Ortho/ Rheumatology Flashcards
1
Q
What is osteoarthritis and who might it affect?
A
- = Degenerative joint disorder in which there is progressive loss of hyaline cartilage and bone remodelling.
- Typically affects people >50y. “Wear and tear”
- Risk factors: Age, obesity, previous injury, joint abnormality, haemachromatosis.
2
Q
Presentation of osteoarthritis
A
- Pattern= asymmetrical. Large weight bearing joints.
- Hand signs:
- Deformity
- Periarticular tenderness
- Muscle wasting/ weakness
- Heberden’s and Bouchard’s nodes.
- Joint instability.
- Fixed flexion deformity.
- Thumb squaring.
- Bony osteophytes. No oedema, erythema or synovitis.
- Limited to joint involvement.
3
Q
Ix of Osteoarthritis
A
- Bedside- SHx and ADLs
- Bloods- no change.
- Imaging- x-ray:
- Loss of joint space
- Osteophytes
- Subchondral cysts
- Subchondral sclerosis
- Special - ?joint aspirate –> WCC <2000
4
Q
Tx of osteoarthritis
A
- Conservative- physio, OT, hydrotherapy, walking aids, home modification, weight loss, hot and cold packs
- Med- analgesia (paracetamol, NSAIDs, tramadol). Joint injections- local anaesthetic, steroids, synthetic synovial fluid.
- Surg- arthroscopic arthroplasy or washout. Osteotomy.
5
Q
What is Rheumatoid Arthritis? Who might present with it?
A
- = Chronic systemic inflammatory disease. Characterised by symmetrical deforming peripheral polyarthritis. Inflamed synovial membranes.
- Associations:
- AI disease - female, post-partum, genetics, smoking. Eg thyroid, DM.
- Female : Male 3:1
- Any age
- Genetics- Rh Factor, HLA-DR4
6
Q
Presentation of RA
A
- Symmetrical
- Small joints - MCP, MTP, DIP sparing
- Limited movement due to pain and stiffness (>1h morning). Stiffness improves with exercise.
- Boggy swelling. Red + hot.
- Joint signs:
- Deformity + ulnar deviation
- Warm and tender joints
- Muscle weakness
- Synovitis/ effusion
- Swan neck / Boutonierre deformity
- Z deformity
- Subluxation
- RA nodules - Firm. Elbows, hands, feet, lungs
- MULTISYSTEMIC!
7
Q
Extra-articular features of RA
A
- Lungs- interstitial lung disease, pulmonary fibrosis, pleurisy, fibrosing alveolitis, nodules (Caplan syndrome = RA + pneumoconiosis esp coal miner)
- Skin - nodules. Firm, non-tender.
- Neuro - Cervical myelopathy, carpal tunnel
- Eyes - Sjogren’s, uveitis, iritis, scleritis
- CVS - vasculitis, pericarditis, Reynaud’s
- Weight loss (inflammation)
8
Q
Ix of RA
A
- Bloods:
- FBC- normocytic, normochromic anaemia
- Rh factor +ve in 70%
- Imflammation- raised CRP, ESR, platelets
- Anti-CCP
- ANA
- Imaging:
- X-ray: loss of jointn space, erosions, soft tissue swelling, osteopoenia.
- ?USS
- ?MRI
- Special- joint aspirate WCC >2000
9
Q
Diagnosis of RA
A
- 4/7 of:
- Morning stiffness >1h for 6 weeks
- Arthritis in >3 joints
- Arthritis of hand joints
- Symmetrical
- Rheumatoid nodules
- +ve Rh factor
- Radiographic changes
10
Q
Tx of RA
A
- Conservative- Physio, OT, reg exercise, education, safety netting.
- Med:
- Analgesia- paracetamol, NSAIDs (+PPI), opiates
- Steroids - IM, PO, intra-articular. For exacerbations.
- Manage CVS risk
- ?Bisphosphonates to prevent osteoporosis
- DMARDs = 1st line
- Biologics if 2 DMARDs failed
11
Q
Examples of DMARDs and SE
A
- All can cause myelosuppression –> pancytopoenia
- Methotrexate - SE: low folate, teratogenic, hepatotoxic, pulm oedema. Reg bloods.
- Hydroxychloraquin - SE: retinopathy, seizures. Safer in preg.
- Sulfasalazine - ABx + aspirin. SE: hepatotoxic, SJS, orange urine, low sperm count
12
Q
What are biologics? Examples + SEs
A
- = Monoclonal Abs used in refractory RA.
- NB to screen for a Tx TB 1st
- Anti-TNFalpha: Infliximab, adalimubab. SE: infection, AI disease, cancer.
- Anti-CD20: rituximab.
13
Q
What screening tool is used to monitoro RA?
A
- DAS28: Disease Activity Score
- Tender joints (28)
- Swollen joints (28)
- ERP/ CRP
- Patient’s VAS score (Patient’s global assessment of their health)
- –> guides management. >5.1= active disease
14
Q
Psoriatic Arthirits - patterns of joint involvement
A
- Asymmetrical oligoarthritis (60%)
- Distal arthritis of DIPs
- Symmetrical polyarthritis (inc. DIPs)
- Arthritis mutilans
- Psoriatic spondylitis
15
Q
Presentation, Ix and Tx of psoriatic arthritis
A
- Asymmetrical arthritis including DIPs
- Extra-articular:
- Nail changes
- Synovitis –> dactylitis
- Plaques
- Achilles tendonitis, plantar fasciitis
- Ix- X-ray= ‘pencil in cup’ and ‘plantar spur’
- Tx:
- NSAIDs
- DMARDs
- Biologics
16
Q
What is enteropathic arthritis? Presentation, Tx
A
- = Chronic inflammatory arthritis in those with IBD (1/5)
- Presentation:
- Arthritis- asymmetrical, commonly peripheral limbs (esp legs). May have sacroilitis.
- Abdo pain
- Change in bowel habit
- Tx: Tx the IBD!
- Self-limiting 6w
- Acute- NSAIDs, intra-articular joint injections
17
Q
Reactive arthritis - presentation, Ix, Tx
A
- = Sterile arthritis 1-4w after urethritis (chlamydia) or dysentry (campylobacter, salmonella, shigella)
- Reiter= can’t see, can’t pee, can’t climb tree
- Presentation:
- Asymmetrical lower limb oligoarthritis esp knee
- Eyes- iritis, conjunctivitis
- Keratoderma blenorrhagia (plaques on soles and palms)
- Circinate balanitis (painless penile ulceration)
- Ix- stool sample, swabs/ urine. bloods (raised CRP/ESR), x-ray
- Tx- splint, NSAIDs, local analgesia. DMARDS if >6w.
18
Q
Septic arthritis - RF, organism, presentation, DDx
A
- Source= local or haematogenous.
- Organism- Staph. A, gonococcus, streps
- RF: Overlying infection, prosthesis, age, immunosuppression
- Presentation:
- V. quick onset
- Triad: Fever, pain, reduced ROM
- Hip + knee = most common. Knee > hip > ankle
- Severe pain, swelling, redness, heat
- Systemically unwell
- DDx - gout, reactive arthritis
19
Q
Ix, Tx and complications of septic arthritis
A
- Ix:
- Bloods- cultures, FBC, ESR, CRP (raised)
- X-ray
- Joint aspiration - ++WCC
- Tx:
- Cons- splint, rest. Physio once resolved. Mobilise to avoid deformity
- Med- IV ABx- fluclox/ clindamycin
- Surg- washout, arthroscopic drainage
20
Q
What is Gout? + RF/ causes
A
- = Monoarthropathy (or polyarthropathy) due to accumulation of monosodium urate crystals in and around joint –> erosive arthritis.
- RF:
- Dietary purines (red meat), ++ alcohol
- FHx
- Male
- Renal failure/ dehydration
- DM
- Obesity
- Psoriasis
- Haemolysis
- Preciptants- surgery, infection, fasting, diuretics
21
Q
Presentation of Gout
A
- Usually monoarthropathy with severe joing inflammation (red, hot, swollen)
- Site- 60% MTP. Also ankle, foot, hand, wrist, elbow, knee
- Tophi - urate deposits
- Renal disease- stones, interstitial nephritis
- Associations to check for- IHD, HTN, metabolic syndrome
22
Q
Ix of Gout
A
- Bloods- serum urate
- X-ray- early= soft tissue swelling. late= loss of joint space, punched out periarticular
- Synovial fluid LM- -vely birefringent needle shaped crystals
23
Q
Gout Tx
A
- Acute- NSAIDs + colchicine. (Steroids if renal impairment), rest.
- Prevention:
- Cons- lose weight, no alcohol
- Med- allopurinol if recurrent attacks, tophi or renal stones. Sx free 4w.
24
Q
What is pseudogout? Presentation, Ix and Tx
A
- = Calcium pyrophosphate deposition
- Presentation- usually spont. Acute monoarthropathy, typically in elderly
- Ix= synovial fluid LM. +ve birefringent rhomboid crystals
- Tx= cool packs, rest, NSAIDs +/- colchicine
25
What is ankylosing spondylitis and who is likely to get it?
* Chronic disease of unknown aetiology characterised by stiffening and inflammation of the spine and sacroiliac joints.
* Epidemiology:
* M:F 6:1
* Men present earlier (teens-20s)
* 90% HLA B27 positive
26
Conditions associated with HLA B27
PAIR
* Psoriasis
* Ankylosing spondylitis
* IBD
* Reactive arthritis
27
Presentation of Ankylosing Spondylitis
* Gradual onset
* Lower back pain. Worse at night, relieved by exercise. Can radiated into buttocks.
* Spinal stiffness + progressive loss of movement
* ? mark posture/ bamboo back
* Eyes- acute ititis/ uveitis
* Osteoporosis
* Costochondritis
* Apical pulmonary fibrosis + reduced thoracic expansion
* Aortic valve incompetence
28
Ix and Tx of Ankylosing Spondylitis
* Dx= clinical with Schrober's test and occipital wall distance.
* Bloods- CRP, ESR, HLA
* Imaging- X-ray signs are late:
* Sacroilitis (blurring and narrowing)
* Squaring of vertebra
* Bamboo spine- calcification of ligaments
* Tx:
* Cons- EXERCISE, physio
* Med- NSAIDs, local steroid injections, bisphosphonates, anti-TNFalpha if severe
* Surg- hip replacement
29
What is osteoporosis and it's RF?
* = reduction in bone mass --\> fragility fractures
* RF= SHATTERED + female, age
* Steroids
* Hyperthyroid/hyperparathyroid
* Alcohol/ tobacco
* Thin (BMI \<22)
* Testosterone
* Early menopause
* Renal/liver disease
* Erosive/ inflammatory joint disease
* Diet- malabsorption, low calcium
30
Presentation and Ix of osteoporosis
* Presentation- usually ASx. Present with fragility fracture - NOF, vertebral crush fracture, distal radius
* Ix:
* qFracture score - 30-99y
* FRAX score (40-90y)= 10y risk of fragility fracture. ?Education + repeat 2-3y. ?BMD scan? Risk \>20% --\> treat!
* Bloods- FBC, ESR/CRP, U+Es, calcium testosterone, immunoglobulins, albumin, Mg, phosphate, ALP. (Bone profile, rule out DDx)
* Imaging- X-ray fracture, DEXA scan
31
What bloods are in a bone profile?
* Calcium
* Albumin
* Phosphate
* Magnesium
* ALP
32
Indications and meaning of DEXA scan results
* Indications- Low impact fracture, women \>65y with 2 or more RF, long term steroids, PTH disorder, myeloma, HIV, early menopause
* T score= no. SD away from youthful average.
* Z score= age matched
* Results:
* -1 - +1= Normal
* -1 - -2.5= Osteopoenia
* \<-2.5= Ostoporosis
33
Tx of osteoporosis
* Cons- quit smoking and alcohol, weight bearing, calcium/ vit D in diet, falls prevention.
* Med:
* Bisphosphonates= 1st line. Eg alendronic acid. (Take with ++ water, sitting up). SE: GO, oesophageal erosis, MSK pain, osteonecrosis of jaw
* Strontium ranelate
* Calcium + vit D supplement
* Calcitonin
* HRT
* Surg- fix fracture
34
What is osteomalacia and how might it present?
* = Loss of bone mineral content. Uncalcified osteoid/ cartilage. Normal bone mass, lower quality.
* Presentation:
* Children= Rickets. Knock-kneed/ bow-legged, bone pain, craniotabes, growth retardation, Harrison's sulcus, rachitic rosary
* Adults= Osteomalacia. Bone pain, fractures, proximal myopathy (low phosphate)
35
Causes of osteomalacia
* Vit D deficiency
* Liver/ renal failure (Vit D hyroxylation)
* Inherited Vit D resistance
* AEDs
* Malignancy- hypophosphataemia
36
Ix and Tx of osteomalacia
* Ix:
* Bloods - low calcium, PO4, vit D. High ALP, PTH
* X-ray- loss of cortical bone. Cupped mataphyses in rikets. Looser's zones (pseudofractures)
* Tx:
* Cons- dietary Calcium D3
* Med- Vitamin D replacement. Monitor Calcium
37
What is fibromyalgia + its RF
* = chronic disease with widespread MSK of medically unexplained cause
* RF:
* Female (x10)
* Middle aged
* Depression/ anxiety/ stress
* Marital probs
* Low income/ work satisfaction
* Associations: Chronic fatigue, IBS, chronic headache
38
Presentation and Tx of fibromyalgia
* Presentation:
* Chronic widespread MSK pain
* Mornign stiffness
* Fatigue
* Low mood
* Sleep disturbance
* Poor concentration
* Tx:
* Cons- education, CBT, graded exercise prog
* Med- amitryptiline, pregabalin, venlafaxine
39
What is Sjogren's syndrome and what is it associated with?
* = Keratoconjunctivitis sicca
* Classification:
* Primary. F:M 9:1. 4th-5th decade
* Secondary: RA\< SLE, systemic sclerosis
* Associations:
* AI- thyroid, AIH, PBC
* MALT lymphoma
40
Presentation of Sjogren's syndrome
* Xerostomia (dry mouth)
* Dry eyes
* Bilat. parotid swelling
* Vaginal dryness and dyspareunia
* Systemic- polyarthritis, Raynaud's, pulm. fibrosis, vasculitis, myositis
41
Ix and Tx of Sjogren's syndrome
* Ix:
* Bedside- schirmer test
* Bloods- ANA Ro + La, Rh factor, hypergammaglobulinaemia
* Special- Parotid biopsy
* Tx:
* Cons- artificial tears, saliva replacement
* Med- NSAIDs/ hydroxychloraquin for arthralgia. Severe- immunosuppression
42
What is Raynaud's phenomenon and how is it classified?
* = Peripheral digital ischaemia precipiated by cold/ emotion.
* Classification:
* Primary- Idiopathic Raynaud's disease
* Secondary- Systemic sclerosis, SLE, RA, Sjogren's, thrombocytosis, beta blockers
43
Presentation and Tx of Raynaud's
* Presentation:
* Digital pain + triphasic colour change: white --\> blue --\> crimson
* Digital ulceration + gangrene
* Tx:
* Cons- wear gloves
* Med- ACEi, CCB eg nifedipine, IV prostacyclin.
44
Bone mets- common primaries + presentation + Ix + Tx
* Primaries: Breast, lung, prostate, thryroid
* Presentation:
* Bone pain
* Pathological fracture
* Hypercalcaemia
* SC compression
* Ix- urinalysis, bone profile (high calcium, alk phos and phosphate), x-ray, bone scan, CT, MRI, PET
* Tx- Physio, OT, hormone therapy, chemo/ radio, **bisphosphonates**, surgery
45
Types of primary bone cancer
* Osteosarcoma- teens. More in hip/ leg/ shoulder/ humerus
* Ewing's Sarcoma- Teens. Normally starts pelvis/ fermur/ tibia. + CT tumours
* Chondrosarcoma- 30-60y. Cartilage
* Spindle cell sarcome
* Chordoma
46
Presentation + Tx of achilles tendon rupture
* Presentation:
* Sudden severe pain in ankle when running/ jumping. "kick"
* Limp
* Inability to raise heel from floor when standing on leg
* O/E- palpable gap, Simmond's +ve: kneel on chair and squeeze both calves, less plantar flexion on affected side.
* Tx:
* Conservative- cast 6-8w. Equinous position --\> neutral
* Surg- surgical tendon repair. Young athletic/ late presentation
47
Rotator cuff presentation, Ix and Tx
* = Damage to supr/infraspinatus, subscapularis.
* Causes- age related, trauama
* Presentation:
* Shoulder weakness and pain
* --\> impingement syndrome --\> painful arch
* Night pain
* Ix- USS, MRI
* Tx- arthroscopic repair
48
Adhesive capsulitis- associations, presentation, Tx
* = Frozen shoulder
* Associations: cervical spondylitis, DM, thyroid.
* Presentation:
* Severe pain in shoulder, ++ at night
* Reduced ROM in shoulder
* Phases:
1. Freezing (\<1y) ++ pain, reduction in acitve + passive movement. Abduction +/- external rotation
2. Frozen (6-12m) Stiff. Less pain.
3. Thawing phase (1-3y). Slowly regain movement
* Tx:
* Cons- physio
* Med- NSAIDs, steroid joint injections
* Surg- Release, arthroscopic arthrolysis
49
What is Dupuytren's contracture? RF + Tx
* = Progressive, painless fibrotic thickening of plamar fascia w/ skin thethering --\> MCP joint flexion.
* More little/ ring finger. Often bilat.
* Causes: Genetic, smoking, DM, antiepileptics
* Tx:
* Med- injectable clostridium histolyticum
* Surg- fasciotomy
50
What is a ganglion cyst and how may it be treated?
* = Smooth, multilocular swelling containing jelly like fluid. In communication with joint capsule/ tendon sheaths.
* Tx:
* Cons- go spont/ under pressure
* Surg- aspiration/ surgical dissection if pain/ pressure
51
What is trigger finger? How does it present? Tx
* Caused by swelling of flexore tendon or tightening of sheath --\> A1 pulley catches --\> locked in flexion --\> can sometimes 'trigger' back into place.
* More common in DM
* Presentation:
* Pain of MCP
* Locking
* Tx:
* Cons- rest, splinting
* Med0 steroid injections
* Surgery
52
What is osteomyelitis? Types and common RF/ organisms
* = Infection of bone. Organisms: **Staph A**., pseudomonas, E. coli, strep.
* RF: Prosthesis, recent ortho surgery, fracture, Immunosuppression esp DM, neuropathy
* Types:
* Acute haematogenous
* Secondary to local infection
* Direct innoculation - trauma/ surgery
53
Presentation of osteomyelitis
* Common site:
* Vertebra (adults)
* Long bones of leg (children)
* Humerus
* Pelvis
* Presentation:
* Pain, gradual onset
* Lump/ red/ warm over site
* Pus into joint/ skin
* Systemic- fever, malaise
* ?fracture
54
Ix and Tx of osteomyelitis
* Ix:
* Bedside- swabs
* Bloods- CRP, ESR, WCC, culture
* Imaging
* X-ray (after 10-14d), haziness, loss of density, necrotic bone fragments
* MRI
* Special- bone biopsy= gold standard
* Tx:
* Cons- physio, supportive
* Med- 6w IV ABx: vancomycin, cefotaxime
* Surg- Bone debridement of sequestra and graft. Indications: abscess, spread to other structures.
55
What is Polymyalgia Rheumatica and how might it present?
* = inflammatory condition of unknown cause.
* Shares demographics with GCA- F\>M, \>50y.
* Presentation:
* Subacute (\<2w) onset of bilateral aching/ tenderness with morning stiffness \<45 mins in shoulders and proximal limb muscles.
* \*\* Not weaknes \*\*
* +/- Mild polyarthritis, tenosynonvitis, carpal tunnel
* +/- systemic: fatigue, fever, weight loss, anorexia, depression
56
Ix and Tx of PMR
* Ix= Bloods:
* ++ CRP/ ESR. ESR usually \>40
* Raised ALP in 30%
* CK normal
* Tx:
* Physio, educate on risk of **GCA**!
* Med- prednisolone 15mg/d PO. Massive improvement 1w. Wean down 1mg/ week.
* Gastric and bone protection
57
Principles of fracture management
* Reduce
* Hold
* Rehabilitate
58
How to describe a fracture
* Type of fracture- spiral, oblique, transverse, segmental, wedge, comminuted
* Impacted/ compressed
* Displaced vs undisplaced - Describe DISTAL segment in relation to proximal
* Shifted
* Angulated (describe apex)
* Rotated
* Overlapped
* Distracted
* Dislocated/ subluxed
* Open/ compound
59
Complications of fracture
* Early:
* General- other injuries, VTE, fat embolism
* Bone- infection, neurovascular injury
* Soft tissue- Infection, plaster injuries, compartment syndrome
* Late:
* General- chest infection, UTI, pressure sore
* Bone- Non-union/ malunion/ delayed union, avascular necrosis
* Soft tissue- tendon rupture, nerve compression, complex regional pain, contracture
60
Most common sites of avascular necrosis
* Anatomically at risk- talus, scaphoid
* Most common- head of humerus, head of femur (NOF, SUFE)
61
Non-traumatic causes of avascular necrosis
* Radiotherapy
* Chemotherapy
* Steroid use
* Drug addicts
* Alcoholism
62
What is compartment syndrome, how might it present and how would you treat it?
* Muscles in compartments surrounded by fibrous septa.
* Fracture or soft tissue injury --\> increased pressure --\> loss of venous return --\> more pressure --\> loss of arterial supply --\> necrosis --\> renal failure (UO and K+) and death
* Presentation: Dx= clinical!
* ++ Pain, out of proportion
* Pain on passive muscle stretching
* Looks and feels tight/ swollen
* 6Ps= late sign
* Intracompartmental pressure= \>30
* Tx:
* Cons- loosen tight dressings
* Surg- **Fasciotomy**
63
Spinal Fractures: Causes, types, Ix and Tx
* Causes
* Low energy- osteoporosis, malignancy
* High energy- trauma
* Types:
* Compression- osteoporosis, tumour
* Axial burst- fall from height
* Chance- seat belt injury
* Ix= Xray
* Tx:
* Minor- cervical bracing
* Complex- traction/ surgery
64
Humerus fractures - mechanism, Ix, Tx
* Shaft fracture:
* Mechanism- fall with direct blow/ torsional force
* Ix- X-ray. Rule out radial n. damage
* Tx: Cast. Or surival ORIF with plate and screws
* Condylar fracture:
* Mechanism- Impaction. Condyle splits into T/ Y.
* Types= intracondylar/ supracondylar
* Tx:
* Intracondylar- reduction + cast. ?replacement if elderly
* Extracondylar- cast. ORIF if displaced.
65
What is a monteggia fracture?
Ulnar fracture with dislocation of proximal radioulnar joint
66
Scaphoid fracture- mechanism, presentation, Ix, Tx
* Mechanism- Fall onto outstretched hand
* O/E- fullness in anatomical snuffbox. Tender volar surface
* Ix- scaphoid series
* Tx- below elbow in neutral position
67
Distal radius fracture- mechanism, types, Ix, Tx
* Mechanism= Fall onto outstretched hand
* Types:
* Colles' = extra-articular fracture of DR with dorsal diplacement and angulation. 'Dinner fork'
* Smith's = Extra-articular fracture of DR with volar displacement and angulation
* Barton's= intra-articular fracture with dislocation of radio-carpal joint
* Ix- neurovascular assessment, x-ray
* Tx:
* Cons- closed reduction, backslab, physio
* Surgery- K-wire fixation
* Complications= medican n. damage, malunion.
68
Pelvis fracture- mechanism, presentation, Tx and complications
* Mechanism- \<60y= RTA/ high impact. \>60y= fall from standing
* 1 break= stable. 2 breaks= unstable
* O/E- neuro/ GI/ GU injury? Risk of massive haemorrhage
* Ix: X-ray of inlet and outlet
* Tx:
* Single fracture- mobilise early.
* Multiple fracture= unstable --\> ex-fix --\> pelvic stabilisation with ORIF and screws.
* Complications- Haemorrhage, shock. ST injury, VTE, OA, neuro damage
69
Classification of fractured NOF
* Intracapsular- subcapital, basocervical
* Extracapsular- intertrochanteric, subtrochanteric
* Garden Classification I-IV
70
Presentation of fractured NOF
* Cause- low energy (eg fall in elderly/ osteoporotic), high energy eg RTA
* Presentation:
* Pain in groin/ hip
* Bruising/ swelling
* Inability to weight bear
* Shortened and externally rotated
* Unable to straight leg raise
* \*\* full neurovascular exam \*\*
71
Ix and Tx of fractured NOF
* Ix:
* Bedside- delirium screen, urine dip
* Bloods- FBC, U+Es, coags, G+S, ?CK
* X-ray- 2 views. Disruption of Shenton's line?
* Tx:
* Cons- falls prevention, physio, OT, good basic care, early mobilisation
* Med- DVT prophylaxis, analgesia, IVT
* Surg:
* Intracapsular- hemiarthroplasty/ complete hip replacement
* Extracapsular- DHS
72
Complications of fractured NOF
* Mortality= 30% at 1y
* Avascular necrosis - primary blood supply from medial femoral circumflex artery
* Dislocation
* Future falls
* Infection
* UTI/ pneumonia
* Pressure sores
* DVT
* Peri-prosthetic fracture
73
Femoral shaft fracture- mechanism, Tx and complications
* Mechanism- high energy eg RTA, osteoporosis, mets
* Ix/ Tx:
* ABCDE, access, IVT
* Bloods- FBC, U+Es, G+S
* Realign and splint with Thomas splint
* Open- IV ABx
* Surg- intramedullary nailing, plate and screw
* Complications- compartment syndrome + general complications of fracture
74
Goalsl for fractures NOF management
* Seen by orthogeriatricians
* Early surgery \<36h
* Early mobilisation
* Assessment of delirium
* Basic care eg feeding, preventing pressure sores
* FRAX score and falls prevention
75
Ankle fracture - mechanism, presentation, and classification
* Mechanism- low energy rotational force
* Presentation:
* Fracture of proximal fibula = ankle fracture or dislocation until proven otherwise
* Bruising/ swelling
* Deformity
* ?Open
* Examine whole fibula for tenderness
* Weber classification: A= below syndesmosis, B= at syndesmosis, C= above syndesmosis
* Tibia + fibular = paired bones. If one fractured, other must be or damaged syndesmosis
76
Tx of ankle fracture
* Displaced/ dislocation= Emergency. Reduce ASAP --\> backslab
* Stable- lat. malleolus only + no medial tenderness --\> below knee cast for 6w.
* Unstable - Weber B/C with no medial tenderness --\> backslab + elevate + ICE --\> ORIF and cast
77
What's involved of pre-op assessment for arthroplasty?
* 6w before. ?co-morbidities and ability to cope?
* Exam- CVS, resp, GI, MSK, airway
* Bloods- FBC, U+Es, G+S, cross-match
* Urinalysis
* Others- ?CXR, ?spirometry, ECG
* Explain complications and give written info
78
Indications for hip/knee arthoplasty
* Pain (esp at night)
* Disability
* Mod-severe RA/ OA
* Avascular necrosis
* Congenital dislocation
79
Types of hip arthroplasty + lifespan
* Total- head of femur and acetabulum. Metal-on-plastic (or metal)
* Hemiarthroplasty- only head of femur replaced
* +/- cement
* Lifespan 9-10y
80
Types of knee replacement
* Unicompartmental
* Unconstrained bicompartment
* Contrained (less bone)
81
Post-op care of arthroplasty
* Early mobilisation
* Involve physio and OT
* Optimise care
* DVT and PE prophylaxis
* Follow up
* Falls prevention
82
Complications of knee/ hip arthroplasty
* Dislocation - esp after revision
* Prosthetic loosening - esp metal-on-metal
* Periprosthetic fracture
* Infection - fever, pain, reduced ROM. Esp strep. Tx- earlyl debridement, ABx. Prophylaxis with gentamicin impregnated cement
* Joint stiffening
* General- DVT, PE, infection etc
* Damage to surrounding structures?
83
What is systemic sclerosis? Who might get it? What are the 2 different types?
* = Multisystemic. Excessive deposition of collagen in skin and internal organs
* Demographics: F\>M, usually 30-40s
* Types:
* Limited- upto elbows, knees + face
* Diffuse- beyond elbows
84
Features of diffuse systemic sclerosis
* Ab= **Scl-70**, RNA, polymerase III
* Presentation:
* Raynaud's
* Digital ulceration
* Diffuse skin thickening - morphea= thick and waxy. (also morphea linear, en coup de sabre)
* Systemic (early)- ILD, GI, renal, cardiac
* Tx= vascular and immunosuppression
85
Features of limited systemic sclerosis
* Ab= **Anti-centromere**
* Presentation= CREST
* Calcinosis - Ca2+ deposits in finger clubs
* Raynaud's
* oEsophageal- GI in general
* Sclerodactyly
* Telangectasia
* Other- scleroderma of face and neck, fibrotic lung disease, HTN, GI disease
* Tx= vascular- sildenafil, bosentan
86
Ix and Tx of systemic sclerosis
* Ix: \*\*monitor renal and lung function\*\*
* Bedside- urine dip, **BP**, weight, nailfold capillaroscopy, **PFTs**
* Bloods- U+Es, FBC
* Imaging- CXR, HRCT, ECHO every 2y, OGD/colonoscopy/ barium swallow
* Tx:
* Cons- keep hands warm, skin lubricants
* Med- Tx complications. ACEi (BP), immunosuppression- cyclophosphamide
* Raynaud's- CCB
* Oesophageal- PPI
87
What is myositis and its types? Who might get it?
* Myositis= Inflammatory myopathies of striated muscle. --\> weakness and elevated muscle enzymes
* 2 types- polymyositis, dermatomyositis
* RF:
* Female
* **Paraneoplastic**- lung, pancrease, ovaries, bowel
88
Presentation of polymyositis and dermatomyositis
* Progressive symmetrical muscle weakness (sparing distal and occular muscles)
* Wasting of shoulders and pelvic girdle
* Dysphagia, dysphonia, resp weakness. LIFE THREATENING.
* Associated with: myalgia, arthralgia, arthritis, fever, pulm. fibrosis, Raynaud's, myocarditis, arrhythmias
* Dermatomyositis= + skin signs:
* Helitrope rash on eyelids w/ oedema
* Macular rash- photosensitive. Shawl sign.
* Nail fold erythema
* Gottren's papulse - knuckles, elbows, knees
* Painful rough skin, cracking
* Retinopathy- haemorrhages, cotton wool spots
89
Polymyositis/ Dermatomyositis- Ix and Tx
* Ix:
* Bedside- **PFTs**, EMG
* Bloods- **CK**, **Anti-Jo1**, raised AST/ALT/LDH, tumour markers
* Imaging- screen for malignancy- CXR, mammogram, pelvic/ abdo USS, CT
* Special- muscle biopsy (CD4 infiltrate)
* Tx:
* Cons- screen for malignancy
* Med- Immunosuppression: steroids, cytotoxics (azathioprine, methotrexate).
90
What is Marfan's and how might it present?
* = Inherited CT disease. Autosomal dominant (spont in 25%). Mutation in FBN1 gene --\> fibrillin 1 --\> elastin
* Presentation:
* Cardiac- aortic root dilatation --\> regurg, aortic aneurysm + dissection, mitral valve prolapse/regurg
* Ocular- lens dislocation
* MSK- high arched palate, arachnodactyly, arm span\>height, pectus excavatum, scoliosis, joint hypermobility
* Dx= 2/3 organ systems
91
Ix and Tx of Marfan's
* Ix:
* Bedside- slit lamp, ECG
* Imaging:
* CXR- wide mediastinum, scoliosis, pneumothorax
* ECHO- aortic root dilatation
* MRI
* Special- genetic testing
* Tx: (ortho, cardio, ophthalmology)
* Cons- less cardiotensive sports
* Med- beta blockers
* Reg ECHO --\> surg when \>5cm
92
What is Ehlers Danlos syndrome and how might it present?
* = Group of collagen disorders.
* Presentation:
* Hyperelastic skin
* Hypermobile joints
* Fragile BVs
* Poor healing
* Cardiac- MVP, AR, MR, aneurysms
93
What is anti-phospholipid syndrome and what are it's key features? + Tx
* = Mostly primary disease. 30% related to SLE.
* Anti-cardiolipin + lupus anticoagulant --\> CLOTS (esp renal and cerebral)
* Coagulation defect
* Livedo reticularis
* Obstetric - miscarriage and eclampsia
* Thrombocytopoenia
* Tx- Good obstetric advice/ care. Low dose aspirin/ warfarin.
94
Diagnostic criteria of anti-phospholipid syndrome
* At least 1 clinical and 1 lab
* Clinical:
* Vascular thormbosis confirmed by scan
* Pregnancy morbidity- spont abortion, prem birth, \>2 unexplained consecutive spont abortions
* Lab:
* High anticardiolipin
* High lupus anticoagulant
* +ve on 2 occasions 12w apart
95
What is SLE and who might it affect?
* = Systemic Lupus Erythematous
* AI disease - autoAb to a variety of autoantigens --\> formation and deposition of immune complexes.
* Epidemiology:
* Females of child bearing age
* Afro-Caribbeans and Asians
* Genetic- HLA DR2/3
* Environmental trigger- infection, UV radiation
96
Multisystemic signs and Sx of Lupus
* Constitutional- Malaise, myalgia, fever, weight loss
* Eyes- Sjogren's, conjunctivitis
* Mucocutaneous- Malar/ discoid rash, ulcers, Raynaud's, lymphadenopathy, vasculitis
* MSK- Arthralgia, mornign stiffness, arthritis, synovitis, Jaccoud's deformity
* Cardiopulm- Pericarditis, pleuritis, lupus pneumonitis
* Reproductive- stillbirth/ miscarriage
* Nervous- Headaches, psych, seizures, neuropathy
* GI- Abdo pain, loss of appetite
* **Renal**- "lupus nephritis". HTN, GN, nephritis, nephrotic syndrome
97
Lupus Ix
* Bedside- urine dip, BP, ECG, o2 sats
* Bloods:
* FBC- macrocytic anaemia (--\> direct Coomb's), low lymphocytes, low platelets
* U+Es
* LFTs
* CRP (?norm), ESR ++
* Complement C3/4 low
* Autoantibodies- ANA, dsDNA, ENA Ro/La, Antiphospholipids (cardiolipid/lupus anticoagulant), anti-histone (drug-induced)
* Monitoring disease activity- Anti-dsDNA, complement, ESR
* Imaging- CXR may show complications
98
Diagnostic criteria of Lupus
4 or more (at least 1 clinical and 1 lab) or biopsy proven lupus nephritis
* Clinical criteria:
* Acute cutaneous lupus
* Oral/nasal ulcers
* Non-scarring alopecia
* Arthritis
* Serositis
* Renal
* Immunologic
* Haemolytic anaemia
* Leukopenia
* Thrombocytopoenia
* Immunologic:
* ANA
* Anti-dsDNA
* Anti-Sm
* Antiphospholipid Ab
* Low complement
99
Causes and presentation of drug-induced lupus
* Causes- phenytoin, hydralazine, **isoniazid**
* Mostly skin and lung signs
* Ix- anti-histone Ab
* Usually remits once drug removed
100
Management of SLE
* Specialist SLE and nephritis clinics
* Cutaneous Sx- prevention with suncream, Tx with topical steroids
* Maintenance of skin and joint Sx- NSAIDs, hydroxychloraquin +/- low dose steroids
* Lupus nephritis- ACEi for proteinuria, GN --\> immunosuppression
* Tx complications- OP, CVS disease
101
What is vasculitis and what might cause it?
* Inflammation of BVs --\> swelling, necrosis, stenosis, occlusion, aneurysms.
* Usually AI
* Primary or secondary: SLE, RA, Hep B/C, HIV, Sjogren's, malignancy, infection, drugs (allopurinol, sulfasalazine)
102
Classification of vasculitis
* Large vessel- GCA, Takayasu's. Claudication, absent pulses, bruits, asymmetric BP
* Medium vessel- Polyarteritis nodosa, Kawasaki. Livedo, gangrene, ulceration, mononeuritis multiplex, microaneurysms
* Small vessel- purpura, GN, alveolar haemorrhage, eye involvement
* ANCA +ve: pANCA= EGPA, microscopic polyangitis. cANCA= GPA
* ANCA -ve: HSP, Goodpasture's, cryoglobulinaemia
103
Ix of vasculitis
* Bedside- **urinalysis**, BP, ECG
* Bloods- FBC, U+Es, LFTs, bone profile, CRP, ESR, ANCA, autoAb, complement
* Imaging- ECHO, CXR, USS, MRI, **angiography**
* Special- **Biopsy**
104
Key features of Takayasu's
* = Pulseless disease
* Japan. F\>M. 20-40y
* Clinical phases:
1. Inflammatory- fever, flu-like Sx
2. Ischaemic pulseless phase- aorta and branches
3. Burnout + remission
* Features- fever, fatigue, weight loss, HTN, weak pulses in upper extremities, claudication, visual disturbance
* Ix- stenotic lesions
* Tx- Immunosuppression, CVS management, surg in remission
105
Key features of polyarteritis nodosa
* Rare in Uk. M\>F. Young adults.
* Associated with **Hep B**
* Presentation:
* Skin- purpura, ulcers, livedo
* Constitutional
* Renal impairment
* GI --\> abdo pain + melaena
* Neuopathy
* Ix: HbSAg, angio (aneurysms, stenosis)
* Tx: Pred, cyclophosphamide
106
Key features of Kawasaki Disease
* = childhood PAN variant, esp Japan
* Features:
* 5d fever
* Conjunctivitis
* Oral mucositis - strawberry tongue
* Cervical lymphadenopathy
* Coronary artery aneurysms --\> CVS complications
* Polymorphic rash - macularpapular. Palms and soles.
* Tx= IV immunoglobulin, aspirin
107
Key features of Microscopic Polyangitis
* pANCA +ve
* Presentation:
* Constitutional
* Abdo pain and bleeding
* GN + nephritic syndrome
* Haemoptysis
* Mononeuritis multiplex
* Palpable purpura
* Tx- Steroids, cyclophosphamide
108
What is EGPA and its core features? + Ix and Tx
* = Eosinophilic Granulomatosis with Polyangitis
* "Churg-Strauss"
* Features:
* Triad of **adult onset asthma, eosinophilia and vasculitis**
* Skin lesions
* Neuropathy- mono/poly
* GI Sx - bleeding
* Rapidly progressive **GN**
* Ix:
* Bedside- urine, BP
* Blood - **pANCA, eosinophilia**
* Imaging- Pulm. infiltrates
* Biopsy
109
Key features of GPA
* = Granulomatosis with Polyangitis
* Presentation:
* Systemic- Fever, weight loss, arthralgia, ulcers, rash, myalgia
* URT- sinusitis, epistaxis, saddle nose deformity
* LRT- cough, haemoptysis, pleuritis
* Renal- RPGN, haematuria, proteinuria
* Ocular- conjunctivitis, keratisis, uveitis
* Ix:
* Bedside- urine dip, BP
* Bloods- cANCA
* Imaging- CXR, CT head/ sinus
* Biopsy
* Tx: steroids +/- methotrexate/ cyclophosphamide/ rituximab
110
What is Behcet's Disease? Features + Tx
* = Systemic inflammatory disease targetting venules. HLA-B5
* Features- oral/ genital ulcers, uveitis, skin lesions, arthritis, vasculitis
* Tx- colchicine (ulcers), azathioprine/ cyclophosphamide
111
Key features of HSP
* = Henoch-Schonlein Purpura. Childhood IgA nephropathy variant.
* Presentation:
* Follows URTI
* Deposition of IgA in skin/kidney/bowel
* Palpable purpura on buttocks
* Colicky abdo pain
* Arthralgia
* Haematuria
* Ix= BP, urinalysis, ANCA -ve, biopsy of BV/skin/kidney- IgA. RPGN, crescents
* Tx- supportive. ?NSAIDs
112
What is mixed connective tissue disease?
* Mixture of RA, SLE, myositis, scleroderma
* Features- Raynaud's, arthritis, ILD, skin changes
* Antibody= Anti-RNP
