ORTHOPAEDICS Flashcards
What are some risk factors for poor fracture healing?
- older age
- comorbidities (especially DM)
- recent trauma
- smoker
- osteoporosis
- corticosteroids
- NSAIDs
- local fracture complications
What are the steps involved in describing x-rays?
- Site of fracture - which bone/which part of bone
- Type of fracture - transverse, oblique, spiral
- Simple or comminuted
- Displaced or not
- Angulated or not - comment on direction of distal fracture
- Is bone normal consistency or is there signs of pathology?
What will the bone profile be like in osteomalacia/rickets?
Raised ALP
Ca, phosphate normal or low
- Vitamin D low by definition
What will the bone profile be like in bony mets?
Raised ALP
- Ca + phosphate raised/normal
What are the causes of hypercalcaemia with a raised phosphate?
RAISED ALP:
- bony mets
- sarcoidosis
- thyrotoxicosis
- lithium
NORMAL ALP:
- myeloma
- hypervitaminosis D
- sarcoid
What are the causes of hypercalcaemia with a normal/low phosphate?
- primary or tertiary hyperPTH
- familial benign hypercalciuria
- paraneoplastic-PTHrp
What will ECG show in hypercalcaemia?
short QT interval
How is hypercalcaemia managed?
Find + treat underlying cause
- REHYDRATE
- 1L 0.9% NaCl over 4h
- monitor hydration status - FRUSEMIDE
- start when pt volume replete
- use with caution - BISPHOSPHONATES
- only if malignancy is cause
- zolendronic acid infusion
What is the most common type of shoulder dislocation?
Anterior
- common in young males playing sport who have forced arm into abduction, extension + external rotation
What is a Colles’ Fracture?
extra-articular fracture of distal radius with dorsal displacement of distal radius
- dinner fork deformity
What is the most common scaphoid fracture type?
scaphoid
- associated with FOOSH
- AVN is serious complication
What does a shortened, externally rotated leg imply?
Neck of Femur Fracture
How do you manage an undisplaced intracapsular fracture?
Internal fixation with DHS
- if major illness do hemiarthroplasty
How do you manage a displaced intracapsular fracture?
If aged under 70 = internal fixation
If over 70 = total arthroplasty
If major/immobile do hemiarthroplasty
What are the symptoms of fat embolism? When does it tend to occur?
Usually 3-10 days post-long bone fracture.
- altered mental status
- pyrexia, SOB, tachycardia
- petechial rash
- subconjunctival + oral haemorrhage
What does pain on passive muscle stretching indicate?
Compartment syndrome
What does a positive scarf test indicate?
ACJ OA
What are the risk factors for osteoporosis? HINT: shattered.
S - Steroids H - Hyperthyroid, Hyperparathyroid, Hypercalcaemia A - Alcohol excess T - Thin (BMI below 22) T - Testosterone reduced E - Early menopause R - Renal/Liver failure E - Erosive or Inflammatory arthritis D - Dietary calcium low, malabsorption, T1DM
If some has osteoporosis, what treatment is there?
LIFESTYLE - STOP smoking + reduce alcohol - weight bearing exercise - balance exercises to reduce falls - calcium + vitamin D rich diets - falls prevention programme PHARMACOLOGICAL - bisphosphonates (alendronate) - calcium + vit D - HRT - strontium ranelate
What is the difference between rickets + osteomalacia?
Rickets is when growing
Osteomalacia after epiphyses have fused
What is the difference between osteoporosis + osteomalacia?
In osteoporosis, bones are brittle + porous
- mineral to collagen ratio is normal
In osteomalacia, they are soft
- mineral to collagen ratio is reduced
What are the typical features of Rickets?
knock-knee
bow leg
features of hypocalcaemia
How do you manage osteomalacia/rickets?
Calcium with vitamin D tablets
What is Paget’s disease?
Increased bone turnover
- disorder of osteoclasts with excessive osteoclast resorption followed by increased osteoblast activity
- common but only symptomatic in 1 in 20mins
What is the typical presentation of Paget’s?
Older male with bone pain + isolated rise in ALP
How do you manage Paget’s?
No cure - but treatment can help relieve symptoms
Bisphosphonates or calcitonin can be given
- Supportive therapies e.g. physio, OT, walking stick, orthotics, brace for spine
What is multiple myeloma a cancer of?
Plasma cells
- type of B lymphocyte that produces antibodies
What are the symptoms of multiple myeloma?
- Backache + bone pain
- pathological #s + vertebral collapse - BM infiltration = anaemia, neutropenia, thrombocytopenia
- Renal disease = AKI
- hypercalcaemia - Hyper-viscosity = easy bruising/bleeding or reduced/loss of sight
What investigations should be performed in multiple myeloma? What will they show?
- FBC - anaemia
- Raised Ca + normal ALP
- Raised ESR
- Serum electrophoresis + serum immunoglobulins
- Bence-jones protein on urine electrophoresis
BM Trephine biopsy is essential for diagnosis
What complications can arise as a result of multiple myeloma? How do you treat them?
- Hypercalcaemia
- IV fluids, bisphosphonates, frusemide - Cord Compression
- MRI, dex + radiotherapy - Hyperviscocity
- plasmapheresis - AKI
- rehydration + dialysis
How do you manage mechanical back pain? What is its typical course?
Self-limiting, 70% recover within 3-weeks + 90% by 6-weeks
- 50% experience another ep w/in 1 year
1. Pain relief - paracetamol + ibuprofen
2. Exercise to improve function, rest for only 48h
3. Lifestyle to prevent recurrence
4. Psychosocial issues
What are the most common levels of lumbar disc prolapse?
L4/L5 disc
L5/S1 disc
What is Lasegue’s sign positive? What condition does it suggest?
Pain on straight leg raise
- indicative of lumbar disc prolapse
What signs/symptoms will pts have in L4/L5 compression? HINT L5 compression
- weak ankle dorsiflexion (test by having walk on heels)
- weak foot inversion
- Decreased sensation on dorsum of foot
- reflexes intact!!!
What signs/symptoms will pts have in L5/S1 compression? HINT S1 compression.
- Sensory loss sole of foot + back of calf
- Weak plantarflexion + eversion
- Reduced ankle reflex
What is the management of lumbar disc prolpase?
Similar to that of other mechanical back pain
= analgesia, physiotherapy, exercises
BUT if symptoms persist (e.g. after 4-6 weeks) then referral for consideration of MRI is appropriate - may need discectomy
What tends to cause cauda equina syndrome?
Usually from large prolapses or hernation of lumbar discs, but may be from extrinsic tumours, primary cord tumours, spondylosis or spinal stenosis
How do you diagnose cauda equina syndrome?
MRI!
Refer to neurosurgery URGENTLY
How do you diagnose + treat lumbar spine stenosis?
MRI
- decompressive laminectomy gives good results if NSAIDs, epidural steroid injection + corsets fail to help
What is spondylolisthesis? What tends to cause it?
Displacement of one lumbar vertebrae on another
- usually forward
- usually L5 on S1
Causes = congenital malformation, spondylosis, osteoarthritis
What are the symptoms of spondylolithesis? What investigation is required?
Onset of pain usually in adolescence/early adulthood
- worse on standing, may have sciatica, hamstring tenderness, abnormal gait
PLAIN RADIOGRAPH - lateral view important
What are the clinical features of ankylosing spondylitis?
- male with low back pain, worse at night + morning stiffness more than 30mins, relieved by exercise
- progressive loss of movements in all directions
- can have kyphosis or neck hyperextension
- enthesitis = achilles, plantar fasciitis
- acute iritis
How do you manage ankylosing spondylitis?
- Exercise, not rest
- NSAIDs
- Adalimumab (TNF-a blocker)
- Steroids during flares
- Bisphosphonates - prevent osteoporosis
- Surgery
What cancers tend to metastasise to the spine?
- breast
- lung
- prostate
- lymphoma
- myeloma
What conditions may present as a monoarthritis?
- septic arthritis
- crystal arthritis
- osteoarthritis
- trauma = haemoarthrosis
What can present as an oligoarthritis? (5 joints or less)
- crystal arthritis
- psoriatic arthritis
- reactive arthritis
- ankylosing spondylitis
- OA
What are causes of polyarthritis? (more than 5 joints affected)
SYMMETRICAL
- RA, OA, viruses e.g. Hep A, B, C, mumps
ASYMMETRICAL
- reactive arthritis
- psoriatic arthritis
EITHER
- systemic disease e.g. SLE, sarcoid, endocarditis
What are the tests required in a pt with a hot, swollen joint?
- JOINT ASPIRATION
- WCC, gram stain, polarised light microscopy, culture - BLOODS
- FBC, ESR, urate, U+E, CRP
- blood culture
- RhF, anti-CCP, ANA
- HLA-B27 - RADIOLOGY
- OA = loss of joint space, osteophytes, subchondral sclerosis + cysts
- RA = juxta-articular osteopenia, soft tissue swelling, joint deformity, loss of joint space
- Gout = periarticular erosions, normal joint space, soft tissue swelling
What are the risk factors for osteoarthritis?
- females more than men
- increasing age
- obesity
- known joint abnormality
What are the symptoms of osteoarthritis?
Affects knees, hips, DIPs, PIPs + CMC of thumb (squaring of thumb base)
- pain worse with movement, worse at end of day
- stiff after rest, lasts less than 30 mins
- decreased ROM
How do you manage osteoarthritis?
CONSERVATIVE - pt education, exercise + weight loss - physio, OT, hold/cold, walking aids, supportive footwear, home modifications MEDICAL - regular paracetamol + NSAIDs - steroid injections SURGICAL = arthroplasty
What are the genetic associations of RA?
HLA-DR4 or DR-1
How does RA tend to present?
- ARTHRITIS - symmetrical, polyarthritis of MCPs, PIPs of hands + feet
- NODULES - elbows, fingers, feet, heel
- TENOSYNOVITIS - DeQuervain’s, atlanto-axial subluxation
- IMMUNE - AIHA, vasculitis, amyloidosis, lymphadenopathy
- CARDIAC - pericarditis + pericardial effusion
- CARPAL TUNNEL
- PULMONARY - fibrosing alveolitis, pleural effusions
- OPHTHALMIC - episcleritis, scleritis
- RAYNAUDS
- FELTYS - RA + splenomegaly + neutropenia
How do you manage RA?
- CONSERVATIVE
- rheum referral, regular exercise, physio + OT input - MEDICAL
- DMARDs, then biologicals
- steroids for flares + for bridging treatment
- NSAIDs for symptoms
- manage CV risk
- prevent osteoporosis + gastric ulcers - SURGICAL
- ulna stylectomy or joint prosthesis
What scoring system if used in RA to monitor disease severity?
DAS-28
- aim for below 3
- above 5.1 is severe
What is the follow-up for pts with RA?
- rapid access specialist care for flares
- R/V every 6-months after achieving treatment target
- extensive r/v annually
How do you differentiate seronegative spondyloarthritis (psoriatic) from RA?
- Presence of dactylitis
- Absence of anti-CCP
- DIP involvement
- Sacroiliitis
- Oligo/monoarticular joint involvement
What are the clinical features of psoriatic arthritis?
- joint pain + morning stiffness
- enthesitis
- dactylitis
- psoriatic plaques
- nail changes = onycholysis, pitting + subungal hyperkeratosis
What investigations should be done in suspected psoriatic arthritis?
Complete PEST tool questionnaire - if high score refer to rheum
- X-Ray hands + feet
- pencil in cup deformity
- erosion in DIP joints - ESR + CRP
- not always raised - RhF + Anti-CCP to r/o RA
- Uric acid level - r/o gout
- Lipid profile + Blood glucose
- increased risk of metabolic syndrome in psoriasis - Synovial fluid aspiration
- MRI sacroiliac joints - AS may be present
What is arthritis mutilans?
most severe form of psoriatic arthritis, occurs in phalanxes
- osteolysis of bones around joints in digits. Leads to progressive shortening of digit
- gives appearance of ‘telescopic finger’
What are the HLA-B27 associated conditions? (HINT: PAIR)
P - psoriasis
A - Ankylosing spondylitis/Anterior uveitis
I - IBD
R - Reactive arthritis
What tends to trigger reactive arthritis?
Gastroenteritis
STI - Chlamydia (most common) or gonorrhoea (more common to cause septic arthritis)
What are the typical features of reactive arthritis?
Can’t see, pee or climb a tree
- bilateral conjunctivitis
- anterior uveitis
- circinate balanitis (dermatitis of head of penis)
- asymmetrical lower limb oligoarthritis (knee)
- mouth ulcers and/or enthesitis
How do you manage reactive arthritis?
Treat according to hot swollen joint policy until SA excluded
- NSAIDs + treat underlying cause e.g. STI
- Steroid injection
- Systemic steroids
- most resolve within 6-months + do not recur.
What are risk factors for septic arthritis?
- pre-existing joint disease
- DM
- immunosuppression
- CKD
- recent joint surgery
- prosthetic joints
- IVDU
- aged over 80y
How do you treat septic arthritis?
Follow SEPSIS 6
- start Abx once aspirate taken. Flucloxacillin (or clindamycin)
- obtain orthopaedic opinion for lavage, arthrocentesis, debridement
What are the causes of hyperuricaemia? HINT: can be impaired excretion or impaired production
- IMPAIRED EXCRETION
- chronic renal disease
- drugs = thiazides, aspirin
- HTN
- lead toxicity
- primary hyperPTH or hypothyroid
- raised lactic acid from alcohol, exercise, starvation
- G6PD deficiency - INCREASED PRODUCTION
- increased purine synthesis
- increased turnover of purines
What are the typical joints affected by gout?
- base of big toe (1st MTP)
- wrists
- base of thumb (1st MCP)
What investigations are performed in suspected gout? What do they show?
Must r/o septic arthritis
- JOINT ASPIRATION
- MC+S to r/o SA
- polarised light microscopy shows crystals that are negatively birefringent needle-shaped crystals - SERUM URATE
- usually raised but not useful in acute setting - X-RAY
- punched out erosions in juxta-articular bone
- flecked calcification
- WCC + ESR often raised
How do you manage an acute attack of gout?
- NSAIDs
- Colchicine - if NSAIDs contraindicated
- diarrhoea v. common SE - Steroids
How to you manage gout prophylactically?
- LIFESTYLE = weight loss, stay hydrated, minimise purine intake (alcohol, meat, seafood)
- URATE LOWERING THERAPY
- allopurinol or febuxostat
- wait until 3wks after acute ep to start + cover with NSAID/cochicine for 6wks
What are the indications to start urate lowering therapy?
- more than 1 attack in 12 months
- tophi
- renal stones
- CKD stage 2+
Aim is to reduce attacks + limit damage from crystal stones
What investigations should be performed in suspected pseudogout? What will they show?
- JOINT ASPIRATION
- no bacterial growth
- calcium pyrophosphate crystals
- positively birefringent rhomboid shaped crystals - X-RAY
- chrondrocalcinosis
How do you manage pseudogout?
Symptoms usually resolve spontaneously.
Symptomatic management with:
- NSAIDs, colchicine, joint aspirate, steroid injection etc.
What medications can cause drug-induced lupus? What antibody will pts have?
COMMON = procainamide or hydralazine OTHERS = isoniazid, minocycline, phenytoin, penicillamine
Anti-histone antibody
What organs can SLE affect? What clinical features does it cause?
- Arthritis - symmetrical small joint arthralgia
- Renal - proteinuria + HTN. Lupus nephritis (nephrotic syndrome)
- Skin - butterfly malar rash, Discoid rash, photosensitive, Raynaud’s
- Lungs - pleurisy + pleural effusions, pulmonary fibrosis
- Eyes - retinal vasculitis, 2ndary sjogrens
- Neuro - seizures, psychosis, depression
- CV - pericarditis, increased risk IHD + stroke
- Haem = AIHA, low WCC, low platelets
What are the most important investigations for SLE?
- Anti-dsDNA titres
- Complement C3 + C4 - reduced
- ESR
- Urinalysis + PCR
- blood + protein denotes lupus nephritis
If someone has a multisystemic disorder with raised ESR + normal CRP, what should you be thinking of?
SLE
What antibody will majority of SLE pts be positive for?
ANA
What antibody is most specific for SLE?
Anti-dsDNA
- anti-smith is also specific but not very sensitive
What antibodies are associated with Sjogren’s?
Anti-Ro + La
What antibodies are associated with diffuse systemic sclerosis?
Anti-Scl70
What antibodies are associated with dermatomyositis?
Anti-Jo1
How do you manage SLE?
- SEVERE FLARES e.g. AIHA, nephritis, pericarditis or CNS disease
- IV cyclophosphamide
- high dose prednisolone - JOINTS
- hydroxychloroquine
- NSAID
- prednicolone - SKIN
- sunscreen, avoid sun
- hydroxycholorquine or methotrexate - LUPUS NEPHRITIS
- cyclophosphamide/tacrolumus/ciclosporin
What antibodies are associated with antiphospholipid syndrome?
- lupus anticoagulant
- anti-cardiolipin antibodies
- anti-beta-2-glycoprotein 1 antibodies
What are the clinical features of antiphospholipid syndrome? (HINT: CLOT)
C - coagulation defect
L - livedo reticularis (purple lace-like rash gives skin mottled appearance)
O - obstetric (miscarriages)
T - thrombocytopenia (reduced platelets)
How do you manage anti-phospholipid syndrome?
Long term warfarin
- use LMWH + aspirin in pregnancy
What are examples of (i) Large vessel (ii) medium vessel vasculitis?
(i) GCA/PMR or Takayasu
(ii) polyarteritis nodosa or Kawasaki disease
What are causes of small vessel vasculitis?
P-ANCA - MPA, glomerulonephritis, EGPA C-ANCA = GPA ANCA negative - HSP - goodpasture's - cryoglobulinaemia
Who does polyarteritis nodosa tend to affect?
Middle aged men
Hep B infection
What are the features of PAN?
- fever, malaise, arthralgia
- weight loss
- hypertension
- mononeuritis multiplex, sensorimotor polyneuropathy
- testicular pain
- livedo reticularis
- haematuria, renal failure
What are the buzzwords for Takayasu’s? How is it managed?
Buzzwords: - South –east Asia - 20-40 FEMALE - Pulseless disease - Dizziness Raised ESR/CRP TREAT: Reduce BP (high due to Renal artery stenosis) + steroids
What can cause secondary sjogren’s?
SLE or RA
How do you manage Sjogren’s?
Artificial tears and saliva
Vaginal lubricants
Hydroxychloroquine to halt progression of disease
What are the symptoms of diffuse cutaneous systemic sclerosis?
Features of CREST plus:
- CV = HTN + CAD
- Lungs = pulmonary HTN + fibrosis
- Kidneys = GN + scleroderma renal crisis
How do you manage fibromyalgia?
BIOPSYCHOSOCIAL
- educate pt, exercise, CBT, acupunture, hydrotherapy, mindfulness
- screen for anxiety + depression
- Medications = duloxetine, pregabalin, tramadol, venlafaxine, amitriptyline
What are polymyositis + dermatomyositis commonly associated with?
MALIGNANCY
- lung
- breast
- ovarian
- gastric
What are the skin features of dermatomyositis?
- gottron lesions on knuckles, elbows, knees
- photosensitive rash on back, shoulders + neck
- purple rash on face + eyelids
- periorbital oedema
- subcutaneous calcinosis
