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3b > Ortho & Rheum > Flashcards

Ortho & Rheum Flashcards

1
Q

Types of fracture (8)

A 
Fissure
Impaction
Greenstick
Transverse
Avulsion
Comminuted
Oblique
Spiral
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2
Q

Displacement of bones (3)

A

Translation (sideways movement, as % of bone diameter)
Angulation (bend in degrees)
Shortening (collapse, in cm)

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3
Q

Fractures causing avascular necrosis

A

Scaphoid fracture

Femoral head

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4
Q

Wrist fratures

A

Colles’ (distal radius with dorsal displacement fragments) - Forward fall. Dinner fork on lateral X ray

Smith’s (distal radius with volar displacement) - Backward fall. Garden spade on lateral x ray.

Scaphoid (*vulnerable blood supply)

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5
Q

NOF fracture
Types & Management (3)
Presentation
Complications

A

Intracapsular - Femoral neck between edge of femoral head and insertion to capsule
50% damage medial/lateral circumflex artery
May disrupt blood supply to femoral head - avascular necrosis - Surgery within 36 hours (Undisplaced - Internal fixation with screws. Displaced - hemiarthroplasty)

Extracapsular trochanteric # distal to insertion, involving or between trochanters - Nail/screw fixation

Extracapsular subtrochanteric # below lesser trochanter to 5cm distal - Nail/screw fixation

Pain in outer upper thigh or groin, radiate to knee, no wt bearing
Affected leg shortened, adducted and externally rotated

Pressure sores, DVT, bedbound, avascualr necrosis.
Total hip replacements dislocate more than hemis

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6
Q

Fracture healing time

A

Simple fractures take 3 weeks - Metaphyseal, closed, paediatric, upper limb.

Any complicating fracture doubles healing - Adult, diaphyseal, lower limb, open.

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7
Q

Stages of fracture healing

A

Haematoma formation *hours
MP and inflamm leukocytes move to area and begin secreting pro-inflammatory agents

Fibrocartilaginous callus formation (soft callus) *days
Inflammation leads to angiogenesis and increased number of chondrocytes. Secrete collagen and proteoglycans - fibrocartilage

Bony callus formation *weeks
Endochondral ossification and direct bone formation. Soft callus replaced by woven bone

Bone remodelling *months
Woven bone replaced by organised cortical bone. Continually remodelled therefore no scarring

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8
Q

NOF fracture grading

A

Gardens

  1. Incomplete #
  2. Complete but not dispisplaced
  3. Comp displaced <50%
  4. Comp, displaced > 50%
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9
Q

Femoral shaft fractures

A

High-velocity, and high-energy e.g. RTA

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10
Q

Joints in the ankle and pres of #

A

2 joints: ankle (tibia and fibula meet talus), syndesmosis joint (tibia to fib)

Similar to severe sprain: immediate severe pain, swelling (localised or along leg), bruising, tenderness - consider the mechanism

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11
Q

Ottawa ankle rules

A

When to X ray
>55
Inability to wt bear (4 steps) now and at time of injury
Bone tenderness at posterior edge or tip of lateral malleolus (6cm)
Bone tenderness at posterior edge or inf tip medial malleolus

(+ XR midfoot) bone tenderness at base of 5th metatarsal, cuboid or navicular

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12
Q

Preventing NOF#

A

Prevent falls - Good lighting, less sedation
Exercise and balance training - Tai Chi
Prevent osteoporosis - Bisphosphonates & Exercise
Vitamin D supplements

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13
Q

Management of ankle breaks

A

If neurovascular compromise or dislocation (obvious deformity) then reduce immediately
Reduce
Stabilise (4-6 weeks) moulded cast
Analgesia
Elevation
Re-assess neurovascular status
XR at reduction, 48 hours, 7 days, then 2 weekly

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14
Q

Ankle # Classifcation

A

Danis-Weber - Relative to the tibofibular syndesmosis
Below
At the level of
Above

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15
Q

Main complication of #

A

Compartment syndrome
6Ps - Pain out of proportion, parasthesia, pallor, paralysis, perishingly cold

When - Post fracture or reperfusion
Reduce risk by prompt fracture reduction and loose dressings

Treatment - Prompt fasciotomy

Post complications - Rhabdomyolysis -> renal failure (So give fluids)

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16
Q

Frozen shoulder

A

Thickening and contraction of glenohumeral joint capsule ± formation of adhesions - pain and loss of function either spont or post rotator cuff injury

40-65, Diabetes, thyroid

Loss of external rotation
Analgesia (paracetamol, NSAID), tens, activity, physio

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17
Q

Bone remodelling process

A

Osteocytes send signal to osteoclasts and osteoblasts
Osteoclasts resorb bone matrix: resorption pit - increases serum Ca
Osteoclasts undergo apoptosis and send signals to osteoblasts
Osteoblasts synthesise bone matrix
Bone matrix undergoes mineralisation

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18
Q

Hormones involved in bone remodeling (4)

A

PTH, 1,25-dihydroxyvitamin D, calcitonin, oestrogen

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19
Q

Osteoporosis
Definition
Location of #
Symptoms

A

T-score < -2.5 (s.d. below young healthy adult mean)

-2.5 < T

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20
Q

Risk factors for Osteoporosis

A

SHATTERED + FRAX (parental fracture) + SEDENTARY (decreased loading)
S - steroids + Cushing’s (>7.5mg for 3 months) - Decrease Ca absorption from gut, Increase osteoclast activity & Decrease muscle mass
H - hyperTh, hyperPTh, hypercalciuria
A - alcohol and tobacco
T - thin (BMI<19) or AN
T - testosterone decreased - primary hypogonadism, or anti-androgens @ PrCa
E - early menopause (<45)
R - renal/liver function - renal osteodystrophy in CKD, chronic liver disease
E - erosive/inflammatory disease: RA, multiple myeloma, metastasis
D - dietary Ca/T1DM - malabsorption, malnutrition

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21
Q

Osteoporosis managament

A

Lifestyle: smoking, alcohol, wt bearing exercise, balance (fall risk), calcium + vit D rich diet, fall prevention
Meds: Bisphosphonates + Ca + vit D supplements - AdCal D3, Accrete D3
Fall prevention: avoid polypharmacy
If low testosterone add testosterone
If intolerant bisphosphonates use denosumab (monoclonal aB to RANKL)
Raloxifene can be used for women (selective oestrogen receptor modulator)

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22
Q

Bisphosphonates
Egs
Mechanism
Side effects

A

Alendronic acid, risedronate, zoledronic acid

Inhibit osteoclastic bone resorption

Upper GI therefore take sitting upright with plenty of water first thing before food - crap absorption (1 hour before food)
Difficulty swallowing, oesophagitis, gastric ulcers
Osteonecrosis of the jaw

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23
Q

Osteoporosis blood tests

A

Ca, PO4, ALP, PTH all normal

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24
Q

Osteomalacia
Presentation
Blood test results

A

Widespread bone pain + tenderness (low back pain and hips)
Proximal muscle weakness - waddling gait (if severe)
Fatigue
Symptoms of underlying disease
Costochondral swelling, spinal curvature, hypocalcaemia (tetany, carpopedal spasm)

Ca - Decreased
PO4 - Decreased
ALP - Increased
PTH - Increased

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25
Q

Symptoms of low phosphate

A

Muscle weakness, parasthesia

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26
Q

Primary hyperPTH blood results

A

Ca - Increased
PO4 - Decreased
ALP - Increased
PTH - Increased

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27
Q

CKD (secondary hPTH) blood results

A

Ca - Decreased
PO4 - Increased
ALP - Increased
PTH - Increased

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28
Q

Pagets
2 Phases
Presentation
Complications (3)

A

Lytic phase - increased bone resorption by osteoclasts
Sclerotic phase - *Rapid bone formation by osteoblasts: disorganised and mechanically weaker and deformity/larger.

Bone pain and deformity with increased skin temperature. Fam history as AD mutation

Deformity: sabre tibia, kyphosis, skull bossing, enlarged maxilla/jaw
Pathological fracture (heavy bleeding as v.vascular)
Deafness/tinnitus compression of CN 8 by ear ossicles

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29
Q

Pagets Ix findings
X-ray
Bloods

A

Osteolysis and osteosclerosis (lytic and scleortic lesions)
Blade of grass lesion between healthy and sclerotic long bone
Cotton wool pattern of multifocal sclerosis in skull

Ca - Normal
PO4 - Normal
ALP - Increased
PTH - Normal

Nb further Ix - Isotope bone scans

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30
Q

Management of Pagets

A

Pain: NSAIDs and paracetamol

Antiresorptive: bisphosphonates
N.b. IV may give flu-like symptoms
Zoledronate popular as good with single IV dose

Monitor ALP

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31
Q

Ca and PO4 regulation by
VitD
PTH

A

Skin makes Cholecalciferol (D3) -> liver = 25 hydroxyvitamin D3 (inactive circulating) -> kidney = 1,25 dihydroxyvitamin D3 (active hormone)
To bone: increases Ca mobilisation, increases osteoclast function
To intestine: increases Ca absorption, increases PO4 absorption
To PTG: decreases PTH

Low Ca -> increased PTH
To bone -> increase osteoclast function
To kidney -> increases 1,25vD3 (1-alphahydroxylase), + decreases Ca excretion + increases PO4 excretion

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32
Q

Osteomalacia vs rickets

A

Disorder of mineralisation of bone matrix (osteoid) after fusion of epiphyses

Disorder of mineralisation of bone matrix prior to fusion of epiphyses

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33
Q

Causes of osteomalacia/rickets (8)

A

Lack of sunlight
Lack of adequate diet
GI malabsorption: surgery, short bowel, pancreatic disease, CF, CD, coeliac
Renal disease: -> defective 1,25 form = renal osteodystrophy
Liver disease: -> cirrhosis
Drugs: anticonvulsants, rifampicin (liver, stop 25-hydroxy)

Rare:
Tumour induced hypophosphataemia
Fanconi syndrome (proximal renal tubule dysfunction)
Renal tubular acidosis

Genetic

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34
Q

Rickets presentation

A

Bony abnormalities:
Leg bowing - genu varum
Knock knees - genu valgum
In first few months: craniotabes (softening of skull), frontal bossing, rachitic rosary (enlarged end segment ribs) -> rachitis lung
Dental abnormalities (enamel)
Delayed walk/waddling gait, impaired gait
Symptoms of hypocalcaemia: convulsions, irritable, tetany, apnoa, cardiac arrest

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35
Q

Joint pain causes

A

ARTHRITIS
Arthritis, reactive arthritis, tendon/muscle damage, hyperuricaemia, referred pain, immune (e.g. SLE), tumour, ischaemia, sponyloarthtitides

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36
Q

Inflammatory vs Degenerative

A

Ease on use, stiffness worse in morning (>60 mins), hot and red (r/d/c/t/LoF), responds to NSAIDs, swelling *synovial and bony, young/psoriasis/fam Hx

Worse with use, morning stiffness (<30 mins), mainly evening, prior occ, sport, *no swelling, not inflamed.

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37
Q 
Osteoarthritis 
Pathology 
Which joints
RF
Diagnostic triad
A

Deterioration of *articular cartilage and formation of new bone - osteophytes at joint margins

Knees, hips, small joints hands, spine

Age, female sex, obesity, occupation/hobbies, genetic (50%), joint laxity

Aged > 45 + activity related jt pain + no morning stiffness (<30 minutes)

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38
Q

Symptoms & Signs of OA

A

Joint swelling/synovitis - warmth + effusion
Reduced ROM

Crepitus
Pain on movement *may lead to disuse atrophy and weakness
Bony swelling and deformity - osteophytes: DIP (Heberden’s) + PIP (Bouchard’s)
No systemic features

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39
Q

X ray findings of OA

A 
LOSS
Loss of joint space
Osteophytes
Subchondral/subarticular sclerosis
Subchondral cysts
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40
Q

Management of OA (3 tiers)

A

Patient education, weight loss, screen depression, *exercise for muscle strength, aids and devices (walking sticks, tap turners)

Local analgesia: capsaicin or topical NSAID (first line)
+ Paracetamol (2)
+ NSAIDs ± PPI (3)
Intra-articular steroid injections (methylpred) for acute exacerbation

Replacement (arthroplasty), fusion (arthrodesis)

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41
Q

RA
What
Who
Pathology

A

Chronic inflammatory autoimmune disease characterised by inflammation of synovial joints leading to symmetrical joint and periarticular tissue destruction

Women (especially pre menopause), Fam history, Smokers

Inflammation of synovium
Increased angiogenesis, influx inflammatory cells + CKs, cellular hyperplasia
Cells (MP, TCells, plasma cells) release IL1/IL6/TNF - promote proliferation -> joint destruction
Proliferation
Angiogenesis and hypertrophic synovium form pannus over articular cartilage

42
Q

Serum antibodies in RA

A

Anti CCP
Rheumatoid factor (70%)
ANA (30%)

43
Q

Clinical features of RA (7)

A 
Morning stiffness
Symmetrical swelling
Swan neck
Boutonniere
Z-deformity thumb
Ulnar/Radial deviation
Muscle wasting hands
44
Q

Extra articular manifestations of RA

A

Rheumatoid nodules @ extensor surface of tendons (palisade ring of MP and fibroblasts with necrotic core) and *lungs

Vasculitic lesions - commonly skin rashes, leg ulcers (@Feltys)

Pleuritic chest pain - pleuritis or pericarditis

Eye problems: secondary Sjogren’s: scleritis and episcleritis

Neurological: peripheral nerve entrapment, atlanto-axial subluxation (C1,C2) - soft tissue swelling within rigid tunnel

Respiratory system: rheumatoid nodules, Caplan’s syndrome, pulmonary fibrosis

Anaemia of chronic disease

45
Q

Feltys syndrome

A

Triad of:
RA
Neutropenia - increased susceptibility to infection, lung and skin infections
Splenomegaly - LUQ pain and anaemia of chronic disease

46
Q

Management of RA & Dug side effects

A

Physiotherapy, OR, psych services (depression), podiatry
DAS 28 - Severity scoring

DMARDS
Methotrexate (+ folic acid) - SE Neutropenia, pul fibrosis, cirhosi,s mouth ulcers
Sulfasalazine - SE Hepatits, Mouth ulcers, oligospermia. Can use in pregnancy.
Azathioprine

Adjunct: corticosteroid (low dose pred) + NSAID (lowest effective dose) short term
Second line: biologicals - Infliximab, etanercept

47
Q

Methotrexate CI in which drugs

A

trimethoprim and phenytoin due to being folate inhibitors

48
Q

Gout
What
Caused by
Protective

A

Arthritis due to deposition of monosodium urate (MSU) crystals within joint

Trauma + surgery (cell damage), starvation (increased insulin), infection (cell damage), diuretics (reduced renal excretion)
Alcohol (beer highest), purine rich foods (red meat/sea food), fructose (sugary drinks/cakes), diuretics, DM, CKD, CHD, HTN, hyperlipidaemia

Dairy, coffee, vitamin C

49
Q

Hyperuricaemia ->

A

Gout and uric acid stones

50
Q

Gout management
Acute
Chronic

A

First line: NSAIDs e.g. naproxen 10-14 days: high dose then reduce at 48 hours
If NSAIDs poorly tolerated use colchicine

Prophylactic drugs: allopurinol or febuxostat (xanthine oxidase inhibitors)
Start 2 weeks post attack
Co-prescribe NSAID or colchicine for acute attack for 3 months

51
Q

Pseudogout

A

Calcium pyrophosphate deposition in articular and periarticular tissues
More commonly in the *elderly

No specific therapies therefore symptomatic:

52
Q

SLE
What
Genetics
Presentation

A

Inflammatory, multisystem autoimmune disease with antinuclear antibodies

HLAB8/DR3

Multisystem disease with raised ESR but normal CRP
Criteria + systemic: fatigue, fever, weight loss, lymphadenopathy

53
Q

Criteria for SLE

A

4/11 of DOPAMINE RASH
Discoid rash - over malar eminence
Oral ulcers - usually painless
Photosensitivity
Arthritis - 2 or more peripheral joints
Malar rash - fixed erythema, spares nasolabial folds
Immunological phenomena - anti-dsDNA, anti-Smith, antiphospholipid aBs
Neurological symptoms - seizures, migraines, polyneuropathy
ESR raised (*not CRP)
Renal disorder - proteinuria > 0.5g/day or +++, or casts
ANA +ve
Serositis - pleuritis (pleural rub on ausc or pleural effusion), pericarditis (on ECG, pericardial rub)
Haematological disorders - haemolytic anaemia (with reticulocytes) or leukopenia (<4x10^9), lymphopenia, thrombocytopenia

54
Q

Ix for SLE

A

ESR/CRP - ESR raised, CRP normal
FBC - anaemia, leukopenia, thrombocytopenia
Autoantibodies: ANA (95%), anti-dsDNA (Dop specific) (60%), antiSmith (30%)
Complement levels: low C4 and C3 - active disease
Urinalysis: haematuria, casts, proteinuria
U+E (renal disease)
CXR: pleural effusions, cardiomegaly
ECG: pericarditis

55
Q

Management of SLE

A

Joints - NSAID ± hydroxychloroquine ± steroids (GI and bone protection)
Mucocutaneous - Sunscreen, mouthwash (chlorhexidine), saliva, tears + oral hydroxychloroquine
Nephritis - cyclophosphamide + prednisolone + hydroxychloroquine

56
Q 
Antiphospholipid syndrome 
What
Antibodies
Diagnosis
Presentation 
Treatment
A

AI disorder characterised by arterial/venous thrombosis and adverse pregnancy outcomes

Anticardiolipin, antiB2glycoprotein1, lupus anticoagulant

One clinical criteria and one lab criteria
Clin: vascular thrombosis, pregnancy morbidity (unexplained death beyond 10 weeks or x3 before 10 weeks)
Lab: Lupus antiocoagulant or anti-cardiolipin or anti-B2 glycoprotein 1 present on 2 occasions (12 weeks apart)

Thrombosis, DVT, pregnancy loss, pre-eclampsia, thrombocytopenia, livedo reticularis: violaceous lace like on trunk, stroke

Warfarin: target 2-3
Avoid clotting lifestyle: smoking, contraceptive pill, healthy diet, low alcohol

57
Q 
Sjogrens
What
HLA type
Presentation
Ix
A

AI condition with lymphocytic infiltration of exocrine glands

DR3 (SLE)

Dry eyes, dry mouth, enlarged parotid gland, dysphagia, alterter taste
May present alone or with SLE, RA, systemic sclerosis, CREST

Schirmer tear test (filter paper, +ve if less than 5mm in 5 mins)
Autoantibodies anti-Ro (SS-A), anti-La (SS-B) ± RF, ANA, APLS AAb
Sialometry/sialography

Artificial tears & Artificial saliva, drink plenty
Oral pilocarpine

58
Q

Systemic sclerosis
What
Types

A

Multisystem AI disease with increased fibroblast activity -> *excessive collagen -> fibrosis -> *vascular damage + immune system activation.

Limited cutaneous (70%) - face, forearms and lower legs
Diffuse cutaneous (30%) - rest of skin + *organ fibrosis
59
Q

Autoimmune Rheumatic disease

A 
RA
SLE
Sjogrens 
Systemic sclerosis 
Antiphospholipid
60
Q

Limited cutaneous systemic sclerosis features

A 
CREST syndrome though usually raynauds for many years then followed by skin changes
Calcium deposits in fingers
Raynords
eSophageal refulx/reduced motility 
Sclerodactially
Telangecasia
61
Q

Diffuse cutaneous systemic sclerosis features (4)

A

Skin changes happen more rapidly and are more widespread. Early involvement of organs

Gastrointestinal involvement - Heartburn + reflux oesophagitis, bowel pseudo obstruction.
reduced motility
Renal involvement - Scleroderma renal crisis: accelerated HTN, headache, oliguria
Lung disease - Pul fibrosis & Pul Hypertension
Myocardial fibrosis - Arrhythmias

62
Q

Ix of Systemic sclerosis

A

FBC (microcytic if GI bleed, haemolytic in renal crisis), ESR/CRP,
U+E (elevated Ur + Cr @ renal crisis)

LuFT + diffusing capacity (restrictive) - disproportionate drop in DLCO to FVC - pul HTN
ECG - arrhythmia
CXR - lung disease = infiltrate, heart disease = cardiomegaly + heart failure
Barium swallow = oesophageal disorders and delayed emptying

*Serum autoantibodies
ANA - 90%
Anti-Scl70 - diffuse disease

63
Q

Management of systemic sclerosis

A

Raynauds = *Nifedipine (only drug licensed) - could try PDE5 inhibitors (sildenafil)

GI - PPI for life

Pulmonary = Cyclophosphamide (fibrosis), sildenafil (PAH) + O2

Joints = Prednisolone

Skin = Topical emollient ± topical corticosteroid (for itch) ± cyclophosphamide (for thickening)

Renal = AKI, HTN use ACEI ± other antihypertensives

64
Q

Ehler Danlos
What?
Presentation (5 system)
Management

A

Defect in structure, production or processing of collagen

Women > men x 8
Skin: increased elasticity + fragility
Joints: laxity, hypermobility, pes planus, prone to dislocation
CV: dizziness, palpitations, heart valve abnormalities, mitral valve prolapse, aortic root dilatation
Ocular: abnormal globe, cornea
Hearing: tinnitus due to ossicle laxity

Physiotherapy, regular gentle exercise, genetic counselling
Periodic echo for floppy mitral valve or aortic root dilatation

65
Q

Marfan’s
What
Presentation (6 systems)
Signs (2)

A

AD disorder of decreased extracellular microfibril formation.

Skin: striae
CV: aortic dilatation, dissection, mitral regurgitation
Lungs: pleural rupture - pneumothorax
Eyes: lens dislocation, closed angle glaucoma
Skeleton: arachnodactyly, hypermobility, pectus excavatum
Facial: retrognathia, high arched palate, enopthalmos

Walker’s sign - encircles wrist with overlapping pinky and thumb
Steinberg’s - Thumb extends past fingers when held in closed fist.

66
Q

Marfans management

A

Annual ECHO - aortic root width
CV MRI - every 5 years
MDT: geneticist, ophthalmologist, cardiologist, orthopaedics
Avoid maximal exertion: scuba diving, weight lifting

Prophylactic beta-blockers - propanolol
Reduce MAP and pulse rate

67
Q 
Polymyositis + dermatomyositis
What?
Which muscles 
Cause
Blood tests (3)
A

AI connective tissue disorders characterised by inflammation of striated muscles

Proximal muscles

Virus implicated: HIV, coxsackie

CK elevation, LDH, aldolase
AAb: anti-Jo1

68
Q

Polymyositis

Presentation

A

Not painful
Progressive symmetrical proximal muscle weakness - pelvic girdle
Difficulty rising from chair, climbing stairs, combing hair
Pharyngeal weakness - dysphagia
Interstitial lung disease and AV nodal disease

69
Q

Dermatomyositis

A 
Rash: (may be UV related)
Heliotrope violaceous eyelid
Gottron’s papules - purple scaly patches on extensors
Nailfold erythema
Shawl sign - macular rash 
Systemic upset: fever, arthralgia, malaise, weight loss
AV conduction defects
Interstitial lung disease 50%
GI ulcers
70
Q 
Seronegative arthropathies
Diseases
Associations
HLA number?
Criteria
A

Ankylosing spondylitis, Reiter’s syndrome, enteropathic arthritis, psoriatic arthritis, Behcet’s disease, JIA

Anterior uveitis, IBD (similar to Crohn’s)

HLA B27

Inflammatory spinal pain or synovitis (in lower extremities) +
Fam Hx: anky spon, psoriasis, reactive arthritis, IBD
Past or present psoriasis
Past or present IBD
Past or present pain alternating between buttocks
Past or present pain spontaneous pain and achilles or plantar fascia
Diarrhoea one month before arthritis

71
Q

Ankylosing spondylitis
What?
Presentation (6)

A

Seronegative spondyloarthropathy of axial skeleton sacroiliitis and spondylitis (vertebral inflammation)

Inflammatory back pain + enthesitis
Stiffness and pain waking in early morning
Gradual onset
Improvement with movement, no improvement with rest
Age at onset < 40
Tenderness at sacroiliac region (felt in buttocks) or limited spinal motion

72
Q

Extra articular features of Ank spond (6)

A 
The As of association (6)
Apical fibrosis - LuFT
Apical fibrosis
Anterior uveitis
Aortic regurg
Achilles tendonitis
AV node block
Amyloidosis
73
Q

Ank spond management

A

No cure: symptomatic control and control of complications
Physiotherapy + rehabilitation + exercise
First line: NSAIDs (± analgesics - paracetamol)
If pain refractory to NSAIDs (2) - TNFalpha inhibitor
-Methotrexate doesnt work

Local enthesitis - intra-articular corticosteroid injection
Peripheral arthalgia - DMARD: sulfasalazine

74
Q 
Reactive arthritis
What?
Organisms?
Reiter’s (Most common)
Ix 
Management
A

Occurs 1-4 weeks post exposure to GI and GU infections

Campylobacter/salmonella/shigella or chlamydia

Can’t see, can’t wee, can’t bend your knee (typically lower limb)
Conjunctivitis, non-gonococcal urethritis + post-infectious arthritis
Acute asymmetrical, lower extremity oligoarthritis
Lower back pain + heel pain (enthesitis)

ESR/CRP very high, FBC - WCC
Joint aspiration - rule out septic or crystal arthropathies
Culture: stool, throat UG tract - for causative organism
Serology chlamydia: PCR or NAAT and contract tracing

NSAID + rest ± intra-articular steroids ± ABX chlamydia (azithromycin injx single or doxy week)

75
Q

Vasculitis egs.
Large vessel
Medium
Small

A

Large vessel: PMR, GCA, Takyasu’s arteritis
Medium vessel: PAN, Kawasaki’s
Small vessel: Wegener’s/GPA, Churg-Strauss (non-ANCA = HSP)

76
Q 
LVV - Giant Cell arteritis 
What?
Main serious complication?
Who?
Presentation?
Diagnosis?
A

Inflammatory granulomatous arteritis of aorta and large cerebral arteries (extracranial branches of carotid)

Women > 50 & associated with PMR - 50%

Recent onset temporal headache + scalp tenderness + transient visual symptoms (diplopia) + jaw claudication (on chewing) + malaise + myalgia + fever

Abnormality on palpation of temporal artery (absent pulse, beaded, tender)

ESR > 50mm/hr + temporal artery tenderness + *temporal artery biopsy
Granulomatous inflammation, multinucleated giant cells, intimal hypertrophy and inflammation

77
Q

LVV - GCA complications

A

Anterior ischaemic optic neuritis
Stenoses of branches of aortic arch - subclavian and axillary arteries - 20%
Aortic aneurysm (x17)
Subclavian steel - Retrograde blood flow in vertebral artery due to proximal stenosis of subclavian artery

78
Q

LVV - GCA management

A

High dose oral prednisolone 1mg/kg/day for 4 weeks then taper

79
Q

LVV - Polymyalgia rheumatica
What?
Diagnosis?
Treatment?

A

Severe bilateral pain and morning stiffness: shoulders, neck, pelvic girdle (>2 weeks) with systemic features at onset (malaise, fever, fatigue)

Age > 50
Symp > 2w
Morning stiffness > 45 mins
Evidence of acute phase response ESR/CRP

Prednisolone - see improvement in 24-48 hours for 2 years (tapering dose down to minimum.
Steroid induced osteoporosis - DEXA + bisphosphonate + Ca + Vit D

80
Q

LVV - Takyasus arteritis
What
Stages & Symptoms

A

Chronic, progressive, inflammatory, occlusive disease of aorta and branches

Systemic stage + occlusive stage

Systemic: fever, fatigue, wt loss, arthralgia, tenderness on arteries

Occlusive: 
Limb claudication
Cardiac: angina, dyspnoea (CHF)
Neurological: dizziness, headache, TIA, visual disturbance, stroke
Vascular: claudication of jaw, back pain (aortic arch), *HTN
Pulmonary: haemoptysis
GI: abdo pain from ischaemia/infarction
Renal: haematuria
81
Q

LVV - Takyasus
Signs
Managment

A

*Difference in SBP of >10mmHg between arms
Impalpable peripheral pulse
High BP - renal artery stenosis
Arterial bruits on all arteries and aortic regurgitation
ESR > 50 CRP elevated with active disease

Glucocorticoids + aspirin + bone protection
If persistent use TNF alpha antagonist

82
Q

MVV - Polyarteritis nodosa
What?
Presentation

A

Necrotising inflammation of medium sized or small arteries without glomerulonephritis

Any organ BUT spares pulmonary and glomerular arteries
Nerves and skin most common
Nerves: *mononeuritis multiplex
Skin: purpura, subcutaneous nodules, necrotic ulcers, *livedo reticularis
Systemic symptoms: fever, wt loss, headache, myalgia

83
Q

MVV - Polyarteritis nodosa
Management
Complications

A

Prednisolone ± DMARD (cyclophosphamide) - if relapse

Renal failure - not due to glomerulonephritis - due to microaneurysms and infarcts - accelerated HTN - requires regular renal monitoring - poor prognosis = half die within 3 months

84
Q

MVV - Kawasaki’s
What?
Symptoms?
Management?

A

Idiopathic self-limiting systemic vasculitis in children 6M - 5Y (mainly asian)

CRASH and BURN
Conjunctivitis (bilateral + non-purulent)
Rash - non vesicular
Adenopathy (cervical + unilateral)
Strawberry tongue + inflammation of lips and mouth (cracked lips)
Hands/feet - palmar erythema/swelling/desquamation (2-5 days after onset)
Fever > 5 days

First line IVIg + high dose aspirin
Coronary artery aneurysm and dilatation - echo

85
Q

SVV - ANCA - Wengers presentation

A

Upper resp: otorrhoea, sinus pain, nasal discharge, hoarseness, stridor
-Saddle nose deformity, nasal septal perforation, subglottic stenosis
Lower resp: SOB, cough, haemoptysis, chest pain, dyspnoea, rhonchi, reduced air entry
Renal: oedema, HTN, haematuria (later)

86
Q

SVV - ANCA - Wengers management

A

Life threatening/organ involvement
Remission with IV methylpred (3d) + pred oral + cyclophosphamide
Non-life threatening:
Remission with IV methylpred (3d) + oral prednisolone + methotrexate
Maintain remission with oral pred + methotrexate + folic acid

87
Q

SVV - Non ANCA - IgA vascultits
What?
Presentation
Management

A

HSP
Young man with previous URTI - GpA strep (pyogenes)
IgA immune complexes deposited in small vessels

Low grade fever, *abdominal pain and vomiting, purpuric rash on buttocks and extensor, joint pain
Arthralgia, abdo pain, rash
In 40%-> nephrotic syndrome

Urinalysis: proteinuria, RBC, casts, 24 hour urine protein
Joint or abdo pain: ibuprofen or paracetamol
Kidney function: steroids

88
Q

SVV - ANCA - Churg-Strauss
What?
Presentation

A

Tissue eosinophilia, granulomatous inflammation, vasculitis

Asthma (wheeze), eosinophilia in peripheral blood, paranasal sinusitis, pulmonary infiltrates, histological confirmation vasculitis, *mononeuritis multiplex

89
Q

Anti-GBM disease
What?
Ix
Management

A

Lungs and kidneys: pulmonary renal syndrome -> glomerulonephritis and pulmonary haemorrhage -> haemoptysis and renal failure

Renal function: abnormal
Renal biopsy: crescentic glomerulonephritis - perform *urgently
Anti-GBM - positive

If reversible renal or any pulmonary involvement - oral prednisolone + cyclophosphamide + plasmapheresis

90
Q

Septic arthritis
What?
Oragnisms?
Risk factors?

A

Bacterial infection of a joint - can destroy a joint in under 24 hours - Usually in the knee

S.aureus
Streptococci e.g. GBS (staph and strep account for 90%), gonococcal in sexually active (tends to be with pustules, remember Reiter’s is chlamydia)

*Prosthetic joint (x10), RA, OA, IV drug abuse, alcoholism, diabetes, immunosuppression, skin infection

Nb. Suspect in anyone with a swollen red joint

91
Q

Septic arthritis
Ix
Management

A

Urgent joint aspiration - synovial fluid Gram stain and culture
Blood culture x2 ± gonococcal cultures (rectal, urethral, pharyngeal)
Acute phase markers: ESR, CRP, WCC raised

Surgical drainage and lavage (wash) + high dose IV abx
IV abx 2/3 weeks then oral 3/4 weeks - 6 total
If suspect G+ use vancomycin, if suspect G- use 3rd gen cephalosporin
When cultures back
For staph flucloxacillin
If suspect MRSA vancomycin
If gonococcal arth or G- cefotaxime or ceftriaxone

92
Q

Osteomyelitis
What?
Organisms?

A

Infection of bone marrow, may spread to cortex and periosteum via Haversian canals, leading to inflammatory destruction of bone.

Commonly s.aureus (or MRSA risk if diabetes or immunocompromised or IVDU)
Potts disease - vertebral osteomyelitis from haematogenous spread of TB

93
Q

Osteomyelitis
Ix
Management

A 
FBC (WCC)
Blood cultures (+ve)
Acute phase markers: ESR + CRP + WCC
Plain radiograph - Areas appear dark, soft tissue swelling, periosteal thickening (at 7 days), patchy osteopenia (lytic changes are late)
Cultures from debrided bone

Analgesia and limb splinting if long bone
Initial broad spec: vancomycin + cefepime (IV)
Culture directed ABX + debridement
IV for 2 weeks then oral for 4 weeks

94
Q

Back pain fed flags

A

TUNA FISH
Trauma
Unexplained weight loss, loss of appetite - cancer/myeloma
Neurological symptoms including bowel bladder dysfunction - cauda equina
Age > 50 or < 20
Fever and night sweats - osteomyelitis/cancer
IVDU/immunosuppression - osteomyelitis
Steroid use - immunocompromise + osteoporotic fracture
History of cancer (prostate, breast, lung, renal)

95
Q

Cervical back pain
Common cause?
Presentation?

A

Cervical spondylosis - chronic disc degeneration (CERVICAL OSTEOARTHRITIS)

Simple neck pain + radiculopathy (pain, numbness, tingling, weakness in upper limbs) + myelopathy (spinal cord)
Worse on movement
Cervical stiffness (limited all movements)
C5 - C7 -> diminished reflex (biceps + supinator = C5/C6, triceps = C7)

Plain XR - osteophytes, narrowing of disc space, encroachment of intervertebral foramen
If neuropathy -> require MRI

96
Q 
Lower back pain DDx
15-30yrs
30-50yrs
50+yrs
Ix
A

Trauma, fracture, pregnancy, anky spon, prolapsed disc, mechanical

Degenerative spinal disease, prolapsed disc, malignancy (breast, bronchus, prostate, kidney)

Degenerative, osteoporotic collapse, myeloma, spinal stenosis, malignancy, Paget’s (pelvis 70%, lumbar 50%)

FBC, ESR, CRP, UE, Alk phos, serum/urine electrophoresis, PSA

97
Q 
Osteosarcoma
Who?
Associations?
Where?
Presentation?
Course
X ray
A

Most common malignant in children (15-19)

Paget’s

In epiphyses of long bones - knee (75%) or proximal humerus

Painless

Destroys bone and spreads locally, rapidly *mets to lung

Combined bone destruction and formation. Soft tissue calcification = sunburst/hair on end + Codman’s triangle (area of new subperiosteal bone created when tumour raises periosteum from bone

98
Q 
Ewigs sarcoma
What?
Who?
Presentation?
Xray
A

Primitive neuroectodermal tumour

15 yo boy

Mass or swelling, long bones of arms or legs, pelvis, chest
Pain, redness, malaise, fever

Bone destruction with onion skin layers of periosteal bone formation + Codman’s triangle

99
Q

NSAID side effects (5)

A 
Increase in BP
Oedema
Gastric/Duodenal ulcer
Headaches
Liver and Kidney damage through decrease of prostaglandins
100
Q

Cauda equina syndrome
Signs (4)
Causes

A 
Saddle anaesthesia + Sciatica 
Upgoing plantars,
Loss of reflexes 
Reduced anal tone
Urinary retention

Degenerative - Slipped disk
Inflamatory - Ank spond
Infective - Potts, Abcess
Trauma - Fractures/ Haematoma from spinal

3b (15 decks)

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