Orthopaedics and Rheumatology Flashcards
1
Q
Describing fractures
- complexity
- comminution (types of break)
- location
- displacement
A
- Simple = closed, comminuted = open
- impaction, greenstick, transvers, oblique, spiral, compounded
- distal/proximal/mid shaft
- degree of translation/angulation/shortening
2
Q
What score used for 10 year fracture risk
A
FRAX (3 person, 3 frac, 3 put in, 2 conditions)
- Age Sex BMI
- Previous fracture, parent hip fracture, low BMD on femoral neck
- RA, secondary osteoporosis (T1DM, osteogenesis imperfects, hyperthyroid etc)
3
Q
5 commonest fractures
A
Clavicle, Arm, Wrist, Hip, Ankle
4
Q
Fractures at risk for avascular necrosis
A
Scaphoid Femoral Head (intracapsular)
5
Q
Bones of the wrist
A
Scared lovers try positions that they can’t handle
- Scaphoid
- Lunate
- Triquentrum
- Pisiform
- Trapezium
- Trapezoid
- Capitate
- Hamate
6
Q
Types of Wrist fracture
A
Colles (dorsal displacement)
Smiths (Volar displacement)
Scaphoid
7
Q
Wrist fracture Tx
A
Manipulation under anaesthetic (Biers) if indicated
Immobilisation
May need K-wires or ORIF
8
Q
Scaphoid
- Mechanism
- Sign
- XR efficiency
- Tx
A
FOOSH
Tenderness in anatomical snuffbox
Difficult to view (missed in 20%) esp initially
Cast immobilisation, repeat exam and XR iat 10-14 days.
May need surgical management
9
Q
Which nerve in anatomical snuffbox
A
Radial nerve (sensory branch)
10
Q
Complication of scaphoid fracture
A
avascular necrosis
11
Q
Colles
- who at risk
- mech
- complication
- Tx
A
fall with osteoporosis
FOOSH with dorsiflexed wrist
Median nerve damage (also ulnar)
Reduction (±internal fixation) and immobilisation
12
Q
Smith
- mech
- complication
- Tx
A
Fall backwards
Median nerve damage
Reduction and surgical fixation then immobilisation
13
Q
Fractures NOF
- definition
- types (3)
A
up to 5cm below lesser trochanter
- intracapsular (may disrupt blood supply to femoral head - avasc necrosis)
- extra capsular trochanteric (distal to capsule, involving or between trochanters)
- extra capsular subtrochanteric (below lesser trochanter up to 5cm distal)
14
Q
NOF
- Typical cas..
- RF
- Presentation
A
- Post minor trauma in elderly
- Falls (instability, lack of core strength, gait disturbance), FRAX, Osteoporosis, Malignancy
- Pain in outer upper thigh or groin, radiates to knee, not weight bearing, Leg adducted and externally rotated
15
Q
NOF investigations
A
AP/Lateral XR
MRI if not obvious on XR
16
Q
Grading #NOF
A
Gardens classification
1-4
1 = incomplete fracture 4 = complete fracture, displaced in over 50%
17
Q
NOF Initial Tx
A
Analgesia (not NSAIDs bleed risk)
Surgery within 1 day
18
Q
Intracapsular #NOF surgery
A
Undisplaced/young = internal fixation with cannulated screws
Displced = hemiarthroplasty to replace femoral head
19
Q
Extracapsular #NOF surgery
A
internal fixation with screws
If more distal and femoral support needed, DHS
20
Q
#NOF mortality 1 month, 3 month
A
10%
33%
21
Q
NOF surgery complications
A
infection, haemorrhage, avascular necrosis, DVT (dalteparin), pneumonia
22
Q
When get femoral shaft fracture
A
high velocity, high energy e.g. RTA.
High energy mean often assoc with soft tissue damage
23
Q
Which bones commonly broken in ankle fracture
A
Tid, Fib, Talus
24
Q
Two joints of ankle
A
Ankle (where tis and fib meet talus) & Syndesmosis (between tis and fib)
25
When to consider ankle break
Obvious deformity, inability to weight bear, bony tenderness
26
When to XR ankle
Ottawa ankle rules
- over 55
- can't wt bear 4 steps
- Bone tenderness over posterior edge or tip of lateral/medial malleolus
AP/Lateral/Oblique (15 degrees)
27
Ankle # Tx
If NV comp or dislocation then reduce under sedation
```
surgical reduction and fixation
4-6 weeks in moulded cast
Analgesia
Elevation
Re-assess NV status
```
XR of reduction (48 hr, 7 day, 2 weeks
28
Main worrying complication of fracture
Compartment syndrome
29
When to suspect compartment syndrome and Tx
- pain out of proportion, 6 Ps (pain, parasthesia, Pallor, Paralysis, Perishingly cold) --> Prompt Fasciotomy
30
Compartment syndrome pathology
- Increase pressure due to blood and intracompartmental swelling
- leads to muscle and nerve ischaemia --> necrosis --> vicious cycle
31
Diagnosis of compartment syndrome
Compartment pressure over 20 = suggestive, over 40 = diagnostic
32
2 main complications of compartment syndrome
| &Prevention
Neuromuscular necrosis (fasciotomy)
Myogloinuria --> renal failure (Aggressive IV fluids)
33
Stages of fracture healing
1) Haematoma (hrs): Macrophages and leukocytes move to area and secret inflammatory agents
2) Fibrocartilaginous soft callus (days): inflammation leads to angiogenesis and inc chondrocytes to secrete collagen and proteoglycans (soft callus)
3) Bony Callus (weeks): Endocondral ossification and direct bone formation. Woven bone replaces soft callus
4) Bone remodelling (months): woven bone replied by organised cortical bone (osteoclast/blast activity) continuous remodelling = no scarring
34
Fracture healing time
3-12 weeks
35
Frozen shoulder
- Joint affected
- Mechanism
- Pres
- Age
- Assoc
- Classic sign
- Tx
Glenohumeral
Thickening and contraction of glenohumeral joint capsule ± formation of adhesions. spontaneous or post injury
Pain and loss of function
40-65
Diabetes (esp if bilateral), thyroid
Loss of external rotation
Analgesia (Para, NSAID), Physio, activity
36
Bone remodelling process
Osteocytes send signal to osteoclasts/blasts
Osteoclasts resorb bone matrix (resorption pit) and inc serum calcium
Osteoclasts undergo apoptosis and signal osteoblasts
Osteoblast synthesise new bone matrix which then undergoes mineralisation by Ca/phosphate
37
Osteoprotegrin function
Osteoprotegrin secreted by Osteoblasts inhibits activation of RANK by RANKL - this is lost following menopause and inc osteoclastic activity
38
RANK and RANKL
RANK = osteoclast receptor
RANKL = ligand released by osteoblasts which activate RANK (reduced activate by Osteoprotegrin)
RANKL activates RANK
39
Osteoporosis
| - Definition
Skeletal disease with low bone mass leading to fragility and fracture (at mechanical which wouldn't usually #)
40
T-score & interpretation
Z-score
Using DEXA for BMD
- Gives number for S.D below healthy adult mean
Score -2.5 T -1 = Osteopenia
Score less than -2.5 = Osteoporosis
Z = compared to age matched mean
41
Common Osteoporotic #
Spine (vertebral crush)
Wrist (distal radius)
Hip (proximal femur)
42
Osteoporosis pathophys
Decreased bone formation - Osteoblasts
Increase bone breakdown - Osteoclasts
BMD decreases with age (primary) and other (secondary e.g. steroids).. depends on peak attained BMD in life
43
Osteoporosis symptoms
None until Fracture
Loss of height, Kyphosis
44
RF/secondary osteoporosis
SHATTERED (Use FRAX to look at 10 year risk of #)
```
S steroids + Cushings
H hyperTH/PTH
A alcohol&tobacco
T thin
T Testosterone dec
E early menopause
R Renal/Liver dysfunc
E Erosive/inflam dis (RA, myeloma, mets)
D dietary Ca/T1DM (malabsorption of calcium/Vit D)
```
45
Drug causes osteoporosis
Steroids
46
What is used for Bone mineral density
DEXA scan
47
Investigations in osteoporosis
DEXA
Blood: FBC, U&E (Ca), LFT, TFT,
Serum: Ig, paraproteins, Bence Jones
Bony profile: Ca, PO4, ALP, PTH all normal
48
Osteoporosis Tx
Lifestyle: smoking, alcohol, wt bearing exercise, balance (reduce fall risk), Calcium and Vit D rich diet
Med: Bisphosphonates (Alendronic acid) + Ca/Vit D
Raloxifen is selective oestrogen receptor modulator and can be used in women
49
Bisphosphonates
- E.G
- Mech
- SE
Alendronic acid, Risedronate
inhibit osteoclastic bone resorption
Take before food (rubbish absorption) and large tablet
GI SE: difficulty swallowing, Oesophagitis, Gastric ulcers, osteonecrosis of the jaw
50
Osteoporosis - Ca PO4 ALP PTH
All normal
51
Osteomalacia (rickets) - Ca PO4 ALP PTH
Ca & PO4 decreased
ALP & PTH increased
- Vit D deficiency and other try to compensate
52
Hyper PTH (primary) - Ca PO4 ALP PTH
Ca, ALP and PTH increased
PO4 decreased
- high PTH
53
CKD - Ca PO4 ALP PTH
Ca decreased
| All other increased (to compensate for renal loss)
54
Pagets - Ca PO4 ALP PTH
All normal apart from ALP increase
55
What is Osteomalacia
Disorder of bone mineralisation
Low Vit D leading to low Ca and PO4
56
PTH functions
Inc Osteoclast function (inc Ca mobilisation)
GI: inc absorption of PO4 and Ca
Kidney: inc activation Vit D (1,24vD3 via 1-alphahydroxylase: CALCITRIOL) decreases Ca excretion + Increases PO4 excretion
57
Who is at risk Vit D deficiency
Dark skin, Old/Young, Obese, Alcohol, vegetarian, low socioeconomic
58
Causes of Vit D deficiency
Lack of sun, inadequate diet
Renal disease: defective 1,25 form = osteodystrophy
Drugs: anticonvulsants, rifampicin (Liver - stop 25-hydroxycholecalciferol)
Genetic: Vit D dependant Rickets Type I & type II
59
Rickets
- What
- Pres
This is osteomalacia in children (soft bone formation due to low VitD/Ca
Leg bowing, knock knees, softening skull (craniotabes), Dental abnormalities (enamel)
Symptoms of hypocalcaemia (Confulsions, arrhythmia/arrest, Tetany, Spasms)
60
Osteomalacia
- Symptoms
- Signs
Widespread bone tenderness (low back pain and hips)
Proximal muscle weakness, Fatigue
Costochondral swelling, spinal curvature, hypocalcaemia (CATS)
61
Osteomalacia/Rickets investigations
Serum 25-Hydroxyvitamin D (low)
U&E/Renal/LFT/PTH
Ca & PO4 low
PTH high, ALP very high
DEXA low BMD, Iliac crest biopsy (failed mineralisation)
62
Management of Vit D deficiency
Ca and Vit D
63
Pagets
- What is happening
- Phases
- Which bones
Increased bone turnover
Lytic phase: increase osteoclastic resorption
Sclerotic phase: Rapid bone formation by osteoblasts (disorganised and mechanically weaker)
Axial skeleton: lumbosacral spine, pelvis, skull, femur, tibia
64
Pagets Presentation
Bone pain and Deformity
Pain at night
70% asymptomatic
65
What is raised in Paget's
Alk Phos
66
Bone deformities seen in Paget's
Sabre tibia (Large and bowing)
Kyphosis
Skull bossing
Enlarged jaw
67
Paget's complications
Pathological fractures (heavy bleeding - v vascular)
Deafness/tinnitus (CN8 compression by ossicles
Osteosarcoma
Inc bone vascularity may lead to high output cardiac failure
68
Paget's investigations
ALP high
CA, PO4, PTH normal
XR: Lytic and sclerotic bone lesions, cotton wool pattern of multifocal skull sclerosis
Isotope bone scans (radioisotope scan shows increased boney metabolism)
69
Paget's Tx
Pain - NSAID & Paracetamol
Reduce progression - Bisphosphonates (Zoledronate single IV dose)
Monitor - ALP
70
Inflammatory Vs Degenerative arthopathy
Inflam: Worse morn, ease on use, red/hot/swollen (synovial and boney), responds to NSAIDs
Degen: Worse with use, mainly evening, prior, not inflamed, little swelling (may have boney)
71
Which joints in hands affected:
RA
OA
RA: MCP, MTP, PIP
OA: DIP, base of thumb
72
What stimulates acute phase proteins
IL1, IL6, TNF
--> inc fibrinogen (ESR) & CRP
Inflammation and infection processes
73
What is ESR
What affects it
RBCs cross linked due to higher fibrinogen production by Liver as response to IL6. they sediment quicker.
Infection/inflammation, RBC shape/No, Drugs - steroids, obesity (fat makes IL6)
74
Which acute phase protein is faster on and off?
CRP (1 day peak) is faster coming on and going off after inflammation than ESR (7 day peak)
75
What is CRP
Acute phase protein which increases in inflammatory conditions, connective tissue disorder, neoplasia, infection (esp bacterial)
76
OA pathology & XR
degeneration of articular cartilage/failure to maintain cartilage matrix synthesis
Lost joint space, osteophytes at margins
77
Common joints in OA
Knees, hips, DIP, Base of thumb, spine
78
OA RF
Age, Female, Obese, Occupation, Genetics, Joint laxity/instability
79
Common OA presentation
Patient over 45
Activity related joint pain (relieved by rest)
No morning stiffness
Some stiffness after rest (gelling)
80
OA signs
Reduced ROM
Crepitus
Pain on movement (disuse atrophy and weakness poss)
Boney swelling/deformity: osteophytes, DIP (Heberden's) & PIP (Bouchard's)
81
OA XR 4 features
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
82
Investigations in OA
XR - 4 features
Bloods - normal
Joint aspirate - (Septic/Gout?) normal
RF, Anti-CCP + ANA negative
83
Ddx for hip and knee OA
Bursitis
Referred pain (hip to knee)
gout
Seropositive and seronegative arthritidies
84
Management of OA
Lifestyle
- weight loss, screen depression, exercise supporting muscles
Pain
- Local capsaicin/topical NSAID (1st line)
- +Paracetamol
- + NSAID ± PPI (gastro-protection)
Other
- intra-articular steroid injection (methylpred)
Surgery
- Arthoplasty for persistent disease affecting QoL
85
Pathophysiology underlying:
Joint space loss
Sclerosis
cysts
- Cartilage loss
- Micro fracture due to loss of cartilage
- Seeping of synovial fluid
86
RA Xray
Periarticular erosions
Osteopenia
Soft tissue swelling (may be seen on XR)
87
RA definition
Chronic autoimmune disease with inflammation of synovial joints leading to joint/periarticular tissue destruction
88
RA & OA symmetry
RA = Symmetrical
OA = Asymmetrical
89
Joints affected in RA
Small joints of hands and feet
90
Pathology of RA
Inflammation of synovium.
increased angiogenesis, influx of inflammatory cells (T cells, Macrophages, Plasma cells), release of LI1/IL7/TNF
Joint destruction
91
Pannus
This is proliferation of reactive synovium - Locally invasive synovial tissue
Synovial hypertrophy over articular cartilage during active disease. causes destruction
92
Features seen in RA
RF +ve in 80%
Anti CCP in 70% ( most specific test)
HLA DR in 25%
Ulnar deviation, morning stiffness,
Swan neck, Boutonniere, Z-deformity
Cervical spine (Atlanto-axial instability)
93
Pattern of RA
Small joints, symmetrical, MCP, MTP, PIP swelling.
94
Extrarticular RA features
Nodules: extensor surface of tendon s and lungs
Serositis: Pleuritis/pericarditis (pleuritic chest pain
eye: Sjogrens (scleritis, episcleritis)
Resp: nodules, caplans syndrome, pulmonary fibrosis
Anaemia of chronic disease
95
RA lung disease
- % of RA
- symptoms
- Types
seen in 30%
dyspnoea, cough, wheeze
Interstitial fibrosis
Nodules (may lead to effusion)
Caplans (when seen with coal workers pneumoconiosis - round peripheral lesions)
96
RA investigations
```
RF (antibody to IgG) in 70%
Anti-CCP in 70%
XR hands and Feet
- periarticular erosions and osteopenia
FBC - normocytic anaemia of chronic disease
ESR/CRP raised
```
97
Monitoring RA
DAS28 (Disease activity score) less than 3.2 = well controlled over 5.1 = active
98
RA Treatment
1st line: DMARD (Methotrexate plus sulfasalazine)
Corticosteroid bridging therapy and as an adjunct (Prednisolone)
NSAIDs in short term
2nd line: Biologics
99
EGs of DMARDs (Mm CASH)
```
Methotrexate
Sulfasalazine
Ciclosporin
Azathioprine
Hydroxychloroquine
```
100
How is Methotrexate given?
Weekly
| Folic acid 5mg (24 hours after)
101
How doe MTX work & SE
Antimetabolite
Inhibits DNA synthesis
BM suppression, Mucosal damage, mouth ulcers, hepatic cirrhosis, pulmonary fibrosis
102
MTX contraindications
Other folate antagonists: Trimethoprim, phenytoin
103
MTX monitoring
```
CXR
FBC
LFT
U&E
Monitoring: before starting, two weekly until established, 3 monthly
6 weekly after changing dose
```
104
Possible SE of all DMARDS
Myelosuppression (sore throat, fever), irreversible retinopathy, Teratogenicity
105
Biologics mechanism of action?
MABs
(etanercept is a receptor fusion protein)
Rituximab - Anti CD20
Tocilizumab - IL6 receptor therapy
Abatacept - Anti T-cell
106
RA pathology
```
Autoimmune activation of T-cells against body tissues (inc synovium)
Cytokine release (IL1/6/TNF) activating other immune cells (neutrophils, macrophages)
```
B-cells products RF
Osteoclast activation and inflammatory destruction cause erosive damage
107
Causes of high Urate (in Gout)
- Reduced renal excretion (90%)
- Drugs (diuretics impart orate excretion)
- High insulin/Sugars also impairs excretion
- High intake (diet)
- High cell turnover
- High cell damage: surgery, trauma, infection
- High cell death: chemo
108
What is Gout
Monosodium Urate crystals in joint
109
Features of hyperuricaemia
Gout
| Uric acid stones
110
Gout RF
Alcohol (beer), purine rich food (red meat, seafood), diuretics, DM, CKD, CHD, HTN
111
Gout presentation
Acute monoarthropathy (commonly 1st MTP joint) can also be knee, mid tarsal, wrist, ankle
Severe joint inflammation, fever, malaise.
112
Ddx Gout
Septic arthritis (mono arthritis)
113
What are Tophi
Aggregates of crate crystals.
Common in joints/tendons
114
Gout investigations
Serum urate - raies
Joint aspirate - Negatively birefringent needles shape (MSU)
XR: soft tissue swelling, punched out lesions, tophi, sclerosis
115
Gout management:
- Acute
- Prophylaxis
NSAIDs e.g. Naproxen 10-14 days (high dose initially then reduce)
```
Lifestyle, manage RF (diuretics, DM)
Prophylactic drugs (start two weeks post attack): Allopurinol/febuxastat (Xanthine oxidase inhibitors
```
116
How is Uric acid produced?
purines(nucleotides) --> Xanthine --(xanthine oxidase)--> uric acid
117
Pseudogout crystals
Calcium Phospopyrate
Positively birefringent rhomboids
118
Precipitants to pseudogout
Dehydration, illness, hyperparathyroid (inc calcium)m Wilsons, long term steroids
119
Presentation of pseudogout
Acute joint pain/swelling/inflammation/hot
Monoarticular
if chronic - similar to OA but more severe: pain, stiff, swelling, crepitus
120
Investigations pseudogout
Joint aspirate: positively birefringent Rhomboids, neutrophils
--> exclude septic arthritis
Joint XR: opacification of articular cartilage on joint surface
121
Management of pseudogout
No specific, just symptomatic
Ice packs, elevation, aspiration, NSAID, Into-articular steroid injections
122
Pathophysiology of connective tissue disorders
IgG antibody antigen form complex
complex deposition in tissue
Complexes attract complement
Complement reactions attract neutrophils causing inflammation
Enzymes/cytokines etc cause further inflammation
123
What is SLE
Inflammatory multisystem autoimmune disorder with antinuclear antibodies
124
HLA mutation in SLE
DR2/DR3 (Again: Think Dopamine Rash)
125
SLE other possible presentations
```
Raynauds (50%)
Other autoimmune (alopecia, thyroiditis, arterial/venous embolus - antiphospholipid syndrome)
```
126
Criteria for SLE (needs to meet 4 of these)
DOPAMINE RASH
```
D discoid rash
O oral ulcers
P photosensitivity
A arthritis
M malar rash
I immunology (anti-Smith, anti-dsDNA, Antiphospholipid)
N neurological symptoms (seizures/psychosis)
E ESR raised (NOT CRP)
R renal disorder (proteinuria)
A ANA positive
S serositis (pleura/pericardia)
H haematological (pancytopenia)
```
127
SLE investigations
ESR/CRP - ESR raised only
FBC: pancytopenia
AAB: ANA (95%), antidsDNA (60%), antiphospholipid antibodies (anticardiolipin
Complement levels; low C3/C4 in active disease (complement action against immune complexes in CTD)
Urinalysis: casts, haematuria, proteinuria
U&E: Renal disease (raised Urea and creatinine)
CXR: Pleural effusions
ECG: pericarditis (saddle)
128
SLE management
Lifestyle: smoking, sun protection, exercise
Joints: NSAID ± hydroxychloroquine ± steroids
Nephritis: cyclophosphamide/tacrolimus/mycophenolate + prednisolone + hydroxychloroquine
129
Antiphospholipid syndrome
Autoimmune condition against phospholipids (don't confuse with good pastures - antiGBM)
130
Antiphospholipid syndrome AAB
Anticardiolipin
| lupus anticoagulant
131
Antiphospholipid syndrome assoc diseases
SLE 30%
RA
Systemic sclerosis
Sjogrens
132
Antiphospholipid syndrome Presentation
Vascular thrombosis
Adverse preg outcomes ( one after 10 weeks OR 3x before 10 weeks) - pregame's loss, pre-eclampsia
Stroke
Thrombocytopenia
133
Investigations and diagnosis of Antiphospholipid syndrome
Lupus anticoagulant/anti-cardiolipin present on two occasions 12 weeks apart
Low platelets and prolonged APTT (even though thrombosis tendency)
134
Antiphospholipid syndrome treatment
Lifestyle: avoid smoking, avoid OCP, healthy diet, low alcohol.
Warfarin target INR 2-3
135
Sjogren's syndrome Def
Autoimmune condition with lymphocytic infiltration of exocrine glands
136
What is Sicca syndrome
Assoc with Sjogren's syndrome
Dry eyes (eye and conjunctiva), Dry mouth, Enlarged parotids
137
Assoc diseases with Sjogren's syndrome
SLE
RA
Systemic sclerosis
(CREST)
138
Epidemiology of Sjogren's syndrome
More in women
30-40 yr old
139
Sjogren's syndrome presentation
Dry/eyes/mouth/vaginal
(diminished lacrimal and salivary activity)
Enlarged Parotid
Other: Fatigue, myalgia, Raynaud's (20%), vasculitis
140
Areas affected by Sjogren's (affects exocrine secretions)
Mouth: difficulty eating, altered taste, oral candidiasis
Bronchi: dry cough
Pharynx/Oesoph: dysphagia
Pancreas: malabsorption
141
Sjogren's syndrome investigations
Schirmer tear test (tear test): +ve if less than 5mm in 5 mins
AAb: anti-Ro, RF, ANA, anti-La
Sialography (salivary gland radiography)
Biopsy of gland: mononuclear infiltrate (B and T cells)
Rose-Bengal stringing eyes
142
Sjogren's syndrome Tx
Artificial tears, artificial saliva (drink plenty), Oral pilocarpine (Muscarine parasympathomimetic)
Joint pain: NSAID + hydroxychloroquine + Steroid (Prednisolone)
143
CREST meaning and what is the disease?
Systemic sclerosis
Calcinosis - calcium deposits in the skin
Raynauds (vasospasm in response to cold/stress medial fingers)
Esophageal dysfunction - Acid reflux and decrease motility
Sclerodactyly - thick/tight skin on fingers/hands
Telangiectasia - dilatation of superficial capillaries giving red marking on skin surface
144
Systemic sclerosis pathophys
Multisystem autoimmune
Inc fibrosis is central part of disease
increased fibroblastic activity = excessive collagen/Fibrosis
Immune system activation = vascular damage (Raynaud's, renal, GI, heart, lungs)
145
RF Systemic sclerosis
FH
Viral infection (EBV, CMV)
Chemical exposure (pesticides, plastics)
Drugs: Bleomycin, Vit K
146
Systemic sclerosis Presentation
Skin hardening/tightening in hands/face
Oesophagela symptoms
Raynauds
Fatigue and weight loss
147
Complications of Raynauds
Peripheral digital ischaemia due to recurrent spasm of digital arteries
(Raynauds occurs dur to SSc, SLE, Beta-block, Thrombocytosis
148
Skin features of Systemic sclerosis
Raynauds, swelling, thick+hard=sclerodactyly, Calcinosis
149
MSK features Systemic sclerosis
Joint pain, swelling, myalgia, ROM loss
150
GI features Systemic sclerosis
Heartburn/reflux/oesophagitis, dysphagia, reduced oesophageal and GI motility (constipation)
151
Pulmonary features Systemic sclerosis
Pulmonary fibrosis (interstitial disease) in 80% - dry cough etc
Pulmonary artery hypertension (leading cause of death)
152
Important complications of Systemic sclerosis
GI bleed (acid)
Renal crisis (ANCA glomerulonephritis and vascular disease)
Pulmonary HTN (leading cause of death)
153
Systemic sclerosis investigations
FBC (microcytic if GI bleed, haemolytic in renal crisis)
U&E (Ur&Cr high in renal crisis)
ESR/CRP (more commonly ESR raised)
Pulmonary function (Spirometry - FVC decreased. As is DLCO -diffusion capacity to CO)
Antibodies: ANA (90%)
154
Systemic sclerosis Tx
Physio, avoid smoking, home exercise, prevent Raynauds (gloves, Nifedipine-CCB)
GI - PPI for life
Pulmonary - cyclophosphamide (fibrosis), sildenafil (PA HTN) + O2
arthritis/synovitis - Prednisalone
Skin - Topical emollient ± topical corticosteroid (itch) ± topical cyclophosphamide (for thickening)
Renal - ACEi for AKI/HTN
155
Monitoring Systemic sclerosis
Yearly lung function (spirometry, lung volumes, DLCO)
Yearly Echo
156
Polymyositis:
- Definition
- which muscles
- Extra-muscular involvement
Autoimmune CTD with inflammation to striated muscles
Proximal
Skin, joints (arthralgia, Raynauds), oesophagus (dysphagia), heart (AV nodal), lungs (Interstitial lung disease)
157
What Ddx to rule out in Polymyositis:
Neoplasms
- Lung (CXR)
- Breast
- Ovary (Ca125)
- Pancreas (Ca19-9)
This phenomenon is seen in paraneoplastic syndrome
158
Polymyositis presentation
Non painful, progressive proximal muscle weakness (esp pelvic girdle - difficulty rising from chairs, stairs)
breathlessness (lung disease)
159
Polymyositis investigations
Creatinine Kinase - Elevated
AAb - anti-Jo-1 (assoc with poor prog: lung disease)
Electromyography and muscle biopsy for confirming Dx (fibrillation potentials at rest)
160
Tx for Polymyositis & Dermatomyositis
Early therapy!
1st line: Steroids (anti-Jo = long term)
If steroids fail immunosuppressive e.g. azathioprine
Lung disease: cyclophosphamide ± ciclosporin
161
Polymyositis complications
Inc risk malignancy
GI ulceration - melaena, haematemesis
Interstitial lung disease
AV nodal disease
162
What is Ehler Danlos
- Skin/joint
- CV
- Occular
- Hearing
Defective collagen structure/processing/production
increased elasticity/hypermobility (prone to dislocation)
Heart valve abnormal (mitral prolapse), Aortic root dilatation, aneurysm
Abnormal globe/cornea
Tinnitus (ossicle laxity)
163
Ehler Danol management
Physiotherapy: regular gentle exercise
Genetic counselling
Echo: mitral valve, aortic root dilatation
164
What is leading cause of Aortic root dilatation
Marfan's
165
Marfan's Pres
- describe person
- skin
- CV
- lungs
- eyes
- joints
tall, skinny, white man. long arms and legs
striae
Aortic dilatation, dissection, mitral regurg, aneurysms
pleural rupture - pneumothorax
closed angle glaucoma
hyper mobility
(can touch thumb to wrist on sam hand)
166
Investigations/ managing Marfan's
Annual echo (aortic root)
CVMRI
MDT: geneticist, ophthalmologist, cardiologist, orthop
Avoid maximal exertion: scuba, weight lifting
Prophylactic beta block: reduce MAP and pulse rate
167
What is meant by seronegative arthropathy
Group of rheumatic diseases where RF is negative.
involvement of axial skeleton, peripheral joints and enthesitis (tendons/ligament), Dactylitis
168
What is Reiter's syndrome?
Seronegative arthropathy with triad of:
1) Conjunctavitis
2) Urethritis
3) Arthritis
4) Dactylitis
Anterior uveitis is also sometimes seen.
169
What is HLA and what HLA mutation seen in seroneg arthropathy
Major histocompatibility complex - contain genes for immune function
Involved in cell surface antigen presenting proteins (chr 6)
HLA B27
170
Examples of Serotonegative Arth
Ankylosing Spondylitis
Reiter's syndrome
Enteropathic arthritis (assoc with IBD)
Psoriatic arthritis
JIA
171
Typical presentation and site of enthesitis
Pain, stiffness, tenderness
Achilles, Sacroilitis, plantar fascia.
172
Ankylosing spondylitis:
- Definition
- Genetics
Seronegative spondyloarthropathy of axial skeleton. Sacroilitis and spondylitis (vertebral inflammation)
HLA B27, Autosomal dominant
173
Diagnostic features of Ank Spond
Inflammatory back pain & enthisitis
Stiff and pain walking an in early morning
Gradual onset
Improvement with movement
Age at onset over 40
Tender sacroiliac region (felt in buttocks
Limited spinal movement
174
Ank Spond presentation
Insidious, relapse and remit
Fever and WL in active disease
Inflammatory back pain
Peripheral enthesitis: Achilles, plantar fasciitis
peripheral arthritis: asymmetric, hips/shoulder/chest wall (chostochondritis)
175
Ank Spond extrarticular features
Eyes: anterior uveitis (painful red eye and photophobia)
CV: aortic dissection and regurgitation (aortitis)
Lung: restrictive disease, limited chest expansion (costovertebral/sternal involvement), apical fibrosis
176
Ank Spond examination findings
Reduced chest expansion
Schobers test: reduced forward flex
177
Ank Spond investigation findings
Pelvis XR: sacroilitis
HLA B27 +ve
XR spine: bamboo spine (late), erosion, squaring, syndesmophwytes (vertebral fusions)
178
The As of association with Ank Spond
```
Apical fibrosis
Anterior uveitis
Aortic regurg
Achilles tendonitis
AV node block
Amyloidosis
```
179
Management Ank Spond
No cure - control symptoms and complications
Physio/Rehab/Exercis
1st line: NSAIDs (±para analgesia)
If NSAIDs don't help pain: TNF alpha inhibition
Enthesitis: corticosteroid injection
For peripheral arthritis: DMARD (sulfasalazine)
180
What is Psoriatic arthritis
Seronegative inflammatory arthritis (axial, peripheral, enthesitis) in those with psoriasis
181
Psoriatic arthritis pattern
DIP most common
Asymptomatic oligoarthritis
Arthritis mutilans: severe and destructive. Osteolysis/bone shortening gives pencil in cup
182
DDX and how to rule out
Similar to RA
This will be antiCCP negative (RA will be more likely +ve)
183
Extra-articular Psoriatic arthritis features
PSORIASIS
Nail pitting, dactylics, Enthesitis
184
Psoriatic arthritis investigations
XR hands and feet
- Erosion in DIP
- Osteolysis
- Pencil in cup deformity
ESR/CRP normal or elevated
AntiCCP -ve
185
Psoriatic arthritis management
NSAID + Physio + Joint injection
If peripheral arthritis / high ESR/CRP: DMARD (methotrexate)
Spondylitis: NSAID + physio + TNF alpha
186
Reactive arthritis
- How long post exposure
- Which microbes
- What is reiters
- Arthritic pattern
1-4 weeks
Campylobacter, salmonella, shigella, chlamydia
Cant see, Cant wee, can't bend knee (triad)
Acute onset lower limb oligoarthritis
187
Investigate reactive arthritis
Ask Hx
GI/GU sample and culture, serology chalmyd
Joint aspirate to rule out septic
188
Reactive arthritis Vs gonococcal
Reactive is cross reaction and can be caused by chlamydia.
Gonococcal is septic arthritis
189
What is enteropathic arthritis?
Arthritis with IBD (mainly UC)
40% of IBD
lower limb peripheral arthritis
Consider sulfasalazine but treating underlying bowel is best
190
Vasculitis
- Definition
- Causes
Inflammation of BV
Primary (50%), Secondary (Infection-20%, Inflammation-20%, drugs etc)
191
Vasculitis infections causes
URTI causes flare of Granulomatosis with Polangitis (weighers)
192
Vasculitis inflammatory causes
SLE, RA, Crohn's
193
Vasculitis drug induced
Beta-lactams
Sulphonamides
194
Vasculitis classification & examples
Large vessel
- GCA
- Takayasu's
- Polymyalgia rheumatica
Medium vessel
- Kawasaki's
- Polyarteritis Nodosa
Small vessel
- Wegners/GPA
- Churg-strauss (
195
GCA
- Definition
- Main complication
- Who
- Presentation
inflammatory granulomatous arteritis
- aorta
- large cerebral arteries
20% get anterior ischaemic optic neuritis (inflame in ophthalmic artery)
- Sudden visual loss = medical emergency
More in women and over 50
Recent temporal headache + Scalp tenderness + Jaw claudication + visual symptoms (transient diplopia, visual loss like curtain coming down)
196
GCA
- Investigation and findings
- Treatment
Palpation of temporal artery: tender, absent pulse
ESR over 50
Temporal artery biopsy shows granulomatous inflammatory arteritis (multinucleate giant cells, intimal hypertrophy)
High dose Prednisolone (1mg/kg/day) 4 weeks
+ Aspirin
(osteoprotect for prednis - Ca+VitD+Bisphos)
If refractory: MTX
197
Polymyalgia Rheumatica
- Pres
- Assoc with
- Investigations and diagnosis
- Tx
Morning pain/stuff shoulder/neck/pelvic girdle. Systemic feature (malaise, fever)
50% with GCA (spectrum)
Inc ESR/CRP
Check FBC, U&E, TFT, Bone profile for ddx
Morning stiff over 45 min for over 2 week in over 50s
Prednisolone start high (15mg for 3 weeks) and taper down. Tx for t yrs (add osteoprotect - VitD/Ca/Bisphos)
198
Takyasu's (Pulseless arteritis)
- who
- pathophys
- features
- complications
Women (esp Japan) 20-40
inflammatory occlusive disease of aorta and branches
fever, wt loss, arthralgia, limb claud/angina/headache/dizzy/abdo pain/haemoptysis/haematuria
stenosis/occlusion/dilatation/aneurysm of aorta and large branches off it
199
Takyasu's Examination findings
Difference in standing BP ovre 1ommHg
High BP (renal stenosis)
Impalpable peripheral pulse
Arterial bruite on all arteries
Aortic regurgitation (dilatation)
200
Takyasu's Investigations
High ESR (over 50)
Aortic angiography (CT/MRI) showing occlusion/stenosis/aneurysm/thickened wall of aorta and large branches & pulmonary arteries)
201
Takyasu's Treatment
Prednisolone + Aspirin + Bone protection
If persistent use TNF alpha blocker (Etanercept, infliximab)
202
E.G of TNF alpha bloceker
Etanercept
Infliximab
203
DMARD commonly used in SLE
Hydroxychloroquine (also useful in Sjögren & Malaria)
204
Kawasaki's
- Who
- Def
Children 6m-5yr
Idiopathic self limiting vasculitis
205
Kawasaki's
- Tx
- Management
Aspirin (normally not recommended due to Reye's)
1st line IV immunoglobulin + high dose aspirin)
long term aspirin + cardiology follow up
206
Kawasaki's Classical features
CRASH & burn
C conjunctivitis (bilateral)
R rash (non-vesicular = no vesicles)
A adenopathy (Cervical&unilateral)
S strawberry tongue (+ inflamed lips/mouth)
H hand/feet - erythema/swelling/desquamation
Burn - fever over 5 days
207
Kawasaki's Complications
Coronary artery aneurysm.
208
Subgroups of small vessel vasculitides
ANCA associated
(C-ANCA and P-ANCA)
Immune complex mediated (IgA vasculitis - Henoch-Schonlein, Anti-GBM disease
209
ANCA assoc small vessel vasculitis
Granulomatosis with polyangitis (Wegners)
Chrug Strauss
210
Granulomatosis with polangitis triad
ELK disease (think of an elk)
ENT - upper resp tract involve (saddle nose, nasal septum perforated)
Lungs - Lower respiratory tract involve (SOB, Haemoptysis, Chest pain)
Kidneys - Glomerulonephritis - nephritic (oedema, HTN, Haematuria)
211
GPA histology
Granuloma, Vasculitis
212
GPA investigations
Kidney: urinalysis (haematuria, proteinuria, RBC casts)
Lung: CT-chest (caveatting lung nodules)
Serology: C-ANCA
FBC (anaemia), ESR raised
213
GPA management of flare
IV Methylprednisolone + Oral Prednisolone + Cyclophosphamide
Maintain with Oral Pred, MTX, Folic acid
214
P-ANCA assoc vasculitis
Churg Strauss: small vessel vasculitis giving sinusitis, glomerulonephritis and Purpuric rash
CXR - pulmonary infiltrates, ground glass attenuation
Biopsy: necrotising granulomas
215
```
IgA vasculitis (Henoch-Scönlein purpura)
- Typical patient
```
Young man with previous URTI - GpA Strep (pyogenes)
216
IgA vasculitis (Henoch-Scönlein purpura) Pathophys
IgA immune complexes in small vessels giving Arthralgia/abdo pain/rash (purpura on buttocks and extensor surfaces)
217
IgA vasculitis (Henoch-Scönlein purpura) Vs IgA glomerulonephritis
Bergers & HSP have very similar Pathophysiology but HSP is more likely nephrotic and Bergers nephritic
218
IgA vasculitis (Henoch-Scönlein purpura) Tx
Ibuprofen/Para for joint and abdominal pain
Steroids for Kidney function
219
Goodpasture's
- Organs affected
- AAb
- Typical patient
Lungs and Kidneys (anti BM)
Glomerulonephritis (Renal failure), pulmonary haemorrhage (haemoptysis)
Male (20-30/60-70), reduced urine output, haemoptysis, oedema, SOB, cough etc
220
Goodpasture's
| Investigations
Renal function: abnormal
Urinalysis: Nephritis (blood+protein)
Renal biopsy: DO THIS URGENTLY! Crescenteric glomerulonephritis
Anti GBM - positive
221
Goodpasture's
| Tx
Oral Prednisolone + cyclophosphamide + Plasmapheresis
222
When is renal biopsy contraindicated
```
Sole native kidney
Neoplasm
Bleeding disease
Uncontrolled severe HTN
acute pyelonephritis
```
223
Vasculitis screen
Haem: FBC, ESR, clotting
Biochem: U&E = Cr (renal function), LFT
CRP
Immunoglobulins: ANCA, RF, complement (C3/4 - SLE), anticardiolipin, cryoglobulins)
Micro: HBV, HCV, urine microscopy and culture
Radiology CXR
224
Septic arthritis
- When to consider
- Why important
- Most common site/organism
Acutely inflamed joint (monoarth) esp if immunocompromised/prosthetic
Ca destroy a joint in under 24 hours
Knee (in 50%)
Staph aureus
225
Septic arthritis
| Causes
Staph aureus +
Strep (GBS) = 90%
Gonococcal if sexual active (don't confuse with Reiter's - Chlamyd)
226
Septic arthritis
| presentation
Hot, Red, Swollen, Immobile
227
Prosthetic Septic arthritis presentation
Prolonged low grade course, gradually inc pain, no swelling or fever
there is cellulitis
228
Septic arthritis
| RF
Prosthetic joint (X10), RA, OA, IVDU, Alcoholism, DM, Immunosuppression, overlying skin infection
229
Septic arthritis
| investigations
URGENT aspiration of synovial fluid - Gram stain and culture + polarised microscopy (exclude crystal arthropathy) CULTURE PRE ABx
Blood culture (X2) ± gonococcal (rectal, urethral, pharyngeal)
Acute phase proteins (ESR, CRP, WCC raise)
CT/MRI for periarticular abscess/osteomyelitis
230
Septic arthritis
| management
Surgical drainage and lavage (wash) + High dose IV abx (2/3 wk)
If suspect:
- G+ Vancomycin,
- G- 3rd gen cephalosporin
For Staph - fluclox
MRSA - Vancomycin/Teicoplanin
Gonococcal - 3rd gen cephalosporin
231
Septic arthritis
| complications
Osteomyelitis
| Joint destruction
232
Prosthetic Septic arthritis Management
Remove joint and put in antibiotic impregnated spacer
233
Osteomyelitis
- Best investigation
- Definition
- Types of sequestration
Plain film Xray
Infection of bone marrow (may spread to cortex/periosteum)
Haematogenous - bacterial seeding from far source(assoc with children with vascular metaphysis)
Direct - overlying infected tissue e.g. following trauma/surgery
234
Osteomyelitis
| - Organism
S Aureus mainly
In IVDU Pseudomonas
In Sickle Cell Salmonella
235
Osteomyelitis RF
Trauma, Prosthetics, DM, PAD, Chronic joint disease, Alcohol/IVDU, immunosuppression
236
Haematogenous Osteomyelitis in children Vs adults
Children - long bones
Adults - Vertebral bodies
237
Osteomyelitis Pres
Acutely febrile, painful (immobile imp, back pain), swelling, tenderness, erythema
(in DM chronic disease may have absent signs of local infection and absent pain due to neuropathy
238
What is Potts disease
This is vertebral Osteomyelitis secondary to TB
239
Osteomyelitis investigations
FBC (WCC)
Blood cultures (+ve)
Acute phase markers (ESR, CRP)
Xray - appears dark, soft tissue swelling, patchy osteopenia
Cultures from derided bone
240
Management Osteomyelitis
Bone and soft tissue debridement
Stabilise and immobilise bone
Local Abx + IV Abx (initial = vancomycin and then culture dependant)
Staph - Fluclox
MRSA- Vanco/Teico
Analgesia
Amputation may be needed in chronic cases e.g. diabetes
241
Fibromyalgia
- definition
- who
- diagnosis
- management
Chronic widespread pain, peripheral hyper excitability and altered pain perception
More in women 20-50
Pain in all 4 quadrants (11.18 tender points) for Over 3 months
1st line: Amitryptaline + CBT
2nd line: Gabapentin/Pregabalin
242
RED Flags back pain
TUNA FISH
Trauma
Unexplained WL (Ca, Myeloma)
Neurological (e.g. bowel/bladder dysfunction - cuada equina)
Night pain
Age (Over 50 or below 20)
Fever & night sweats (osteomyelitis, Ca, Psoas abscess)
IVDU/Immunosuppressed
Steroid use (Immunocomp, Osteoporosis)
History of Cancer (Prostate, Breast, Lung, Renal)
243
Cervical back pain causes
Spondylosis
| Disc degen & Oa
244
Cervical OA complications
Spinal stenosis
245
Thoracic back pain
- Relevance
- Worrying Ddx
- Orthopaedic cause
More commonly due to serious pathology than cervicolumbar pain
Pancoast and other lung tumour, oesophagus, stomach, liver, gallbladder
Degenerative disc disease
246
Lower back pain serious pathologies
Cauda equina - saddle anaesthesia, perianal sensory loss, bladder dysfunction
Ank Spond - Worse on waking
Spinal fracture - sudden onset pain, received by lying down, structural deformity/step
Cancer/infection - Pain remains on lying down, night pain, IVDU, recent infection (haematogenous osteomyelitis)
247
When to refer Lower back pain
TUNA FISH
Over 6 weeks of pain
248
Lower back pain DDX
15-30yrs
Over 50
Trauma, Fracture, Preg, Anky spond, Prolapsed disc
Degen, Osteoporotic collapse, myeloma, spinal stenosis, malignancy, Paget's
249
Back pain investigations
Plain Xray only if indicated by Red flags
MRI good for soft tissue + nerve impingement
ESR, CRP, Alk Phos, PSA, Ca markers
250
Metastatic Lesion types
Prostate = Sclerotic
Lung, Renal = Lytic
Breast = Sclerotic or lytic
251
Back pain/disc herniation/sciatica management
Keep active and analgesia 1st (NSAIDs)
Physio
Psychosocial management if sickness behaviour/depressiom
Opioids if NSAIDs ineffective or contraindicated
Lumbar discectomy (only if severe nerve compression)
252
Bone tumours in Adults & Children epidemiology
In adults secondary tumours/mets more common
In children primary tumours more common
253
Benign bone tumours
Osteoid osteoma, chondroma, osteochondroma
254
Malignant bone tumours
Osteosarcoma
Myeloma
Ewing's sarcoma
255
Cancers that spread to bone
```
Prostate
Breast
Lung
Kidney
Thyroid
Myeloma
```
256
Bone tumour symptoms
```
Bone pain unremitting worse at night
Swelling
Effusion
Deformity
Nodes
Pathological #
weight loss
```
257
Osteoid osteoma
- What is it
- Tx
Benign bone tumour
Pain - NSAIDs
Local excision = curative
258
Osteosarcoma
- Who
- Assoc disease
- Where
- Presentation
- XR findings
Most common in children
Pagets
Epiphysis of long bones (75% knee)
Painless lump, rapidly forms mets to lung
Soft tissue calcification = Hair on end sign. Codman's triangle = tumour raises periosteum from bone and creates new area of bone
259
Ewings sarcoma
- Who
- Pres
- XR
Typically boy around 15
Mass or swelling, long bones, chest, pelvis
Pain, Redness, malaise, Fever
Bone destruction with onion skin layers of periosteal bone formation, Codmans triangle
260
Benign Vs Malignant tumours
Weel defiend, sharp zone of transition from tumour to normal = benign (Vice versa)
Uniform periosteum = benign
Multilayered/sun-ray periosteum = Aggressive
Soft tissue mass = malignant
261
Bone tumour investigations
Isotope bone scans (PET - esp good for mets)
XR
Alk phos/Ca2+ (hypercalcaemia)
CT/MRI for staging
Biopsy (fine needle)
262
Bone tumour Tx
Benign - analgesia and excision
Malignant - Complex MDT. refer to sarcoma clinic
263
Danger of Pathological fractures
Potential for dissemination / local recurrence
264
Initial Tx of RA
MTX + Another (e.g. Sulfasalazine) + Short course Prednisalone
265
What is a sub capital fracture?
| If displaced how tx?
Intracapsualr
Hemiarthroplasty (cannulated screws if not displaced)
