Ortho/Rheum Flashcards
When interpreting a musculoskeletal xray what 4 areas should be described?
Alignment
Bones
Cartilage
Soft tissue
ABCS
When describing fractures what framework should I use?
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.
What are the cardinal signs of OA on xray?
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
What are the cardinal signs of RA on xray?
Loss of joint space
Periarticular osteopenia
Juxta-articular erosions
Soft tissue swellings
What is the cardinal sign of psoriatic arthritis on xray?
Central erosions (pencil in cup appearance
What may be seen on xray of a joint with pseudogout?
Chondrocalcinosis (calcium deposits in the cartilage)
What may be seen on xray of a gouty joint?
Punched out lesions in bone (periarticular tophi)
What are the three principles of fracture management?
Reduce, maintain reduction and rehabilitate
What are some immediate complications of a fracture?
General complication - shock from haemorrhage
Local complication - injury to nerves, vessels and skin
What are some intermediate (occurring during treatment) complications of fractures?
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
What are some late complications of fractures?
General - post-traumatic psychiatric disturbances
Local - malunion, loss of function, regional pain syndrome, late infection, joint stiffness/osteoarthritis
What are the textbook findings in #NOF xrays?
Disruption of Shenton’s line, lesser trochanter more prominent due to rotation, asymmetry of lateral femoral head, sclerosis in fracture plane from impaction.
Which artery is often disrupted in #NOFs?
The medial circumflex artery, which lies directly on the neck of the femur.
Explain the classification of #NOF and how it affects management.
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.
What is the definition of osteoporosis?
A BMD more than 2.5 standard deviations below that of an average young subject from the same race and sex
What are the causes of Dupuytren’s contracture?
Family hx Liver disease/alcohol Anti-epileptic drugs DM As a feature of other collagen disorders: Peyronie's
What are the causes of carpal tunnel syndrome?
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)
What are the clinical features of carpal tunnel syndrome?
Paraesthesia and numbness in lateral 3 fingers
Wasting of the thenar eminence
Symptoms worse at night
Tinel’s and Phalen’s positive
What are the risk factors for osteoarthritis?
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
What are the signs and symptoms of osteoarthritis?
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
What are the signs and symptoms of RA?
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)
What blood tests should be performed when suspecting RA?
CRP, ESR, FBC to check for infection, U+E for baseline, RF, anti-CCP
What are the risk factors for RA?
Female gender
Age 30-50
Genetics: HLA-DR4 and DR1
Smoking
What pharmacological options are available for treatment of RA?
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
What proportion of patients with RA experience extra-articular symptoms?
40%
What score can be used to monitor response to treatment in RA?
DAS-28
What tool can be used for diagnosis of RA?
ACR/EULAR Classification criteria
What are the common seronegative spondyloarthropathies?
Reactive arthritis - post. infection, Reiter’s syndrome (can’t see, can’t pee, can’t climb a tree)
Ankylosing spondylitis
Psoriatic arthritis
Enteropathic arthritis
What are the clinical features in common to the seronegative spondylarthropathies
Usually asymmetrical oligoarthritis affecting more proximal joints than RA.
Sacroiliitis, dactylitis, uveitis and enthesitis are common.
Strong association with HLA-B27
What infections are associated with reactive arthritis?
Enteric: Campylobacter, Salmonella and Shigella spp.
GUM: Chlamydia (most common overall), HIV
What would be seen in the synovial fluid of someone with reactive arthritis?
High WCC with polymorphonuclear leukocytes
Describe the management of reactive arthritis.
In acute phase, rest + NSAIDs + steroid injections +/- abx.
How long does reactive arthritis last?
Typically 3-12 months but recovery can take longer than 12 months. Recurrence is common.
Which two sites are most commonly affected in ankylosing spondylitis?
Sacroiliac joints and the spine.
What are the signs and symptoms of ankylosing spondylitis?
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
What are the risk factors for ank spond?
Male sex
Age 20-30
HLA-B27
Family history (90% of risk determined genetically)
What examination finding can be seen in ank spond?
Schober’s test: reduced spinal flexion (<5cm)
Which joints in the hand does psoriatic arthritis have preference for?
DIP joints
What is the name for the most severe form of psoriatic arthritis?
Arthritis mutilans
Which DMARD should be avoided in psoriatic arthritis?
Hydroxychloroquinone should be avoided as it may worsen psoriasis.
What are the indications for prophylaxis in gout?
Indication for prophylaxis is a diagnosis of gout + >/2 attacks per year, CKD stage >/2, or urolithiasis
What are the two drugs used in gout prophylaxis?
Allopurinol and febuxostat
What are the side effects of allopurinol?
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.
What are the risk factors for gout?
Male sex Old age Use of aspirin, diuretics, ciclosporin Meat, seafood and alcohol consumption Diabetes and obesity HTN
What is the mechanism of action of methotrexate?
It is an inhibitor of dihydrofolate reductase (folate inhibitor) which is essential for synthesis of purines and pyrimadines.
What are the indications for methotrexate?
Inflammatory arthritis (esp. rheumatoid)
Crohn’s disease
Psoriasis
Some chemotherapeutic applications (e.g. ALL)
What are the common adverse effects of methotrexate?
Mucositis
Myelosuppresion
Pneumonitis/pulmonary fibrosis
Liver cirrhosis
What are the requirements for monitoring in methotrexate prescribing?
FBC, U+E + LFTs weekly until patient stable, then every 2-3 months.
What should always be prescribed with methotrexate?
Folic acid 5mg.
What are the red flags for hip pain in a child?
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
What is the differential for hip pain in a child?
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
What are the red flags for adult back pain?
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
What are the yellow flags for back pain and what is a yellow flag?
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.
What investigations can be used in shoulder pain?
2 view plain xray to show anatomy and arthritis
US to show rotator cuff injury
Dynamic tests to show impingement
How long must a patient wait after intra-articular steroid injection before they can have surgical repair of the joint?
3 months
What are the treatment options for muscular back pain?
Paracetamol alone is not effective
NSAIDs + PPI should be offered
Self exercise/PT
What are the side effects of sulfasalazine?
Myelosuppresion
Oligospermia
Hepatitis
Rashes, and potentially SJS
Renal problems+ discoloured urine
List the autoimmune connective tissue diseases
SLE Systemic sclerosis Sjogren's Polymyositis MCTD Behcet's
What autoantibodies are associated with SLE?
ANA, dsDNA, ENAs (Ro, La, Sm, RNP)
Aide memoire = all the ones that end in NA (ANA, dsDNA, ENA)
What autoantibodies are associated with RA?
RF (70%), anti-CCP
What autoantibodies are associated with Sjogren’s?
RF, ANA, Ro, La
What autoantibodies are associated with myositis?
Jo-1
What autoantibodies are associated with systemic sclerosis?
Centromere (limited/CREST), scl-70 (diffuse)
What is CREST syndrome?
Calcinosis Raynaud's Esophageal dysmotility Sclerodactyly Telangiectasia
What are the diagnostic criteria for SLE?
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
What monitoring bloods are done in SLE?
ESR (CRP normal in active disease)
Complement (levels low in active disease)
anti-dsDNA titres can be used in come patients
Which drugs have the best evidence base in mild SLE?
Hydroxychloroquine and methotrexate
Which other condition must be tested for in SLE? (especially in females)
Antiphospholipid syndrome
In severe flares of SLE, what is an appropriate drug regime?
High dose prednisolone + IV cyclophosphamide
The pANCA, cANCA and ANCA -ve classification is used in vasculitides affecting which size of vessel?
Small vessels
List some types of large vessel vasculitides
Giant cell arteritis - old women
Takayasu’s arteritis - young women
List some medium vessel vasculitides
Kawasaki’s disease
Polyarteritis nodosa
List the small vessel vasculitides along with their ANCA classification
pANCA = EGPA + Microscopic polyangiitis
cANCA = GPA
ANCA -ve = HSP, Goodpasture’s, cryoglobulinaemia
What are the symptoms of polyarteritis nodosa?
Constitutional: fever, fatigue, weight loss Rash, subcutaneous nodules and ulcers Mononeuritis multiplex Renal involvement leading to HTN GIT - melaena and abdo pain
What are the symptoms of Kawasaki’s disease?
5 day fever Bilat non-purulent conjunctivits Oral mucositis Cervical lymphadenopathy Polymorphic rash Erythema and desquamation of extremities Coronary artery aneurysms
What are the features of GPA?
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)
What are the features of EGPA?
Late onset asthma - difficult to control (‘brittle’)
Eosinophilia
Granulomatous small vessel disease (RPGN, palpable purpura, GIT bleeding)
pANCA associated (remember pEGPA)
What are the 6 special tests in the shoulder examination and what do they test?
Empty can = supraspinatus
Lift off - subscapularis
Resisted external rotation - infraspinatus
Hornblower’s sign - teres minor
Scarf test - impingement
Painful arc - impingement
What blood tests should be done in a person with suspected vasculitis?
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)
