Ortho/ Rheumatology Flashcards
What is osteoarthritis and who might it affect?
- = 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.
Presentation of osteoarthritis
- 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.
Ix of Osteoarthritis
- Bedside- SHx and ADLs
- Bloods- no change.
- Imaging- x-ray:
- Loss of joint space
- Osteophytes
- Subchondral cysts
- Subchondral sclerosis
- Special - ?joint aspirate –> WCC <2000
Tx of osteoarthritis
- 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.
What is Rheumatoid Arthritis? Who might present with it?
- = 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
Presentation of RA
- 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!
Extra-articular features of RA
- 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)
Ix of RA
- 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
Diagnosis of RA
- 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
Tx of RA
- 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
Examples of DMARDs and SE
- 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
What are biologics? Examples + SEs
- = 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.
What screening tool is used to monitoro RA?
- 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
Psoriatic Arthirits - patterns of joint involvement
- Asymmetrical oligoarthritis (60%)
- Distal arthritis of DIPs
- Symmetrical polyarthritis (inc. DIPs)
- Arthritis mutilans
- Psoriatic spondylitis
Presentation, Ix and Tx of psoriatic arthritis
- 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
What is enteropathic arthritis? Presentation, Tx
- = 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
Reactive arthritis - presentation, Ix, Tx
- = 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.
Septic arthritis - RF, organism, presentation, DDx
- 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
Ix, Tx and complications of septic arthritis
- 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
What is Gout? + RF/ causes
- = 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
Presentation of Gout
- 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
Ix of Gout
- 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
Gout Tx
- 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.
What is pseudogout? Presentation, Ix and Tx
- = 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
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
Conditions associated with HLA B27
PAIR
- Psoriasis
- Ankylosing spondylitis
- IBD
- Reactive arthritis
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
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
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
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
What bloods are in a bone profile?
- Calcium
- Albumin
- Phosphate
- Magnesium
- ALP
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
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
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)
Causes of osteomalacia
- Vit D deficiency
- Liver/ renal failure (Vit D hyroxylation)
- Inherited Vit D resistance
- AEDs
- Malignancy- hypophosphataemia
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
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
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
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
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
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
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
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.
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
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
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
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
Adhesive capsulitis- associations, presentation, Tx
- = Frozen shoulder
- Associations: cervical spondylitis, DM, thyroid.
- Presentation:
- Severe pain in shoulder, ++ at night
- Reduced ROM in shoulder
- Phases:
- Freezing (<1y) ++ pain, reduction in acitve + passive movement. Abduction +/- external rotation
- Frozen (6-12m) Stiff. Less pain.
- Thawing phase (1-3y). Slowly regain movement
- Tx:
- Cons- physio
- Med- NSAIDs, steroid joint injections
- Surg- Release, arthroscopic arthrolysis
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
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
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
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
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
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.
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
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
Principles of fracture management
- Reduce
- Hold
- Rehabilitate
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
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
Most common sites of avascular necrosis
- Anatomically at risk- talus, scaphoid
- Most common- head of humerus, head of femur (NOF, SUFE)
Non-traumatic causes of avascular necrosis
- Radiotherapy
- Chemotherapy
- Steroid use
- Drug addicts
- Alcoholism
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
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
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.
What is a monteggia fracture?
Ulnar fracture with dislocation of proximal radioulnar joint
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
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.
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
Classification of fractured NOF
- Intracapsular- subcapital, basocervical
- Extracapsular- intertrochanteric, subtrochanteric
- Garden Classification I-IV
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 **
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
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
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
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
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
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
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
Indications for hip/knee arthoplasty
- Pain (esp at night)
- Disability
- Mod-severe RA/ OA
- Avascular necrosis
- Congenital dislocation
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
Types of knee replacement
- Unicompartmental
- Unconstrained bicompartment
- Contrained (less bone)
Post-op care of arthroplasty
- Early mobilisation
- Involve physio and OT
- Optimise care
- DVT and PE prophylaxis
- Follow up
- Falls prevention
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?
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
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
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
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
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
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
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).
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
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
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
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.
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
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
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
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
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
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
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
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)
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
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
Key features of Takayasu’s
- = Pulseless disease
- Japan. F>M. 20-40y
- Clinical phases:
- Inflammatory- fever, flu-like Sx
- Ischaemic pulseless phase- aorta and branches
- 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
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
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
Key features of Microscopic Polyangitis
- pANCA +ve
- Presentation:
- Constitutional
- Abdo pain and bleeding
- GN + nephritic syndrome
- Haemoptysis
- Mononeuritis multiplex
- Palpable purpura
- Tx- Steroids, cyclophosphamide
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
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
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
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
What is mixed connective tissue disease?
- Mixture of RA, SLE, myositis, scleroderma
- Features- Raynaud’s, arthritis, ILD, skin changes
- Antibody= Anti-RNP