passmed Flashcards
allopurinol and azathiaprine drug interaction causes what
BM supression –> pancytopaenia and agranulocytosis
why do allopurinol and azathiaprine hv a drug interaction
The reason for the pancytopenia is the drug interaction between azathioprine and allopurinol which can cause bone marrow suppression.
-The allopurinol is a xanthine oxidase inhibitor which metabolises 6-mercaptopurine, hence reducing the amount of inactivated 6-mercaptopurine (active form of azathioprine). Thus more active 6-mercaptopurine is incorporated in the DNA in the bone marrow precursors, reducing the platelet cell lines and red and white blood cell line production.
limited systemic sclerosis AB vs diffuse
Limited (central) systemic sclerosis = anti-centromere antibodies
diffuse = anti-scl70 ABs
Greater trochanteric pain syndrome = TROCHANTERIC BURSITIS
- Due to REPEAT MVMNT of the fibroelastic ILIOTIBILAL BAND
- Insiduos onset
- Pain over the LATERAL side of HIP/THIGH (not extending down entire leg) (worsens with ext rotation of hip)
- Tenderness on palpation of the GREATER TROCHANTER
- Most comm in W aged 50-70Y
Meralgia paraesthetica
Caused by compression of lateral cutaneous nerve of thigh
Typically burning sensation over antero-lateral aspect of thigh
Transient idiopathic osteoporosis
An uncommon condition sometimes seen in the third trimester of pregnancy
Groin pain associated with a limited range of movement in the hip
Patients may be unable to weight bear
ESR may be elevated
primary care rheumatoid arthritis first step of Ix after ABs confirmed
NICE advice x-ray of hands and feet for all patients with suspected rheumatoid arthritis. This patient should be referred urgently (within 3 days of presentation), to rheumatology because the small joints of her hands are affected.
other conditions with positive Rheumatoid Fcator
Other conditions associated with a positive RF include: Felty's syndrome (around 100%) Sjogren's syndrome (around 50%) infective endocarditis (around 50%) SLE (= 20-30%) systemic sclerosis (= 30%) general population (= 5%) rarely: TB, HBV, EBV, leprosy
de quiervans tenosynovitis and finkelsteins test
sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed
- females aged 30 - 50 years old
- Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes PAIN over the RADIAL STYLOID process and along the length of extensor pollisis brevis and abductor pollicis longus
mx of de q tenosynovitis
Management analgesia steroid injection immobilisation with a thumb splint (spica) may be effective surgical treatment is sometimes required
Which of the following tests is essential to be performed prior to starting biologics for Rheumatoid arthritis or UC?
It is important to perform a chest X-ray to look for TB prior to starting biologics for rheumatoid arthritis as they can cause reactivation
-pts should be evaluated for both active and TB infection, which usually involves a CXR as well as a tuberculin skin test or interferon-gamma release assay.
which 2 fractures do we most commonly see compartment syndrome with
SUPRACONDYLAR fractures and TIBIAL SHAFT injuries/#
-NB. numbness and paralysis are late signs
types of shoulder dislocation x3
1.Glenohumeral dislocation (COMMONEST): ANTERIOR shoulder dislocation MOST COMMON 95%
mx - lots of diff techniques for reducing shoulders, limited evidence that one is better than another. If dislocation is recent then reduction w/o any analgesia/sedation. However, other patients may req analgesia +/- sedation to ensure the rotator cuff muscles are relaxed.
- Acromioclavicular dislocation (12%): clavicle loses all attachment with the scapula
- Sternoclavicular dislocation (uncommon)
types of glenohumeral dislocation x4
- ANTERIOR shoulder dislocation - ext rot + abd
- 25-40% recurrent (commonest disorder)
- assoc with greater tuberostiy #, Bankart lesion, Hill-Sachs defect - Inferior shoulder dislocation
- Posterior shoulder dislocation - proportion misdx, rim’s sign, light bulb sign, assoc with trough sign
- superior shoulder dislocation - rare + usus after major trauma
renal compl of systemic sclerosis mx
ACEi
what to do with pt presenting with new synovitis
urgent referral to rheumatology
-likely inflammatory joint dis + req blood test for auto-immune ABs incl ANA + RhF
iliopsoas abscess define and 2x types
= collection of pus in iliopsoas compartment (iliopsoas + iliacus)
primary - haematogenous spread of bacteria - S.Aureus most common
secondary (higher mortality rate) - chrons, diverticultis, colorectal c, UTI, GU cancers, vertebral OM, femoral catheter, lithotripsy, endocarditis, IVDU
iliopsoas abscess clin features
fever
back/flank pain
limp
weight loss
iliopsoas abscess: O/E
Patient in the supine position with the knee flexed and the hip mildly externally rotated
Specific tests to diagnose iliopsoas inflammation:
Place hand proximal to the patient’s ipsilateral knee and ask patient to lift thigh against your hand. This will cause pain due to contraction of the psoas muscle.
Lie the patient on the normal side and hyperextend the affected hip. This should elicit pain as the psoas muscle is stretched.
iliopsoas abscess: Ix
CT abdo
iliopsoas abscess: Mx
Antibiotics
Percutaneous drainage is the initial approach and successful in around 90% of cases
Surgery is indicated if:
1. Failure of percutaneous drainage
2. Presence of an another intra-abdominal
psoriatic arthropathy without psoriatic skin lesions dx?
still psoriasis
-Psoriatic arthropathy can present before psoriatic skin lesions - a positive family history of psoriasis may point towards this diagnosis
RhA X-rAY findings
3 early & 2 late
Early x-ray findings:
loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
Late x-ray findings:
periarticular erosions
subluxation
which classification systems for which fractures: Gartland/ Salter-Harris/ Ottawa rules / Weber/ Garden
Gartland - supracondylar # in children
Salter-Harris - classify # about growth plate in children
Ottawa rules - detect ankle fractures in pts
Weber - classify ankle fractures about the syndesmosis
Garden - #NOF
what additional ix do RhA patients need prior to I&V during pre-op assessments
ANTEROPOSTERIOR + LATERAL C-SPINE RADIOGRAPHS
- atlantoaxial subluxation = rare compl of RhA but imp as can –> cervical cord compression
- screening for it ensures that pt goes to surgery in a C-spine + neck isn’t hyperext on intubation
Referred lumbar spine pain
FEMORAL NERVE COMPRESSION may cause REFERRED PAIN in the HIP
- ->Femoral nerve stretch test may be +
- lie the patient prone. Extend the hip joint with a straight leg then bend the knee. This stretches the femoral nerve and will cause pain if it is trapped
Colle’s fracture - all the Ds
Colles’ fracture - from a FOOSH
- Dorsally Displaced Distal radius → Dinner fork Deformity
- triad of: transverse fracture of radius, 1 inch proximal to radiocarpal jt, and dorsal displacement + angulation
Leriche Syndrome triad (CIA)
Triad in males: CIA
1/claudication of buttocks + thighs
2/impotence (due to paralysis of L1 nerve)
3/atrophy of musculature of legs
indications for urate-lowering therapy (ULT)
-offer to ALL pts after 1st attack of gout
-ULT esp recommended if:
>/= 2 attacks in 12m
tophi
renal dis
uric acid renal stones
prophylaxis if on cytotoxics or diuretics
-1st line = allopurinol with colchicine cover
-2nd line = febuxostat (XO inh)
garden system for NOF - type 1-4
type 1- stable fracture with impaction in valgus
type 2- complete fracture but undisplaced
type 3- displaced fracture, usu rotated + angulated, but still has boney contact
type 4-complete boney disruption
(blood supply most comm aff in T3/4)
lower back pain Mx
1st line = NSAIDs (+PPI if >45)
Other tx:
-exercise programme within NHS
-manual therapy (spinal manipulation, mobilisation, or ST techniques eg massage)
-radifreq denervation
-epidural inj of LA and steroid for acute + severe sciatica
laTeral epicondylitis = TENNIS ELBOW features
Features
- pain and tenderness localised to the lateral epicondyle
- pain worse on resisted wrist extension with the elbow extended or supination of the forearm with the elbow extended
- episodes typically last between 6m and 2y. pts tend to have acute pain for 6-12 wks
Medial epicondylitis = GOLFERS ELBOW
Features
pain and tenderness localised to the medial epicondyle
pain is aggravated by wrist flexion and pronation
symptoms may be accompanied by numbness / tingling in the 4th and 5th finger due to ulnar nerve involvement
Radial Tunnel Syndrome cause
Most commonly due to compression of the POSTERIOR INTEROSSEOUS BRANCH of the RADIAL NERVE
It is thought to be a result of overuse.
Radial Tunnel Syndrome features
Features
Sx are similar to lateral epicondylitis making it difficult to dx
but, the pain tends to be around 4-5 cm distal to the lateral epicondyle
sx may be worsened by extending the elbow and pronating the forearm
Cubital Tunnel Syndrome - due to compr of what nerve + features
Due to the compression of the ulnar nerve.
Features
- initially intermittent tingling in the 4th and 5th finger
- may be worse when the elbow is resting on a firm surface or flexed for extended periods
- later numbness in the 4th and 5th finger with associated weakness
Olecranon Bursitis - what does it affect + who
Swelling over the POST aspect of the ELBOW
- There may be associated pain, warmth and erythema.
- It typically affects MIDDLE-AGED MALE pts.
Scaphoid Fractures initial mx
= 1. immobilisation with a FUTURO SPLINT or standard BELOW-ELBOW BACKSLAB
- REFERRAL to ORTHOPAEDICS
- clinical review with further imaging should be arranged for 7-10 days later when initial radiographs are inconclusive
Scaphoid Fractures- ortho mx
=dependent on the patient and type of fracture
=undisplaced fractures (<0.5mm) of the scaphoid waist
–>cast for 6-8 weeks
–>union is achieved in > 95%
–>certain groups e.g. professional sports people may benefit from early surgical intervention
=displaced scaphoid waist fractures >1.5mm
–>requires SURG FIXATION
=proximal scaphoid pole fractures
–>require SURG FIXATION
open fracture mx with lots of ST damage/involvement
- As a general principle all open fractures should be thoroughly debrided ( and internal fixation devices avoided or used with extreme caution)
- ext fixation can be used temporarily to allow soft tissues to recover
- Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury
what nerve comm damaged during TKA
common peroneal nerve
- 0ne of the terminal branches of the sciatic nerve, beginning at the top of the popliteal fossa
- It then follows the medial border of the biceps femoris, before wrapping around the neck of the fibula
- Its anatomical location means that it is poss for it to be damaged during procedures that involve the knee, such as joint replacements and ligament repairs
- Although damage to both the sciatic nerve (1) and the common peroneal nerve (2) can lead to foot drop, given this patient’s hx of a TKR, the common peroneal nerve is much more likely to be the cause of her complaint.
Ix for occult hip fractures not seen on XR
MRI
L3 nerve root compression
S-sensory loss over ANT THIGH
P-Weak QUADS
R-Reduced KNEE REFLEX
Special tests-+ FEMORAL STRETCH TESTS
L4 nerve root compression
S - sensory loss ANT ASPECT of KNEE
P - Weak QUADS
R - Reduced KNEE REFLEX
Special tests- + FEMORAL STRETCH TEST
L5 nerve root compression
S - Sensory loss DORSUM OF FOOT
P - Weakness in FOOT + BIG TOE DORSIFLEXION
R - Reflexes INTACT
STs- + SCIATIC NERVE STRETCH TEST
if no red flag sx–> conservative mx = trial anti-neuropathic agent (gabapentin, pregabalin, amitriptylline) & physio
-if not resolved in 4-6 weeks –> routine referral to neurosurgery
S1 nerve root compression features
S- Sensory loss of POSTEROLATERAL aspect of LEG + LATERAL aspect of FOOT
P - weakness in PLANTAR FLEXION of FOOT
R - reduced ANKLE reflex
STs- positive SCIATIC N STRETCH TEST
extracapsular hip fractures mx x2
- stable intertrochanteric fractures: DHS
2. if reverse oblique, transverse or subtrochanteric fractures: INTRAMEDULLARY DEVICE
Carpel Tunnel signs o/e
Examination:
weakness of THUMB ABDUCTION (abductor pollicis brevis)
wasting of THENAR eminence (NOT hypothenar)
TINEL’S sign: tapping causes paraesthesia
PHALEN’s sign: flexion of wrist causes
sx
NB. CTS causes action potential prolongation in both sensory and motor axons
Carpal Tunnel Causes
idiopathic pregnancy oedema e.g. heart failure lunate fracture rheumatoid arthritis
Hyperparathyroidism is a RF for what
Pseudogout
inflammatory arthritis vs osteoarthritis when is pain worse
inflammatory arthritis - pain worse in AMs
vs
osteoarthritis - pain worse on exercise
Reactive arthritis skin changes
- CIRCINATE BALANITIS (painless vesicles on the coronal margin of the prepuce)
- KERATODERMA BLENORRHAGICA (waxy yellow/brown papules on palms and soles)
Behcets disease triad, other sx, + epid
ORAL ULCERS + GENITAL ULCERS + ANTERIOR UVEITIS
Bechets = AI small vessel vasculitis that targets venules. = T3 hypersensitivity rtn induced by immune complex deposition in small vessels
Other sx: thrombophlebitis + DVT/ Arthritis/ Neuro invovlement (aseptic meningitis)/ GI: abdo pain, Diarrhoea, colitis/ ENodosum
Epidemiology–> more common + severe in MEN, more common in the eastern Mediterranean (e.g. Turkey), young adults 20-40Y, assoc HLA-B51, 30% + FHx
gout acute flare mx
NSAIDs or colchicine 1st line
- use max dose NSAIDs until 1-2d after it’s settled + PPI if needed
- main SE of colchicine = Diarrhoea
- oral steroids if both CI (pred 15mg/d)
- if pt is established on allopurinol it should continue
when to give prophylactic bisphosphonates
Offer prophylactic bisphosphonates to those with a T-score < -1.5 if they are on steroids / going to be on steroids for 3 or more months (even if <65 years-old
anti-synthetase syndrome AB
= where Myositis with +ve anti-Jo1 antibodies can predispose to lung fibrosis
Sulfasalazine what type of drug, what is it used for + MOA
DMARD - used in mx of inflammatory arthritis eg RhA + IBD
MoA- prodrug for 5-ASA which works through decreasing neutrophil chemotaxis + supresses proliferation of lymphocytes + pro-inflammatory cytokines
Sulfasalazine cautions
G6PD deficiency
Allergy to Aspirin or Sulphonamides (cross-sensitivity)
Sulfasalazine adverse effects
- oligospermia
- SJS
- pneumonitis/lung fibrosis
- myelosupression, Heinz body anaemia, megaloblastic anaemia
- may colour tears –> stained contact lenses
are DMARDs safe in pregnancy + breastfeeding
NO but sulfasalazine is !
1st line Ix for osteoporotic vertebral fracture
X-ray of the spine
ruptured ACL usual mechanism + pres
sport injury
mech - high TWISTING force applied to BENT knee
pres- loud crack, pain + RAPID joint swelling (haemarthrosis)
mx - intense physio or surgery
ruptured PCL mech + pres
mech- hyperextension injuries eg knee hits dashboard in car carsh
pres: tibia looks posterior cf to knee joint
test - posterior drawer test
ruptured MCL mech + pres
mech - leg forced into valgua via force outside the leg
-knee unstable when put into valgus position
meniscal tear mech + pres + best modality to dx it
- rotating sporting injuries
- delayed knee swelling
- joint locking
- recurrent ep of pain + effusions are common, often following minor trauma
- MRI best to DX meniscal tears (90% sensitive)
chondromalacia patellae who gets it, HPC + O/E
teenage girsl, following an injury to knee eg dislocation of patella
- typical hx of pain on going DOWNSTAIRS or at REST
- tenderness, quad wasting
dislocation of patella mech , RF, Ix
-most comm occurs as traumatic primary event, either through direct TRAUMA or severe contraction of QUADS with knee stretched in valgus + ext rotation
RF: genu valgum, tibial torsion, + high riding patella
Ix: skyline XR views of patella required, although displaced patella may be clinically obvious
-20% recurr rate
fractured patella 2 types
2 types:
i. Direct blow to patella causing undisplaced fragments
ii. Avulsion fracture
tibial plateau fracture
- elderly (or after signif trauma in young)
- mech: knee forced into valgus or varus, but knee fractures before ligaments rupture
- varus injury affects medial plateau + if valgus injury, lateral plateau depressed fracture occurs
Cx of THR
PERIOPERATIVE -VTE -intraoperative # -nerve injury -INF LEG LENGTH DISCREPANCY POSTERIOR DISLOCATION - in extremes of hip flexion -pres acutely with a 'clunk', pain + inability to weight bear -O/E IR + shortening of the affected leg ASEPTIC LOOSENING (most common reason for revision ) PROSTHETIC JOINT INF
anti-phospholipid syndromes mx
- primary thromboPROPHYLAXIS
- Low dose aspirin - Secondary thromoprophylaxis
- initial VTE: LIFELONG WARFARIN with target INR 2-3
- recurrent VTE: LIFELONG WARFARIN; if occurred whilst taking warfarin then consider adding LOW-DOSE ASPIRIN, incr target INR to 3-4
- ARTERIAL THROMBOSIS should be tx with LIFELONG W with INR target 2-3
avascular necrosis may follow what 2 things
high dose CS therapy
OR previous hip # or dislocation
-sx can be sudden or gradual
ottawa ankle rules state XR only necessary if pain in MALLEOLAR zone + what 3 things
- inability to weight bear for 4 steps
- tenderness over distal tibia
- bone tenderness over distal fibula
weber classifcation of ankle fractures
related to the level of the fibular #
- Type A - BELOW syndesmosis
- Type B - # start at level of tibial plafond + may extend proximally to involve the syndesmosis
- Type C - ABOVE the syndesmosis which can itself be damaged
mx of ankle fractures
- Depends upon stability of ankle joint and patient co-morbidities.
- All ankle # should be promptly REDUCED to remove pressure on the overlying skin +subsequent necrosis
- Young pts, with unstable, high velocity or proximal injuries will usually req surgical repair. Often using a compression plate.
- Elderly pts, even with potentially unstable injuries usually fare better with attempts at conservative mx as their thin bone does not hold metalwork well
when to prescribe a bisphosphonate in pts with LT- steroid use NICE
If bone-sparing tx is recommended, prescribe a bisphosphonate (alendronate 10 mg once daily or 70 mg once weekly, or risedronate 5 mg once daily or 35 mg once weekly), if there are no CI + after appropriate counselling to:
…
Consider prescribing to:
Ppl who are taking high doses of oral CS (more than or equivalent to prednisolone 7.5 mg daily for 3 months or longer).
stills disease featuers
- arthralgia
- elevated serum FERRITIN
- rash: SALMON-pink, maculopapular
- PYREXIA (typically rises in the late afternoon/early evening in a daily pattern and accompanies a worsening of joint symptoms and rash)
- lymphadenopathy
- RF + ANA negative
achilles tendon rupture RFs
- QUINOLONE use (ciprofloxacin) assoc with tendon disorders
- hypercholesterolaemia (predisposed to tendon xanthomatat|)
mx after osteoporotic fragility fracture by age NICE
-Tx is indicated following osteoporotic fragility fractures in postmenopausal women who are confirmed to have OP on DEXA (a T-score of - 2.5 SD or below).
BUT In women aged 75Y+ , a DEXA scan may not be req ‘if the responsible clinician considers it to be clinically inappropriate or unfeasible’
causes of AVN of hip
long term steroid use
chemo
alcohol excess
trauma
ant shoulder dislocation key
most common type of dislocation
- often follows fall on arm or shoulder
- check pulses + nerves (esp AXILLARY)
- always do XR
- tx: REDUCTION, ANALGESIA, SLING
Post shoulder dislocation key
3Es: Epilepsy, Electrocution, Elderly
- rare
- lightbulb sign on XR
- tx: REFER to ortho surgeons
scaphoid blood supply
retrograde blood supply from dorsal carpal branch of radial artery –> AVN risk
-this risk most commonly comlicates proximal injuries
Scaphoid # presentation
- pain along radial aspect of wrist, at base of thumb
- loss of grip/pinch strength
Scaphoid # signs
- point of max tenderness over anatomical snuffbox
- wrist joint effsion
- pain elicited by telescoping of the thumb (on longitudinal compression)
- tenderness of schapoid tubercle
- pain on ulnar deviation of wrist
scaphoid # Ix
- XRs scaphoid views - PA, lateral, oblique, Ziter view (sensitivity in 1st week is only 80%)
- CT scan
- MRI definitive Ix to confirm or exclude dx (comm used 2nd line)
scaphoid # Initial Mx
- immobilisation with a Futuro SPLINT or standard below-elbow backslab
- REFER to ORTHO
- -> clinical review with further imaging should be arranged for 7-10d later when initial radiographs are inconclusive
Scaphoid # Ortho Mx
-dependent on the pt +type of fracture
-UNDISPLACED fractures of the scaphoid waist
= CAST for 6-8 weeks
=union is achieved in >95%
=certain groups e.g. professional sports people may benefit from early surgical intervention
-DISPLACED scaphoid waist fractures
=requires surgical fixation
-PROXIMAL scaphoid pole fractures
=require surgical fixation
what is commonest site of stress fractures
2nd metatarsal shaft
red flags for lower back pain
age<20Y or >50Y hx of previous malignancy night pain hx of trauma systemically unwell eg WL, fever thoracic or middle back pain sudden onset + progressive
compartment syndrome features
pain, esp on mvmnt (even passive) paraesthesia pallor arterial puulsation paralysis can occur (presence of a pulse doesn't rule it out)
what is mortons neuroma
benign neuroma affecting intermetatarsal plantar nerve - most commonly in 3rd inter-metatarsophalangeal space
F4:M1
mortons neuroma features
-forefoot pain (3rd intermetatarsophalangeal space)
-worse on walking (shooting or burning pain, feels like pebble in shoe)
-mulder’s click (hold neuroma bet finger + thumb + squeeze metatarsals together, click as neuroma moves bet metatarsal heads)
-loss of sensation distally in toes
DX CLINICAL but ULTRASOUND helps
monteggia vs galeazzi fracture
Monteggia Proximal Ulna = man PU = fracture of PROXIMAL ULNA with associated dislocation of proximal radioulnar joint
Galeazzi Distal Radius = galaxy DR = fracture of DISTAL RADIUS with associated dislocation of distal radioulnar joint
