Orthopaedics and Rheumatology Flashcards
Presentation of rheumatoid arthritis
- swollen, painful joints in the hands and feet
- stiffness worse in the morning
- gradually gets worse with larger joints becoming involved
What are the poor prognostic factors for rheumatoid arthritis?
- anti CCP
- rheumatoid factor
- early erosions on X ray (<2 years)
- HLA DR4
- Extra articular features
Management of rheumatoid arthritis
- dMARD with a bridging course of prednisolone
- methotrexate/sulfasalazine
- hydroxychloroquine if mild or palinodromic
How can you monitor response to treatment of rheumatoid arthritis?
- crp
- disease activity score e.g. DAS28
Management of flare of rheumatoid
corticosteroid
Indication for TNF-a in rheumatoid arthritis
Failed response to at least two dMARDs
Name 3 TNFa inhibitors
- etanercept
- infliximab
- adalimumab
X ray findings of rheumatoid arthritis
- loss of joint space
- juxta-articular osteoporosis
- soft tissue swelling
- periarticular erosion
- subluxation
methotrexate side effects
- myelosuppression
- pneumonitis
- liver cirrhosis
Side effects of sulfasalazine
- rashes
- oligospermia
- heinz body anaemia
- interstitial lung disease
hydroxychloroquine side effects
- retinopathy
- corneal deposits
What are the patterns of psoriatic arthritis?
- symmetric
- asymmetrical
- sacroillitis
- DIP joint disease
- arthritis mutilans
Signs of psoriatic arthritis
- psoriatic skin lesions
- periarticular disease: enthesitis, tenosynovitis, dactylitis
- nail changes: pitting, onycholysis
X ray psoriatic arthritis
- pencil in cup appearance
- periostitis
- erosive changes, new bone formation
Management of psoriatic arthritis
- NSAID if mild
- dMARD (methotrexate) if moderate or severe
- monoclonal antibodies such as ustekinumab (targets both IL-12 and IL-23) and secukinumab (targets IL-17)
Pseudogout
deposition of calcium pyrophosphate dihydrate crystals in the synovium
Risk factors of pseudogout
- haemochromotosis
- wilsons
- hyperparathyroidism
- acromegaly
- low magnesium, low phosphate
-age
Features of pseudogout
- knee, wrist, shoulder
- joint aspiration: weakly-positively birefringent rhomboid-shaped crystals
- x-ray: chondrocalcinosis
What are the main features of gout?
- pain
- swelling
- erythema
commonly affected joints in gout
- most commonly the 1st MTP joint
- others: ankle, wrist, knee
Investigations for gout
- measure the uric acid level if >360 supports the diagnosis, if under and symptoms still suggest gout then repeat in 2 weeks
- synovial fluid analysis (needle shaped negatively birefringent monosodium urate crystals)
What is the management of an acute flare of gout?
- NSAIDs
- Colchicine
- if the patient is already taking allopurinol they should continue taking it
What is the main side effect of colchicine?
Diarrhoea
Who should be started on urate lowering therapy and when?
Anyone who has had an attack of gout, two weeks after the attack
Management of gout to prevent an attack
- allopurinol
- lifestyle advice: avoid alcohol, lose weight if obese, avoid food high in purines: liver, oily fish, seafood, yeast products
When is urate lowering therapy particularly recommended?
- ≥2 attacks in the last 3 months
- tophi
- renal disease
- uric acid renal stones
- if on cytotoxics or diuretics
Typical joints osteoarthrtitis
- larger joints
- knee
- hip
- carpometocarpal
- DIP, PIP joints
X ray findings osteoarthritis
- loss of joint space
- subchondral sclerosis
- subchondral cysts
- osteophytes
What is the management of osteoarthritis
- weight loss, local muscle strengthening, general aerobic fitness advice
- topical NSAIDs
- second line: oral NSAIDs and PPI
- intra-articular steroid injections if analgesia not effective (pain relief only lasts 2-10 weeks)
- consideration of joint replacement
What are the most common causes of septic arthritis in adults?
- staph aureus
- n. gonnorhoeae in young adults who are sexually active
Features of septic arthritis
- acute, swollen joint
- warm to touch/fluctuant
- restricted movement
Investigations septic arthritis
- synovial fluid aspiration
- blood cultures
- joint imaging
Management of septic arthritis
- IV antibiotics
- flucloxacillin
- switch to oral antibiotics after 2 weeks
What is reactive arthritis
Arthritis that develops following an infection in which the organism cannot be recovered from the joint
STI reactive arthritis
- chlamydia
post dysenteric arthritis
- shigella
- salmonella
What is the management of reactive arthritis?
- analgesia, NSAIDs, intra-articular steroids
- sulfasalazine or methotrexate if continuing disease
Features of reactive arthritis
- typically develops within 4-6 weeks post infection
- asymmetrical oligoarthritis
- dactylitis
- urethritis
- conjunctivitis or anterior uveitis
- circinate balanitis (painless vesicles on the coronal margin of the prepuce)
keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles)
What are the common features of the seronegative spondyloarthropathies?
- rheumatoid factor negative
- peripheral arthritis and usually asymmetrical
- sacroillitis
- enthesopathy
- extra- articular manifestations (uveitis, pulmonary fibrosis (upper zone), amyloidosis, aortic regurgitation)
What are the sero-negative spondyloarthropathies?
- ankylosing spondylitis
- psoriatic arthritis
- reactive arthritis
- enteropathic arthritis
Features of ankylosing spondylitis
- typically a young man with lower back pain and stiffness of insidious onset
- stiffness worse in the morning, better with exercise
- may experience pain at night which gets better on getting up
clinical exam ankylosing spondylitis
- reduced lateral flexion
- reduced forward flexion (schober’s test)
- reduced chest expansion
- the A’s: apical fibrosis, AV node block, anterior uveitis, aortic regurgitation, achilles tendonitis, amyloidosis
Investigation ankylosing spondylitis
- X ray of sacroiliac joints
- ESR and CRP may be raised
X ray ankylosing spondylitis
- sacroilitis: subchondral erosions, sclerosis
- sparing of lumbar vertebrae
- bamboo spine
- syndesmophytes
- chest x ray: apical fibrosis
Early sign of ankylosing spondylitis if X ray is negative
- bone marrow oedema on MRI
Management of ankylosing spondylitis
- regular exercise e.g. swimming
- NSAIDs are first line treatment
- physiotherapy
- disease modifying drugs can be used if there is peripheral arthritis
- anti- TNF if high level disease activity despite conventional treatments e.g. etanercept
Onset SLE
20-40
ethnicity SLE more common
Afro-Caribbean, asian
sensitivity reaction SLE
Type 3
Genes SLE
HLA B8, DR2, DR3
General features of SLE
- fatigue
- fever
- mouth ulcers
- lymphadenopathy
Skin features of SLE
- malar rash (butterfly)
- discoid rash
- photosensitivity
- raynauds
- livedo reticularis
- non scarring alopecia
msk features of SLE
- arthralgia
- non erosive arthritis
cardiovascular features of SLE
- pericarditis
- myocarditis
Respiratory features of SLE
- pleurisy
- fibrosing alveolitis
Renal features of SLE
- proteinuria
- glomerulonephritis
Neuropsychiatric features of SLE
- anxiety and depression
- psychosis
- seizures
Antibodies in SLE
- 99% are ANA positive (high sensitivity, low specificity
- anti- dsDNA (high specificity, sensitivity 70%)
- 20% rheumatoid factor positive
- anti-smith
- anti- Ro, anti-La
monitoring of SLE
- Inflammatory markers: ESR, crp
- complement C3/4 are low during activity of disease
- anti-ds DNA can be used
management of SLE
- NSAIDs
- sun block
- hydroxychloroquine
What are the 3 types of systemic sclerosis
- limited cutaneous
- diffuse cutaneous
- scleroderma (without internal organ involvement)
limited cutaneous sclerosis
- raynauds
- scleroderma affecting the face and distal limbs
- subtype= CREST: calcinosis, raynauds, esophageal dysmotility, sclerodactyly, telangiectasia
antibodies limited cutaneous sclerosis
anti-centromere antibodies
(ANA also positive in cutaneous sclerosis)
Diffuse cutaneous sclerosis
- scleroderma affecting the trunk and proximal limbs
- respiratory: ILD/pulmonary arterial hypertension
- renal disease and hypertension
What is scleroderma?
Thickening and tightening of the skin
What is sjogrens?
autoimmune disorder affecting the exocrine glands resulting in dry mucosal surfaces
Features of sjogrens
- dry eyes, mouth, vagina
-arthralgia - raynauds
- myalgia
- sensory polyneuropathy
- parotitis
- renal tubular acidosis
- increased lymphoid malignancy
investigations for sjogrens
- rheumatoid factor positive in 50%
- Anti Ro positive in 70%
- Anti La positive in 30%
- ANA positive in 70%
- schirmers test to measure tear formation
Management of sjogrens
- artificial tears and saliva
- pilocarpine may stimulate saliva production
What is polymyositis?
inflammatory disorder causing symmetrical, proximal muscle weakness, thought to be t cell mediated.
Associations of polymyositis
- malignancy
- connective tissue disorders
Features of polymyositis
- proximal muscle weakness/tenderness
- raynauds
- respiratory muscle weakness
- interstitial lung disease
- dysphagia, dysphonia
Investigation polymyositis
- elevated creatine kinase
- elevated muscle enzymes (LDH, AST, ALT)
- EMG
- Muscle biopsy
- anti-jo-1 Antibodies (anti-synthetase antibodies)
Management of polymyositis
- high dose steroids, tapered down
- azathioprine as steroid sparing therapy
What is dermomyositis
- inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions
- idiopathic, related to connective tissue disorders, or malignancy
What should be done prior to a diagnosis of dermomyositis?
Malignancy screen
skin features dermomyositis
- photosensitivity
- macular rash over back and shoulder
- helitrope rash in the orbital area
- gottron’s papule
- mechanic’s hands’: extremely dry and scaly hands with linear ‘cracks’ on the palmar and lateral aspects of the fingers
- nail fold capillary dilatation
histidine tRNA ligase
Anti -jo-1
anti - RNP
SLE/mixed CTD
anti sm
SLE
Antiphospholipid syndrome antibodies
anticardiolipin antibodies
What is antiphospholipid syndrome?
Predisposition to arterial and venous thromboses, fetal loss, and thrombocytopenia
What are the features of antiphospholipid syndrome
- venous/arterial thromboses
- recurrent miscarriages
- livedo reticualris
Investigations antiphospholipid syndrome
- anticardiolipin antibodies
- thrombocytopenia
- prolonged APTT
Management of antiphospholipid syndrome
- Primary thromboprophylaxis: low dose aspirin
- Secondary venous thrombophylaxis: warfarin, target INR 2-3
comminuted fracture
> 2 fragments
segmental fracture
More than one fracture along a bone
Grade 1 open fracture
low energy wound <1cm
grade 2 open fracture
greater than 1cm with moderate soft tissue damage
Grade 3 open fracture
high energy wound >1cm with extensive soft tissue damage
a- adequate soft tissue coverage
b- inadequate soft tissue coverage
c- associated arterial injury
Management of open fracture
- removal of gross debris,
- debridement and irrigation
- IV broad spectrum antibiotics
- immobilise (internal fixation should be avoided)
- monitor the neurovascular function
What are the two main fractures that risk compartment syndrome?
- supracondylar fracture
- tibial shaft
Features of compartment syndrome
- pain, especially on movement (including passive)
- paraesthesia
- pallor
- arterial pulsation
- paralysis of the muscle group
Diagnosis of compartment syndrome
- intracompartmental pressure measurement >20 is abnormal, >40 is diagnostic
Compartment syndrome x ray
Will probably not show anything
What is the management of compartment syndrome
- extensive fasciotomies
- debridement
- consider amputation
What may occur after a fasciotomy?
myglobinuria resulting in renal failure - give aggressive IV fluids
What level does the spinal cord end?
L1-2
What are the features of cauda equina?
- lower back pain
- bilateral sciatica
- saddle anaesthesia
- decreased anal tone
- urinary dysfunction
Investigation for cauda equina
urgent MRI
What is the management of cauda equina syndrome?
surgical decompression
What are the causes of cauda equina syndrome?
- herniated disc
- tumour, metastases
- spondylolisthesis
- abscess
- trauma
What is the management of metastatic spinal cord compression syndrome?
- high dose dexamethasone
- analgesia
- radiotherapy
- surgery
What are the complications of cauda equina syndrome?
- bladder dynsfunction
- bowel dysfunction
- sexual dysfunction
- leg weakness
- sensory impairment
What are the red flags for back pain?
- age<20, >50
- history of previous malignancy
- night pain
- history of trauma
- systemically unwell
Features of spinal stenosis
- gradual onset
- uni or bi lateral leg pain
- numbness
- weakness
- symptoms worse on walking, resolves when sitting, leaning forwards or crouching
What are the causes of mechanical back pain?
- muscle or ligament sprain
- facet joint dysfunction
- sacroiliac joint dysfunction
- herniated disc
- spondylolisthesis
- scoliosis
- degnereative changes
Which cancers metastasise to the bones?
- prostate
- renal
- thyroid
- breast lung
What are the ottawa ankle rules?
An ankle X ray is only required if there is any pain in the malleolar zone and one of the following:
- bony tenderness at the lateral malleolar zone (lateral malleolus to lower 6cm of the posterior border of the fibula)
- bony tenderness at the medial malleolar zone (from tip of the medial malleolus to the lower 6cm of the posterior border of the tibia)
- inability to walk four weight bearing steps immediately after the injury and in the emergency department
Syndesmosis of the ankle
- joins the distal tibia and fibula together
- anterior inferior tibiofibular ligament
- posterior inferior tibiofibular ligament
- interosseous ligament
- interosseous membrane
How is the distal tibia secured to the talus?
By the deltoid ligament
How is the distal fibula secured to the talus?
- anterior and posterior talofibular liaments
How is the distal fibula secured to the calcaneus?
Calcaneofibular ligament
What is a sprain
stretching, partial, or complete tear of a ligament
High ankle sprain
syndesmosis
Low ankle sprain
lateral colateral ligaments (anterior and posterior talofibular ligaments and calcaneofibular ligament)
Presentation of a low ankle sprain
- anterior talofibular ligament most commonly affected
- inversion injury is the most common
- pain, swelling and tenderness over the affected ligaments, sometimes bruising
- patients usually able to weight bear unless severe
Investigation for low ankle sprain
- Follow ottowa rules for x ray
- MRI if persistent pain
Management of low ankle sprains
- Rest, ice, compression and elevation
- cast and/or crutches for short term symptom relief
- MRI and surgical intervention can be considered in extreme cases
Presentation of high ankle sprain
- external rotation of the foot causing the talus to push fibula laterally
- weight bearing painful
- pain when the tibia and fibula are squeezed together at the level of the mid calf (hopkins squeeze test)
What are the causes of avascular necrosis of the hip?
- long term steroid use
- chemotherapy
- alcohol excess
- trauma
Investigation avascular necrosis of the hip
- plain film x-ray may be normal initially (osteopenia/microfractures, crescent sign (collapse of articular surface))
- MRI is the investigation of choice
Management of avascular necrosis of the hip
Joint replacement
What is a baker’s cyst?
Distension of the gastrocnemius-semimembranous bursa. Can be primary (no underlying pathology), or secondary e.g. due to osteoarthritis
- swelling in the popliteal fossa
Presentation of a biceps rupture
- sudden pop or tear either at the shoulder (long tendon) or at the antecubital fossa (distal tendon) followed by pain, bruising and swelling
- popeye deformity
- weakness in the shoulder and elbow, including supination
Investigation biceps rupture
- biceps squeeze test (supination seen in arm)
- ultrasound scan
- for distal tendon rupture MRI urgently, can consider in long tenson
What does paget’s affect?
- spine
- skull
- pelvis
- femur
Bloods pagets
- ALP raised
- other normal
Pagets on x ray
- thickened sclerotic bone
treatment of pagets
bisphosphonates
what happens in pagets?
Focal bone resorption followed by excessive and chaotic bone deposition
osteoporosis bloods
- ALP normal
- calcium normal
Nerve carpal tunnel
Median nerve
Presentation of carpal tunnel
- pain/pin sand needles in the thumb, index and middle finger
- symptoms ascend proximally
- patient may shake their hand to relieve symptoms, classically at night
Examination carpal tunnel
- weakness of thumb abduction (abductor pollicis brevis)
- wasting of the thenar eminence (not hypothenar)
- tinel’s sign: tapping causes paraesthesia
- phalens: flexion of the wrist causes symptoms
What are the causes of carpal tunnel syndrome?
- idiopathic
- pregnancy
- oedema e.g. heart failure
- lunate fracture
- rheumatoid arthritis
Electrophysiology of carpal tunnel
motor and sensory prolongation of the action potential
Treatment of carpal tunnel
- 6 week trial of conservative treatment: corticosteroid injection, wrist splint at night (particularly useful if transient factors present)
- severe or symptoms persist: surgical decompression: flexor retinaculum division
What is a charcot joint?
Joint that has become badly disrupted and damaged secondary to a loss of sensation e.g. diabetes
What is a colles fracture?
- distal radius fracture with dorsal displacement of the fragments
- described as a dinner fork deformity
early complications of colles fracture
- median nerve injury: acute carpal tunnel with weakness or loss of thumb or index finger flexion
- compartment syndrome
- vascular compromise
- malunion
Late complications of a colles fracture
- osteoarthritis
- complex regional pain syndrome
compression of what nerve causes cubital tunnel syndrome
Ulnar nerve
Features of cubital tunnel syndrome
- tingling and numbness of the 4th and 5th finger
- weakness and muscle wasting
- pain worse on leaning on the affected elbow
- often a history of osteoarthritis or prior trauma to the area
Management of cubital tunnel syndrome
- avoid aggravating activity
- physiotherapy
- steroid injections
- surgery in resistant cases
What is the most common cause of discitis?
staphylococcus aureus
complications of discitis
- sepsis
- epidural abscess
Treatment of discitis
- 6 to 8 weeks of IV antibiotics
- blood culture or CT guided biopsy
- assess for endocarditis with a transthoracic echo or transoesophageal echo
Presentation of discitis
- back pan
- pyrexia, rigors, sepsis
- neurological features: changing lower limb neurology if an epidural absecess develops
Causes of dupuytrens contracture
- manual labour
- phenytoin treatment
- alcoholic liver disease
- diabetes
- trauma to the hand
Management of dupuytrens contracture
Metacarpophalangeal joints cannot be straightened and hand cannot be placed flat on the table
Greater trochanteric pain syndrome
- pain over the lateral side of the hip/thigh
- tenderness on palpation fo the greater trochanter
- also called trochanteric bursitis
Which type of hip dislocation is most common?
Posterior
Presentation of posterior hip dislocation
- affected leg is shortened, adducted and internally rotated
Presentation of anterior hip dislocation
- affected leg is usually abducted and externally roated
- no leg shortening
Management of hip dislocation
- ABCDE
- analgesia
- reduction under GA within 4 hours
- physio
Complications of hip dislocation
- sciatic or femoral nerve injury
- avascular necrosis
- osteoarthritis
- recurrent dislocation due to the damage of supporting ligaments
Presentation of hip fracture
Shortned, externally rotated leg
Intracapsular hip fracture
from edge of the femoral head to the insertion of the capsule of the hip joint
extracapsular hip fracture
either trochanteric or subtrochanteric (divided by the lesser trochanter)
Classification for hip fracture
Garden system
Explain the garden system
- type 1: stable fracture with impaction in valgus
- type 2: complete fracture but undisplaced
- type 3: displaced fracture, usually rotated and angulated but still has boney contact
- type 4: complete boney disruption
Management of an undisplaced hip fracture
- internal fixation
- hemiarthroplasty if unfit
Management of displaced intracapsular hip fracture
arthroplasty (total hip replacement or hemiarthroplasty) to all patient with a desplaced intracapsular hip fracture
Which patients with a displaced intracapsular hip fracture should get total hip replacement over a hemiarthroplasty
- able to walk independently out of doors with no more than the use of a stick and
- are not cognitively impaired and
- medically fit for anaesthesia and the procedure
Management of an extracapsular hip fracture
- if stbale intertrochanteric fractures: dynamic hip screw
- if reverse oblique, transverse or subtrochanteric: intramedullary device
Nerve humeral shaft fracture
Radial nerve
