Orthopaedics unit 1 joint conditions - deck 4

Question 1

What are the 2 main crystal arthropathies that we should know about ?

Answer 1

1. Gout
2. Pseudogout

Question 2

How & why do cyrstal arthropathies occur ?

Answer 2

• Crystals of the by-products of body metabolism are deposited in the joints, on the surface of the articular cartilage and within the synovial fluid.
• Because of some abnormality of metabolism resulting in excess production, or because the kidneys are failing to eliminate them.

Question 3

What can crystal arthropathies cause to develop?

Answer 3

• They cause a chronic degenerative change in the joint and may be a cause of secondary arthritis.
• They also cause acute inflammations, which tend to settle spontaneously, although it is common to reduce the painful effects with drugs.

Question 4

Describe what gout is and some of its causes

Answer 4

Gout is a crystal arthropathy caused by urate crystal deposition. Urate is a waste product of cell metabolism

Common causes:

• Dehydration e.g. post surgery, excessive alcohol intake
• After chemotherapy
• Renal underexcretion (which can be exacerbated by diuretics or renal failure) overuse of diuretics is prob the most common cause in the west.

Question 5

What is the typical presenting signs/symptoms of gout and more serious conditions does it mimic ?

Answer 5

• A hot, tender, swollen joint
• It mimics the more serious conditions of infection & septic arthritis

Question 6

What are the joints most commonly affected by gout ?

Answer 6

• Knee most commonly
• Ankle
• First metatarsophalangeal (MTP) joint

Note that it can affect any joint however

Question 7

Why is it important to exclude infection when someone presents with gout like symptoms ?

Answer 7

Because if it is infection and not gout then the infection can do a lot of damage to the articular cartilage before treatment is started.

Question 8

How is gout diagnosed ?

Answer 8

Diagnosis is made by detecting the presence of a high level of uric acid in the blood.

A definitive diagnosis is made by analysing a sample of synovial fluid with polarised microscopy

Question 9

What is the treatment of gout ?

Answer 9

Anti-inflammatory drugs, which as well as reducing inflammation, also help the kidneys eliminate urate.

Question 10

What is pseudogout and what is it caused by ?

Answer 10

It is another crystal arthropathybut, in contrast to gout, it is caused by calcium pyrophosphate crystals.

Question 11

Define the term chondrocalcinosis

Answer 11

When calcium pyrophosphate deposition occurs in cartilage and other soft tissues such as menisci of the knee

Question 12

Describe the typical presentation of pseudogout

Answer 12

Presentation is similar (but usually milder) to acute gout, with acute joint pain and swelling.

Question 13

What can chronic pseudogout do ?

Answer 13

Chronic crystal arthropathy of this kind causes calcification of joint surfaces and the menisci in the knee.

Obv long term = secondary arthritis

Question 14

What is the treatment of pseudogout?

Answer 14

• Symptoms may be controlled with anti-inflammatory drugs

Question 15

Define what septic arthritis is

Answer 15

Septic arthritis is defined as the infection of 1 or more joints caused by either haematogenous spread from a site of trivial infection, such as a boil. Or it may occur very rarely from direct penetration of the joint by a sharp object.

Question 16

What are the 2 main classes of septic arthritis ?

Answer 16

Acute and chronic septic arthritis

Question 17

What are the risk factors for the development of septic arthritis ?

Answer 17

• Increasing age.
• Diabetes mellitus.
• Prior joint damage - eg, rheumatoid arthritis, gout, systemic connective tissue disorders.
• Joint surgery.
• Hip or knee prosthesis.
• Skin infection in combination with joint prosthesis.
• Immunodeficiency - eg, infection with HIV

Septic arthritis is rare unless the joint is already damaged, or the immune defence system is abnormal.

Question 18

Describe the typical presentation of septic arthritis (acute)

Answer 18

• Hot , Swollen, Tender joint
• Restricted joint movement - pain on passive and active movement
• Fever and rigors

Important to note that in children septic arthritis presents with a very unpleasant acute illness during which the child is unwell with a high temperature. along with above joint symptoms

Whereas its important to note in adults often have a much less acute illness. The chronically abnormal joint may give the false impression of a minor upset. The patient remains unwell for many days before presenting with septicaemia (blood poisioning)

Question 19

What are the most common causative organism of septic arthritis at any age ?

Answer 19

Staphylococcus aureus often MRSA is the most frequent in any age

Question 20

What is the most common causative organism of septic arthritis in young adults who are sexually active

Answer 20

Gonnoccocus - also known as Neisseria gonorrhoeae

Question 21

Describe the management of acute septic arthritis ?

Answer 21

Treatment consists of surgery and intravenous antibiotics. The joint should be opened and washed. Antibiotics should be given according to the type of organism causing the infection.

The “first guess” antibiotic should be an anti-staphylococcal agent in children as this is still the most likely infecting organism

Question 22

If treatment of septic arthritis is inadequate what are the risks to the patient ?

Answer 22

Septicaemia ==> sepsis

The articular cartilage is at great risk and may disintegrate, leading to fibrous or even bony fusion of the joint

Question 23

Define what septicaemia is

Answer 23

This is posioning of the blood stream which can lead to sepsis

Question 24

Describe how chronic septic arthritis usually develops ?

Answer 24

It is caused by TB, the TB bacteria spread to the joints via the blood. It is found world-wide although mainly in underdeveloped countries. AIDS patients are particularly prone to this chronic illness

Question 25

What 2 forms of TB infections are often found together ?

Answer 25

Kindey and joint TB (chronic septic arthritis)

Question 26

Describe the clinical presentation of someone with chronic septic arthritis

Answer 26

• Chronic ill health
• weight loss
• Considerable muscle wasting around the affected joint.
• The radiographs, show marked thinning of the bone.

Question 27

What is the treatment of chronic septic arthritis ?

Answer 27

Treatment is by drugs and only rarely is surgery necessary. Combinations of antibiotics such as streptomycin, ethambutol and rifampicin are given for many months.

Question 28

Name the four cardinal symptoms of knee disorders.

Answer 28

1. Swelling
2. Locking
3. Giving way.
4. Pain.

Question 29

Why are meniscal tears much more common in men than women ?

Answer 29

Men are more frequently involved in vigorous contact sports

Question 30

What are the main symptoms associated with meniscal lesions?

Answer 30

1. Pain - often not a tender spot and poorly localised
2. Effusion
3. Sometimes locking and/or giving way

Question 31

Are meniscal lesions common in adolescents and children ?

Answer 31

No they are uncommon

Question 32

Define what an effusion is

Answer 32

It is excess fluid within the joint

Question 33

What meniscal lesion can children sometimes be born with ?

Answer 33

An abnormal lateral meniscus

Question 34

What investigation can be done to confirm clinical suspicion of a menniscal lesion ?

Answer 34

MRI

Question 35

What is the main way in which meniscal lesions happen ?

Answer 35

• A twisting injury, often associated with skiing, or games where studs are worn on shoes or boots e.g. football, rugby etc.
• In these situations the foot gets stuck on the ground and then the femur twists over the stationary tibia causing a wrench to the meniscus which may be torn or pulled off the bone.

Question 36

Which meniscus is more commonly torn ?

Answer 36

The medial meniscus

Question 37

What are the 2 main ways in which a meniscus can tear ?

Answer 37

May be torn at its peripheral attachment to the joint capsule or actually within its substance

Question 38

What is the name given to a meniscal lesion very common in old age in which the meniscus is split horiztonally?

Answer 38

Cleavage lesion

Question 39

What can cleavage lesions cause the development of in the meniscus ?

Answer 39

They can act like flap valves and allow a build up of synovial fluid within the meniscus, forming a fluid-filled cavity known as a cyst.

Question 40

What are the 3 main pathological meniscal tears we should know about ?

Answer 40

1. Bucket handle tear
2. Parrot beak tear
3. Degenerative tear

Question 41

Describe the appearance of a bucket handle meniscal tear

Answer 41

A vertical split, which is anchored at both ends

Question 42

Describe the appearance of a parrot beak meniscal tear

Answer 42

An oblique meniscal tear

Question 43

What is a degenerative meniscal tear ?

Answer 43

A tear due to degeneration (age-related)

Question 44

How can meniscal tears affect the function of a joint and what is the classic meniscal tear to do this ?

Answer 44

The torn part of the meniscus becomes jammed in the joint, stopping it extending.

Classically bucket-handle tears can cause this

Question 45

Once clinical suspicion is aroused of a meniscal tear what should be done ?

Answer 45

Patient should be exammined by arthroscopy

Question 46

What are the surgical management options for acute meniscal tears?

Answer 46

1. Peripheral tears can be reattached with sutures.
2. Tears within the substance of the meniscus have no apparent capacity to repair and so the torn peripheral part should be removed. - most with arthroscopic menisectomy but some require an arthrotomy (a small opening in the joint) to remove the part of the tear

Question 47

Define what an arthroscopy is

Answer 47

A minimally invasive surgical procedure where a small optical instrument like a telescope, illuminated by a fibre light know as an arthroscope, is introduced into the knee joint

Question 48

Define what an arthroscopic menisectomy is

Answer 48

This is a minimally invasive surgical procedure with the removal of a meniscal lesion via an arthroscope

Question 49

What is the advantage of an arthroscopic menisectomy over an open menisectomy ?

Answer 49

Arthroscopic menisectomy has a much quicker recovery time