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
Symptoms of low phosphate
Muscle weakness, parasthesia
26
Primary hyperPTH blood results
Ca - Increased PO4 - Decreased ALP - Increased PTH - Increased
27
CKD (secondary hPTH) blood results
Ca - Decreased PO4 - Increased ALP - Increased PTH - Increased
28
Pagets 2 Phases Presentation Complications (3)
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
29
Pagets Ix findings X-ray Bloods
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
30
Management of Pagets
Pain: NSAIDs and paracetamol Antiresorptive: bisphosphonates N.b. IV may give flu-like symptoms Zoledronate popular as good with single IV dose Monitor ALP
31
Ca and PO4 regulation by VitD PTH
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
32
Osteomalacia vs rickets
Disorder of mineralisation of bone matrix (osteoid) after fusion of epiphyses Disorder of mineralisation of bone matrix prior to fusion of epiphyses
33
Causes of osteomalacia/rickets (8)
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
34
Rickets presentation
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
35
Joint pain causes
ARTHRITIS Arthritis, reactive arthritis, tendon/muscle damage, hyperuricaemia, referred pain, immune (e.g. SLE), tumour, ischaemia, sponyloarthtitides
36
Inflammatory vs Degenerative
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.
37
``` Osteoarthritis Pathology Which joints RF Diagnostic triad ```
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)
38
Symptoms & Signs of OA
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
39
X ray findings of OA
``` LOSS Loss of joint space Osteophytes Subchondral/subarticular sclerosis Subchondral cysts ```
40
Management of OA (3 tiers)
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)
41
RA What Who Pathology
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
Serum antibodies in RA
Anti CCP Rheumatoid factor (70%) ANA (30%)
43
Clinical features of RA (7)
``` Morning stiffness Symmetrical swelling Swan neck Boutonniere Z-deformity thumb Ulnar/Radial deviation Muscle wasting hands ```
44
Extra articular manifestations of RA
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
Feltys syndrome
Triad of: RA Neutropenia - increased susceptibility to infection, lung and skin infections Splenomegaly - LUQ pain and anaemia of chronic disease
46
Management of RA & Dug side effects
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
Methotrexate CI in which drugs
trimethoprim and phenytoin due to being folate inhibitors
48
Gout What Caused by Protective
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
Hyperuricaemia ->
Gout and uric acid stones
50
Gout management Acute Chronic
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
Pseudogout
Calcium pyrophosphate deposition in articular and periarticular tissues More commonly in the *elderly No specific therapies therefore symptomatic:
52
SLE What Genetics Presentation
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
Criteria for SLE
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
Ix for SLE
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
Management of SLE
Joints - NSAID ± hydroxychloroquine ± steroids (GI and bone protection) Mucocutaneous - Sunscreen, mouthwash (chlorhexidine), saliva, tears + oral hydroxychloroquine Nephritis - cyclophosphamide + prednisolone + hydroxychloroquine
56
``` Antiphospholipid syndrome What Antibodies Diagnosis Presentation Treatment ```
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
``` Sjogrens What HLA type Presentation Ix ```
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
Systemic sclerosis What Types
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
Autoimmune Rheumatic disease
``` RA SLE Sjogrens Systemic sclerosis Antiphospholipid ```
60
Limited cutaneous systemic sclerosis features
``` 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
Diffuse cutaneous systemic sclerosis features (4)
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
Ix of Systemic sclerosis
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
Management of systemic sclerosis
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
Ehler Danlos What? Presentation (5 system) Management
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
Marfan's What Presentation (6 systems) Signs (2)
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
Marfans management
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
``` Polymyositis + dermatomyositis What? Which muscles Cause Blood tests (3) ```
AI connective tissue disorders characterised by inflammation of striated muscles Proximal muscles Virus implicated: HIV, coxsackie CK elevation, LDH, aldolase AAb: anti-Jo1
68
Polymyositis | Presentation
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
Dermatomyositis
``` 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
``` Seronegative arthropathies Diseases Associations HLA number? Criteria ```
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
Ankylosing spondylitis What? Presentation (6)
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
Extra articular features of Ank spond (6)
``` The As of association (6) Apical fibrosis - LuFT Apical fibrosis Anterior uveitis Aortic regurg Achilles tendonitis AV node block Amyloidosis ```
73
Ank spond management
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
``` Reactive arthritis What? Organisms? Reiter’s (Most common) Ix Management ```
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
Vasculitis egs. Large vessel Medium Small
Large vessel: PMR, GCA, Takyasu’s arteritis Medium vessel: PAN, Kawasaki’s Small vessel: Wegener’s/GPA, Churg-Strauss (non-ANCA = HSP)
76
``` LVV - Giant Cell arteritis What? Main serious complication? Who? Presentation? Diagnosis? ```
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
LVV - GCA complications
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
LVV - GCA management
High dose oral prednisolone 1mg/kg/day for 4 weeks then taper
79
LVV - Polymyalgia rheumatica What? Diagnosis? Treatment?
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
LVV - Takyasus arteritis What Stages & Symptoms
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
LVV - Takyasus Signs Managment
*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
MVV - Polyarteritis nodosa What? Presentation
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
MVV - Polyarteritis nodosa Management Complications
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
MVV - Kawasaki’s What? Symptoms? Management?
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
SVV - ANCA - Wengers presentation
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
SVV - ANCA - Wengers management
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
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SVV - Non ANCA - IgA vascultits What? Presentation Management
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
SVV - ANCA - Churg-Strauss What? Presentation
Tissue eosinophilia, granulomatous inflammation, vasculitis Asthma (wheeze), eosinophilia in peripheral blood, paranasal sinusitis, pulmonary infiltrates, histological confirmation vasculitis, *mononeuritis multiplex
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Anti-GBM disease What? Ix Management
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
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Septic arthritis What? Oragnisms? Risk factors?
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
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Septic arthritis Ix Management
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
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Osteomyelitis What? Organisms?
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
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Osteomyelitis Ix Management
``` 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
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Back pain fed flags
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
Cervical back pain Common cause? Presentation?
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
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``` Lower back pain DDx 15-30yrs 30-50yrs 50+yrs Ix ```
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
``` Osteosarcoma Who? Associations? Where? Presentation? Course X ray ```
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
``` Ewigs sarcoma What? Who? Presentation? Xray ```
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
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NSAID side effects (5)
``` Increase in BP Oedema Gastric/Duodenal ulcer Headaches Liver and Kidney damage through decrease of prostaglandins ```
100
Cauda equina syndrome Signs (4) Causes
``` 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