Orthopedics & Rheumatology Flashcards
What advice should be given to a woman on methotrexate regarding her contraception and when to try for a baby?
Patients using methotrexate require effective contraception during and for at least 3 months after treatment in men or women
What are the features of a common peroneal nerve lesion? (4)
FOOT DROP Weak foot dorsiflexion Weak foot eversion Sensory loss over dorsum of foot Sensory loss over lower, lateral part of leg
A 35-year-old female presents with pain on the radial side of the wrist and tenderness over the radial styloid process. On examination, abduction of the thumb against resistance is painful, and when the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation. What is the most likely diagnosis?
Pain over radial styloid process on forced abduction or flexion of the thumb (+ve Finkelstein test) - De Quervain’s tenosynovitis
A 28-year-old male presents to the emergency room with severe pain in the right knee following an injury during a football match. He states that he was tackled from behind, and then felt a ‘pop’ and severe pain which was followed by rapid swelling of the joint. On examination there is a right sided knee effusion and a positive Lachman test.
What is the most likely diagnosis?
ACL Rupture
Rapid joint swelling is suggestive of haemoarthrosis which can occur due to ACL or PCL rupture. The mechanism of injury suggests rupture of the ACL. A positive Lachman tests is also very suggestive of an ACL injury.
What is the most common treatment of a mobile patient with an extracapsular hip fracture?
DHS
Dynamic Hip Screw
Which type of hip fracture would be treated with an intermedullary device?
Subtrochanteric
A 22-year-old male presents to the emergency room with pain in the left knee following a twisting injury during a rugby match. He states that it has gradually swollen over the past 24 hours, and he is unable to fully extend it. On examination you note tenderness over the medial joint line, a joint effusion, and the joint is held in a flexed position. There is no laxity on valgus stress test.
What is the most likely diagnosis?
Medial meniscus tear
- Gradual swelling of the knee is suggestive of effusion which often occurs due to meniscal injury. Tenderness over the medial joint line suggests a medial meniscus tear.
- Isolated MCL injuries rarely cause a large effusion. In addition, the lack of laxity on the valgus stress test makes an MCL injury less likely.
An 82-year-old woman with long-standing rheumatoid arthritis presents with a history of recurrent chest infections over the past 6 months. On examination she is found to have splenomegaly. Her current medications include methotrexate and sulphasalazine. Blood results demonstrate neutropenia. MLD?
Felty’s syndrome is a condition characterized by splenomegaly and neutropenia in a patient with rheumatoid arthritis.
What is Morton’s neuroma and who does it classically affect?
Benign neuroma, most common in third IMP space
Classically affects females
How should Morton’s neuroma be managed?
Refer if symptoms persist over 3 months
Supportive orthotics
Which clinical test is most suggestive of Ank Spond?
Schobers test < 5cm
Diffuse systemic sclerosis is associated with which antibodies?
Anti-topoisomerase (also known as anti-Scl-70)
Limited cutaneous systemic sclerosis is assocaited with which antibodies?
Anti-centromere antibodies
Name two signs of limited cutaneous systemic sclerosis?
Scleroderma affecting face and distal limbs mainly
Raynauds may be first sign
What is CREST syndrome and what are the 5 signs?
A subtype of limited cutaneous systemic sclerosis C- Calcinosis R- Raynauds E- oEsophageal problems S- Sclerodactyly T- Telangiectasia
A 23-year-old man wakes up on a Sunday morning unable to extend his wrist . He had been drinking heavily the previous night. What is the likely cause of his weakness?
Radial nerve palsy
A 51-year-old woman with a worsening small joint, symmetrical polyarthritis is seen in the rheumatology clinic and diagnosed with rheumatoid arthritis (RA). Her past medical history includes asthma, eczema and a documented severe allergy to co-trimoxazole.
Which of the following treatments for RA is CI in due to this patient’s past medical history?
Sulfasalazine Methotrexate Hydroxychloroquine Leflunomide Azathioprine
Patients with a documented allergy to a sulfa drug (i.e. co-trimoxazole) should not take sulfasalazine
Co-trimoxazole (also called by its brand name, Septrin) is an antibiotic preparation that combines trimethoprim and sulfamethoxazole, a sulfonamide. Some patients that experience an adverse reaction to sulfonamides also display sensitivity to other drugs which contain a similar chemical structure including sulfasalazine.
Methotrexate should never be prescribed with which antibiotic?
Trimethoprim
(Co-trimoxazole contrains trimethoprim)
Increased risk of bone marrow aplasia and pancytopenia
A 35-year-old female presents with pain on the radial side of the wrist and tenderness over the radial styloid process. On examination, abduction of the thumb against resistance is painful, and when the thumb is flexed across the palm of the hand (+ve finklestein test), pain is reproduced by movement of the wrist into flexion and ulnar deviation. What is the most likely diagnosis?
De Quervain’s tenosynovitis
It typically affects females aged 30 - 50 years old
Features
- pain on the radial side of the wrist
- tenderness over the radial styloid process
- abduction of the thumb against resistance is painful
Name two types of intracapsular fractures?
Femoral head #
Femoral neck #
(Tx is with DHS if not displaced and if displaced THR (if fit and well) or hemiarthoplasty if not mobile)
How does Chondromalacia patellae usually present?
(Softening of the cartilage of the patella)
- Common in teenage girls
- Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
- Usually responds to physiotherapy
(May have quad wasting and pseudolocking of knee)
How does osgood-schlatter disease usually present?
Seen in sporty teenagers
Pain, tenderness and swelling over the tibial tubercle
Worse during activity, better with rest
How does Osteochondritis dissecans usually present?
Pain after exercise
Intermittent swelling and locking
What age and presentation for Slipped upper femoral epiphysis?
10-15 years Obese boys most common - Hip, groin, medial thigh or knee pain loss of internal rotation of the leg in flexion - Either acute or chronic
A 24 year old female patient presents after twisting her knee during a football match, her knee buckled and she felt a popping/ tearing sensation in the knee. You examine the joint and see swelling, plus a loss of extension and widespread tenderness. ???
Torn ACL
Hemarthrosis (joint bleed) causing swelling
Treat Anti-inflammatory, ice and possible surgery
(often associated with injury to meniscus or collateral lig)
An athlete presents after running in a downhill race on concrete. He has pain in his medial tibial area with tenderness and swelling. He says it was worst at the start, eased off and then became bad again. ???
Medial tibial stress syndrome (Inflammation due to microfractures) -SHIN SPLITS
Rest for two weeks, possible NSAID/ Icing
A 23yr old male presents with slow onset of back pain, buttock pain, neck pain, especially when moving. They are also very fatigued. What is the first thing you would consider?
Ankylosing spondylitis (Inflammation of spine and sacroiliac joints most common)
A 57yoF presents with pain in her knee, made worse when she tries to get up or walk around, and better when she sits down. Sometimes she hears a crunching sounds when she moves the joint. She says after she gets up the joint is very stiff for around 10mins. She shows you that she can not fully extend her knee when sitting down and trying to do so causes pain. She has no fever or rash. MLD?
A diagnosis of OA can be made clinically without investigations if a person:
- Is aged 45 years or over; and
- Has activity-related joint pain; and
- Has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes. if this is present send for investigation (Xray/ FBC/ MRI if needed)
What is the most common 3 sites affected by gout?
Big toe
Ankle
Knee
(In that order)
Name 4 differentials for swelling in the hand?
Trauma
Non-inflammatory arthopathy (OA)
Inflammatory arthropathy (RA, seronegative, septic, crystal)
Soft tissue injury
What is de Quervain’s tenosynovitis, how does it present?
Pain on radial side of wrist, aggrevated by lifting the thumb (hitchhiker position)
What are the changes seen in RA on XR?
Loss of joint space
Erosions
Subluxation
Soft tissue swelling
What are the changes in on OA on XR?
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cyts
Name 3 risk factors for Carpel Tunnel?
Pregnancy Obesity RA Diabetes Any cause of oedema Idiopathic
Name two specific antibodies for SLE?
Anti-Smith
Anti-dsDNA
(Both 99% specific, dsDNA is more sensative)
What antibody is most associated with diffuse systemic sclerosis?
Anti-Scl70
What antibody is most assocated with limited systemic sclerosis?
Anti-centromere
Sjogren’s syndrome causes what symptoms?
Autoimmune attacking of exocrine glands
- Dry eyes
- Dry mouth
- Dry vagina
(Anti-Ro and Anti-La)
Heliatrope rash is associated with?
Dermatomyocytis
Anti-Jo1
How does APLS present?
Coagulation defect
Livedoreticularis
Obstetric sequelae
Thrombocytopenia
Name 5 complications of RA?
Lung fibrosis Uveitis IHD Crohns Osteoporosis Depression Infections
What are the key features of gout? (3)
Monoarthropathy
1st MTP most common
What is seen on aspiration of gout?
Needle crystals
-ve birefringent
(Urate crystals)
What is seen on aspiration of pseudogout?
Rhomboid crystals
+ve birefringent
(Calcium crystals)
What organisms cause septic arthritis in a) younger patients and b) older patients?
a) Gonococcal
b) Staph aureus (or IVDU, not just old)
Name 3 examples of seronegative arthritis?
Reactive arthritis (within 1mth of infection)
Ank spond
Psoritic arthritis
Entropathic (if IBD as well)
How do you manage ank spond?
Exercise
Physio
NSAIDS
Biologics
NO role for DMARDS
How does SLE present?
Serositis Oral ulcers Arthritis Photosensative rash Blood disorders Renal involvement ANA +ve Immune markers (Anti-dsDNA, Anti-Smith) Neuro disorders Malar rash Discoid rash
How is SLE treated?
Hydroxychloroquine
2) +
Mycophenolate/ cyclophosphamide/ azathioprine
What test is done for De Quervains?
Finklestein test
Thumb in palm, close fingers around, rotate in ulnar direction, should recreate pain
What antibody is associated with Mixed Connective Tissue Disorder?
Anti-RNP
A 19-year-old soldier has just returned from a prolonged marching exercise and presents with a sudden onset, severe pain, in the forefoot. Clinical examination reveals tenderness along the second metatarsal. Plain x-rays are taken of the area, these demonstrate callus surrounding the shaft of the second metatarsal. What is the most likely diagnosis?
Stress fracture
A short history of pain together with clinical examination and radiological signs affecting the second metatarsal favour a stress fracture.
How is Marfan’s inherited? Give three features?
Autosomal dominant
- Tall, big arms
- Pectus excavatum + scoliosis
- Heart (aneurysm, AR, Mitral prolapse)
- Pneumothorax
You are about to treat a 59yoF with RA (treated with methotrexate) for a UTI, what antibiotic should be avoided?
Trimethoprim
Name three antibodies associated with SLE?
- ANA (95% sensitive but not specific) – a negative NA almost excludes SLE
- Anti-dsDNA (Very specific but only 70% sensitive)
- Anti-Smith (most specific but only 40% sensitive)
What classification system is used for intercapsular NOF fractures, what is the treatment?
Garden Classification
I/ II are nondisplaced = DHS
III/ IV are displaced = THR or hemiarthroplasty
What criteria should be used when deciding between THR and hemiarthroplasty in Garden III/ IV NOFs? (3)
For THR:
- Mobile with stick or less (no zimmer frame etc)
- No cognitive impairment
- Fit for surgery
Name 5 factors which can cause delayed healing of fractures?
Site (Scaphoid, base 5th metatarsal) Diet Diabetes Smoking Steroid or NSAID use HIV or other infection
What are the features of osteopetrosis? (3)
- Bones become harder and more dense.
- Autosomal recessive condition.
- It is commonest in young adults.
- Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone.
What is osteogenesis imperfecta? What are some of it’s features?
- Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.
- Failure of maturation of collagen in all the connective tissues.
- Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification)
How do you distinguish between osteoporosis, osteomalacia, pagets and myeloma on bloods?
Osteoporosis: Normal
Osteomalcia: Low phosphate/ vitD/ calcium. Raised ALP
Paget’s: Normal calcium/ phosphate. Raised ALP
Myeloma: Main finding is paraprotein, can have raised calcium
How does CTS present?
Tingling, numbness in thumb, index and middle fingers, can radiate up arm
How should CTS be investigated?
Phalens (reverse prayer) and tinnels (tapping) to see if worsen
Electroneurography is gold standard but not done unless doesn’t respond to 1st line tx
How is CTS managed?
Symptoms should resolve in 6 months, lose weight, wrist splint possible, often self-resolve in 6 months
2nd Line: Steroid injections
3rd line: Release surgery (do if no change in 3 months)
What is pagets disease? How does it present and what is done to treat it?
Uncontrolled bone turnover (thickened/ deformed areas)
- Bone pain with isolated raised ALP (Ca, VitD, phosphate are normal)
- Treat with bisphosphonates and correct Ca/ VitD
How does supraspinatus tendonitis present?
Painful arc of abduction between 60 and 120 degrees
Tenderness over anterior acromion
How does adhesive capsulitis present?
Pain, stiff movement
Limited movement in all direction (mainly loss of external rotation)
Name 5 differentials for lower back pain?
Muscular Fracture Spinal stenosis Ank spond Disc prolapse Metastatic compression Peripheral arterial disease
What are the features of a spinal stenosis?
Gradual onset Uni/ bilateral leg pain Numbness and weakness Worse on walking, relieved by sitting down - Normal clinical examination (MRI to diagnose)
What is the classic presentation of ankylosing spondylitis?
£x more in M, under age 30, strong FHx
Inflammatory (improves with activity)
Wakes in early morning
Pain in buttocks
A/w - Achilles tendonitis, plantar fascitis, peripheral arthritis
How do you investigate for ank spond?
Schobers test (<5cm)
X-ray - Sacroilitis, bamboo spine
How do you manage Ank Spond?
1) Physio
NSAIDS
2) Steroid injections
3) Biologics if severe
What are the x-ray findings of an osteoarthritic joint?
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
How is OA managed?
1) Paracetamol + topical NSAID if hand/ knee
- Topical capsaicin as adjunct
2) Add oral NSAID + PPI
- Steroid injections as adjunct
3) Surgical replacement
How is rheumatoid arthritis managed?
1) Methotrexate (new guidance in 2018, monotherapy)
2) plus 2nd DMARD?
(Sulfasalzine, leflunomide or hydroxychloroquine)
3) Add naproxen (with PPI)
4) Add biologic (infliximab)
Steroids for flares
A combination of splenomegaly and neutropenia in a patient with RA suggests what diagnosis?
Felty’s syndrome
What investigations should be performed for suspected RA?
O
B- DAS-28
B- FBC, RF, anti-CCP, ESR/CRP
I- XR of joints
Name 5 systemic complications of RA?
Eyes- Sjorgen's/ episcleritis Rheumatoid nodules Lung fibrosis Thyroid disease Osteoporosis
How is PsA distinguished from RA (as it will often precede the psoriatic rash)
PsA:
Less symetrical
Fewer than 5 joints affected
Seronegative (No RF or anti-CCP)
How is gout managed?
1) Naproxen < CI in renal impairment or bleed risk
2) Steroids
3) Colchicine (if both CI)
When should allopurinol be started for patients with gout?
NOT during acute attack
- If >2 attacks in a year or
- 1 attack + renal impairement, use of diuretics or gouty tophi
How should pseudogout be managed?
Monoarthropathy:
1) Steroid injection
2) NSAIDS
3) Colchicine
Polyarthropathy:
1) Oral NSAIDS
2) Colchicine
What are the characteristic features of reactive arthritis?
2-4wks after GI or GU infection
Asymetrical, acute onset with malaise and fatigue
Seronegative but high ESR/ CRP
What is the diagnostic criteria for fibromyalgia?
Use widespread pain score (>7)
Longer than 3 months
No other disorders can explain
How would you explain fibromyalgia to a patient?
Fibromyalgia is a pain condition, it is not related to inflammation but may be due to chemical changes in the body’s pain pathways.
As well as pain, patients often have problems with sleep as well as other features such as reduced concentration.
The focus is on managing symptoms.
Name 5 possible features of fibromyalgia?
Unrefreshing sleep Tiredness Pain (low back, legs, neck, shoulders) Some morning stiffness Parasthesia Feeling of swollen joints but no objective swelling Headaches and dizziness Anxiety and depression
Who commonly gets fibromyalgia? (2)
10x more common in F
Age 20-50years
How is fibromyalgia treated?
Exercise (only evidence based tx)
2) CBT
3) Paracetamol, antidepressants, pregabalin or gabapentin
What is the characteristic presentation of PMR?
Over 50, 3x more females
>2weeks of bilateral neck, shoulder and pelvic pain with morning stiffness
(Strong associated with GCA so ask about headaches etc)
How should PMR be investigated?
ESR >40mm/hr
CRP
How is PMR managed?
Daily 15mg prednisolone for 3 weeks
Reducing over 1yr
Name 3 risk factors for septic arthritis?
Prosthetic joint Low SES IVDU Diabetes Short Hx of symptoms
What is your first investigation for septic arthritis?
Synovial fluid aspiration
(Culture and WCC)
+ Blood culture, WCC, CRP etc
What is scleroderma?
Tightening or fibrosis of the skin
What are the characteristic features of oesteomalacia?
Softening of bones (due to low vitD, calcium and phosphate)
- Bone pain, aches and weakness
How do you treat osteomalacia?
VitD and calcium suppliments
What would bone profile bloods show in osteomalacia?
Low Ca, Vit D, phosphate
Raised ALP
What is the classic history and signs of compartment syndrome?
Following # or surgery (raised pressure in closed space)
> Pain, pallor, parasthesia, pulseless, paralysis (but not perishing cold)
How is compartment syndrome diagnosed?
Measurement of intracompartmental pressure
<20mmHg is abnormal, <40mmHg is diagnostic
How is compartment syndrome treated?
Prompt fasciotomy
Death of muscle occurs in 4-6hours, after this time consider debridement and amputation may be needed
How does GCA present?
60-80yrs
Temporal headache, myalgia, visual disturbance, jaw claudication `
How is GCA investigated?
ESR >50mm/hr
Then temporal biopsy although note skip lesions so negative doe not r/o
How is GCA treated?
High dose (40mg) pred
Refer to opthalmology (IV pred if visual symptoms)
How does Wegner’s (granulomatosis with polyangitis) present?
ELK
- ENT (100%) ulcers, crusting of nose, sores
- Lungs (most) - haemoptysis, cough etc
- Kidney (haematuria)
Also joint pain and many other syx
How are Wegner’s or Churg-Strauss managed?
High dose steroids
+ specialist review
How does churg-strauss (eosinophillic granulomatosis with polyangitis) present?
Asthma + esosinophillia + multiorgan involvement = Churg Strauss
(Can affect coronary, pulmonary, cerebral, nasal polyposis, abdo etc.)
How does Takayasu’s arteritis present?
Systemic vasculitis (malasie, headache etc)
- Unequal BP in upper limbs
- Carotid bruit
- Intermittent claudication
- Aortic regurg
Who commonly gets kawasaki disease and how does it present?
Children Presentation: - Fever (high, resistent to anti-pyretic) - Conjunctival injection Strawberry tongue - Cervical lymphadenopathy - Red palms on hands and feet - Red, cracked lips
How is Kawasaki managed?
(clinical diagnosis)
- High dose aspirin
- IVIG
Echo (as associated with coronary artery aneyrysms)
A 32-year-old man presents with a painful swelling over the volar aspect of his hand after receiving a hard blow to his palm. On examination, he experiences pain on moving the wrist and on longitudinal compression of the thumb. What is the fracture?
Scaphoid
Scaphoid fractures usually occur as a result of direct hard blow to the palm or following a fall on the out-stretched hand. The main physical signs are swelling and tenderness in the anatomical snuff box, and pain on wrist movements and on longitudinal compression of the thumb
A 25-year-old man attends the emergency department after being involved in a road traffic accident. He was in the driver’s seat when a lorry in front lost control and became trapped when the dashboard and footwell were pushed forward on impact.
He is currently stable but has significant pain in his right leg. His right leg is shortened, internally rotated, slightly flexed and adducted compared to the left.
What is the diagnosis?
Posterior hip dislocation
- Posterior are most common. Dislocations tend to happen in young males following trauma.
How do you manage Reiter’s syndrome?
Can’t see, can’t pee, can’t climb a tree (a type of reactive arthritis)
- Symptomatic = Ibuprofen
Persistent = Sulfasalazine or methotrexate
Who should receive a FRAX screening assessment?
Any female > 65
Any male > 75
Young patients with RF’s
What is the main complication of concern in a posterior hip dislocation?
Sciatic nerve injury
How does frozen shoulder present?
Over a few days
Painful, restricted movements both active and passive
External rotation worst
Painful freezing phase > adhesive phase > recovery phase
How is frozen shoulder treated?
Physio
NSAIDS
Steroid injections
62 year old woman due to have surgery under general anaesthetic. She has rheumatoid arthritis. She is fit and well. She used to take 10mg of prednisolone 3 years ago. What is the most appropriate investigation to undertake? A. Chest X-ray B. FBC C. Cervical spine X ray D. LFT E. Short synacthen test
C - Cervical spine X-ray
(Because RA patients can get damage to atlantoaxial joint, if this is moved awkwardly during intubation could be fatal consequences)
