Musculoskeletal Health Block Flashcards
1
Q
What 7 things must be addressed when describing a fracture?
A
- Qualities of the xray
- Site of the fracture
- Type of fracture (transverse, oblique, spiral)
- Simple or comminuted
- Displaced or not
- Angulated or not
- Is the bone of normal consistency or not
2
Q
Name the 3 categories of rheumatological conditions and 3 examples that fall under each category.
A
- Joints
- Rheumatoid arthritis
- Osteoarthritis
- Gout and pseudogout - Vessels
- Granulomatosis with polyangitis (GPA; small vessel disease)
- Polyarthritis nodosum (PAN; medium vessel disease)
- Giant cell arteritis (GCA; large vessel disease) - Connective Tissue Disease
- SLE (and anti-phospholipid syndrome)
- Scleroderma
- Sjogren’s syndrome
3
Q
What joint is typically affected in gout?
A
1st metatarsophalangeal (MTP) joint
4
Q
What is the cause of gout? (1)
A
Build up of uric acid
5
Q
What are the 4 main symptoms of lupus?
A
- Facial butterfly rash
- Abnormal sensitivity to sunlight
- Cold, numb fingers
- Joint pains
6
Q
What are 5 deformities of the hands characteristic of rheumatoid arthritis?
A
- Z-thumb
- Ulnar deviations
- Boutonnaire finger deformity (flexion of the PIPJ and hyperextension of the DIPJ)
- Swan neck finger deformity (hyperextension of the PIPJ and flexion of the DIPJ)
- Guttering (muscle wasting seen on dorsum of the hand)
7
Q
What are 3 management options for gout?
A
- Anti-inflammatories
- Colchicine
- Steroids
8
Q
What cells drive inflammation? (2)
A
- T cells (cell-mediated response)
2. B cells (humoral response)
9
Q
What are the 2 types of bone and their respective function?
A
- Compact bone = hard/dense + serves mechanical function
2. Trabecular bone = porous + contains bone marrow
10
Q
What 7 areas are important to address in an MSK history?
A
- Age
- Sex
- Occupation
- Hand dominance (for upper limb injuries)
- PMH/anaesthetics history (especially previous joint surgeries)
- Relevant family history
- Current meds/allergies
11
Q
What are 5 likely signs of an inflammatory disease?
A
- Pain worse at rest/in morning
- Morning stiffness for > 30min
- Night pain troublesome
- Systemic symptoms present (fatigue, aches, weight loss)
- Acute/subacute presentation
12
Q
What test is used to diagnose carpal tunnel syndrome?
A
Phalen’s test
13
Q
What 8 things are you looking for when inspecting a patient’s knee?
A
- Scars
- Swelling
- Skin changes
- Posture
- Varus (bow leg) or valgus (knock knee) deformity
- Muscle wasting
- Asymmetry
- Cysts
14
Q
What is the clinical presentation of a neck of femur fracture? (2)
A
- Shortened limb
2. Externally rotated
15
Q
What are 3 bone fixation methods for fractures?
A
- Open Reduction Internal Fixation (ORIF) -> plate/screws
- Closed Reduction Internal Fixation (CRIF) -> k-wires percutaneously; less common
- Intermedullary Fixation of Long Bones -> wires/nails
16
Q
What is the benefit of compression on a fracture? (1)
A
Allows primary bone healing without callus formation
17
Q
What is the most important factor when deciding how to treat a hip fracture?
A
Determining whether the fracture is intra-capsular or extra-capsular
- Blood supply to head of femur is damaged in intra-capsular fractures
18
Q
How do yo decide whether to use a screw or replace a hip?
A
Using the Garden fracture classification (1-4)
“1,2 give it a screw, 3,4 Austin-Moore” (Austin-Moore is n old type of hip replacement)
19
Q
What are the 4 x-ray features of osteoarthritis?
A
“LOSS”
L-loss of joint space
O- osteophytes
S- subchondral cysts
S- subchondral sclerosis
20
Q
What is the acute management of an infected joint? (4)
A
- Joint aspiration
- Send for gram stain (often staph. or strep.)
- Microscopy + culture
- IV empirical antibiotics (flucloxacillin 4-6wks; vancomycin if MRSA; clindamycin if penicillin allergy)
21
Q
What is a complication of an infected joint?
A
Septic arthritis -> septic shock
22
Q
What 3 medications can be used in septic arthritis?
A
- Flucloxacillin IV (4-6wks)
- Vancomycin (if pt has MRSA)
- Clindamycin (if pt allergic to penicillin)
23
Q
What is the gold standard imaging for osteomyelitis?
A
MRI
- Added contrast will show the periosteal reaction nicely
24
Q
What are 3 possible causes of osteomyelitis?
A
- Local infection
- Diabetic foot ulcer
- Embolic phenomenon (i.e. infective endocarditis + new back pain)
25
What are the 2 main causative organisms for osteomyelitis?
1. Staph
| 2. Salmonella osteomyelitis (in sickle cell patients)
26
What medication is used for osteomyelitis?
1. Flucloxacillin IV ± rifampicin for first 2wks (duration for 6wks)
2. Clindamycin IV ± rifampicin for first 2wks (if penicillin allergy)
27
What is the difference in crystal shape in gout vs pseudo gout? (2)
Gout = needle-shaped, bifringent crystals
Pseudo-gout = rhomboid, most are not bifringent
28
What are 3 causes of a joint effusion?
1. Crystal arthropathy
2. Inflammatory arthritis
3. Infection
29
What are 2 autoantibodies that are positive in RA?
1. Anti-CCP (high specificity/sensitivity)
| 2. Rheumatoid Factor
30
What 2 autoantibodies are positive in SLE?
1. Anti-dsDNA (high specificity/sensitivity; monitor disease flare)
2. ANA (present in 5% of normal population)
31
What autoantibody is used to diagnose small-vessel vasculitis?
ANCA
1. c-ANCA = granulomatosis with polyangiitis (GPA)
2. p-ANCA = eosinophilic GPA
32
How is inflammation treated? (3)
1. Analgesia (paracetamol)
2. Anti-inflammatories (NSAIDs)
3. Immunosuppression - DMARDs (steroids; steroid-sparing agents; biologic agents)
33
What are 5 examples of steroid-sparing agents?
1. Methotrexate
2. Azathioprine
3. Sulfasalazine
4. Hydroxychloroquine
5. Leflunomide
34
What are 9 side effects of long-term steroid treatment?
1. Eyes - cataracts, glaucoma
2. Heart - cardiovascular disease
3. Skin - hirtuism, skin thinning
4. Stomach - gastric ulcers
5. Metabolism - diabetes, weight gain, Cushings
6. Brain - psychiatric symptoms
7. Bone - osteonecrosis, osteoporosis
8. Muscle - Myopathy
9. Infections
35
What protective treatments are often given alongside long-term steroid treatment?
1. Vitamin D
2. Calcium
3. Bisphosphonates
36
Give 2 examples of biologic therapies
1. Infliximab
| 2. Rituximab
37
What is 1 adverse effect of biologic therapies?
Reactivation of latent TB (thus essential to screen for TB before commencing therapy)
38
What adverse effect links all the steroid-sparing DMARDs? (i.e. methotrexate)
Bone marrow suppression
39
What is a common target for monoclonal antibody/biologic therapy? (1)
TNF (tumour necrosis factor)
40
What is at the centre of the osteon of bone? (1)
Haversian canal, which contains blood vessels and nerves
41
What are 3 adverse effects of bisphosphonates?
1. Esophagitis (most common!)
- Take 30min before breakfast
- Drink lots of water
- Sit upright
2. Atypical femur fracture
3. Osteonecrosis
42
Name 5 investigations that should be performed for blunt trauma patients
1. ABCDE assessment
2. Secondary survey
3. Chest x-ray
4. Pelvic x-ray
5. FAST (focused assessment with signography in trauma)
43
What is the trauma triad of death?
1. Coagulopathy
2. Acidosis
3. Hypothermia
44
When does the trauma triad of death occur?
If blood loss > fluid resuscitation
45
What are the 6 components when assessing patient airway (ABCDE assessment)?
1. C-spine immobilisation
- manual, collar, bags, tape
2. Airway clear
- opening, foreign material
3. Oxygen
- High flow oxygen via non-rebreathe mask
4. Adjuncts
- oro/nasopharyngeal tube; bag + mask
5. Definitive
- Endo-tracheal tube; surgical airway
6. Help
- anaesthetists
46
What are the 6 components when assessing patient breathing (ABCDE assessment)?
1. Pulse oximetry
2. Trachea
3. Palpation of chest
4. Chest expansion
5. Chest percussion
6. Chest auscultation
47
Where would you perform an emergency thoracocentesis?
Second intercostal space, mid-clavicular line
48
What are the 4 components when assessing patient circulation (ABCDE assessment)?
1. BP (-> fluids)
2. Pulse
3. ECG
4. Auscultate the heart
49
What are the 3 components when assessing patient disability (ABCDE assessment)?
1. Blood glucose
2. Glasgow coma scale
3. Pupils
50
What are the 4 components when assessing patient exposure (ABCDE assessment)?
1. Temperature
2. Remove all clothing
3. Maintain 37C
4. Help if needed (ITU?)
51
How would you manage an open fracture in A&E and why? (6)
1. Examine neurovasculature of the limb
2. Have gross contamination removed + photograph taken (to avoid repeatedly taking on/off dressing)
3. Cover wound in saline soaked gauze
4. Backslab splint
5. IV antibiotics (every 8h until wound debridement)
6. Theatre wound washout + debridement + stabilization of fracture within 24h
52
What are the 3 principles of treating fractures?
1. Reduce
2. Stabilise and preserve blood supply
3. Rehabilitate
53
What are the methods used to stabilize the fracture? (6)
1. Casts/splints
2. Intramedullary devices
3. Plates + screws
4. Tension band wires
5. K-wires
6. External fixators
54
What is a pathological fracture?
A fracture through abnormal bone
55
Name 7 causes of pathological fractures
1. Osteoporosis
2. Osteomalacia
3. Osteopenia
4. Tumour
5. Infection
6. Metabolic bone disease
7. Medications
56
What are the steps of the WHO analgesic ladder? (3)
1. Mild pain = Non-opioid ± adjuvant analgesia
2. Mild-moderate pain = Opioid + non-opioid ± adjuvant analgesia
3. Mod-severe pain = Opioid + non-opioid ± adjuvant analgesia
57
What are 4 dose-related side effects of opioids?
1. Nausea
2. Vomiting
3. Sedation
4. Respiratory depression
58
Name 3 opioid agents commonly used for PCA (patient controlled analgesia)?
1. Morphine
2. Fentanyl (good in patients with renal failure)
3. Pethidine
59
What condition should you think of in pain that is not responding to analgesia?
Compartment syndrome
60
What is compartment syndrome?
When the pressure within a fascial compartment exceeds the perfusion pressure within the compartment, causing ischemia of the tissues in the compartment
61
What are 7 signs of compartment syndrome?
5Ps (of ischemia)
1. Pain
2. Pallor
3. Paresthesia
4. Pulselessness
5. Paralysis
6. Swollen
7. Stiff
62
How is compartment syndrome treated?
Emergency fasciotomy
63
What is delayed union of bone healing?
Failure to reach bony union at 6mo post injury
64
Name 4 local factors that can lead to delayed/non-union of bone
1. Location (scaphoid, distal tibia, base of 5th metatarsal are at risk b/c of blood supply)
2. Stability
3. Infection
4. Pattern (segmental fractures are at higher risk)
65
Name 5 systemic factors that can lead to delayed/non-union of bone
1. Diabetes
2. Diet
3. Smoking
4. HIV
5. Medications (NSAIDs, corticosteroids)
66
In a midshaft humerus fracture, what is the associated nerve injury?
Radial nerve
67
In a fibula neck fracture, what is the associated nerve injury?
Common peroneal nerve
68
In a supracondylar fracture, what is the associated nerve injury?
Median nerve
69
In a shoulder dislocation, what is the associated nerve injury?
Axillary nerve
70
In a hip dislocation, what is the associated nerve injury?
Sciatic nerve
71
What are the 3 classifications of nerve injuries?
1. Neuropraxia (reversible conduction block due to injury to the axon sheath)
2. Axonotmesis (disruption of the myelin sheath and the axon)
3. Neurotmesis (complete nerve division + disruption of the endoneurium)
72
What 2 nerves does the common peroneal nerve split into?
1. Superficial peroneal nerve (sensory)
| 2. Deep peroneal nerve (supplies the anterior compartment muscles)
73
What is the WHO definition of osteoporosis?
Bone mineral density 2.5 standard deviations below that of a young subject from the same race and sex
74
What is the most accurate clinical sign to diagnose compartment syndrome?
Pain exacerbated by passive stretching
75
What compartment is most commonly affected by compartment syndrome?
Anterior compartment
76
What 4 muscles and 2 vessels are located in the anterior compartment of the lower leg?
Muscles:
1. Tibialis anterior
2. Extensor hallicus longus
3. Extensor digitorum longus
4. Peroneus tertius muscles
Nerve + artery:
1. Deep peritoneal nerve
2. Anterior tibial artery
77
What are 3 signs of osteogenesis imperfecta?
1. Deafness
2. Blue sclera
3. History of fractures
78
What examination is important to perform in the context of a fractured limb? (1)
Neurovascular exam checking for neurovascular injury
79
A white hand with no pulse in the context of an arm fracture indicates which structures may have been damaged?
1. Brachial artery (trapped, kinked, torn, or intimal tear)
| 2. Median nerve (ulnar/radial nerves less common)
80
What is the commonest form of paediatric elbow fracture?
Supracondylar fracture
81
What are 2 steps to determine if there is a supracondylar fracture on x-ray?
1. Use anterior humeral line
| 2. Anterior humeral line should intersect the middle 1/3 of the capitellum
82
How long are children's fractures immobilized?
4 weeks = upper limb fracture
6-8 weeks = lower limb fractures
83
How would a supracondylar fracture be reduced? (2)
1. K-wires
| 2. Plaster cast
84
What is the growth plate?
An area of cartilage which proliferates and the leading edge calcifies
85
What is the significance of a growth plate injury? (2)
1. Growth may seize, the limb is shortened
| 2. Deformity + angulation may occur
86
Name 4 common fracture locations in children
1. Supracondylar fractures
2. Buckle wrist fracture
3. Clavicle
4. Distal humerus
87
What is a Greenstick fracture?
A fracture of the bone, occurring typically in children, where one side of the bone is broken and the other is only bent.
88
Why do Greenstick fractures occur? (1)
1. Children's bones are more flexible and softer than adults
| - so instead of breaking completely they often crack when bent.
89
What are the 2 main differences between child and adult fractures?
1. Child fractures may remodel with growth, thus minor deformity can be accepted
2. Child fractures heal faster
90
How can median nerve damage be assessed?
Get the patient to make an O with their thumb + index finger
91
What are 2 typical osteoporotic fracture sites?
1. Neck of femur
| 2. Colles wrist fracture (fall on outstretched hand)
92
List 4 methods to control displaced unstable fractures
1. Elastic nails
2. Moulded plasters
3. Plates
4. Wires
93
What are 2 features of connective tissue diseases?
1. Systemic features (weight loss, lethargy, fever, sweats)
| 2. Multisystem involvement
94
What does it mean to be seronegative in the context of inflammatory arthritis? (2)
1. Negative for rheumatoid factor (RF)
| 2. Negative for cyclic citrullinated factor (CCP)
95
Name 3 possible signs in seronegative arthritis conditions?
1. Skin psoriasis
2. Changes in bowel habits
3. Red/painful eyes
96
What are the 4 sub-categories of inflammatory arthritis?
1. Connective tissue disease
2. Vasculitis
3. Seropositive
4. Seronegative
97
What are 4 examples of seronegative arthritis?
1. Ankylosing spondylitis
2. Psoriatic arthritis
3. Reactive arthritis
4. Inflammatory bowel disease arthritis
98
What is 1 example of seropositive arthritis?
Rheumatoid arthritis
99
What syndrome is associated with Rheumatoid arthritis?
Sjogrens syndrome (dry eyes + dry mouth)
100
What swelling is indicative of inflammatory arthritis?
"Boggy" swelling indicating synovitis
Bony swelling is seen in osteoarthritis
101
What joints does rheumatoid arthritis typically affect? (2)
1. Metacarpophalangeal (MCP) joints
| 2. Proximal interphalangeal joints
102
What joints are commonly affected in osteoarthritis + psoriatic arthritis? (1)
1. Distal interphalangeal joints
103
If suspecting a patient to have RA, what are your immediate next steps? (2)
1. Prescribe analgesia for symptomatic relief
| 2. Refer urgently to rheumatology
104
What pain relief would you initially prescribe for a patient with RA?
Naproxen 500mg tablets twice daily
105
What investigations would you request to confirm an RA diagnosis? (5)
1. Baseline bloods (FBC, LFTS, U+Es)
2. Inflammatory markers (CRP, ESR)
3. Thyroid function (TFTs)
4. Immunology (RF, CCP, ANA)
5. Plain x-ray of hands, feet
106
What are 5 possible explanations for anemia in RA?
1. Anemia of chronic disease
2. Iron deficiency anemia secondary to use of NSAIDs or another cause
3. Felty's syndrome (anemia, leucopenia, splenomegaly)
4. Pernicious anemia (autoimmune disease)
5. Autoimmune hemolytic anemia
107
What blood test is raised in hemolytic anemia?
LFTs - bilirubin is high
108
What 5 abnormalities might be seen on x-ray of RA in later disease?
1. Periarticular (juxta-articular ) osteopenia
2. Erosions
3. Joint space narrowing (uniform)
4. Deformity
5. Soft tissue swelling
109
What are 3 conditions of the lungs that are associated with rheumatoid arthritis?
1. Pulmonary fibrosis
2. Lung nodules
3. Pleural effusions
110
What criteria is used to diagnose rheumatoid arthritis? (4)
The 2010 ACR RA classification criteria:
1. Joint involvement (i.e. > 10 joints + at least 1 small joint)
2. Serology (i.e. RF, CCF)
3. Acute-phase reactants (i.e. ESR, CRP)
4. Duration of symptoms (i.e. ≥6 weeks)
111
What are 3 broad risk factors for developing RA?
1. Genes
2. Environment (i.e. infection)
3. Smoking (i.e. development of anti-CCP antibodies)
112
What imaging is used to assess the presence of synovitis?
Ultrasound
113
Once a patient sees a rheumatologist, what medications will be prescribed for their RA? (3)
1. DMARD (i.e. methotrexate - takes 6-8wks for effect)
2. Steroid (i.e. depromadone -for short term relief of symptoms)
3. Biologic DMARD therapy (i.e. rituximab - if not responding to DMARD alone)
114
What are 14 extra-articular features of RA?
1. Carpal tunnel syndrome
2. Palmar erythema
3. Pleural effusions
4. Pericardial effusion
5. Interstitial lung disease + fibrosis
6. Vasculitis
7. Lymphadenopathy
8. Splenomegaly
9. Felty's syndrome
10. Episcleritis
11. Keratoconjunctivitis sicca (dry eyes/mouth)
12. Normochromic normocytic anemia
13. Amyloidosis
14. Fatigue, low-grade fever, weight loss
115
What are the 3 pathophysiological features of RA?
1. Synovitis (infiltrate of inflammatory cells)
2. Cartilage degradation (by matrix-degrading enzymes)
3. Bone erosion (by matrix-degrading enzymes)
116
What blood test is most likely to be affected if RA treatment with DMARD is affecting a patient's liver?
ALT (more sensitive than ALP)
117
A 72 year old lady with longstanding rheumatoid arthritis has a DAS 28 score of 6.01, she is afebrile and haemodynamically stable but is noted to have a purpuric rash on her legs.
What would you do next?
Urine dipstick
- sounds like small vessel vasculitis
- look for blood + protein
118
What are the 6 common sites for osteoarthritis?
1. Cervical spine
2. Lumbar spine
3. Hips
4. Knees
5. Feet
6. Hands (DIPJ, PIPJ, CMCJ of thumb)
119
What are 2 differentiating features of osteoarthritis from rheumatoid arthritis?
1. Insidious onset (4-5y)
| 2. Worsening of stiffness/pain throughout the day
120
What differentials would you consider with swollen knees and pain? (5)
1. Crystal - pseudo gout/gout
2. Septic arthritis
3. Mechanical disruption (meniscal, ligaments, bursa)
4. Rapidly progressive OA
5. Osteonecrosis
121
What group of drugs increase the risk of gout? (1)
Diuretics
122
What examination findings would be consistent with osteoarthritis of the knee? (8)
1. Small cool effusion
2. Painful flexion of knee to 90º
3. Crepitus
4. Antalgic gait + instability
5. Weakness ± muscle wasting
6. Joint line tenderness
7. Deformity
8. Bony swelling
123
What is the term for finger joint swellings associated with OA?
Nodal osteoarthritis
124
What are the terms for DIPJ swelling and PIPJ swelling associated with OA? (2)
DIPJ swelling = Heberdens nodes
PIPJ swelling = Bouchards nodes
125
What investigations, following examination, would you consider to confirm a diagnosis of OA? (2)
1. Bloods (FBC, U+E, CRP, ESR, RF, CCP)
- Renal function given diclofenac use for arthritis tx
- Rule out inflammatory condition + RA
2. X-ray knees + hands
126
What are the management options for osteoarthritis? (3)
1. Conservative (education, weight loss, exercise/physio)
2. Pharmacological
- Analgesia (topical anti-inflammatory/capsaicin cream, WHO ladder)
- Intra-articular steroid injection for moderate to severe pain
3. Surgery
- Symptoms that are refractory to non-surgical tx + affecting quality of life
127
When can osteoarthritis be diagnosed without investigations? (3)
All 3 criteria must be met:
1. Patient > 45y
2. Activity-related joint pain
3. No morning stiffness, or stiffness lasting < 30min
128
What are the risk factors for osteoarthritis? (11)
1. Age
2. Female
3. BMI
4. Previous joint injury
5. Intense sport activities
6. Occupation (hand, hip)
7. Quadriceps strength (knee)
8. Alignment (knee)
9. Pistol grip deformity (hip)
10. Genetic
11. Secondary osteoarthritis
129
What is the main modifiable risk factor for osteoarthritis?
BMI
130
What are 5 categories of secondary causes of osteoarthritis?
1. Metabolic (i.e. gout, acromegaly, hemochromatosis, wilsons disease)
2. Traumatic (i.e. joint injury, surgery, fracture)
3. Anatomical/congenital (i.e. slipped femoral epiphysis, Perthe's disease, unequal leg lengths)
4. Neuropathic (i.e. diabetes, syphilis)
5. Inflammatory (i.e. septic arthritis, any inflammatory arthropathy)
131
What 3 x-ray findings are typical of RA?
1. Periarticular erosions
2. Osteopenia
3. Joint ankylosis/fusion (in advanced stages of RA)
132
What spinal x-ray finding is typical of ankylosing spondylitis? (1)
Sydesmophytes
133
What are 6 possible differentials for a hot, swollen joint?
1. Septic arthritis
2. Gout
3. Pseudogout
4. Hemarthrosis
5. Psoriatic arthritis
6. Reactive arthritis
134
What are 6 risk factors for gout?
1. Male
2. Alcohol
3. High purine intake: steak, oily fish, marmite
4. Diuretics
5. Obesity
6. Metabolic syndromes (diabetes, hypertension)
135
What is the gold standard investigation for gout/pseudogout?
Joint aspiration + synovial fluid analysis with microscopy
| - polarising microscopy can identify monosodium urate crystals
136
What is the most appropriate medication for acute gout? (2)
1. NSAID + PPI
| 2. Colchicine 500ug BD/TDS
137
When should prophylactic therapy be introduced with urate-lowering drugs in gout? (4)
There is an established diagnosis of gout AND:
1. 2+ attacks of gout/year
2. Tophi by clinical/imaging study
3. CKD stage 2 or worse
4. Urolithiasis (kidney stones)
138
What is the aim of urate-lowering drug (ULD) therapy?
To maintain a lower serum uric acid ≤ 300 micromoles/L
- "treat to target"
- lower the sUA, the greater the chances of trophi dissolution
139
How soon after an acute gout attack would a urate-lowering drug be introduced?
2-4 weeks after an acute attack has subsided
140
What is the first-line urate-lowering drug used in gout?
Allopurinol (xanthine oxidase inhibitor)
- start at 100mg/day (50mg/day with CKD stage 4+)
- titrate every 2-5 weeks
- can precipitate acute gout attacks for first 6mo of tx
- continued for life!!
**Should be prescribed alongside NSAID + colchicine for 6mo to protect against acute attacks**
141
What is a rare side effect of allopurinol?
Allopurinol Hypersensitivity Syndrome
- mortality 20-25%
- seen in first few months of tx
- more common in asian demographic
142
What is an alternative urate-lowering drug if allopurinol is not tolerated?
Febuxostat
143
What is the pathophysiology of gout (2)
1. Excess production of uric acid
| 2. Impaired excretion of uric acid from the kidney
144
What are 3 differentials for hyper mobility in children?
1. Marfans
2. Ehlers Danlos
3. Osteogenesis imperfecta
145
What are the red flag features of 4 differentials of an acute childhood limp?
1. Nocturnal pain, night sweats, weight loss = acute lymphoblastic leukemia
2. High fever holding leg abducted (no internal rotation due to pain) = septic arthritis
3. High fever, non weight bearing = osteomyelitis of femur pelvis
4. Changeable history/unusual history regarding mechanism of history = non-accidental injury
146
After examining the hip, which other areas would you examine (referred pain)? (3)
1. Abdomen (hepatosplenomegaly, mass)
2. Groin (hernias + external genitalia)
3. Knee
147
What are 5 features of transient synovitis of the hip?
1. More common in boys (age 4-8y)
2. Acute onset limp (with or without pain)
3. Reduced hip movements
4. Self-limiting (should resolve in a few days - urgent assessment needed if not resolved)
5. Often preceded by a viral illness (URTI, gastroenteritis)
148
What are 2 risk factors for slipped upper femoral epiphysis?
1. Overweight
| 2. Hypothyroidism
149
What are the 2 signs of Perthes' disease?
1. Gradual onset limp
| 2. Painless
150
What is the cause of Perthes' disease?
Avascular necrosis due to the interruption of blood supply to the femoral epiphysis
151
What is the cause of a slipped upper femoral epiphysis?
Proximal femoral growth plate becoming unstable and the epiphysis + diaphysis can slip
152
What are 4 signs of developmental dysplasia of the hip?
1. Asymmetrical skin folds
2. Leg length discrepancies
3. Buttock flattening
4. Walking with the affected leg in external rotation
153
What is the red flag symptom of bone tumour?
1. Nocturnal bone pain which responds to NSAIDs
154
What is the red flag symptom of haematological malignancy in children?
Splenomegaly with abdominal mass
155
What are the 7 types of juvenile idiopathic arthritis?
1. Systemic JIA - whole body affected
2. Oligoarthritis - ≤ 4 joints affected
3. Polyarticular arthritis, RF negative - 5+ joints affected
4. Polyarticular arthritis, RF positive - or CCF positive, highest risk for joint damage with erosions compared to other JIA
5. Psoriatic arthritis - psoriatic rash, fingernails + toes may also be affected
6. Enthesitis-related arthritis - affects only legs + spine, associated with juvenile ankylosing spondylitis + IBD arthritis
7. Undifferentiated arthritis - doesn't fit into the above categories
156
What treatments are given for transient synovitis of the hip ('irritable hip')? (2)
1. Ibuprofen
| 2. Paracetamol
157
What signs are always red flags in a child with joint pain and need urgent assessment by paediatrics + orthapedics? (2)
1. Fever with a limp (or non-weightbearing limp)
158
What are the 4 regions of a bone?
1. Epiphysis
2. Epiphyseal plate
3. Metaphysis
4. Diaphysis
159
How do long bones increase in length?
New cartilage is deposited at the epiphyseal plate
160
A 7 year old boy presents with unilateral hip pain of gradual onset. There is no diurnal variation.
What is the most likely diagnosis?
Perthes' disease
161
A child presents with a warm swollen knee. The problem has lasted over 8 weeks with pain worse on waking up in morning and no fever or systemic symptoms. Fixed flexion deformity of knee on examination which is warm with pain on end range hyperextension.
What is the most likely diagnosis?
Juvenile idiopathic arthritis
162
What is the most likely cause of hip pain which has developed gradually over weeks in a 13 year old boy?
Slipped upper femoral epiphysis
163
An 11 year old girl who is a keen dancer presents with knee and ankle pain after activity.
What is the most likely diagnosis?
Joint hypermobility
164
What are 2 suggestive features of cauda equina syndrome?
1. Bilateral leg weakness/'saddle anaesthesia'
| 2. Bladder or bowel symptoms
165
Name 3 conditions where there is referred pain to the back
1. Peptic ulcer disease
2. Leaking aortic aneurysm
3. Pyelonephritis
166
What are the 11 red flags in the evaluation of spinal pain?
1. Age < 20 or > 50
2. Fever
3. Pain at night, progressive/constant pain, pain lying flat
4. Alcohol/drug use
5. Trauma
6. Weight loss
7. Reduced appetite
8. Neurology - weakness, numbness
9. Bladder or bowel symptoms
10. History of cancer
11. Significant trauma (or acute back pain in elderly? osteoporotic wedge fracture)
167
What is the Schober's test, and which condition is it seen in?
Schober's test looks for reduced lumbar spine flexion (<5cm)
Seen in Ankylosing spondylitis
168
What are 3 typical managements for mechanical low back pain?
1. NSAIDs ± low dose opioid
2. Physiotherapy exercise program
3. CBT
169
What is the natural history of recovery for patients with low back pain?
Most patients recover fully within 6-12 weeks
Patients who fail to recover by 4 months are more likely to progress to longterm chronic back pain
170
Name 1 clinical sign that supports the diagnosis of sciatica pain?
Positive straight leg raise test
171
What is the commonest cause of sciatica in patients under 50y? Over 60y? (2)
< 50 = disc herniations
> 60 = spinal stenosis
172
What imaging is recommended for sciatica back pain? (1)
MRI
173
Name 3 medications for chronic back pain
1. Neuropathic pain killer (gabapentin, amitryptiline)
2. Topical analgesics (capsaicin, lidocaine)
3. Facet joint injections of corticosteroids
174
TENS is often used by pain clinics in the treatment of resistant lower back pain. What is TENS?
Transcutaneous Electrical Nerve Stimulation
- based on Gate Theory of Pain (stimulation of large unmyelinated fibres at the level of the spinal cord block transmission of pain by small unmyelinated fibres)
175
What does a well circumscribed lesion situated directly behind a vertebral body likely suggest?
A neoplasm, possibly a neurofibroma
176
What gene test is used in the diagnosis of ankylosing spondylitis?
HLA-B27
177
What are the 4 special tests that can be performed in a shoulder examination, and what pathology do they test for?
1. Empty can test (supraspinatus injury)
2. Lift off test (subscapularis injury)
3. Scarf test (acromio-clavicle joint pathology)
4. Hawkins-Kennedy Test (supraspinatus tendon damage)
178
What is the movement and nerve supply of supraspinatus?
Abduction
| Suprascapular nerve
179
What is the movement and nerve supply of ifraspinatus?
External rotation
| Suprascapular nerve
180
What is the movement and nerve supply of teres minor?
External rotation
| Axillary nerve
181
What is the movement and nerve supply of subscapularis?
Internal rotation
| Upper + lower subscapular nerves
182
What initial investigation would you request for a patient with shoulder pain?
2 view plain x-ray
| - will see typical changes of osteoarthritis and not in frozen shoulder
183
What is tendon cuff arthropathy?
Rotator cuff tear + arthritis
184
What are the 3 treatment options for tendon cuff arthropathy?
1. Conservative (NSAIDs + physio)
2. Injection (into steroid + local anaesthetic into subacromial space)
3. Surgical intervention (arthroplasty)
185
Before joint injections what 3 factors need to be taken into account?
1. Anticoagulation
2. Diabetes (injection could increase BM, risk of infection)
3. Systemically well (no antibiotics, allergies)
186
What are 7 risks of joint injection?
1. Failure to work
2. Infection (1 in 10 000)
3. Pain
4. Worsening of symptoms temporarily
5. Bruising
6. Bleeding
7. Skin dimpling
187
Does having a joint injection put any restrictions on future management?
Patient cannot have surgical management for at least 3mo after joint injection due to high risk of infection
188
In which areas are tendon ruptures most commonly seen? (2)
1. Type III collagen areas
2. Hypovascular areas
i.e. Achilles Tendon
189
What ligament injuries commonly occur in adults? In children? (2)
Adults = mid-substance tears
Kids = avulsion injury
190
What are the 3 phases of tendon healing?
1. Inflammation
2. Proliferation (type III collagen)
3. Remodelling (type I collagen)
191
Name the 3 ligaments of the gleno-humeral joint
1. Superior
2. Middle
3. Inferior ligaments
192
What ligament plays a role in the restrictive element of frozen shoulder? (1)
Middle gleno-humeral joint ligament
193
What are the 4 rotator cuff muscles?
1. Supraspinatus
2. Infraspinatus
3. Subscapularis
4. Teres minor
194
What are the 2 categories of rotator cuff tears?
1. Traumatic
| 2. Degenerative
195
What tendon is most commonly affected in rotator cuff tears?
Supra ± infraspinatus tendon
196
What movement is restricted in both osteoarthritis + frozen shoulder?
External rotation
197
A past medical history of Diabetes or Thyroid disease predisposes to which pathology of the shoulder?
Frozen shoulder/adhesive capsulitis
198
What is the most commonly injured nerve in shoulder dislocation?
Axillary nerve
199
How is axillary nerve damage tested? (2)
1. Sensation in the regimental badge area
| 2. Through deltoid contraction
200
Is anterior or posterior dislocation of the shoulder more common?
Anterior dislocation
201
Name 2 situations where posterior dislocation of the shoulder can occur?
1. Electrocution
| 2. Seizure
202
Widespread fatigue + pain + unrefreshed sleep could indicate what? (1)
Fibromyalgia
203
What is the cardinal feature of fibromyalgia?
Chronic widespread pain
- >3mo duration
- on both sides of the body
- above + below the waist + along the axial spine
204
What are 3 signs of fibromyalgia?
1. Chronic widespread pain
2. Difficulty sleeping
3. Difficulty concentrating/memory
205
What examination must be performed to diagnose fibromyalgia?
18 well recognized "tender points" must be palpated
- pressure applied with pulp of thumb until nail blanches
Patients reporting pain in 11+ sites = fibromyalgia
206
What are the 3 diagnostic criteria for fibromyalgia?
1. Fibromyalgia pain (widespread pain index score of 7 and symptom severity scale score of 5; or WPI 3-6 + SS of 9)
2. Symptoms present at a similar level of intensity for at least 3mo
3. No other disorder that would explain the pain
207
What investigations would you undertake to rule out any other differential diagnoses when considering fibromyalgia? (7)
1. TFT (exclude hypothyroidism)
2. 25-hydroxy vitamin D (low levels = muscle pain)
3. Vitamin B12 (very low levels = pain + fatigue)
4. Iron studies (fatigue + poor sleep + depressive symptoms)
5. Magnesium (low levels = muscle spasms)
6. ESR/CRP (normal in fibromyalgia, raised in inflammatory arthritis)
7. Antibody screen (ANA, RF, anti-CCP antibodies if considering inflammatory arthritis/connective tissue disease)
208
How is fibromyalgia managed? (3)
1. Exercise
2. Psychological therapy (CBT)
3. Pharmacological (duloxetine, pregabalin, tramadol for severe pain; low dose amitriptyline, cyclobenzaprine, or pregabalin for sleep problems)
209
What are 6 risk factors for fibromyalgia?
1. Female sex
2. Low household income
3. Lack of further education
4. Family history of fibromyalgia
5. Having been through a traumatic event (ie. car crash)
6. Certain medical conditions (ie. RA)
210
What are the 2 pathophysiological theories of fibromyalgia?
1. Central sensitization (pain hypersensitivity, dynamic tactile allodynia)
2. Parallel processing
211
Which medication should be avoided in the treatment of fibromyalgia?
NSAIDs
212
What is the most likely explanation for peripheral oedema + heavy proteinuria in urine?
Nephrotic syndrome
- systemic disease affecting kidneys (amyloidosis, SLE, diabetes)
- primary kidney disorders (membranous nephropathy, focal segmental glomerulosclerosis)
213
What is nephrotic syndrome? (3)
1. Heavy proteinuria (>3-5g/24h)
2. Hypoalbuminemia
3. Oedema
214
What are the defining characteristics of nephritic syndrome? (6)
1. Hematuria (microscopic or macroscopic)
2. Proteinuria (<2g/24h)
3. Hypertension (caused by salt + water retention)
4. Oedema (periorbital, peripheral or sacral)
5. Oliguria
6. Uremia
215
What 2 antibody tests are used in SLE that determine if the disease is active?
1. dsDNA (high if active)
| 2. compliment levels (low if active)
216
What happens to ESR/CRP in SLE?
```
ESR = raised
CRP = normal (if raised check for infection)
```
217
What anti-nuclear antibodies are associated with SLE? (3)
1. dsDNA
2. Smith
3. nRNP
218
What anti-nuclear antibodies are associated with Sjorgen's syndrome? (2)
1. Ro(SSA)
| 2. La(SSB)
219
What anti-nuclear antibody is associated with dermatomyositis? (1)
Jo-1
220
What anti-nuclear antibody is associated with SCLE? (2)
1. Ro(SSA)
| 2. La(SSB)
221
What anti-nuclear antibody is associated with PSS? (1)
Sci-70
222
What anti-nuclear antibody is associated with CREST? 91)
Centromere
223
What anti-nuclear antibody is associated with MCTD? (1)
nRNP
224
What is the relevance of Ro(SSA) and La(SSB) positivity in pregnancy?
Can cross the placenta and result in neonatal lupus
225
What are signs of neonatal lupus? (3)
1. Lupus rash
2. Complete heart block
3. Blood abnormalities (ie. cytopenias)
226
What is anti phospholipid syndrome characterized by? (2)
1. Elevated anti phospholipid antibodies
| 2. Acquired thrombophilia or clotting tendency
227
How is antiphospholipid syndrome diagnosed? (2)
1. Positive anti phospholipid antibodies present (lupus anticoagulant, anticardiolopin antibody, anti-b2 glycoprotein) on 2+ occasions at least 12weeks apart
2. Vascular thrombosis or pregnancy morbidity
228
What immune responses occur in SLE? (2)
1. Type II hypersensitivity reaction
| 2. Type III hypersensitivity reaction
229
What are the 4 common features of SLE?
1. Fever
2. Rash
3. Joint pain
4. Woman of child bearing age
230
How is SLE diagnosed? (11)
Patient must have 4+ of the following:
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Nonerosive arthritis
6. Pleuritis/pericarditis
7. Renal disorder (persistant proteinuria/red cell casts)
8. Neurological disorder (seizure/psychosis)
9. Hematological disorder (hemolytic anemia/leukopenia/lymphopenia/thrombocytopenia)
10. Immunological disorder (anti-DNA, anti-Sm, antiphospholipid antibodies)
11. Positive ANA
231
How is lupus nephritis classified by WHO? (6)
Class I = mesangial immune deposits without mesangial hypercellularity
Class II = mesangial immune deposits with mesangial hypercellularity
Class III = focal glomerulonephritis (<50% of glomeruli affected)
Class IV = diffuse glomerulonephritis (>50% of glomeruli affected)
Class V = membranous lupus nephritis
Class VI = advanced sclerotic lesions
232
What is the typical treatment for lupus? (3)
1. Hydroxychloroquine
2. NSAIDs
3. Steroids (prednisolone)
233
What are risk factors for SLE? (7)
1. Sunlight exposure
2. Infection
3. Medications (i.e. isoniazid)
4. Smoking
5. Female sex
6. Age 15-45
7. Race (african-american, asian, hispanic)
234
What is Samter's triad?
1. Nasal polyps
2. Asthma
3. Aspirin sensitivity
235
What is the triad of symptoms for reactive arthritis?
1. Arthritis
2. Urethritis
3. Conjuctivitis/uveitis
236
When sending fluid off from joint aspiration, which tests should you ask to be performed? (2)
1. Microscopy
| 2. Cytology
237
What is a good blood test to perform assessing if an inflammatory process is occurring? (1)
Plasma viscosity
| - thicker the blood = more inflammation occurring
238
What is a common cause of eosinophilia? (2)
1. Drug related
| 2. Allergen related
239
How can the origin of renal disease be determined using the urea:creatinine ratio? (3)
Ur:Cr ratio <40 = post renal disease
Ur:Cr ratio 40-100 = renal disease/mixed pathology
Ur:Cr ratio >100 = pre-renal disease
240
Which systems are typically involved in vasculitis? (5)
1. Joints
2. Skin
3. Nerves
4. Lungs
5. Kidneys
241
What are examples of large vessel vasculitis? (2)
1. Giant cell arteritis
| 2. Takayasu's arteritis
242
What are examples of medium vessel vasculitis? (2)
1. Kawasaki's disease
| 2. Polyarteritis nodosum
243
What are examples of small vessel vasculitis? (3)
1. Microscopic polyangiitis
2. Granulomatosis with polyangiitis (Wegener's granulomatosis)
3. Eosinophilic granulomatosis with polyangiitis (Churg-Strauss Disease)
244
What is positive ANCA indicative of? (1)
Small vessel vasculitis
245
Where is c-ANCA's target commonly found? (1)
In the cytoplasm (hence the "c")
246
What condition is positive c-ANCA indicative of? (1)
Granulomatosis with polyangiitis (Wegener's)
247
What are the characteristic features of granulomatosis with polyangiitis (Wegener's granulomatosis)? (3)
1. Nasal crusting
2. Cavitating lesions in the lung
3. Saddle-nose deformity
248
Where is p-ANCA's target commonly found? (1)
Peri-nuclear region (hence the "p")
249
What conditions have positive p-ANCA? (2)
1. Microscopic polyangiitis (found at diagnosis)
| 2. Eosinophilic granulomatosis with polyangiitis (less commonly found at diagnosis)
250
What is the triad of criteria (Lanham diagnostic criteria) for diagnosing eosinophilic granulomatosis with polyangiitis/Churg-Strauss disease? (3)
1. Asthma
2. Eosinophilia ( > 1500/mm3)
3. Multi-organ involvement
251
What drug can cause neutrophilia?
Steroids
252
What are the best investigations for a person following diagnosis with Eosinophilic granulomatosis with polyangiitis? (2)
1. Chest x-ray (cavitating lesions)
| 2. Urine dip (glomerulonephritis)
253
What heart condition can be associated with vasculitis? (1)
Pericarditis
| - see saddle-shaped global ST elevation + PR depression on ECG
254
What glomerulonephritis diseases are associated with vasculitis? (2)
1. Diffuse proliferative glomerulonephritis (most common type of lupus nephritis associated with complement)
2. Crescentric glomerulonephritis (serious complication of ANCA-associated vasculitis; crescent formation in glomerulus)
255
What diseases are associated with membranous glomerulonephritis? (4)
1. Malignancies
2. Drugs (gold, penicillamine, captopril)
3. Autoimmune diseases (SLE, RA, thyroid)
4. Infections (Hep B, Syphilis)
256
What causes membroproliferative glomerulonephritis? (2)
1. Hepatitis C
| 2. Renal transplant causes relapse
257
How is crescentic glomerulonephritis treated? (1)
High-dose steroids (immunosuppression)
258
What conditions are associated with IgA nephropathy? (3)
1. Celiac disease
2. Henoch-Scholein purpura
3. Dermatitis herpetiformis
259
What is the treatment for small vessel vasculitis? (3)
1. Steroids (prednisolone or methylprednisolone)
2. Second immunosuppression (cyclophosphamide or rituximab)
3. Steroid-sparing agent once in remission (methotrexate, azathioprine, mycophenolate mofetil)
260
What factors do you need to consider before starting a patient on high-dose steroids? (4)
1. Gastro-protection
2. Bone protection
3. Screen for diabetes
4. Monitor BP/weight
261
EGPA is a multi-systemic disease with a wide range of presentations. What are the common manifestations and complications that can occur? (8)
1. Lower respiratory tract (asthma, hemoptysis, pneumonitis)
2. Upper respiratory tract (allergic rhinitis, paranasal sinusitis, nasal polyps)
3. Heart (pericardial effusion, MI, myocarditis)
4. Skin (purpura skin nodules, livedo reticularis)
5. Renal (crescentic glomerulonephritis, HTN, renal failure)
6. Nervous system (mononeuritis monoplex, stroke)
7. Ophthalmology (anterior uveitis)
8. Gastroenterology (mesenteric infarction, bowel perforation)
262
Which drug classically causes an exacerbation of asthma symptoms in someone with EGPA? (1)
Montelukast
| - leukotriene receptor antagonists
263
What genes are associated with EGPA? (2)
1. HLA-DRB1
| 2. HLA-DRB4
264
What are acquired risk factors for EGPA? (5)
1. Allergens
2. Infections
3. Vaccinations
4. Drugs
5. Silica exposure
265
What is brittle asthma?
Rare form of severe asthma characterized by a wide variation of Peak Expiratory Flow, in spite of heavy doses of steroids.
266
How is remission from EGPA assessed? (2)
Defined using the Birmingham Vasculitis Activity Score (BVAS) of 0 and OGC dose < 4mg/day
267
Why does proper management of giant cell arteritis require a chest x-ray? (1)
Because it can also affect the aorta
268
What are the signs of Kawasaki disease? (5)
1. Persistent fever (>5 days)
2. Lymphadenopathy
3. Strawberry tongue
4. Bilateral non-infective conjunctivitis
5. Desquamating rash
269
What is a complication of Kawasaki disease? (1)
Coronary artery aneurysm (hence coronary angiogram + ECHO very important)
270
How is Kawasaki disease treated medically? (2)
1. Aspirin (one of few indications in children)
| 2. IV immunoglobulin
271
What is Reyes' syndrome?
Rare disorder that causes brain + liver damage as a result of aspirin administration in children
272
What infection is polyarteritis nodosa associated with? (1)
Hepatitis B
273
What are signs of Takayasu's disease? (2)
1. Absent pulses in upper limbs ('pulseless disease')
| 2. Kidney damage
274
What are the components of a comprehensive vasculitis screen? (10)
1. FBC
2. U+E
3. LFT
4. TFT
5. PV (plasma volume)
6. CRP
7. ANA
8. ANCA
9. Chest x-ray
10. Urine dip
275
Peri-nuclear distribution of ANCA reflects the presence of which target? (1)
Myeloperoxidase (MPO)
276
What is the key target in c-ANCA positive vasculitis? (1)
Proteinase-3 (PR-3)
277
What are the 6 ACR (American college of Rheumatology) criteria for diagnosing EGPA?
4+ must be met:
1. Asthma
2. Eosinophilia
3. Neuropathy
4. Pulmonary infiltrates non-fixed
5. Paranasal sinus abnormalities
6. Extravascular eosinophils
278
What is the main complication associated with cyclophosphamide (used in initial tx of EGPA)?
Hemorrhagic cystitis due to toxic accumulation of drug in bladder
279
What is the antidote for cyclophosphamide? (1)
Mesna
