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Year 4 Medicine Revision > Ortho/Rheum > Flashcards

Ortho/Rheum Flashcards

1
Q

When interpreting a musculoskeletal xray what 4 areas should be described?

A

Alignment
Bones
Cartilage
Soft tissue

ABCS

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2
Q

When describing fractures what framework should I use?

A

SOD

Site - what bone? where in the bone? intra-articular?

Obliquity - completeness, direction, skin penetration, condition of bone

Displacement - translation (% of bone diameter in AP or ML direction), angulation (in degrees, AP or ML), rotation (in degrees), shortening or lengthening.

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3
Q

What are the cardinal signs of OA on xray?

A

Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts

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4
Q

What are the cardinal signs of RA on xray?

A

Loss of joint space
Periarticular osteopenia
Juxta-articular erosions
Soft tissue swellings

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5
Q

What is the cardinal sign of psoriatic arthritis on xray?

A

Central erosions (pencil in cup appearance

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6
Q

What may be seen on xray of a joint with pseudogout?

A

Chondrocalcinosis (calcium deposits in the cartilage)

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7
Q

What may be seen on xray of a gouty joint?

A

Punched out lesions in bone (periarticular tophi)

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8
Q

What are the three principles of fracture management?

A

Reduce, maintain reduction and rehabilitate

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9
Q

What are some immediate complications of a fracture?

A

General complication - shock from haemorrhage

Local complication - injury to nerves, vessels and skin

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10
Q

What are some intermediate (occurring during treatment) complications of fractures?

A

General - DVT/PE, Chest infection, kidney stones, fat embolism syndrome (confusion and resp difficulty), crush syndrome

Local - compartment syndrome, gangrene, pressure sores and nerve palsies from splints, infection, loss of alignment

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11
Q

What are some late complications of fractures?

A

General - post-traumatic psychiatric disturbances

Local - malunion, loss of function, regional pain syndrome, late infection, joint stiffness/osteoarthritis

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12
Q

What are the textbook findings in #NOF xrays?

A

Disruption of Shenton’s line, lesser trochanter more prominent due to rotation, asymmetry of lateral femoral head, sclerosis in fracture plane from impaction.

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13
Q

Which artery is often disrupted in #NOFs?

A

The medial circumflex artery, which lies directly on the neck of the femur.

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14
Q

Explain the classification of #NOF and how it affects management.

A

GARDEN CLASSIFICATION

1) incomplete, non-displaced
2) complete, non-displaced
3) complete, partially displaced
4) complete, fully displaced

1,2 give it a (DHS) screw, 3, 4, throw the head on the floor (THR). All surgery within 36 hours.

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15
Q

What is the definition of osteoporosis?

A

A BMD more than 2.5 standard deviations below that of an average young subject from the same race and sex

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16
Q

What are the causes of Dupuytren’s contracture?

A 
Family hx
Liver disease/alcohol
Anti-epileptic drugs
DM
As a feature of other collagen disorders: Peyronie's
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17
Q

What are the causes of carpal tunnel syndrome?

A 
V - none
I - none
T - trauma (e.g. fracture or haematoma)
A - rheumatoid arthritis
M - diabetes, hypothyroidism, obesity and acromegaly
I - idiopathic
N - ganglion or lipoma (benign)
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18
Q

What are the clinical features of carpal tunnel syndrome?

A

Paraesthesia and numbness in lateral 3 fingers
Wasting of the thenar eminence
Symptoms worse at night
Tinel’s and Phalen’s positive

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19
Q

What are the risk factors for osteoarthritis?

A 
Age
Obesity
Female sex
Family history
Sports activities

Secondary: pre-existing joint damage (fracture, RA, gout, septic arthritis, Paget’s), metabolic disease (haemochromatosis, chondrocalcinosis, acromegaly). systemic disease (haemophilia, neuropathy, haemoglobinopathy

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20
Q

What are the signs and symptoms of osteoarthritis?

A 
Painful joints
Heberdens and Bouchards nodes
Squaring of the base of the thumb
Big toe
Larger joints affected such as hip and knee
Reduced internal rotation of hips
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21
Q

What are the signs and symptoms of RA?

A

ANNOYIN SCARS

Arthritis - symmetrical polyarthritis with morning stiffness. Boutonniere or swan neck deformity, Z deformity of the thumb, ulnar drift, piano key deformity of the ulnar styloid, hallux-valgus deformity of the great toe.

Nodules - elbows, feet, achilles tendon

Nails and skin - longitudinal ridges, clubbin (w/ lung fibrosis), vasculitis

Ophthalmology - keratitis, scleritis, episcleritis, secondary Sjogren’s

lYmphadenopathy - proximal to affected joints

Immunocompromise

Neurology - peripheral (e.g. carpal tunnel), vasculitic mononeuritis multiplex

Systemic - fatigue, fever, anorexia, weight loss

Cardiac - pericarditis, myocarditis, endocarditis

Anaemia of chronic disease

Respiratory - fibrosis, pleurisy

Still’s disease and Syndrome of Felty (RA, splenomegaly, neutropenia)

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22
Q

What blood tests should be performed when suspecting RA?

A

CRP, ESR, FBC to check for infection, U+E for baseline, RF, anti-CCP

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23
Q

What are the risk factors for RA?

A

Female gender
Age 30-50
Genetics: HLA-DR4 and DR1
Smoking

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24
Q

What pharmacological options are available for treatment of RA?

A

NSAIDs for symptomatic relief

Short course steroids to induce remission

DMARDs to maintain remission (methotrexate, sulfasalazine, hydroxychloroquinone) and should be given in combination in patients where dose escalation has not induced remission as measured with DAS-28

TNF-a blockers (etanercept, infliximab) or other biologics if DMARDs not tolerated after 6 months and DAS-28 score remains above 5.1

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25
Q

What proportion of patients with RA experience extra-articular symptoms?

A

40%

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26
Q

What score can be used to monitor response to treatment in RA?

A

DAS-28

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27
Q

What tool can be used for diagnosis of RA?

A

ACR/EULAR Classification criteria

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28
Q

What are the common seronegative spondyloarthropathies?

A

Reactive arthritis - post. infection, Reiter’s syndrome (can’t see, can’t pee, can’t climb a tree)
Ankylosing spondylitis
Psoriatic arthritis
Enteropathic arthritis

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29
Q

What are the clinical features in common to the seronegative spondylarthropathies

A

Usually asymmetrical oligoarthritis affecting more proximal joints than RA.

Sacroiliitis, dactylitis, uveitis and enthesitis are common.

Strong association with HLA-B27

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30
Q

What infections are associated with reactive arthritis?

A

Enteric: Campylobacter, Salmonella and Shigella spp.

GUM: Chlamydia (most common overall), HIV

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31
Q

What would be seen in the synovial fluid of someone with reactive arthritis?

A

High WCC with polymorphonuclear leukocytes

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32
Q

Describe the management of reactive arthritis.

A

In acute phase, rest + NSAIDs + steroid injections +/- abx.

33
Q

How long does reactive arthritis last?

A

Typically 3-12 months but recovery can take longer than 12 months. Recurrence is common.

34
Q

Which two sites are most commonly affected in ankylosing spondylitis?

A

Sacroiliac joints and the spine.

35
Q

What are the signs and symptoms of ankylosing spondylitis?

A

Pain: back stiffness/buttock pain, worse in morning +/- asymmetric arthritis affecting pelvic and shoulder girdles

Reduced spinal movement: question mark posture

Peripheral enthesitis of achilles, tibial tendonitis and plantar fasciitis

Extra-articular symptoms: uveitis, aortic regurg, lung fibrosis, renal amyloidosis, osteoporosis, cauda equina and cervical myelopathy

6 As (atlantoaxial subluxation, anterior uveitis, apical fibrosis, aortic regurgitation, amyloidosis, achilles tendonitis) and osteoporosis

36
Q

What are the risk factors for ank spond?

A

Male sex
Age 20-30
HLA-B27
Family history (90% of risk determined genetically)

37
Q

What examination finding can be seen in ank spond?

A

Schober’s test: reduced spinal flexion (<5cm)

38
Q

Which joints in the hand does psoriatic arthritis have preference for?

A

DIP joints

39
Q

What is the name for the most severe form of psoriatic arthritis?

A

Arthritis mutilans

40
Q

Which DMARD should be avoided in psoriatic arthritis?

A

Hydroxychloroquinone should be avoided as it may worsen psoriasis.

41
Q

What are the indications for prophylaxis in gout?

A

Indication for prophylaxis is a diagnosis of gout + >/2 attacks per year, CKD stage >/2, or urolithiasis

42
Q

What are the two drugs used in gout prophylaxis?

A

Allopurinol and febuxostat

43
Q

What are the side effects of allopurinol?

A

Rash (10%), allopurinol hypersensitivity, increase in risk of gout attacks for first 6 months. Therefore all patients must be prescribed colchicine or NSAIDs for 2 weeks prior to commencement of urate lowering therapy.

44
Q

What are the risk factors for gout?

A 
Male sex
Old age
Use of aspirin, diuretics, ciclosporin
Meat, seafood and alcohol consumption
Diabetes and obesity
HTN
45
Q

What is the mechanism of action of methotrexate?

A

It is an inhibitor of dihydrofolate reductase (folate inhibitor) which is essential for synthesis of purines and pyrimadines.

46
Q

What are the indications for methotrexate?

A

Inflammatory arthritis (esp. rheumatoid)
Crohn’s disease
Psoriasis
Some chemotherapeutic applications (e.g. ALL)

47
Q

What are the common adverse effects of methotrexate?

A

Mucositis
Myelosuppresion
Pneumonitis/pulmonary fibrosis
Liver cirrhosis

48
Q

What are the requirements for monitoring in methotrexate prescribing?

A

FBC, U+E + LFTs weekly until patient stable, then every 2-3 months.

49
Q

What should always be prescribed with methotrexate?

A

Folic acid 5mg.

50
Q

What are the red flags for hip pain in a child?

A

Nocturnal pain, night sweats and weight loss - ALL

High fever, holding leg abducted - septic arthritis

High fever, non weight bearing - osteomyelitis of femur

Unusual history - non-accidental injury

51
Q

What is the differential for hip pain in a child?

A

Transient synovitis - acute onset limp, usually preceded by viral illness (URTI or gastro), diagnosis of exclusion

Septic arthritis

Osteomyelitis

Perthe’s disease - more common in boys aged 4-8 years, gradual onset limp, can be painless

SUFE - more common in boys aged 10 and older, RFs include being overweight an hypothyroidism, can present acutely or gradually

Developmental dysplasia of the hip - more common in girls, may see asymmetrical skin folds, leg length discrepancies, buttock flattening and walking with leg in external rotation

Bone tumour, juvenile arthritis, testicular torsion, inguinal hernia, appendicitis, leukaemia

52
Q

What are the red flags for adult back pain?

A

Age <20 or >50 at onset

Fever

Night pain (or pain lying flat, or constant pain)

IVDU

Trauma

Weight loss, fever, night sweats

Neuro deficits (muscle weakness and saddle anaesthesia)

Bladder or bowel disturbance

Hx of cancer

Prolonged steroids or immunosuppressants

53
Q

What are the yellow flags for back pain and what is a yellow flag?

A

Yellow flag = high risk of chronicity. Use biopsychosocial model

Yellow flags include: belief that pain and activity are harmful, sickness behaviours, withdrawal, low mood, anxiety, stress, work problems, over-protective family, lack of support network and inappropriate expectation of treatment.

54
Q

What investigations can be used in shoulder pain?

A

2 view plain xray to show anatomy and arthritis

US to show rotator cuff injury

Dynamic tests to show impingement

55
Q

How long must a patient wait after intra-articular steroid injection before they can have surgical repair of the joint?

A

3 months

56
Q

What are the treatment options for muscular back pain?

A

Paracetamol alone is not effective

NSAIDs + PPI should be offered

Self exercise/PT

57
Q

What are the side effects of sulfasalazine?

A

Myelosuppresion

Oligospermia

Hepatitis

Rashes, and potentially SJS

Renal problems+ discoloured urine

58
Q

List the autoimmune connective tissue diseases

A 
SLE
Systemic sclerosis
Sjogren's
Polymyositis
MCTD
Behcet's
59
Q

What autoantibodies are associated with SLE?

A

ANA, dsDNA, ENAs (Ro, La, Sm, RNP)

Aide memoire = all the ones that end in NA (ANA, dsDNA, ENA)

60
Q

What autoantibodies are associated with RA?

A

RF (70%), anti-CCP

61
Q

What autoantibodies are associated with Sjogren’s?

A

RF, ANA, Ro, La

62
Q

What autoantibodies are associated with myositis?

A

Jo-1

63
Q

What autoantibodies are associated with systemic sclerosis?

A

Centromere (limited/CREST), scl-70 (diffuse)

64
Q

What is CREST syndrome?

A 
Calcinosis
Raynaud's
Esophageal dysmotility
Sclerodactyly
Telangiectasia
65
Q

What are the diagnostic criteria for SLE?

A

SOAP BRAIN MD

Serositis (pleruritis or pericarditis)
Oral ulcers
Arthritis
Photosensitivity

Blood disorders
Renal involvement
ANA +ve
Immunologic tests (dsDNA, Ro, La, Sm)
Neurological disturbances

Malar rash
Discoid rash

4 or more must be present including one clinical and one immunological criterion

66
Q

What monitoring bloods are done in SLE?

A

ESR (CRP normal in active disease)

Complement (levels low in active disease)

anti-dsDNA titres can be used in come patients

67
Q

Which drugs have the best evidence base in mild SLE?

A

Hydroxychloroquine and methotrexate

68
Q

Which other condition must be tested for in SLE? (especially in females)

A

Antiphospholipid syndrome

69
Q

In severe flares of SLE, what is an appropriate drug regime?

A

High dose prednisolone + IV cyclophosphamide

70
Q

The pANCA, cANCA and ANCA -ve classification is used in vasculitides affecting which size of vessel?

A

Small vessels

71
Q

List some types of large vessel vasculitides

A

Giant cell arteritis - old women

Takayasu’s arteritis - young women

72
Q

List some medium vessel vasculitides

A

Kawasaki’s disease

Polyarteritis nodosa

73
Q

List the small vessel vasculitides along with their ANCA classification

A

pANCA = EGPA + Microscopic polyangiitis

cANCA = GPA

ANCA -ve = HSP, Goodpasture’s, cryoglobulinaemia

74
Q

What are the symptoms of polyarteritis nodosa?

A 
Constitutional: fever, fatigue, weight loss
Rash, subcutaneous nodules and ulcers
Mononeuritis multiplex
Renal involvement leading to HTN
GIT - melaena and abdo pain
75
Q

What are the symptoms of Kawasaki’s disease?

A 
5 day fever
Bilat non-purulent conjunctivits
Oral mucositis
Cervical lymphadenopathy
Polymorphic rash
Erythema and desquamation of extremities
Coronary artery aneurysms
76
Q

What are the features of GPA?

A

URT - chronic sinusitis, epistaxis, saddle-nose deformity

LRT - cough, haemoptysis, pleuritis

Renal - RPGN, haematuria, proteinuria

Palpable purpura and ocular -itides

cANCA associated (remember GPAc, kinda like 2pac)

77
Q

What are the features of EGPA?

A

Late onset asthma - difficult to control (‘brittle’)

Eosinophilia

Granulomatous small vessel disease (RPGN, palpable purpura, GIT bleeding)

pANCA associated (remember pEGPA)

78
Q

What are the 6 special tests in the shoulder examination and what do they test?

A

Empty can = supraspinatus

Lift off - subscapularis

Resisted external rotation - infraspinatus

Hornblower’s sign - teres minor

Scarf test - impingement

Painful arc - impingement

79
Q

What blood tests should be done in a person with suspected vasculitis?

A

FBC (sepsis), U+E (renal involvement), LFTs (drugs used), CRP, ESR, TFTs (rule out thyroidisms), plasma viscosity, hepatitis serology (B ass. with PAN, C ass. with mixed cryoglobulinaemia)

Year 4 Medicine Revision (4 decks)

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