Orthopaedics and Rheum Flashcards
describing a fracture
complexity = simple (closed), compound (open)
type = fissure, impaction, greenstick, transverse, avulsion, comminuted, oblique, spiral
comminuation = number of pieces broken into
location
displacement = degree of movement of bone from normal location: Translation (sideways movement, as % of bone diameter), angulation (bend in degrees), and shortening (collapse, in cm)
FRAX
explain
fracture risk assessment score
estimates 10 year fracture risk with BMD for people 40-90
3 person, 3 frac, 3 put in, 2 conds 3 person = age, sex, BMI 3 frac = prev frac, parent hip frac, low fem neck BMD 3 put in = alc, smoke, glucocorticoids 2 conds = RA, secondary osteo
low risk: reassure and give lifestyle advice
intermediate risk: offer BMD test
high risk: offer bone protection treatment
5 most common fractures
important fractures
what to assess
5 most common clavicle arm wrist (colles') hip ankle
important fract
scaphoid
fem head
- both these can lead to avascular necrosis progressing to joint destruction and osteoarthritis
assess
mech of injury
sound/feeling of break
loss of function
wrist fractures
bones in wrist
3 types
mgmt
Scared lovers try positions that they can’t handle
[1] bottom next to thumb - Scaphoid, lunate, triquetrum, pisiform, [2] top next to thumb - trapezium, trapezioid, capitate, hamate
3 types
Colles’ (distal radius with dorsal displacement fragments)
Smith’s (distal radius with volar displacement)
Scaphoid (*vulnerable blood supply) - fall onto outstretched hand in 20-30yr olds
mgmt
Reduction via manipulation with anaesthesia
Immobilisation initially avoid full cast as swelling may impede circulation
scaphoid fracture sign
ix
mgmt
comp
tenderness in anatomical snuffbox
ix
difficult to view on XR so need 4 views!!
mgmt
Presumptive cast immobilisation (6-8 weeks) + repeat exam and XR at 10-14 days
comp
avascular necrosis - distal blood supply
what in anatomical snuffbox
radial nerve sensory branch
scaphoid bone
colles fracture what who patho appearance comp mgmt
what
distal fracture of radius +/- ulnar with dorsal displacement of fragments
who
fall with OA
patho
FOOSH with forced dorsiflexion of wrist
appearance onXR
dinner fork on lateral view
comp
median nerve damage
mgmt
reduction
immobilisation
smiths fracture what patho appearance comp
what
reverse colles: distal fracture of radius with volar
patho
fall backwards
appearance
garden spade deformity
comp
median nerve damage
NOF def why imp types causes RF pres ix grading mgmt mortality comps
def Proximal to 5cm below lesser trochanter
why imp
most common
types
Intracapsular #
- Femoral neck between edge of femoral head and insertion to capsule
- 50% (medial and lateral circumflex artery)
- May disrupt blood supply to femoral head - avascular necrosis
Extracapsular trochanteric # distal to insertion, involving or between trochanters
Extracapsular subtrochanteric # below lesser trochanter to 5cm distal
causes
Post minor trauma in elderly, osteoporosis, + metastatic disease
RF
falls - instability, lack of core strength, gait disturbance, sensory impairment, frax
pres pain in outer upper thigh or groin radiates to knee no weight bearing affected leg shortened, adducted and externally rotated loss of internal rotation in flexion
ix
FBC, crossmatch, renal, glucose, ECG
AP and lateral XR (Shenton’s line)
MRI if # suspected but not obvious on XR
grading
Intracapsular NOF - Garden’s 1 = incomp, 2 = comp not disp, 3 = comp disp <50%, 4 = comp, disp > 50%
mgmt
analgesia - NOT NSAID
surgery within 1 day
intracapsular undisplaced = internal fixation with screws
IC displaced = replace fem head with haemiarthroplasty OR total hip replacement
EC = dynamic hip screw
post replacement care = do not flex beyond 90 (use long handled shoe horn), do not cross legs (pillow between legs at night), exercise to strengthen hip abductors
mortality = 10% in 1 month, 33% in 3 months
comps infection haemorrhage avascular nec DVT pneumonia -> give dalte
why you get fem shaft fractures
high velocity
high energy
RTA
ankle factures joints pres when to XR views classification types mgmt monitor
joints
2 - where tibia and fibula meet talus + syndesmosis (tibia to fib)
true joint = tibiotalar, plantar, dorsiflexion
subtalar joint - talus and calcaneus - inversion/eversion
pres similar to severe sprain immed severe pain swelling (localised or along leg) bruising tenderness consider break if obvious deformity, inability to weight bear, bony tenderness
when to XR
ottawa ankle rules:
>55
inability to weight bear for +4 steps
bone tenderness at ost edge or tip of lateral malleolus/medial
(+XR midfoot) bone tenderness at base of 5ht metatarsal, cuboid or navicular
views
AP
lateral
oblique - 15 deg
class danis-weber
types
potts - Distal tibia and fibula (bimalleolar) - unstable and require urgent Rx
snowboarders - Lateral process of talus - by dorsiflexion and inversion
mgmt If neurovascular compromise or dislocation (obvious deformity) then reduce immediately (before XR, under sedation or analgesia) Reduce Stabilise (4-6 weeks) moulded cast Analgesia Elevation Re-assess neurovascular status
monitor
XR at reduction, 48 hours, 7 days, then 2 weekly
main worrying comp of fracture when worry mgmt when it happens for dx comp post mgmt treatment for that
COMPARTMENT SYNDROME
when worry
Pain out of proportion: 6Ps, pain, parasthesia, pallor, paralysis, perishingly cold
mgmt
prompt fasciotomy
when it happens
Post fracture or reperfusion
for dx
compartment pressures >20 = suggestive, >40 = diagnostic
comp
myoglobinuria -> RF
mgmt
aggressive IV fluids
fracture healing
time
stages
time 3-12 w phalange - 3w radius 4-6 humerus 6-8 NOF or femur 12
stages
- haematoma formation - hours
- fibrocartilaginous callus formation - soft callus = days (secrete collagen + proteoglycans)
- bony callus formation - weeks (direct bone formation)
- bone remodelling = months (organised cortical bone), continuously remodelled therefore no scarring
frozen shoulder joint affected patho age assoc classic pres mgmt
joint = glenohumeral
patho
Thickening and contraction of glenohumeral joint capsule ± formation of adhesions - pain and loss of function either spont or post rotator cuff injury
age
40-65
assoc
diabetes
thyroid
pres
LOSS OF EXTERNAL ROTATION
mgmt
analgesia - para/NSAID, tens, activity, physio
remodelling process of bone
Osteocytes send signal to osteoclasts and osteoblasts
Osteoclasts resorb bone matrix: resorption pit - increases serum Ca
Osteoclasts undergo apoptosis and send signals to osteoblasts
Osteoblasts synthesise bone matrix
Bone matrix undergoes mineralisation
what is RANK
RANKL expressed by osteoblasts interacts with RANK receptor on osteoclasts
OsteoProteGerin secreted by osteoblasts inhibits RANKL activation of RANK
what happens in post menopausal women to cause osteoporosis
mgmt
Overexpression of RANKL overrides inhibitory Osteoprotegerin
mgmt
bisphosphonates
Osteoporosis def who to assess locations patho pres RF meds for dx ix mgmt
def Skeletal disease characterised by low bone mass and micro-architectural deterioration leading to increasing fragility and fracture risk
who
all women >65 and men >75 should be asessed for it
younger and presence of RF:
prev #, steroids, falls, fh of NOF, secondary osteo, low BMI, smoke, alc
location
Spine (vertebral crush), wrist (distal radius), hip (proximal femur), pelvis
patho
Increased breakdown by osteoclasts
Decreased bone formation by osteoblasts
pres
asymp until frcture
loss of height
kyphosis
RF
SHATTERED + FRAX or QFracture + SEDENTARY
S = steroids + cushings (>7.5mg for 3m)
H = hyperth, hyperPTH, hypercalciuria
A = alc + tobacco
T = thin or AN
T = testosterone decreased - primary hypogonadism or anti-androgens @ PrCa
E = early meno <45
R = real/liver function - renal osteodystrophy in CKD, chronic liver disease
E= erosive/inflam disease (IBD), RA, MM, mets
D = dietary ca/T1DM - malabsorption, malnutrition
+ FAM HISTORY
meds steroids = Decrease Ca absorption from gut, Increase osteoclast activity, Decrease muscle mass PPI long term SSRI antiepileptics glitazones aromatase inhibs - letrozole
for dx
XR - often normal *nothing seen till lose 30% BMD
- Radiolucency, cortical thinning, biconcave vertebrae
DEXA - at proximal femur
Identify treatable causes and rule out differential Dx of myeloma
OTHERS to exclude:
**FBC, ESR, CRP
**U+E, LFT, TFT, serum Ca
Testosterone/gonadotrophins (in men), prolactin
Serum Ig, paraproteins, Bence Jones protein
**Bony profile: Ca, PO4, ALP, PTH, albumin
24 hour urinary cortisol/dexamethasone suppression test
Endomysial and/or tissue transglutaminase antibodies (coeliac disease)
Isotope bone scan
Markers of bone turnover, when available
Urinary calcium excretion
All normal at osteoporosis
mgmt
Lifestyle: smoking, alcohol, wt bearing exercise, balance (fall risk), calcium + vit D rich diet, fall prevention
Meds: Bisphosphonates (alendronate) + Ca + vit D supplements - AdCal D3, Accrete D3
Fall prevention: avoid polypharmacy
If low testosterone add testosterone
If intolerant bisphosphonates use denosumab (monoclonal aB to RANKL)
Raloxifene can be used for women if alendronate not tolerated (selective oestrogen receptor modulator)
explain dexa score expectation for osteoporosis
T-score < -2.5 (s.d. below young healthy adult mean)
-2.5 < T
Qfracture score
10 year risk of frag #
30-99 yr olds
includes larger RF group
e.g. cardiovascular disease, history of falls, chronic liver disease, rheumatoid arthritis, type 2 diabetes and tricyclic antidepressants
bisphosphonates
examples
mech
SE
examples
Alendronic acid, risedronate, zoledronic acid
mech
Inhibit osteoclastic bone resorption
SE
Upper GI therefore take sitting upright with plenty of water first thing before food - crap absorption (1 hour before food)
Difficulty swallowing, oesophagitis, gastric ulcers
Osteonecrosis of the jaw
what would these results diagnose:
- normal calc, phos, ALP, PTH
- decreased calc, phos, increased ALP, PTH
- increased calc, ALP, PTH decreased phos
- decreased calc, increased ALP, PTH, phos
- normal calc, phos, PTH and increased ALP
- oestoporosis
- ostemalacia
- primary hyperPTH
- CKD - secondary hyper PTH
- pagets
osteomalacia what is it rickets what is it mech RF causes pres rickets + osteomalacia low phos symps ix mgmt
osteo = Disorder of mineralisation of bone matrix (osteoid) after fusion of epiphyses
rickets = Disorder of mineralisation of bone matrix prior to fusion of epiphyses
SOFT BONES
mech
Vitamin D deficiency leads to low calcium and phosphate
Low Ca and PO4 leads to secondary hyperparathyroidism
RFs
Dark skin, old/young, pregnancy, obesity, alcohol, vegetarianism, poverty, fam Hx
casues
1. Lack of sunlight, lack of adequate diet
2. GI malabsorption: surgery, short bowel, pancreatic disease, CF, CD, coeliac
3. Renal disease: -> defective 1,25 form = renal osteodystrophy
4. Liver disease: -> cirrhosis
5. Drugs: anticonvulsants, rifampicin (liver, stop 25-hydroxy)
6. Rare:
Tumour induced hypophosphataemia (FGF-23 - hyperphosphaturia)
Fanconi syndrome (proximal renal tubule dysfunction)
Renal tubular acidosis
7. Genetic:
rickets pres
Leg bowing - genu varum
Knock knees - genu valgum
In first few months: craniotabes (softening of skull), frontal bossing, rachitic rosary (enlarged end segment ribs) -> rachitis lung
Dental abnormalities (enamel)
Delayed walk/waddling gait, impaired gait
Symptoms of hypocalcaemia: convulsions, irritable, tetany, apnoa, cardiac arrest
osteomalacia pres
Widespread bone pain + tenderness (low back pain and hips)
Proximal muscle weakness - waddling gait (if severe)
Fatigue
Symptoms of underlying disease
Costochondral swelling, spinal curvature, hypocalcaemia (tetany, carpopedal spasm - trousseau sign and chvostek)
low phos symps
muscle weakness
parasthesia
ix
Serum 25-hydroxyvitamin D - low
Renal function, electrolytes, LFT, PTH
Ca: low, PO4: low (generally at renal phosphate wasting), PTH: high, ALP: very high
FBC: anaemia if malabsorption
Urinary calcium - low, urinary phosphate - high
XR - *Looser pseudofractures with sclerotic borders (parallel) - bilateral at femoral neck
DEXA - low BMD
Iliac crest biopsy - failed mineralisation
mgmt
Ca + Vit D - (CaCO3 + cholecalciferol) e.g. accrete
Monitor Ca regularly for a few week
source of vit d
90% sunlight, dietary - oily fish, liver, egg yolks, fortifited cereals (not dairy)
vit d physiology
Cholecalciferol (D3) -> liver = 25 hydroxyvitamin D3 (inactive circulating) -> kidney = 1,25 dihydroxyvitamin D3 (active hormone)
To bone: increases Ca mobilisation, increases osteoclast function
To intestine: increases Ca absorption, increases PO4 absorption
To PTG: decreases PTH
PTH physiology
Low Ca -> increased PTH
To bone -> increase osteoclast function
To kidney -> increases 1,25vD3 (1-alphahydroxylase), + decreases Ca excretion + increases PO4 excretion
pagets disease of the bone def where genetic pres comp assoc ix mgmt
def
Increased turnover of bone
Lytic phase - increased bone resorption by osteoclasts
Sclerotic phase - *Rapid bone formation by osteoblasts: disorganised and mechanically weaker and deformity/larger.
where
axial skeleton: lumbosacral spine, pelvis, skull, femur, tibia
gene
AD SQSTM1 mutation
pres
asymp
classically - older male with bone pain and isolated raised ALP
bone pain + deformity with increased skin temp
pain at night
comp
Bone pain
Deformity: sabre tibia, kyphosis, skull bossing, enlarged maxilla/jaw
Pathological fracture (heavy bleeding as v.vascular)
Deafness/tinnitus compression of CN 8 by ear ossicles
Increased vascularity may lead to high output cardiac failure
assoc
osteosarcoma
ix ALP - high ca, phos, PTH normal XR - Osteolysis and osteosclerosis (lytic and scleortic lesions), *Blade of grass lesion between healthy and sclerotic long bone, Cotton wool pattern of multifocal sclerosis in skull isotope bone scan
mgmt
Control pain and reduce or prevent progression
Pain: NSAIDs and paracetamol
Antiresorptive: bisphosphonates
N.b. IV may give flu-like symptoms
Zoledronate popular as good with single IV dose
Monitor ALP
causes of joint pain
differences between inflam, degen, and which joints
causes
ARTHRITIS
others = reactive arthritis, tendon/muscle damage, hyperuricaemia, referred pain, immune (e.g. SLE), tumour, ischaemia, sponyloarthtitides
inflam = Ease on use, worse in morning (>60 mins), hot and red, responds to NSAIDs, swelling *synovial and bony, young/psoriasis/fam Hx
deg = Worse with use, morning (<30 mins), mainly evening, prior occ, sport, *no swelling, not inflamed
which joints -
OA - distal interphalageal
RA = MCP, MTP, PIP
inflammation
acute phase proteins examples
ESR increases with?, phase, how works
CRP increases with? phase, how works, imp negs
Levels fluctuate wrt injury e.g. trauma/MI/burns
exampls
CRP, ESR, fibrinogen, ferritin, C3/C4, caeruloplasmin etc.
ESR
Increases with inflammation and infection. More fibrinogen produced, RBCs crosslinked and sediment quicker. Affected by RBC shape and number
<22mm/Hr (men), <29mm/Hr (women)
also increases with… Age, sex, drugs e.g. steroids, obesity (fat produces IL-6)
Slow on, slow off: peak at 7 days
CRP
Acute phase protein which increases in inflammatory conditions, connective tissue disorders, neoplastic disease and infection (esp bacterial)
Quick on, quick off - peak at 1 day, normal at 7 days
SLE, OA, UC
Binds to damaged cells and activates complement, phagocytosis by M
osteoarthritis def patho common joints rfs dx - triad pres classic XR other ix ddx mgmt
def Clinical syndrome of joint pain + functional limitation + reduced QoL
patho
Deterioration of *articular cartilage and formation of new bone - osteophytes at joint margins
common joints knees hips small joints hands spine
rfs
Age, female sex, obesity, occupation/hobbies, genetic (50%), joint laxity
dx triad
Aged > 45 + activity related jt pain + no morning stiffness (<30 minutes)
pres
Jt pain exacerbated exercise + relieved rest, stiffness after rest (gelling), reduced function
Joint swelling/synovitis - warmth + effusion
Reduced ROM
Crepitus
Pain on movement *may lead to disuse atrophy and weakness
Bony swelling and deformity - osteophytes: DIP (Heberden’s) + PIP (Bouchard’s)
squaring of the thumbs - fixed adduction
No systemic features
classic XR LOSS Loss of joint space Osteophytes Subchondral/subarticular sclerosis Subchondrial cysts
other ix
bloods - normal
joint aspiration - ?SA/gout
RF + ANA negative
ddx hip + knee = bursitis referred pain gout all arthritis
mgmt
Patient education, weight loss, screen depression, *exercise for muscle strength, aids and devices (walking sticks, tap turners)
Local analgesia: topical NSAID for knee or hand + para (first line)
+ oral NSAID +/- PPI, opioids, capsaicin cream , intrarticular steroids - methylpred (2)
non-pharmacological treatment options include supports and braces, TENS and shock-absorbing insoles or shoes
For persistent pain affecting QoL:
Replacement (arthroplasty), fusion (arthrodesis)
pathogenesis of OA joints
Failure to maintain homeostasis of cartilage matrix synthesis and degradation
Synovial inflammation - IL1/6/TNF stimulates chondrocyte production
Chondrocytes produce increased MMP (matrix metalloproteinases e.g. collagenase) catalyse collagen and proteoglycan degradation
Increased catabolic cytokines (IL-1), loss of anabolic CKs (IGF-1)
Cartilage loss -> decreased joint space -> increased stress on subchondral bone
Microfracture, new bone (sclerosis) and synovial fluid seep (cysts)
surgical techniques in OA hip post op recovery advice to minimise risk of hip replacement dislocation comps
hip - cemented hip replacement, uncemented, sometimes hip resurfacing over femoral head
recovery
physio
home exercises
walking sticks/crutches - 6w
advise avoiding flexing the hip > 90 degrees avoid low chairs do not cross your legs sleep on your back for the first 6 weeks
comps
wound and joint infection
thromboembolism - LMWH for 4w post op
dislocation
OA vs RA xrays
OA LOSS Loss of jt space Osteophytes Subchondral cysts Subchondral sclerosis
RA LESS Loss of jt space Erosions Softening of bones (osteopenia) Soft tissue swelling
Rheumatoid arthritis def who main joints patho pres extra articular ix mgmt monitoring
def Chronic inflammatory autoimmune disease characterised by inflammation of synovial joints leading to joint and periarticular tissue destruction
who
40/50 yr old women
main joints
HANDS + FEET
patho
INFLAMMATION OF SYNOVIUM:
1. Increased angiogenesis, influx inflammatory cells + CKs, cellular hyperplasia
2. Cells (MP, TCells, plasma cells) release IL1/IL6/TNF - promote proliferation and MMP expression -> joint destruction
PROLIFERATION
1. Angiogenesis and hypertrophic synovium form pannus over articular cartilage
LOCALLY INVASIVE SYNOVIAL TISSUE
Pres
Active Symmetrical Polyarthritis >6w in 50 yr old woman
RHEUMATISM
RF+ve (80%), radial deviation wrist
HLA DR(rheumatism) 1/4
ESR/extra-articular e.g. restrictive lung disease/nodules
Ulnar deviation fingers
Morning stiffness, MCP, MTP, PIP swelling
ANA +ve (30%), assoc AnkSpon/AI
T-cell (CD4) and TNF
Inflammatory synovial tissue, IL1/IL6
Swan neck, boutonniere, Z-deformity thumb, loss of knuckle valleys when making a fist
Muscle wasting hands
+ cervical spine instability - atlanto-axial joint subluxation
extra articular
Rheumatoid nodules @ extensor surface of tendons (palisade ring of MP and fibroblasts with necrotic core) and *lungs
Vasculitic lesions - commonly skin rashes, leg ulcers (@Feltys)
Pleuritic chest pain - pleuritis or pericarditis, effusion
Eye problems: secondary Sjogren’s: scleritis and episcleritis, oral dryness
Neurological: peripheral nerve entrapment, mononeuritis multiplex, atlanto-axial subluxation (C1,C2) - soft tissue swelling within rigid tunnel
Respiratory system: rheumatoid nodules, Caplan’s syndrome, pulmonary fibrosis
Anaemia of chronic disease
ix
RF - 70% +ve
Anti-CCP abs - 70%, very specific so more likely erosive
XR hands and feet - erosions + soft tissue swelling, loss of jt space, periarticular osteopenia, absent osteophytes, deformity, subluxation
FBC - (normochromic normocytic chronic dis)
ANA (+ve 30%)
ESR/CRP raised
ferritin high, Pt high (reactive thrombocytosis)
U/E , LFTs
mgmt
Physiotherapy, OR, psych services (depression), podiatry
First line:
one DMARD (not working, increase dose)
Second Line if not winning >6m: Combination DMARD (with *methotrexate)
Choice DMARD = methotrexate or sulfasalazine or leflunomide
Adjunct - bridging treatment if really active to get under control: corticosteroid (low dose pred) + NSAID (lowest effective dose) short term
If not winning >1 yr: biologicals (expensive)
monitoring DAS28 (disease activity score) <3.2 = well controlled, >5.1 = active + CRP at each visit
rheumatoid lung
how many have it
symps
types
30%
symps
dyspnoea, cough, wheeze
types
- interstitial lung disease - often middle age men with dry cough and dyspnoea, mgmt corticosteroids
- rheumatoid nodules - benign but lead to pleural effusion
- caplans - assoc with coal workers pneumoconiosis (massive fibrosis) - well rounded nodules at lung periphery
- methotrexate pneumonitis - not common, cough, dyspnoea, fever
feltys syndrome
triad
+ other symps
TRIAD
RA, neutropenia, splenomegaly
+ leg ulcers, brown pigment of legs, lymphadenopathy
rheumatoid hands
palmar erythema wasting of thenar eminence - carpal tunnel sydnrome fixed flexion contracture swan neck button hole z thumb
due to rheumatoid tenosynovitis
explain anatomy of boutonneire deformity
and swan neck
boutonneires
rupture of central slip but lateral slips intact
finger pushes up
swan neck
rupture of lateral slip of extensor expansion, so proximal pharyngeal joint is extended
when they say examine hands where else should you look?
elbows and ears
ears for gouty tophus and elbows can have rheumatoid nodules
what is rheumatoid factor
IgM against your own IgG
lots of normal people have it
high titres assoc with progressive disease
what is seronegative rheumatoid
identical to sero posi but unlikely to have nodules or extra articular features
no IgM just IgG
40% hve antibodies to CCP - if so more progressive
methotrexate administration bits and bobs adverse effects excretion inhibs by CI monitoring
once per week
with folic acid on a non-MTX day
adverse effects
bone marrow suppression
renal and liver tox
pneumonitis/pulm fibrosis
excretion inhibs by - NSAIDs
CI
trimethoprim
monitoring
FBC, eGFR, LFT every 4-6 weeks in first year
what need to do prior to prescribing biological
tuberculin skin test or interferon gamma release assay
chest radiograph
hep B,C, HIV serology
treat latent TB
warn significant risk of serious infection
what is atlanto-axial subluxation
top of cervical spine is held together by tendons which can be weakened by rheumatoid tenosynovitis
if the odontoid peg subluxes backwards over days and weeks -> compress upper cervical cord causing progressive spastic tetraparesis
if compression is sudden - a rapid output of inhibitory impulses down vagus can cause cardiac arrest
so preoperatively I would arrange a lateral upper cervical radiograph in gental flexion
ddx for RA
RA
psoriatic arthropathy
systemic lupus
OA with inflammatory component
other DMARD SE
myelosuppression - watch out for sore throat, fever
biologics examples
what are they
SE
patho
infliximab
anti-TNF alpha
SE
increased infection
lupus like symptoms
reactivate TB
patho
T cell -> CK release -> activated MP (IL1/6/TNFa) + activated B cell (AA, RF, IL6) -> osteoclast and chondrocyte -> inflammation and destruction
crystal arthropathy patho
Purines -> xanthine (by *xanthine oxidase) -> uric acid monosodium urate
Uric acid (low urinary excretion) -> allantoin (high urinary excretion) (by *urate oxidase)
Uricase promotes (urate oxidase) Allopurinol (xanthine oxidase)
mechanisms of high urate
Reduced renal excretion (90%)
Drugs (diuretics impair urate excretion), high insulin levels/sugars (lower urate excretion)
High intake (diet), cell turnover (production), cell damage (surgery), cell death (chemo)
gout def precip causes who rfs protective pres important ddx site asoc duration of attack ix acute mgmt prophy
def Arthritis due to deposition of monosodium urate (MSU) crystals within joint
precip Trauma + surgery (cell damage), starvation (increased insulin), infection (cell damage), diuretics (reduced renal excretion)
cause
chronic hyperuricaemia
who
men 30-60
rfs Alcohol (beer highest), purine rich foods (red meat/sea food), fructose (sugary drinks/cakes), diuretics, DM, CKD, CHD, HTN, hyperlipidaemia
protective
diary
coffee
vit c
pres
acute monoarthropathy with severe joint inflam + fever + malaise
florid synovitis
extreme tenderness and erythema
ddx
in monoarthritis - SA
site - 50% of all attacks are big toe - MTP
also knee, midtarsal, wrist, ankles
assoc
tophi - onion like aggregates of urate crystals: common at pinna, tendons, joints
duration of attack - will resolve without treatment in 5-15 days
ix
serum urate - raised
demonstrate MSU in synovial fluid - Joint aspiration and polarised light microscopy of synovial fluid: Negatively birefringent needles of MonoSodium Urate monohydrate
XR - soft tissue swelling, late/chronic: punched out lesions, tophi, sclerosis, eccentric erosions, no periarticular osteopenia
acute mgmt
1st line - NSAIDs high dose for 48 hours then reduce for 10-14days, if not tolerated = colchicine (SE diarrhoea)
if already on allopurinol - continue this
if both CI - corticosteroids
prophylaxis -
lifestyle mods + manage RFs (thiazide + loop diuretics, HTN, ReFu, hyperlipidaemia)
drugs - allopurinol or febuxostat (xanthine oxidase inhibitors) - start post attack
Start low and increase until SUA < 300 micromol/L
Co-prescribe NSAID or colchicine for acute attack for 6 month
pseudogout what is it who gets it precipitants where pres ix mgmt
what
Calcium pyrophosphate dihydrate crystal deposition in synovium
who
elderly
precipitants
Dehydration, illness, hyperparathyroidism, haemochromatosis, Wilson’s, low mag/phos, long term steroid use, surgery/trauma
where
knee or wrist or shoulders
pres
similar to gout
acute joint pain and swelling, hot, monoarticular
chronic - similar to OA but may be more severe - pain, stiffness, crepitus, LoF
ix
Joint fluid aspiration: positively birefringent rhomboids, neutrophils
Joint XR: chondrocalcinosis - linear opacification of articular cartilage on joint surface
Exclude septic arthritis
mgmt
No specific therapies therefore symptomatic:
Ice packs, elevation, aspiration of joint, NSAIDs, IA steroid injections
or oral steroids as for gout
AI connective tissue pathogenesis
IgG antibody + antigen
Forms complex
Deposition in tissue
Attracts complement
Reaction with complement attracts neutrophils
Inflammation
Enzymes and cytokines cause further inflammation
SLE def involves who genetics environmental triggers suspect in.. pres assoc at risk of main mgmt patho criteria ix mgmt
def Inflammatory, multisystem autoimmune disease with antinuclear antibodies
involves
Skin, joints, kidney, brain
Serositis, nephritis, haematological cytopenias, neurological complications
who
Women in reproductive years
afro-caribbeans/asians
genetics
HLA DR2/DR3/B8
environmental triggers
UV light, virus (EBV), smoking -> sun protection and exercise
suspect…
Multisystem disease with raised ESR but normal CRP
pres
Criteria + systemic: fatigue, fever, weight loss, lymphadenopathy
assoc
Raynaud’s (50%), other AI e.g. alopecia, thyroiditis, venous or arterial thrombosis
at risk of…
HTN, dyslipidaemia, diabetes, NHL, APLS (anti-phospholipid syndrome)
main mgmt
Hydroxychloroquine - ocular toxicity
patho
type 3 hypersenstivity
Immune complex formation and deposition
Complement activation and influx of neutrophils
criteria
4/11 of DOPAMINE RASH
Discoid rash - over malar eminence
Oral ulcers - usually painless
Photosensitive rash - skin rash from sunlight
Arthritis - non erosive 2 or more peripheral joints
Malar rash - fixed erythema, spares nasolabial folds BUTTERFLY
Immunological phenomena - anti-dsDNA, anti-Smith, antiphospholipid aBs
Neurological symptoms - seizures or psychosis, anxt, dep
ESR raised (*not CRP)
Renal disorder - proteinuria > 0.5g/day or +++, or casts, glomerulonephritis
ANA +ve
Serositis - pleuritis (pleural rub on ausc or pleural effusion), pericarditis (on ECG, pericardial rub), myocarditis
Haematological disorders - haemolytic anaemia (with reticulocytes) or leukopenia (<4x10^9), lymphopenia, thrombocytopenia
ix
ESR/CRP - ESR raised, CRP normal
FBC - anaemia, leukopenia, thrombocytopenia
Autoantibodies: ANA (99%), antidsDNA (60%), antiSmith (30%), RF (20%), anti-ro, anti-la
Complement levels: low C4 and C3 - active disease
Urinalysis: haematuria, casts, proteinuria
U+E (renal disease)
CXR: pleural effusions, cardiomegaly
ECG: pericarditis
Antiphospholipid antibodies: lupus anticoagulant, anti-cardiolipin
mgmt
dietry advice, smoking cessation, sun protection, exercise
joints = NSAID ± hydroxychloroquine ± steroids (GI and bone protection)
mucocutaneous = sunscreen, mouthwash, saliva, tears, + oral hydroxychloroquine
lupus nephritis = cyclophosphamide/tacrolimus/mycophenolate + prednisolone + hydroxychloroquine
neuropsych = cyclophos + pred or IVIG
if life threat = cyclophos
antiphospholipid syndrome def AAB assoc criteria pres ix mgmt
def AI disorder characterised by arterial/venous thrombosis and adverse pregnancy outcomes
AAB
Anticardiolipin, antiB2glycoprotein1, lupus anticoagulant
assoc SLE RA SS sjorgrens
criteria
One clinical criteria and one lab criteria
Clin: vascular thrombosis, pregnancy morbidity (unexplained death beyond 10 weeks or x3 before 10 weeks)
Lab: Lupus antiocoagulant or anti-cardiolipin or anti-B2 glycoprotein 1 present on 2 occasions (12 weeks apart)
pres
Thrombosis, DVT, pregnancy loss, pre-eclampsia, thrombocytopenia, livedo reticularis: violaceous lace like on trunk, stroke
ix
paradoxically low platelets - FBC
prolonged APTT - LFT
This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade
mgmt
primary - low-dose aspirin
secondary:
warfarin - 2-3 target
avoid clotting, increase to 3-4 if clot when on warfarin
lifestyle - smoking, contraception, healthy diet, low alc
sjorgrens def genetics pres assoc who ix mgmt comp
def AI condition with lymphocytic infiltration of exocrine glands
genetics
HLA DR3
pres
sicca complex diminished lacrimal and salivary glands:
dry eyes (xerophthalmia, keratoconjunctivitis sicca),
dry mouth (xerostomia) - cant eat dry food, altered taste, oral candidiasis
enlarged parotid gland
dry vagina
Fatigue (80%), myalgia/polyarthralgia, Raynaud’s (20%), vasculitis
dry cough
assoc SL RA SS CREST
who
w>m
30-40yrs
ix
Schirmer tear test (filter paper, +ve if less than 5mm in 5 mins)
Autoantibodies anti-Ro (SS-A), anti-La (SS-B) ± RF, ANA, APLS AAb
Sialometry/sialography
Biopsy salivary gland - mononuclear cell infiltrate (B and T cells)
Rose-Bengal staining eyes
mgmt artificial tears, saliva drink plenty oral pilocarpine joint pain - NSAID + hydroxychlorquine + steroid
comp
low C4 - risk of NHL
infections - eyes, mouth, parotid gland
systemic sclerosis def locations types RF pres ix mgmt monitoring
def multisystem AI disease with increased fibroblast activity -> excessive collagen -> fibrosis -> vascular damage + immune system activation
locations vascular - raynauds and renal skin GI tract heart lungs
types
LIMITED CUTANEOUS ‘below elbow scleroderma’
- 70% face, forearms + lower legs
- synonymous with CREST - calcinosis, raynauds, oesophageal dysmotility, sclerodactyly, telangiectasia + organ fibrosis
DIFFUSE CUTANEOUS 30% ‘malignant scleroderma’ - rest of skin + organ fibrosis
much higher risk of lung, gut, heart or renal involvement
RF fam hist viral - CMV/EBV chemicals - pesticides, plastics drugs - bleomycin, vit k
pres
SKIN - Raynaud’s, swelling, thick + hard skin - sclerodactyly, calcinosis
FACE = small mouth, beaked nose, wrinkled skin
MSK = Joint pain, swelling, myalgia, loss of ROM due to sclerosis
GI = Heartburn + reflux oesophagitis, dysphagia, watermelon stomach (gastric antral vascular ectasia - bleeding), delayed gastric emptying, reduced motility (constipation)
PULM = *Pulmonary fibrosis (interstitial lung disease) in 80% - dry cough etc…
*Pulmonary artery HTN - in 12% = leading cause of death
CARDIAC = Microvascular CAD - MI, accelerated atherosclerosis, arrhythmias
RENAL = ANCA glomerulonephritis
*Scleroderma renal crisis: accelerated HTN, headache, oliguria
GU = ED
limited = slow onset, so internal comps in pres
diffuse = rapid onset, skin thickening
fatigue
weight loss
ix
FBC
esr/crp
u/e
Spirometry - restrictive picture, disproportionate drop in DLCO to FVC - pul HTN
ECG - arrhythmia
CXR - lung disease = infiltrate, heart disease = cardiomegaly + heart failure
Barium swallow = oesophageal disorders and delayed emptying
serum autoantibodies - ANA, AntiScl70 - diffuse, Anti-centromere - limited, anti-topoisomerase 1 - ILD
mgmt
Physiotherapy, avoid tobacco, home exercise, prevention of Raynaud’s (gloves, no smoking)
PPI for life
pulm? cyclophosphamide (fibrosis), sildenafil (PAH) + O2
Synovitis/arthritis - pred
skin - topical emollient +/- topical corticosteroid for itch +/- cyclophosphamide (skin thickening)
renal crisis - ACEi +/- other antiHTN
monitoring
BP weekly
yearly spiro, lung volumes, DLCO
echo for ILD + PAH
raynauds
what is it
pres
mgmt
peripheral digital ischaemia due to recurrent spasm of digital arteries
phenomenon may be secondary to SS, SLE, BB, thrombocytosis
pres
cold hands go white then blue then red when warmed
mgmt
nifidipine
could try sildenafil
polymyositis + dermatomyositis def locations causes who extra-muscular rule out/worry POLY - pres, ix, imp ddx DERMA - pres, ix mgmt comp
def AI connective tissue disorders characterised by inflammation of striated muscles
location proximal muscles skin joints oesophagus lungs heart
causes
HIV
coxsackie
who
women>men x 2
onset 30-60
extramuscular fever arthralgia raynauds ILD
rule out
neoplasm - lung, breast, ovary
POLY
pres - Not painful
Progressive symmetrical proximal muscle weakness - pelvic girdle
Difficulty rising from chair, climbing stairs, combing hair
Pharyngeal weakness - dysphagia
Interstitial lung disease and AV nodal disease
ddx - paraneoplastic syndrome
ix - CALL JO
CK elevated x 50
AAb - anti Jo-1 (poor prognosis - lung disease) in ⅓
Elevated muscle enzymes: LDH, aldolase
*EMG and muscle biopsy - for Dx and confirmation - fibrillation potentials at rest
Ca125 (ovary), Ca19-9 (pancreas) to screen for malignancy
DERMATO pres RASH (may be UV related) - Heliotrope - violaceous eyelid - Gottron’s papules - purple scaly patches on extensors - Nailfold erythema - Shawl sign - macular rash SYSTEMIC upset: fever, arthralgia, malaise, weight loss AV conduction defects Interstitial lung disease 50% GI ulcers IX - CK elevation, LDH, aldolase AAb: anti-Jo1 (more common in poly), anti-Mi2, ANA EMG and muscle biopsy CXR LuFT HRCT
mgmt
steroids - if anti-jo long term
second line - azathioprine
lung disease - cyclophosphamide +/- ciclosporin/tacrolimus
comp GI ulceration - malaena or haematemesis high risk malig ILD AV nodal disease
Ehler Danlos patho genes suspect in who pres mgmt
patho
defect in collagen
genes
COL5A/3A
when suspect
joint + skin + hypermobility
who
women>men
pres
Skin: increased elasticity + fragility
Joints: laxity, hypermobility, pes planus, prone to dislocation
CV: dizziness, palpitations, heart valve abnormalities, mitral valve prolapse, aortic root dilatation
Ocular: abnormal globe, cornea
Hearing: tinnitus due to ossicle laxity
mgmt
Physiotherapy, regular gentle exercise, genetic counselling
Periodic echo for floppy mitral valve or aortic root dilatation
marfans def patho genetics leading cause of death suspect pres arachnodactyly ix mgmt
def Inherited connective tissue disorder with characteristic skeletal, dermatological, cardiac, aortic, ocular malformations
patho
Decreased extracellular microfibril formation. Fibrillin 1 - elastin matrix glycoprotein (missense)
genetics
AD fibrillin gene FBN1
death
aortic root dilatation
aortic dissection
suspect
tall skinny white man with long arms and legs/fingers
(arachnodactyly)
pres
skin - striae
CV - aortic dilation, dessection, MR
Lung - pleural rupture - pneumothorax
Eyes: lens dislocation, closed angle glaucoma
Skeleton: arachnodactyly, hypermobility, pectus excavatum
Facial: retrognathia, high arched palate, enopthalmos
arachnodactyly
Walker’s sign - encircles wrist with overlapping finger and thumb
ix
annual ECHO - aortic root width
CV MRI - every 5 yrs
mgmt
MDT - geneticist, ophthalmologist, cardiologist, orthopaedics
Avoid maximal exertion: scuba diving, weight lifting
Prophylactic beta-blockers - propanolol
Reduce MAP and pulse rate
seronegative arthropathies def extra features gene class diseases criteria
def
Group of rheumatic diseases with involvement of:
1) axial skeleton - sacrolitis
2) peripheral joints,
3) enthesitis (tendons and ligaments) and dactylitis - Pain, stiffness and tenderness without much swelling @ achilles, patellar
rheumatoid factor negative
other features
ant uveitis
IBD
gene
HLA B27
Chromosome 6
class Class II (D) antigen from outside of cell to CD4 T cells for Abs, class I (A,B,C) presents peptides from inside cell to CD8 T cells (2x4 = 1x8)
diseases
- Ankylosing spondylitis,
- Reiter’s syndrome,
- enteropathic arthritis,
- psoriatic arthritis,
- Behcet’s disease,
- JIA
criteria
Inflammatory spinal pain or synovitis (in lower extremities) +
- Fam Hx: anky spon, psoriasis, reactive arthritis, IBD
- Past or present psoriasis
- Past or present IBD
- Past or present pain alternating between buttocks
- Past or present pain spontaneous pain and achilles or plantar fascia
- Diarrhoea one month before arthritis
what is HLA
Major histocompatibility complex - contains large number of genes relating to immune system function. Cell surface antigen presenting proteins
ankylosing spondylitis def for dx who genetics pres extra-articular overlap with O/E ix mgmt comp
def Seronegative spondyloarthropathy of axial skeleton sacroiliitis and spondylitis (vertebral inflammation)
dx
Inflammatory back pain + enthesitis
Stiffness and pain waking in early morning
Gradual onset
Improvement with movement, no improvement with rest
Age at onset < 40
Tenderness at sacroiliac region (felt in buttocks) or limited spinal motion
who
20-30
m>f
genetics
90% HLA B27 (if positive 1-2% develop AS), AD
pres
Insidious onset, relapse and remit
In active disease: fever and wt loss (systemic)
Inflammatory back pain
Peripheral enthesitis (50%): Achilles and plantar fascia
Peripheral arthritis (50%): asymmetrical, hips, shoulder girdle, chest wall (costovertebral, costochondritis)
extra-articular
EYES - ant uveitis - 40% (painful red eye and photophobia)
CV - aortitis, dissection + aortic regurg
LUNG - restrictive: costovertebral/sternal involvement limits chest expansion, apical fibrosis
overlap with
psoriatic arthritis
enteropathic arthritis (IBD)
reactive arthritis
O/E
Reduced chest expansion <5cm
Schober’s test: reduced forward flexion <5cm + loss of lumbar lordosis
Reduced lateral flexion
ix
Pelvic XR: sacroiliitis (blurring, loss of definition), uni or bilateral, grade 1-4
HLA B27: +ve
XR of whole spine: *Bamboo spine (late + uncommon) erosions, squaring, syndesmophytes (bony spud) BESS
?LuFT - spiro - restrictive
mgmt no cure symptom control physio, rehab, exercise NSAIDs (+/- para) if pain refractory to NSAID - TNFalpha inhibitor enthesitis - intra-articular corticosteroid injection peripheral arth - DMARD sulfalasine
comps THE 6 A's Apical fibrosis Ant uveitis Aortic regurg Achilles tendonitis AV node block Amyloidosis \+ cauda equina
psoriatic arthritis def patterns imp ddx pres ix mgmt
def
Seronegative inflammatory arthritis (axial, peripheral and enthesitis) in people with psoriasis
correlates poorly with the skin cond
patterns
- Distal interphalangeal joint arthritis (DIP)
- Asymmetric oligoarthritis (up to 5) - typically hands and feet
- Symmetric polyarthritis (similar to RA) - women
- Arthritis mutilans - severe destruction, osteolysis and bone shortening - gives classic pencil in cup in fingers/hand ‘telescoping fingers’
- Psoriatic spondylitis with sacroiliac and spinal involvement (sim AS) - men
imp ddx
Symmetric polyarthritis from RA: by dactylitis and no anti CCP
pres
NAILS - Nail pitting, onycholysis (splitting of nail from bed)
FINGERS - dactylitis
TENDONS - enthesitis
ix Plain film XR feet and hands: Erosion in DIP Periarticular new bone formation Osteolysis *Pencil in cup deformity ESR/CRP (normal or elevated) RF (+ve or -ve) *+ve in 2-10% Anti CCP (-ve)
mgmt
Limited peripheral: NSAID + physio ± joint injection
Progressive peripheral high ESR/CRP: DMARD (methotrexate)
Dactylitis: NSAID + physio
Spondylitis: NSAID + physio + TNF alpha
reactive arthritis def which infections reiter's syndrome triad pres extra-articular ix mgmt
def Occurs 1-4 weeks post exposure to dysentry and STI infections
infections
Campylobacter/salmonella/shigella or chlamydia
reiters
cant see pee or climb a tree (typically lower limb)
Conjunctivitis, non-gonococcal urethritis + post-infectious arthritis
pres
acute asymmetrical, lower extremity oligoarthritis
lower back pain + heel pain (enthesitis)
extra-articular
Conjunctivitis
Skin: erythema nodosum or circinate balanitis (painless penile lesions)
Nails: psoriatic nail changes
GI: intermittent abdo pain and diarrhoea
CV: aortitis ± aortic regurgitation if prolonged
ix
ESR/CRP very high, FBC - WCC
Joint aspiration - rule out septic or crystal arthropathies
Culture: stool, throat UG tract - for causative organism
Serology chlamydia: PCR or NAAT and contract tracing
mgmt
NSAID + rest ± intra-articular steroids ± ABX chlamydia (azithromycin injx single or doxy week)
oral pred if multiple joints
enteropathic arthritis
def
symp
mgmt
def Arthritis associated with IBD (CD or UC), coeliac or reactive…
symp
Axial arthritis + peripheral arthritis (lower limb) + enthesitis + bowel symptoms + anterior uveitis
mgmt
Similar + treat bowels - consider sulfasalazine (bowel and rheumatic)
Behcet’s disease
pres
assoc
mgmt
pres
multisystem - recurrent oral ulcers, genital ulcers, eye lesions (anterior uveitis), skin (erythema nodosum), joints - non-erosive arthritis (lower limb)
assoc
HLA B51
mgmt
topical corticosteroids
systemic steroids - 1/2 yrs
name common large, medium and small vessel vasculitis
Large vessel: Polymyalgia rheumatica, Giant Cell Arteritis, Takyasu’s arteritis
Medium vessel: Polyarteritis nodosa, Kawasaki’s
Small vessel:
ANCA assoc = Wegener’s/granulomatosis with polyangiitis, Churg-Strauss
Immune complex mediated = HSP
giant cell arteritis/ temporal arteritis def main worry who assoc pres O/E ix mgmt comp
def Inflammatory granulomatous arteritis of aorta and large cerebral arteries (extracranial branches of carotid)
main worry
anterior ischaemic optic neuritis - inflam of ophthalmic artery - sudden vision loss = MED EMERGENCY
who
w>m
age >50
assoc
PMR
pres
Recent onset temporal headache + scalp tenderness + transient visual symptoms (diplopia) + jaw claudication (on chewing)
B symps = + malaise + myalgia + fever + night sweats + anorexia
O/E
Abnormality on palpation of temporal artery (absent pulse, beaded, tender)
other vessels - thoracic aortic aneurysm
ix
diagnosis = ESR > 50mm/hr + temporal artery tenderness + *temporal artery biopsy
biopsy = Granulomatous inflammation, multinucleated giant cells, intimal hypertrophy and inflammation, skip lesions
consider aortic arch angiography - stenosis or occlusion
mgmt
High dose oral prednisolone 1mg/kg/day for 4 weeks then taper
+ Aspirin (lower visual problems)
Osteoporosis prevention - Ca + Vit D + bisphosphonate
If refractory - methotrexate
if visual problems - urgent ophthalmology review
comp
stenosis of branches of arch of aorta - subclavian and axillary arteries - 20%
aortic aneurysm
subclavian steal - Retrograde blood flow in vertebral artery due to proximal stenosis of subclavian artery
polymyalgia rheumatica pres assoc who ix mgmt comp
pres
Severe bilateral pain and morning stiffness: shoulders, neck, pelvic girdle (>2 weeks) with systemic features at onset (malaise, fever, fatigue)
assoc
50% with GCA
who
>50
ix
diagnosis: Symp > 2w, Morning stiffness > 45 mins, Evidence of acute phase response ESR/CRP
others: ESR/CRP, FBC, UE, LFT, Bone profile, protein electrophoresis, TFT, creatinine kinase, RF, urinalysis
mgmt
prednisolone - 2 yrs
start high 15mg and lower
comp
steroid induced osteoporosis - DEXA + bisphos + ca + vit d
takyasu arteritis synonym who def stages O/E ix mgmt
synonym
pulseless disease
who
rare
young women 20-40
def
Chronic, progressive, inflammatory, occlusive disease of aorta and branches that leads to:
Stenosis, occlusion, dilatation, aneurysm
stages
Systemic stage + occlusive stage
1. Systemic: fever, fatigue, wt loss, arthralgia, tenderness on arteries
2. Occlusive:
Limb claudication
Cardiac: angina, dyspnoea (CHF)
Neurological: dizziness, headache, TIA, visual disturbance, stroke
Vascular: claudication of jaw, back pain (aortic arch), *HTN
Pulmonary: haemoptysis
GI: abdo pain from ischaemia/infarction
Renal: haematuria
O/E
*Difference in SBP of >10mmHg between arms
Impalpable peripheral pulse
High BP - renal artery stenosis
Arterial bruits on all arteries and aortic regurgitation
ix
ESR > 50 CRP elevated with active disease
Aortic angiography: (CT/MRI) of aorta and main branches and pulmonary arteries: occlusion, stenosis, aneurysm, thickened arterial wall
mgmt glucocorticoids aspirin bisphos persistant - TNFalpha antagonist ?PCP pneumonia proph + flu + pneumococcal
polyarteritis nodosa def assoc features patho ix mgmt comps
def Necrotising inflammation of medium sized or small arteries without glomerulonephritis
assoc
HBV
features
Any organ BUT spares pulmonary and glomerular arteries
Nerves and skin most common
Nerves: *mononeuritis multiplex
Skin: purpura, subcutaneous nodules, necrotic ulcers, *livedo reticularis
Systemic symptoms: fever, wt loss, headache, myalgia
Renal: *not glom - *HTN or AKI
GI: 50% - postprandial abdominal pain from ischaemia
ix
HBsAg - 30%
p-ANCA - negative
Acute phase response: leukocytosis/neutrophilia, ESR
Complement - reduced C3/C4
*Arteriography: microaneurysms in small and medium sized arteries + focal narrowing = ROSARY SIGN
Small artery biopsy: necrotising inflammation (but can do skin or muscle biopsy) - focal and segmental transmural necrotising inflammation
Urinalysis: proteinuria
mgmt
Prednisolone ± DMARD (cyclophosphamide) - if relapse
If active Hep B: antivirals and plasma exchange
comps
*Renal failure - not due to glomerulonephritis - due to microaneurysms and infarcts - accelerated HTN - *requires regular renal monitoring - poor prognosis = half die within 3 months
kawasaki who def features assoc mgmt
who
6m-5yrs
asian
def idiopathic self-limiting systemic vasculitis
features
CRASH and BURN
Conjunctivitis (bilateral + non-purulent)
Rash - non vesicular
Adenopathy (cervical + unilateral)
Strawberry tongue + inflammation of lips and mouth (cracked lips)
Hands/feet - palmar erythema/swelling/desquamation (2-5 days after onset)
Fever > 5 days
assoc
coronary art aneurysm + dilation - echo
mgmt
first line IVIG + high dose aspirin
comp
reyes from aspirin treatment
what is ANCA
Anti-neutrophilic cytoplasmic antibodies
C-ANCA - cytoplasmic major antigen proteinase-3
P-ANCA - perinuclear major antigen myeloperoxidase
wegeners / granulomatosis with polyangiitis classic triad other features pres ix mgmt worry about
classic triad ELK disease (ENT, lungs, kidneys) Upper respiratory tract involvement Lower respiratory tract involvement Glomerulonephritis
others
Cutaneous, ocular, MSK
pres
- Upper resp: otorrhoea, sinus pain, nasal discharge, hoarseness, stridor
* Saddle nose deformity, nasal septal perforation, subglottic stenosis - Lower resp: SOB, cough, haemoptysis, chest pain, dyspnoea, rhonchi, reduced air entry
- Renal: oedema, HTN, haematuria (later)
- Ocular: redness, pain, tearing, proptosis, visual blurring marked bilateral periorbital oedema from kidney…
- Cutaneous: palpable purpura or petechia
- MSK: myalgia and arthralgia
Neurological: numbness, weakness, etc
ix
Kidney: urinalysis and microscopy + renal biopsy - Haematuria, proteinuria, RBC casts, epithelial crescents in bowman’s capsule
Lung - CT chest/CXR - lung nodules (cavitating)
ANCA by immunofluorescense- c-ANCA (anti-PR3)
FBC - anaemia, ESR - raised
mgmt
Life threatening/organ involvement
-> Remission with IV methylpred (3d) + pred oral + cyclophosphamide
Non-life threatening:
-> Remission with IV methylpred (3d) + oral prednisolone + methotrexate
Maintain remission with oral pred + methotrexate + folic acid
worry about
AKI
Resp failure
churg stauss suspect when pres - triad + dx criteria + ELK ix score mgmt
suspect when
adult onset asthma
pres
triad = tissue eosinophilia, granulomatous inflammation, vasculitis
dx criteria = Asthma (wheeze), eosinophilia in peripheral blood, paranasal sinusitis, pulmonary infiltrates, histological confirmation vasculitis, *mononeuritis multiplex
ELK
ENT - allergic rhinitis, paranasal sinusitis, nasal polyposis
Lower RT - pneumonitis, haemoptysis
Renal - glomerulonephritis - HTN
ix
p-ANCA (antimyeloperoxidase Ab) - 40%
FBC - eosinophilia + anaemia, elevated ESR/CRP
CXR - pulmonary infiltrates
Pulmonary CT - peripheral consolidation - ground-glass attenuation
Biopsy small necrotising granulomas and necrotising vasculitis
score
five factor
Proteinuria, serum creatinine, GI tract involve, cardiomyopathy, CNS involvement -> higher mortality
mgmt corticosteroids remission = IV methylpred 3d then oral pred if score include cyclophosphamide \+ asthma mgmt
microscopic polyangiitis ANCA when suspect where mgmt
p-ANCA
suspect
Rapidly progressive glomerulonephritis and pulmonary haemorrhage
where
lungs + kidney
mgmt
pred
cyclophosphamide
cryoglobulinaemic vasculitis pres assoc ix ANCA
pres
Arthralgia, purpura, hepatic involvement, Raynaud’s, glomerular disease
assoc
Hep C
ix
Cryoglobulins, Hep C serology
ANCA -ve
IgA vasculitis synonym who what is it pres ix mgmt
synonym
Henoch- Schonlein purpura
who
Young man with previous URTI - GpA strep (pyogenes)
what
IgA immune complexes deposited in small vessels
pres
triad - Arthralgia, abdo pain, rash
Low grade fever, *abdominal pain and vomiting, purpuric rash on buttocks and extensor, joint pain
40% -> nephrotic syndrome
ix
urinalysis - proteinuria, RBC, casts, 24 hour urine protein
mgmt
joint or abdo pain - ibuprofen or paracetamol
kidney - supportive/ steroids
1/3 relapse
anti-GBM disease/goodpastures patho AAb/gene who pres ix mgmt comp
patho
Lungs and kidneys: pulmonary renal syndrome -> glomerulonephritis and pulmonary haemorrhage -> haemoptysis and renal failure (AKI)
AAb
Alpha 3 chain of type 4 collagen -> glomerular basement membrane and alveoli, anti-GBM Ab
HLA DR2
who
male 20-30 or 60-70
pres
Reduced urine output, haemoptysis, oedema, SOB, cough
ix
Renal function: abnormal
Renal biopsy: crescentic glomerulonephritis - perform *urgently
Anti-GBM - positive
mgmt
If reversible renal or any pulmonary involvement - oral prednisolone + cyclophosphamide + plasmapheresis
If pulmonary haemorrhage: supportive + smoking cessation
comp pulm haem things that increase the likelihood of that: - smokig - LRTI - pulm oedema - inhalation of hydrcarbons - young males
CI renal biopsy
Sole native kidney ESRD Neoplasm Bleeding disease Uncontrolled severe HTN Acute pyelonephritis
vasculitis screen
haem - FBC, ESR, clotting
biochem - U/E, cr, LFT, PAN and cryo assoc HBV, HCV, CRP, immunoglobs + protein electrophoresis
immunology - ANCA, RF, C3/4, anti-cardiolipin, cryoglobulins
micro - HBV/HCV serology, urine micro + culture
radio - CXR
septic arthritis when consider why imp where organisms pres RF ix mgmt comp
when consider
Any patient with acutely inflamed joint *less dramatic if immunocompromised
why imp
destroy joint in under 24 hours
where
knee
organism
most common - s.aureus
strep eg GBS
gonococcal
pres
Hot, red, swollen, *immobile/restricted
if prosthetic - Prolonged, low grade course, gradually increasing pain. No swelling/fever. *Cellulitis
RF
*Prosthetic joint (x10), RA, OA, IV drug abuse, alcoholism, diabetes, immunosuppression, skin infection
ix
Urgent joint aspiration - synovial fluid Gram stain and culture, WCC, polarised microscopy (exclude gout)
Blood culture x2 ± gonococcal cultures (rectal, urethral, pharyngeal)
Acute phase markers: ESR, CRP, WCC raised
XR - limited value - Early: Oedema and effusion - fat pad displacement, swelling of capsule and soft tissue, joint space widening
Late: joint space narrowing (cartilage destruction), subchondral bone loss, joint destruction
CT/MRI - most sensitive for periarticular abscess, osteomyelitis
mgmt
Surgical drainage and lavage (wash) + high dose IV abx
IV abx 2/3 weeks then oral 3/4 weeks - 6 total
If suspect G+ use vancomycin, if suspect G- use 3rd gen cephalosporin
When cultures back
For staph flucloxacillin
If suspect MRSA vancomycin or teicoplanin (IV vanc then oral clindamycin)
If gonococcal arth or G- cefotaxime or ceftriaxone
if had prosthesis - remove joint and fill with abx impregnanted spacer
comp
Osteomyelitis
Joint destruction
osteomyelitis def types organism staging RF pres - long bone + vertebrae worry about ix mgmt comp
def infection of bone marrow may spread to cortex and periosteum via haversian canals, leading to inflammatory destruction of bone
types
- haematogenous - bacterial seeding from far source - common assoc with children - children = metaphysis of long bones, adults = vertebral bodies
- direct/contiguous - more localised, contact of infected tissue with bone ie post surg or trauma
organism
s.aureus - MRSA if diabetic or IVDU or immuno comp
salmonella - sickle cell anaemia
staging
1 = medullary cavity only
2 = superficial involving cortical bone only
3 = localised involving medullary and cortical bone
4 = diffuse entire bone thickness
RF
Trauma, prosthetics, diabetes, PAD, chronic joint disease, alcoholism, IVDU, immunosuppression
pres -
LONG - Acutely febrile + bacteraemic + painful immobile *limb - swelling and tenderness and erythema - *exacerbated by movement
VERTBRAE - post acute septicaemic episode, localised oedema, erythema, tenderness or chronic back pain
potts disease - vertebral osteomyelitis from haematogenous spread of TB - damage to two neighbouring vert - collapse and cold abscess formation
worry about
With diabetic foot ulcers may be absent signs local infection and absent pain due to neuropathy
ix FBC (WCC) Blood cultures (+ve) Acute phase markers: ESR + CRP + WCC MRI - modality of choice *Plain radiograph- Areas appear dark, soft tissue swelling, periosteal thickening (at 7 days), patchy osteopenia (lytic changes are late) Cultures from debrided bone
mgmt 1) Bone and soft tissue debridement, 2) stabilise bone + immobilisation, 3) local ABX - fluclox or clinda in pen allergic, 4) reconstruction Analgesia and limb splinting if long bone Culture directed ABX + debridement IV for 2 weeks then oral for 4 weeks Chronic treatment is for 12 weeks
comp
amputation - diabetic
spread to joint if breaks through cortex
what is sequestrum
when dead bone detaches from healthy bone
fibromyalgia def who patho assoc where ix for dx tender points mgmt
def Chronic widespread pain disorder
who
Women > men x 10, normally 20-50 years old
patho
Peripheral and central hyperexcitability, altered pain perception, somatisation
assoc
fatigue, memory problems, mood difficulties, stress
where
everywherre
mgmt
1st - amitriptylline + CBT
2nd - gabapentin or pregablin
back pain RED FLAGS
and MAIN WORRIES
RED FLAGS
TUNA FISH
Trauma
Unexplained weight loss, loss of appetite - cancer/myeloma
Neurological symptoms including bowel bladder dysfunction - cauda equina
Age > 50 or < 20
Fever and night sweats - osteomyelitis/cancer
IVDU/immunosuppression - osteomyelitis
Steroid use - immunocompromise + osteoporotic fracture
History of cancer (prostate, breast, lung, renal)
MAIN WORRIES Cauda equina - bowel or bladder dysfunction, bilateral sciatica, saddle anaesthesia - high possibility of being sued!!! Multiple myeloma Metastatic cancer Psoas abscess
cervical back pain usually caused by.. pres common location ix mgmt
usually caused by..
Chronic disc degeneration (CERVICAL OSTEOARTHRITIS)
pres
simple neck pain + radiculopathy (pain, numbness, tingling, weakness in upper limbs) + myelopathy (spinal cord)
worse on movement
stiffness
referred pain to -> occiput, between shoulder blade, retro-orbital/temporal (C1/2)
ix
radiculopathy -
Spurling test: flex neck laterally, rotate and push -> radicular pain
c5-c7 -> diminished reflex - biceps + supinator = c5/6, triceps = c7
pain xr - osteophytes, narrowing of disc space, encroachment of intervertebral foramen
neuropathy - require MRI
mgmt
3-4 weeks = reassurance + keep normal movement
4-12 weeks = physio + yoga + pilates + alexander method
define spondylosis
wear and tear osteoarthritis
thoracic back pain why worry causes red flags disc collapse pres comp mgmt imp ddx
why worry
More commonly due to serious spinal pathology than cervical or lumbar
causes
Most common = muscular irritation, trauma, sudden injury
red flags
As before = TUNA FISH esp. Bladder symptoms = myelopathy or collapse
disc collapse pres
Pain localised to spine + relevant radiculopathy, sensory disturbance in dermatomal distribution
comp
May cause significant restrictions and exclusion of domestic, leisure, educational activities
mgmt
Many resolve without Rx
ddx
Problems affecting the lung (including Pancoast tumour), oesophagus, stomach, liver and gallbladder
lower back pain RF red flags ddx 15-30, 30-50, 50+ ix mgmt
RF
Demanding jobs, prolonged standing, awkward lifting, *psychosocial work stress
red flags
CES: saddle anaesthesia, perianal sensory loss, bladder dysfunction, loss of anal tone
Spinal fracture: sudden onset pain relieved by lying down, structural deformity e.g. step
Cancer or infection (e.g. discitis) - PAIN REMAINS ON LYING DOWN, night pain>50 or <20, recent infx, IVDU etc….
ddx
15-30 = Trauma, fracture, pregnancy, anky spon, prolapsed disc, *mechanical
30-50 = *Degenerative spinal disease, prolapsed disc, malignancy (breast, bronchus, prostate, kidney)
50 + = Degenerative, osteoporotic collapse, myeloma, spinal stenosis, malignancy, Paget’s (pelvis 70%, lumbar 50%)
ix
FBC, ESR, CRP, UE, Alk phos, serum/urine electrophoresis, PSA
Imaging only if serious pathology indicated e.g. red flags (not simple back pain)
Plain XR: not routine, only if fracture likely
- Prostate = sclerotic
- Lung, renal = lytic
- Breast = sclerotic or lytic
MRI good for soft tissue, disc lesion and impingement of nerves
mgmt
keep active + analgesia
acupuncture
physio
psychosocial -Beliefs that activity is harmful, sickness behaviour, withdrawal, dissatisfaction at work, depression, manage expectations
lumbar discectomy - only in severe nerve compression
refer - 6w of sciatica: disabling and distressing
most common buttock pain
facet joint issues
only consider sciatica if shooting pain to bottom of foot
bone tumours
primary classification
symps
Benign or malignant
Benign: bone osteoid osteoma, cartilage chondroma/osteochondroma, fibrous tissue fibroma, BM eosinophilic granuloma
Malignant: bone osteosarcoma, cartilage chondrosarcoma, fibrous fibrosarcoma, BM myeloma, Ewing’s sarcoma
Uncertain: Giant cell tumour
symps
Bone pain: unremitting, worse at night
swelling, effusion, deformity, nodes, pathological fracture, wt loss
osteoid sarcoma describe who XR mgmt
<1cm, surrounded by dense osteoid
Young adults
XR
Radiolucency surrounded by dense bone
mgmt
Pain with NSAIDs, local excision = curative
osteochondroma describe who where pres
Most common benign
Young adults
Next to epiphyseal plate
Painless lump or joint pain, nerve compression = spur on XR
Chondroma
what
where
mgmt
Single or multiple lesions
Hands or feet, tubular bones
Excise lesion + graft bone
Giant cell tumour what where who XR mgmt
An osteoclastoma = 20% of all, aggressive, recurrent
where
Sub-articular cancellous region of long bones after closure of epiphyses
20-40
XR
Asymmetrical area at end of long bone
mgmt Excise lesion (don’t graft)
osteosarcoma what who assoc where pres mets to XR
what
most common malignant
who
children 15-19
assoc
pagets
where
epiphyses of long bones - knee 75% or proximal humerus
pres
painless
destroys bone and spreads locally, rapidly
mets to lung
XR
combine bone desctution and formation
soft tissue calcification = sunburst/hair on end + codmans triangle - area of new subperisosteal bone created when tumour raises periosteum from bone
Ewings sarcoma what who pres xr
primitive neuroectodermal tumour
who
15 boy
pres
mass or swellling in long bones of arms/legs, pelvis, chest
pain, redness, malaise, fever
xr
bone destruction with onion skin layers of periosteal bone formation + codmans triangle
?bone tumour
ix
mgmt
Isotope bone scans (for mets) XR Alk phos/Ca CT/MRI for stage Biopsy fine needle or core
mgmt
Benign - manage symptoms (analgesia ± excision)
Malignant = complex MDT - refer to sarcoma clinic
what is a pathological fracture
Potential for dissemination - local recurrence therefore immobilise post biopsy (with external splint, not internal fixation)
why do mets to bone
high vascular
where is hip joint felt in patient
groin
medial knee
four painful conditions of the shoulder excluding trauma/ dislocation
rotator cuff - supraspinatus tendonitis
adhesive capsulitis - true frozen shoulder (all movements prohibited) - cant move hands out with shoulders tucked in
acromio-clavicular joint arthritis
OA shoulder - glenohumeral
painful arc of shoulder what causes pain where
OA of acromioclavicular joint = top bit
supraspinatus tendonitis = middle bit
full thickness tear of supraspinatus = lower portion (cannot initiate abduction)
rotator cuff muscles and what movements
infraspinatus + teres minor - external rotation
supraspinatus = abduction
subscapularis = internal rotation
coracohumeral ligament -> stengthens ant capsule and implicated in the restricted external rotation of adhesive capsulitis
how to approach orthopaedic xrays
- projection
- need at least two views
- normally AP + lateral
- shaft of a long bone fractured then should always xr the joint above and below
- comment on maturity of bone - open epiphyseal plates? - patient details
- technical adequacy
- entire area in
- exposure
- rotation - obvious abnormalities
- SR of xray
- look around all edges for fractures
- look at medulla for lucent or sclerotic lines
- assess for soft tissue swelling + joint effusion
- look at joint surfaces for evidence of subluxation or dislocation
- assess for degenerative (LOSS) or inflammatory (LESS) changes
- review bone density and texture looking for any abnormal lucent or sclerotic areas
explaining a fracture to a consultant
which bone
which part - proximal 1/3, middle or distal, intra-articular
fracture pattern - simple, open, comminuted, impacted
type of fracture - transverse, oblique, spiral, greenstick, vertical
translocation displacment - relationship of distal fracture to proximal (essential to use two xrays to assess this)
angulation - movement of the distal fragment in relationship to the proximal one in degrees
rotation - internal or external (long bone fractures)
shortening
joint space - smaller? foreign bodies?
joint cartilage
bone texture - radiolucency?
simmonds sign
positive in achilles tendon rupture
suspect achilles tendon rupture if hear a pop in ankle and sudden onset pain in calf or ankle and inability to walk
when patients arrive in a+e with fracture whats the mgmt
reduction and realignment
backslab for 1-2 weeks to accomodate swelling
repeat xray
then apply full cast for 6 weeks
