femur usually worsened by moving knee & inability to weight bear

224
Q

Pelvic fractures

A

fractures of the fused ring of the ischium, ilium, pubis often occurring with polytrauma e.g. from RTC

can lead to life threatening haemorrhage & may be shocked

present with pelvic pain, pelvic instability, unequal leg length, haemutria/rectal bleeding, and bruising of the labia/scrotum/flank

classified by Young-burgess classification

investigate with pelvic X-ray / CT

managed surgically if unstable along with angiography for embolisation

225
Q

Pubic rami fractures

A

low energy pelvic fractures seen in old people with osteoporosis

generally stable fractures

226
Q

Ankle fractures

A

a fracture of ≥1 of the bones of the ankle joint i.e. the tibia / fibula / talus

most common lower limb fracture

227
Q

Presentation of ankle fracture

A 
local pain & tenderness
swelling & haematoma 
↓ ROM
inability to weight bear
skin abnormalities e.g. lacerations/dislocation/tenting 
joint deformity
228
Q

Investigating ankle fractures

A

Physical examination:
Ottawa ankle rules to see if X-ray indicated

X-rays (AP, lateral, oblique views)

229
Q

Classifying ankle fractures

A

Weber classification
Related to the level of the fibular fracture.

Type A is below the syndesmosis, usually stable,
syndesmosis intact

Type B fracture at level of syndesmosis, potentially
involving it

Type C fibula fracture above syndesmosis indicating
syndesmosis rupture, usually unstable

230
Q

Ottowa ankle rules

A

To indicate if X-ray is indicated

These state that x-rays are only necessary if there is pain in the malleolar zone and:

  1. Inability to weight bear
  2. Tenderness over the distal tibia
  3. Bone tenderness over the distal fibula
231
Q

Patella fracture

A

may be caused by direct blow to patella, sudden forceful knee flexion or contraction of quads

typically presents with considerable swelling & bruising + pain & tenderness around knee / patella

diagnosis with AP & lateral knee X-ray

managed with analgesia, immobilisation (knee brace) if undiscplaced/able to extend knee

managed with tension band wire & knee brace if displace/inability to extend knee

232
Q

Lisfranc fracture

A

tarsometatarsal fracture that can involve damaged to cartilage of the mid foot joints leading to fracture dislocation

presents with severe mid foot pain, inability to weight bear, bruising & swelling of mid foot

often easily missed on standard foot X-ray so CT =investigation of choice

generally requires ORIF

233
Q

Metatarsal fractures

A

relatively common fracture, most frequently affecting 5th metatarsal

presents with pain, bony tenderness, swelling & antalgic gait

diagnosed on foot X-ray

non-displaced = k wire fixation & plaster support
displaced = internal fixation e.g. percutaneous pinning
234
Q

Metatarsal stress fracture

A

most common stress fracture often seen in healthy athletes

usually affects shaft of 2nd metatarsal

235
Q

Clavicle fracture

A

one of the most common acute shoulder injuries, usually due to fall onto lateral shoulder

most common site = middle 1/3 of clavicle

~2-5% of adult fractures, most common paediatric fracture

236
Q

Presentation of clavicle fractures

A

history of fall/trauma

pain / swelling / tenderness around clavicle
tenting of skin due to upward distraction by SCM of medial fracture segment
sagging of shoulder due to downward traction force of weight of arm on lateral fracture segment

237
Q

Investigating clavicle fractures

A

AP X-ray of clavicle
CXR ( if lung injury suspected)

if sternoclavicular/acromioclavicular joint injury suspected perform MRI/CT

238
Q

Classifying clavicle fractures

A

Allman classification: (according to fracture location)

Type I mid shaft/middle third (most common, ~80%)
Type II lateral third (10-15%)
Type III medial third, rare (5%)

239
Q

Management of clavicle fractures

A

generally conservatively managed with simple shoulder sling

if open fractures / excessive shortening / displacement = surgery

240
Q

Humerus fractures

A

common fracture, usually trauma related but may also be associated with pathological fractures & osteoporosis in the elderly

proximal humerus fractures are most common

241
Q

Types of humerus fractures

A

Proximal humeral fractures: (4-5% of all fractures)
common in elderly, usually FOOSH

Humeral shaft fractures: (3% of all fractures)
usually due to trauma/torsion on upper arm
usually associated with radial nerve injury (wrist drop)

Distal humeral fractures:
supracondylar - more common in children
trans condylar - more common in adults

242
Q

Presentation of humeral fractures

A

sever local pain exacerbated during palpation or movement of arm
local swelling, deformity, crepitus

243
Q

Investigating humeral fractures

A

AP & lateral X-ray of humerus ± trans thoracic & axillary views of shoulder

244
Q

Management of humeral fractures

A

Conservative:
if non displaced / closed fracture
= having arm cast or splint & sling

Surgical:
if displaced / open fracture /neurovascular injury
= ORIF or external fixation

245
Q

Supracondylar fractures

A

a fracture of the distal humerus superior to the elbow joint, typically transverse fracture over medial & lateral condyles caused by FOOSH
most common paediatric elbow fracture (age 5-7yrs)

presents with pain & refusal to move arm

seen on lateral & AP X-rays ( anterior fat pad (sail) sign = lucent triangle on lateral projection & posterior fat pad sign)

managed with surgical repair followed by elbow immobilisation at 90°

246
Q

Olecranon fractures

A

low energy fractures commonly seen in the elderly

presents with swelling & tenderness over olecranon & ↓ ROM + inability to extend elbow

seen on true lateral elbow X-ray

generally requires ORIF (due to unopposed traction of triceps causing displaced fractures)

247
Q

Condylar fractures

A

more commonly lateral than medial

seen on lateral & AP X-ray

248
Q

Capitellum fracture

A

rare but require prompt diagnosis & management as it may lead to severe functional impairment due to intraarticular & displaced

usually require CT

249
Q

Radial head & neck fractures

A

a type of elbow fracture commonly caused by FOOSH

radial head fracture = most common elbow fracture in adults
radial neck fracture = more common in children

presents with swelling over lateral elbow & ↓ ROM, elbow effusion, bruising, point tenderness of radial head
pain worse on rotation

Seen on AP & lateral elbow X-ray ± oblique view (often findings subtle & easily missed)

managed conservatively if non displaced, otherwise ORIF

250
Q

FOOSH

A

fall onto outstretched hand

251
Q

Colles fracture

A

distal radial fracture with dorsal displacement of fragment, strongly associated with osteoporosis

most common distal radial fracture

diagnosed on AP & lateral X-ray

252
Q

Freatures of colles fracture

A

transverse fracture of radius ± ulna (ulna styloid) involvement
2-3 cm proximal to radio-carpal joint
dorsal displacement & angulation

253
Q

Colles fracture in the elderly

A

warrants investigation for osteoporosis due to strong association

254
Q

Presentation of Colles fracture

A

dorsally displaced & angulated (dinner fork deformity)
after FOOSH

may have ulnar or median nerve damage

255
Q

Management of colles fracture

A

generally closed reduction under anaesthesia (e.g. haematoma block) & cast immobilisation

surgical reduction if unstable or intra-articular

256
Q

Smiths fracture

A

distal radial fracture ± ulna involvement that has volar (anterior) displacement of the distal fragment (reverse Colles)

due to falling backward onto outstretched hand , presents with garden spate deformity

AP & lateral X-rays (similar to colles but anterior displacement)

usually managed with closed reduction & casting unless fracture dislocation

257
Q

Barton fracture

A

distal radial fracture & dislocation of radial carpal joint i.e. colles/smith fracture with dislocation

usually requires ORIF

258
Q

Chaufferus fracture

A

intra-articular fracture of the radial styloid process, usually secondary to direct blow to wrist

tend to be unstable even if undisplaced so fixed with K wires

259
Q

Greenstick fractures of the wrist

A

a fracture with unilateral cortical breech i.e. periosteum remain intact (convex surface is fractured but concave surface is intact)

a fracture of childhood (<10y/o) more common in forearm

usually associated with some degree of angulation, but unless majorly angulated can be managed with cast immobilisation

260
Q

Galaezzi fracture

A

radial shaft fracture + disruption of the distal radial ulnar joint

more common in children

AP & lateral X-rays show displaced fracture of the radius & prominent ulnar head due to dislocation

uncomplicated in children so can be managed with closed reduction

261
Q

Monteggias fracture

A

ulna shaft fracture + concomitant dislocation of radial head

X-rays show ulnar fracture & radial head dislocation

usually uncomplicated in children so can be managed with closed reduction & casting

262
Q

Ulnar shaft fracture

A

usually due to direct blow to ulna e.g. when raising arm in defence from an attack

263
Q

Both bone forearm fracture

A

usually significant force injury e.g.

usually displaced in adults so requires ORIF

264
Q

Scaphoid fracture

A

Most common fractured carpal bone (50-80%), usually secondary to FOOSH

usually seen in men aged 20-30 yrs

265
Q

Blood supply of scaphoid bone

A

~80% of bloods supply from dorsal carpal branch of radial artery in a retrograde manner
interruption of blood supply risks avascular necrosis of the scaphoid (most commonly seen in proximal fractures)

avascular necrosis occurs in up to 50% of cases

266
Q

Presentation of scaphoid fracture

A

pain when applying pressure to the anatomical snuffbox (tenderness of anatomical snuffbox)
↓ grip strength
painful pincing & grasping
pain in scaphoid area on longitudinal thumb compression

267
Q

Investigations for scaphoid fracture

A

X-ray (make clear its suspected scaphoid fracture = PA, sure lateral, semi-pronated oblique & PA with wrist in ulna deviation views)

if X-ray inconclusive = MRI

clinical review with further imaging should be arranged for7-10 days later when initial radiographs are inconclusive

268
Q

Mangement of scaphoid fracture

A

initially immobilisation with future splint/below elbow back slab

undisplaced = cast immobilisation
displaced or proximal fracture = surgical fixation

269
Q

Management of scaphoid fracture

A

initially immobilisation with futuro splint/below elbow back slab

undisplaced = cast immobilisation
displaced or proximal fracture = surgical fixation

270
Q

Complications of scaphoid fracture

A

avascular necrosis

non union = early OA & pain

271
Q

Bennett’s fracture

A

interarticular fracture base of the age of the thumb which is often unstable
seen when pt has punched someone/something

presents as acute & severe pain / swelling at base of thumb & ↓ROM

PA, lateral & oblique views on X-ray (shows oblique fracture line at 1st metacarpal with triangular fragment at ulnar base of 1st metacarpal)

generally requires ORIF or K wire fixation

272
Q

Rolando fracture

A

3 part fracture at the base of the thumb, uncommon fracture

often requires CT

generally requires surgical fixation

273
Q

Phalangeal fracture

A

if distal its often a crush injury with associated nail injury/damage

generally all managed conservatively

274
Q

Enteropathic arthritis

A

umbrella term to describe several patterns of inflammatory seronegative spondyloarthropathies associated IBD (Crohns & UC)

associated with HLA-B27

275
Q

Risk factors for enteropathic arthritis

A 
active bowel disease
FH of IBD
appendectomy 
smoking
presence of extra-intestinal manifestations of IBD
276
Q

Presentation of enteropathic arthritis

A 
axial arthritis (spondyliits/sacarilitis) of IBD:
gradual onset lower back pain radiation to leg
symptoms worse in morning & on prolonged sitting / standing

peripheral arthritis of IBD:
usually associated with presence of GI symptoms, more common in Crohns
asymmetric oligoarthritis affecting lower limbs that tends to be migratory & transient

Entesopathy of IBD:
severe localised heel pain at achilles tendon insertion or other tendon insertions

277
Q

Investigations for enteropathic arthritis

A 
stool microscopy & culture
sigmoidoscopy / colonoscopy
ESR/CRP (↑)
X-ray of affected joints 
autoimmune screen
278
Q

Management of enteropathic arthritis

A

give NSAIDs with care as may worsen GI symptoms
intraarticular / systemic steroids (better for peripheral arthritis)
TNF antagonists

279
Q

Behcet disease / syndrome

A

complex multi system disorder of unknown aetiology associated with systemic vasculitis characterised by deposition of immune complexes in arteries & veins

usually seen in mediterranean, east asian, middle eastern population

peak incidence age 20-40yrs, more common in men

associated with HLA-B51

280
Q

Behcet disease / syndrome presentation

A
  • recurrent oral ulcers
  • recurrent genital ulcers
  • eye lesions (anterior/posterior uveitis, retinal vasculitis)
  • arthritis (non erosive, non deforming asymmetric mono/oligo arthritis usually affecting knees/ankles/hands/wrists)
  • skin lesions (erythema nodosum, acneuform eruptions)
  • GI disease (vomiting, diarrhoea, abdo pain, GI tract ulceration)
  • neurological (memory impairment, impaired balance/speech/movement)
  • cardiac (DVT, superficial thrombophlebitis, aneurysms, material thrombosis)
281
Q

Behcet disease / syndrome investigations

A

pathergy test (+ve) (subcutaneous skin prick, observe for induration ± pustule formation of 48h)

autoantibodies (-ve)

ESR/CRP (↑)

282
Q

Behcet disease / syndrome management

A

topical steroids (for oral / genital ulcers)
topical lidocaine (for pain relief)
colchicine (for arthritis)
immunosuppression with azathioprine or systemic steroids

283
Q

Shoulder dislocation

A

The shoulder is a ball & socket joint but unlike the hip has a relatively shallow socket giving it a greater ROM but also making it less stable, generally traumatic dislocation

one of the most commonly dislocated joint (~50% of all dislocations)

repeated dislocations point to hyper mobility or Ehler-Danlos

284
Q

Epidemiology of shoulder dislocation

A

more common in males

peak incidence is 20-50 yrs in men & 61-80yrs in females

95% of dislocations are anterior
4% posterior (seen in epileptics)
<1% inferior

285
Q

Presentation of anterior shoulder dislocation

A

severe shoulder pain & inability to moved shoulder
arm slightly abducted & externally rotated
humeral palpable below coracoid process
loss of roundness of shoulder

may lead to axillary nerve injury (check regimental badge area) or rotator cuff injury

NB ~30% have associated fracture (consider X-ray to rule out fracture)

286
Q

Presentation of posterior shoulder dislocation

A

severe shoulder pain & inability to moved shoulder
less obvious on examination, arm is adducted & internally rotated

nerve & vascular injury is uncommon

287
Q

Management of shoulder dislocation

A

immobilisation & analgesia
reduction (closed)
surgery (if closed reduction fails)

neurovascular monitoring during & after reduction

288
Q

Takayasu vasculitis

A

Type of large vessel vasculitis

289
Q

Takayasu vasculitis

A

Type of large vessel vasculitis with granulomatous inflammation of the aorta & its major branches leading to thickening & stenosis

more common in females & asian population, presenting age 15-45 yrs

presents with malaise, headache, arthralgia, syncope, angina, carotid bruits, unequal BP in upper limbs, weak/absent limb pulses, intermittent claudication & raynauds

investigations include ESR (↑), angiography = gold standard (stenosis), biopsy of affected vessel

managed with corticosteroids & immunosuppression e.g. azathioprine / methotrexate

290
Q

Kawasaki disease

A

medium vessel vasculitis in children

presents with >5 days of high fever, strawberry tongue, cervical lymphadenopathy, conjunctival injections, erythema of soles of feet / palms if hand, cracked red lips

291
Q

Polyarteritis nodosa

A

medium vessel vasculitis with necrotising inflammation leading to aneurysm formation associated with Hep B infection

usually seen in middle aged men (45-65 yrs)

Presents with fever, malaise, weight loss, arthralgia, HTN / renal impairment, ↑ MI risk, sensorimotor polyneuropathy, abdo pain, N&V, lived reticular

investigations include ESR/CRP (↑), Hep B/C serology (+ve), tissue biopsy, angiography (multiple small aneurysms)

managed with corticosteroids & cyclophosphamide

292
Q

Antibody for Granulomatosis with polyangiitis (Wegener’s granulomatosis)

293
Q

Granulomatosis with polyangiitis (Wegener’s granulomatosis

A

systemic ANCA associated vasculitis of small & medium vessels characterised by necrotising granulomatosis affecting upper respiratory tract & kidneys

294
Q

Granulomatosis with polyangiitis (Wegener’s granulomatosis presentation

A 
epistaxis
nasal crusting
saddle nose deformity
dyspnea
haemoptysis
oral ulcers
treatment resistant pneumonia
rapidly progressing glomerulonephritis 
vasculitic rash

NB upperrepsiratory tract manifestations are most common

295
Q

Granulomatosis with polyangiitis (Wegener’s granulomatosis investigations

A

ESR/CRP (↑)
cANCA (+ve)
CXR (generally abnormal, with variety of presentations)
kidney biopsy (epithelial crescent in Bowmans capsule)
urine dip (haemturia, proteinuria)
tissue biopsy (necrotising granulomas)

296
Q

Granulomatosis with polyangiitis (Wegener’s granulomatosis mangement

A

steroids
cyclophosphamide (90% response rate)
plasma exchange

297
Q

Antibody for Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

298
Q

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)

A

small vessel ANCA associated vasculitis characterised by granulomatous vasculitis with eosinophilia

more commonly involves skin & lungs

299
Q

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) presentation

A 
asthma (chief complaint) with severe allergic attacks
allergic rhinitis/sinusitis
mononeuritis multiplex
skin nodules
palpable purpura
Pauci-immune glomerulonephritis
300
Q

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) investigations

A

FBC (eosinophilia i.e. ↑ eosinophils >250/μL)
pANCA (+ve)
IgE (↑)
biopsy (confirmatory test)

301
Q

Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome) management

A

corticosteroids ± cyclophosphamide

302
Q

Microscopic polyangitis

A

necrotising ANCA associated small vessel vasculitis affecting skin, pulmonary & renal vessels

manifests similar to granulomatosis with polyangitis but spares nasopharynx i.e. pauci-immune glomerulonephritis, HTN, palpable purport, haemoptysis, cough, dyspnoea

investigations include pANCA/cANCA (either may be +e), biopsy (fibrotic necrosis with neutrophil infiltration and no granulomas)

managed with corticosteroids ± cyclophosphamide

303
Q

Anti-glomerular basement membrane (GBM) disease (Good-Pastures syndrome)

A

Non ANCA associated, rare small vessel vasculitis caused by anti-GBM antibodies

presents with pulmonary haemorrhage (cough, dyspnoea, haemoptysis), renal (rapidly progressive glomerulonephritis)

investigated with renal biopsy (linear IgG deposits along basement membrane), abnormal renal function tests, anti-GBM antibodies (+ve)

managed with corticosteroids ± cyclophosphamide

304
Q

Cryoglobulinaemic vasculitis

A

non ANCA associated small vessel vasculitis characterised by temperature dependent deposition of immunoglobulins/immmune complexes (IgG/IgM) into the wall of blood vessels

associated with type I/II cryoglobulinaemia often in conjunction with Hep C infection

presents with skin lesions, malaise, fatigue, arthralgia, raynauds, hepatosplenomegaly

investigate include cryoglobulinaemia, Hep C/B serology (often +ve), skin/renal biopsy (cryoglobulin deposits)

managed with corticosteroids & rituximab

305
Q

Hypersensitivity vasculitis

A

necrotising vasculitis of cutaneous small vessel caused by formation of immune complexes

most common vasculitis seen in clinical practice

presents 7-10 days post drug exposure (e..g NSAIDs, Abc, phenytoin) with painful, palpable prupura

investigated with skin biopsy (gold standards)

managed by discontinue underlying drug + steroids

306
Q

Biceps tendon rupture

A

injury to the biceps muscle leading to complete/partial severing of the tendon from the bone

more common in men
proximal rupture usually in older pts >60yrs
distal rupture usually in middle aged men

307
Q

Types of Biceps tendon rupture

A

Proximal
rupture of the origin the short head (coracoid process) or long head (glenoid)
most common type ~95% of all cases are of the longe head

Distal:
rupture at the insertion of the biceps tendon i.e. radial tuberosity
~5% of cases
usually in middle aged men

308
Q

Presentation of biceps tendon rupture

A

sudden pop/tear followed by pain/bruising/swelling
popeye deformity (muscle bulk bulges in the middle of upper arm)
limited ROM

309
Q

Investigating biceps tendon rupture

A

Clinical diagnosis

USS = investigation of choice
consider X-ray or MRI

310
Q

Management of biceps tendon rupture

A

Proximal:
conservative, RICE

Distal:
surgical fixation within 2-3 wks of injury to limit fibrosis of muscle

311
Q

Biceps tendinitis

A

tendinitis of the long head of the biceps tendon at the insertion on the glenoid

presents as anterior shoulder pain that worsen with lifting

clinical diagnosis ±USS

managed with RICE, NSAIDs or later steroid injections

NB chronic tendinitis is associated with tendon rupture

312
Q

Subacromial bursitis

A

inflammation of the bursa located between the acromion, deltoid muscle & head of humerus, usually caused by repetitive overhead motion

presents with joint swelling, erythema, warmth, stiffness + pain on lateral & anterior aspect of shoulder

managed with RICE & NSAIDs

313
Q

Adhesive capsules (frozen shoulder)

A

inflammation & fibrosis of the joint capsule leading to contracture of the shoulder joint, usually seen in 45-65y/o pts, more common in women

presents with restriction of movement of glenohumeral join, gradual onset dull pain, stiffness, inability to sleep on affected side

diagnostic test is inability to externally rotate shoulder

Mangement:
1st line: paracetamol
2nd line: NSAIDs
+physio & corticosteroid injections

314
Q

Subacromial impingement syndrome / supraspinatus tendonitis / painful arc

A

most common cause of shoulder pain

clinical syndrome caused by compression of tissues around the glenohumeral joint when shoulder is elevated

presents with shoulder pain worse on overhead activities & tenderness over acromion, ↓ROM, nocturnal exacerbation of pain when lying on affected side

painful arc test = +ve (pain between 60-90° of shoulder abdduction)
‘empty can’ test +ve if supraspinatus tendonitis

315
Q

Calcifying tendonitis

A

crystalline calcium phosphate depsited in the rotator cuff tendon causing mild pain & ↓ROM

seen as calcium deposit on X-ray

316
Q

Lateral epicondylitis (tennis elbow)

A

reactive tendon pathology of forearm extensor muscle origin (lateral epicondyle) caused by repetitive strain

presents with pain & tenderness over lateral epicondyle / along extensor muscles, pain is worse on wrist extension against resistance with elbow extended & supinated

treated with RICE, NSAIDs/paracetamol, physio, steroid injections

317
Q

Medial epicondylitis (golfers elbow)

A

reactive tendon pathology of forearm flexor muscle origin (medial epicondyle) caused by repetitive strain, most common cause of medial elbow pain

presents with pain over medial epicondyle & along flexor muscles, worse on activity, pain worse on wrist flexion against resistance with elbow extended & pronated

may be accompanied by ulnar nerve neuropathy = ↓sensation & tingling in 4th/5th digits

treated with RICE, NSAIDs/paracetamol, physio, steroid injections

318
Q

Elbow dislocation

A

second most commonly dislocated joint after shoulder, usually caused FOOSH, posterior dislocations are most common

usually seen in ages 10-20yrs

presents with pain, swelling, ↓ROM (inability to flex/extend elbow) & deformity of the elbow
~10% have associated nerve injury

investigated with lateral & AP X-ray (look at radiocapitellar line)

if simple dislocations = closed reduction & immobilise 
if complex (i.e. +fracture) = ORIF
319
Q

Olecranon bursitis (student’s elbow)

A

inflammation of the bursa of the elbow joint that is often caused by leaning on the elbow for long periods

presents with pain & swelling over posterior elbow, with erythema & warmth ± broken skin

generally managed conservatively (RICE + analgesia), consider surgery if olecranon spur contributes to recurrent bursitis

320
Q

Acromioclavicular (AC) joint seperation

A

usually caused by direct injury to acromion during fall onto adducted arm or direct blow to acromion
represents ~50% of all athletic shoulder injuries

presents with local tenderness, swelling, bruising, ↓ROM of shoulder, with a visible/palpable step if clavicular separation present

classified using X-ray

managed surgically or conservatively depending on degree of injury

321
Q

Cubital tunnel syndrome

A

compression of the ulnar nerve as it passes through the cubital tunnel at the elbow, 2nd most common compressive neuropathy

presents with tingling/numbness of 4th/5th digits, hypothenar weakness/atrophy, claw hand, positive Tinel’s test (tapping over cubital turner =pain/tingling/shock-like sensation)

investigated with nerve conduction studies / USS

managed with Rest, physio, steroid injections or surgery if conservative management fails

322
Q

Carpal tunnel syndrome

A

peripheral neuropathy caused by acute/chronic compression of the median nerve the the transverse carpal ligament

most common entrapment neuropathy of the upper extremity (90%)

risk factors include female sex, ↑BMI, pregnancy, wrist trauma, diabetes, RA

323
Q

Carpal tunnel syndrome presentation

A

tingling/numbness/pain in median nerve distribution (palmar aspect of the thumb / index / middle finger & 1/2 of ring finger) NB often worse at night, may cause waking
pain may radiate up arm
weakness in hand grip, opposition/abduction of thumb
wasting of thenar eminence

Phalen test +ve:
flex wrist for 60sec = pain/paraesthesia in median nerve distribution
Tinel test +ve:
tapping over median nerve at wrist = distal paraesthesia
Carpal tunnel compression +ve:
pressure over the proximal edge of the carpal tunnel causes paraesthesia in median nerve distribution

324
Q

Carpal tunnel syndrome investigations

A

EMG (focal slowing of conduction velocity in median nerve across carpal tunnel)

USS (confirmatory test)

MRI (alternative to USS)

325
Q

Carpal tunnel syndrome management

A

wrist splints at night
local corticosteroid injection
surgical decompression of flexor retinaculum

326
Q

De Quervain’s tenosynovitis

A

inflammation of the tendon sheath of extensor polices braves & abductor policies longs of the thumb caused by repetitive strain (e.g. texting a lot/holding baby),

usually seen in females aged 30-50

327
Q

De Quervain’s tenosynovitis presentation

A

presents with pain ± swelling of radial styloid which may radiate to thumb & painful abduction of thumb against resistance

Finkelstein test +ve (grasp effected thumb & exerts longitudinal traction across palm of hand to ulnar side causing pain)

328
Q

De Quervain’s tenosynovitis management

A

NSAIDs, splinting (immobilisation of thumb)

steroid injections

329
Q

Dupuytrens contracture

A

progressive fibroproliferative disorder affecting palmar fascia causing fibrous tissue to shorten & thicken common in men aged >60

~70% of pts have positive FH

330
Q

Presentation of Dupuytrens contracture

A

most commonly affects 4th/5th digits
45% are bilateral
pitting / thickening of palmar skin & loss of skin mobility
nodule formation then cord formation(thickening resembles tendon)
flexion contracture affecting finger

331
Q

Mangement of Dupuytrens contracture

A

physio, splinting, corticosteroid injections

consider surgical treatment (when functional disability e.g. cannot place hand flat on table)

332
Q

Trigger finger

A

common condition associated with abnormal flexion of the digits due to fibrocartilagenous metaplasia of the tendon sheath, usually idiopathic

presents with painless locking of finger in flexed position that releases suddenly with snap/pop ± palpable tender nodule at base of MCP joint

often affects ring finger or thumb

managed with steroid injections ± finger splint

333
Q

Ganglion cyst

A

bening mucin filled cyst developing along tendons/joints usually seen in hand/wrist (especially dorsally on wrist)

usually asymptomatic but may be seen as fluctuant transilluminant swelling

usually observed, or excision if symptomatic

334
Q

osler’s nodes

A

painful red raised lesion found on hands & feet
due to deposition of immune complexes
seen n infective endocarditis

335
Q

Bouchard’s nodes

A

hard bony outgrowths or gelatinous cysts found on proximal interphalangeal joint (PIP) which are a sign of OA

336
Q

Heberden’s nodes

A

pain & nodular thickening of the dorsal aspect of the distal interphalangeal joint (DIP)
may skew fingertips sideways

337
Q

Musculocutaenous nerve injury

A

nerve roots C5-C7

supplies sensory to lateral part of forearm, and motor to elbow flexion & supination via biceps brachii

MOI:
isolated injury is rare, usually injured with brachial plexus

338
Q

Axillary nerve injury

A

nerve roots C6/C6

responsible for shoulder abduction (deltoid) & sensory to inferior region of deltoid (i.e. regimental badge area)

MOI:
humeral head/neck fracture or dislocation

results in flattened deltoid and loss of sensation of regimental badge area

339
Q

Radial nerve function

A

nerve roots: C5-T1
runs in spiral groove of humerus the anterior to lateral epicondyle where it divides

Innervation:
Motor: triceps, brachioradialis, forearm extensors
sensory: radial 2/3 of dorsal aspects of hand & dorsal aspect of radial 3 1/2 fingers (excluding the median nerve innervation i.e. the tips) + 1st web space

340
Q

Radial nerve injury

A

Presentation:
weak supination & elbow flexion
weak wrist & finger extension
loss of hand extension = wrist drop
sensory loss to hand, especially 1st web space
NB if damaged in axilla = triceps paralysis

MOI:
axilla: improper crutch use
midarm: humeral shaft fracture, saturday night palsy/honeymoon palsy (compression of nerve when sleeping intoxicated on furniture)
radial head fracture

341
Q

Median nerve function

A

nerve routes: C5-T1
descends with brachial artery, crosses elbow deep to biceps aponeurosis, then runs deep to flexors digitorum superficialis, enters wrist via carpal tunnel

Innervation:
all forearm flexors (except flexor carpi unlearns & medial 1/2 of flexor digitorum profundus = ulnar nerve),
sensory to palmar aspect of lateral 3 1/2 fingers

342
Q

Median nerve injury

A 
Presentation:
if proximal injury:
hand of benediction (loss of thumb opposition & abduction + loss of index & middle finger flexion)
thenar muscle atrophy
weak wrist pronation & flexion

if distal injury:
inability to pinch small objects
thenar muscle atrophy
ape hand (inability to oppose & abduct thumb)

MOI:
carpal tunnel syndrome, humerus fractures, penetrating injury

343
Q

Ulnar nerve function

A

nerve roots: C8-T1
runs along posterioirmedial aspect of arm via biceps sulcus, then passes the medial epicondylar groove at elbow

Innervation:
motor: flexor carpi unlearns & medial 1/2 of flexor digitorum profundus, intrinsic muscles of hand, hypothenar muscles
Sensory: medial 1 1/2 fingers on dorsal and palmar aspects

344
Q

Ulnar nerve injury

A

Presentation:
atrophy of hypothenar muscles
claw hand deformity (ulnar paradox = claw hand worse in distal nerve lesions)
wasting of intrinsic muscles of hand

MOI:
medial epicondyle fracture, cubital tunnel syndrome

345
Q

long thoracic nerve

A

roots: C5-C7
innervates serrates anterior

damage = winged scapula

346
Q

Hip dislocation

A

MOI: usually direct trauma e.g. RTCs & falls
90% = posterior dislocations
10% = anterior dislocations

Presentation:
posterior: shortened internally rotated & adducted leg
pain in hip, may radiate to knee
anterior: hip pain, inability to walk/adduct leg, leg
externally rooted, abducted & extended

investigated with AP & lateral hip X-ray, consider CT/MRI to rule out fractuer

management with analgesia & reduction under GA

347
Q

Leg positioning in hips dislocation vs hip fracture

A

Hip dislocation:
posterior:
shortened internally rotated & adducted leg
anterior:
leg externally rotated, abducted & extended

Hip fracture:
shortened & externally rotated leg

348
Q

Anterior cruciate ligament (ACL) injury

A

most commonly injured knee ligament

Presentation:
loud crack at point of injury, rapid joint swelling, bruising, pain
anterior draw test (+ve)
Lachmanns test (+ve)

imaged using MRI

managed with surgery & intense physio

349
Q

Posterior cruciate ligament (PCL) injury

A

usually due to non contact hyeprflexion of the knee with platarflexed foot

Presentation:
loud crack at point of injury, rapid joint swelling, bruising, minimal posterior pain
posterior draw test (+ve) & posterior saga test (+ve)

take X-rays (posterior sag of tibia, bony avulsion) & MRI

Managed conservatively if isolated injury, but surgery if complex

350
Q

Medial collateral ligament (MCL) injury

A

direct blow to lateral knee = forced valgus stress ± external rotation

Presentation:
pain, swelling, ecchymosis, deformity, instability of knee, ↑ medial joint laxity
vagus stress test (gently feel for joint line opening when applying valgus stress)

X-ray & MRI to rule out associated injuries

managed conservatively if isolated injury otherwise surgery

351
Q

Lateral collateral ligament (LCL) injury

A

usually due to direct blow to medial knee which is relatively rare due to protected position by other knee
usually associated with ACL/PCL tears

presents with knee swelling, ecchymosis, pain, instability
↑ lateral knee laxity
varus stress test (apply virus stress & feel for joint line opening)

X-rays & MRIs

Management: generally surgery as isolated tears are rare

352
Q

Meniscal tear/injury

A

may be degenerative image in older people or traumatic in young people (sports injury with rotational force)

Presentation
knee pain (↑ with weight bearing & activity)
joint line tenderness, restricted knee movements ± knee instability, knee locking / catching
knee swelling with delayed onset over 2-36h

MRI - modality of choice

Management is usually RICE & physio or surgical repair if functional limitations

353
Q

Chondromalacia patellae

A

inflammation of posterior patella with cartilage softening

usually seen in teenage girls after knee injury

presents with diffuse dull knee pain that is exacerbated by activity e.g. climbing stairs

354
Q

patellofemoral pain syndrome (runners knee)

A

one of the most common causes of anterior knee pain commonly seen in young athletes usually due to overuse

> 50% of cases are bilateral
presents with retro/peripatellar knee pain worse on knee flexion during weight bearing exercise & crepitus

managed with RICE, NSAIDs, Physio

355
Q

Prepatellar bursitis (housemaids knee)

A

inflammation of the prepatellar bursa usually secondary to prolonged kneeling/repeated falls onto knees

presents with swollen, erythematous, warm & painful knee + local tenderness & swelling of bursa
difficulty kneeling & walking

consider aspiration of bursa

managed with RICE & NSAIDs + Abx (if septic)

356
Q

Patellar dislocation

A

patella slips out of trochlear groove usually laterally, usually seen in pts aged 10-17yrs

may be recurrent & spontaneously reduce

presents as severe knee pain, joint effusion, fixed flexion deformity of knee with laterally displaced patella

generally managed with closed reduction under analgesia (entonox) + physio/immobilisation

357
Q

Iliotibial band sydnrome

A

overuse injury due to repeated flexion & extension of knee causing friction between iliotibial band & lateral epicondyle

presents with lateral knee pain ~2-3cm superior to lateral knee joint line, generally sharp pain during activity on foot strike & dull pain at rest

managed with physio, activity modification (change biomechanics) & muscle strengthening

358
Q

trochanteric bursitis

A

common cause of lateral hip pain localised to greater trochanter

managed with physio, rest, NSAIDs

359
Q

Achilles tendinitis

A

overuse injury of the achilles tendon often seen in athletes with recent ↑ exercise intensity

presents with pain & tenderness ~2-6cm above insertion of achilles tendon, with some stiffness

X-ray (may show insertional spur or erosion)

managed with reduced pressure in the area, NSAIDs, RICE, Physio

360
Q

Achilles tendon rupture

A

may rupture during sports where a forceful push off is required most often seen in middle aged (30-50yrs)

presents with popping/snapping sound or sensation at tie of injury, sudden severe pain in achilles tendon, difficulty mobilising, weak/absent plantarflexion 
call swelling ± palpable interruption of affected achilles tendon
Thompson test (squeezing calf with legs extended = absent positive plantar flexion)

USS 1st line imaging or MRI if unclear diagnosis

managed with non-weight bearing ASAP
Surgery if young/athletes
conservative if older/less active

361
Q

Plantar fasciitis

A

most common cause of heel pain in adults due to inflammation of plantar fascia

presents with heel/plantar pain usually around medial calcaneal tuberosity, pain worse after periods of inactivity & prolonged weight bearing
point tenderness along plantar aponeurosis

Investigated with USS (fascial thickening) or X-ray (bony spurs)

managed with RICE, foot exercises/stretches (e.g. rolling ball underfoot), orthotic insoles, NSAIDs
if no improvement steroid injections

362
Q

Morton’s neuroma

A

benign neuroma of the inter metatarsal plantar nerve most common in females

presents with forefoot pain, the sensation of a pebble in their shoe (between 3rd & 4th metatarsal most commonly), may have loss of sensation distally in the toes

investigated with USS

managed by excision if >5mm or USS guided steroid injections + avoiding tight shoes/high heels

363
Q

Hallux valgus (bunions)

A

lateral deviation of the big toe at the MTP joint often with concurrent rotation of the large toe, most common forefoot deformity & common in females

presents with pain & inflammation & prominent metatarsal head ± fluid filled bursa

mamboed with advice on appropriate footwear, analgesia & orthotics

364
Q

Pes planus (flat feet)

A

collpase of the medial longitudinal arch = eversion of the calcaneus in relation to the talus so the foot pronates

presents as flat/convex plantar surface of foot, absent medial arch when standing, foot pain

managed by corrective casting if congenital immediately after birth or orthotics if acquired

365
Q

Thoracic outlet syndrome (TOS)

A

umbrella term for conditions involving compression of neruvascular structures as they pass the lower neck into the axilla, 90% of acmes = neurogenic

can be caused by neck trauma, collar bone fractures, cervical ribs, tumours (e.g. pan coast tumour)

presents with sensory loss, pain in neck/arm, painless wasting of hand muscles, cold/blanching/swelling hands, claudication, ulcers etc
symptoms more pronounced on overhead activity

investigations include provocation manoeuvres, X-rays, CT, angiography

managed with physio, analgesia, decompression surgery

366
Q

Red flags for lower back pain

A 
age <20 or >50 yrs
previous malignancy 
night pain / waking up with pain
history of trauma
systemically unwell
thoracic back pain
367
Q

Facet joint associated back pain

A

may be acute or chronic

pain worse in morning & on standing, worse on extension of back tenderness

tenderness over facets on examination

368
Q

Spinal stenosis

A

usually gradual onset, unilateral/bilateral leg pain ± back pain, numbness, weakness
symptoms worse on walking (relieved on sitting)

often have normal clinical examination

NB MRI required for diagnosis

369
Q

Ankylosing spondylitis back pain

A

typically a young man presenting with lower back pain & stiffness (worse in morning & improves with activity)

370
Q

Peripheral arterial disease

A

pain on walking, relieved with rest, absent/weak foot pulses, may have signs of limb ischaemia

often PMH of smoking & vascular disease

371
Q

Prolapsed disc presentation

A

usually produces clear dermatomal leg pain associated with neurological deficits

leg pain usually worse than back pain
pain worse on sitting

most common site L5/S1 followed by L4-L5

so L5 = loss of sensation on dorsal of foot including big toe

372
Q

Indications for surgical decompression in back pain

A

if significant/progressive neurological deficits
Bladder/bowel dysfunction
cauda equina syndrome

373
Q

Type of hypersensitivity reaction in SLE

A

Type III hypersensitivity reaction

Type 3 is characterised by antigen-antibody complexes.

374
Q

Azathioprine

A

A thiopurine methyltransferase (TPMT) test may be needed to look for individuals prone to azathioprine toxicity.

Adverse effects include
bone marrow depression
nausea/vomiting
pancreatitis
increased risk of non-melanoma skin cancer

significant interaction with allopurinol & hence lower doses of azathioprine should be used.

considered safe to use in pregnancy.

375
Q

The A’s of associated features for Ankylosing spondylitis

A 
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block (heart block)
Amyloidosis
376
Q

Causes of avascular necrosis of the femoral head

A

long-term steroid use
chemotherapy
alcohol excess
trauma

377
Q

Juvenile idiopathic arthritis (JIA)

A

arthritis occurring in someone who is less than 16 years old that lasts for more than 6 weeks. Systemic onset JIA is a type of JIA which is also known as Still’s disease

presentation includes pyrexia, salmon-pink rash, lymphadenopathy, arthritis, uveitis, anorexia and weight loss

ANA may be positive (especially in oligoarticular JIA)
rheumatoid factor is usually negative

NBP pauciarticular JIA refers to cases where 4 or less joints are affected. It accounts for around 60% of cases of JIA

378
Q

Psoas abscess

A

usually caused by staph aureus (often seen in IVDU)

presents with fever, back/flank pain, limp, weight loss, Antalgic gait
hip flexed & externally rotated at rest
Passive extension / internal rotation = pain
Hip flexion against resistance = pain

Passive extension and/or internal rotation of the affected hip elicits pain

CT abdomen is gold standard investigation

Managment:
1st line: ABx & percutaneous drainage

2nd line surgery (if drainage fails)

Year 4 (12 decks)

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