R&O Flashcards
smith fracture
fall on palmar flexed hand
anterior displacement of radius
colles frac
fall on outstretched hand
posterior displacement of radius
dinner fork deformity
forearm: Galeazzi vs Monteggia
- Gal
Radial frac
Ulnar dislocate at Wrist
-Mont
Ulnar frac
Radial head disloc at Elbow
GRUW MURE
scaphoid frac
fall on outstretched hand
look for if no obvious frac at wrist but still painful
- especially tender in anat snuff box
epiphyseal fracture in kids
salter harris classification
fracture neck of femur
v common frac of old age
- esp in females
mortality: 1/3 in 1y; 1/3 into care
risk - oteoporo, cog impair, dm, alcoholism
leg shortened, external rot
xray - loss of shenton’s line, interruption in trabelcular lines
Intracapsular
- compromise vessels, poor healing
- GARDEN classification
- 1 partial, 2 full, 4 full disp
- t: arthroplasty (full or hemi)
Extracapsular
- trochanteric or subtronchanteric
- dynamic hip screw or intramedullary nail
Comps of NOF frac
AVN
- residual pain
- xray showed increased density
Non union
Osteorathritis
- all avoided by total hip replacement
fracture complications
dvt & pe
- stockings, heparin may be indicated
compartment syndrome
traction neuropraxia
later: mal/non union avascular necrosis algodystrophy - aka complex regional pain, reflex symp dystrophy
compartment syndrome
pain out of proportion
pain on passive movement
later: pallor, paraes, pulse, paralysis
do fasciotomy
complex regional pain
algodyst, refelx sym dyst
burning pain, sweating, swelling, stiffness, skin changes
often in hand or foot
neurovascular injuries to look for with fracture
nerve injury = traction neuropraxia
humeral shaft: radial nerve: wrist drop
knee: common peroneal: foot drop
supracondylar: brachial artery and r,m,u nerves
fracture healing
haematoma
inflam and cell prolif
DAYS
callus formation (chondroblasts and osteoblasts)
- soft then hard
- leaves woven bone
WEEKS
consolidation + mineralization
- leaves trabecular bone (aka lamellar)
YEARS
remodelling - blasts and clasts
- leaves compact bone
fracture healing times
kids 3-4 weeks
adult, excluding complication
upper limb 6-8 weeks
lower limb 12 weeks
for each complication (compound, infection) add 6 weeks
fracture management rules
upper limb conservative management
unless displaced: fix with plate and screws
lower limb surgery always required
- intramedullary pin
for hip
DHS if extracapsular of intracapsular, non displaced and < 60
intracapsular displaced or > 60: hemiarthroplasty
open (compound) fracture
break in skin communicating with frac
usually high energy
risk infection
require surgical washout
may require external fixation
OSCE: describing fracture on xray
plain film radiograph
taken on…
of patient…
shows left/right forearm/shoulder/hand etc
in AP/lateral view
adequate exposure/penetration
- show joint above and below
is it a child - epiphyseal plates
fracture
- where on shaft - prox/mid/distal
- displaced or undisplaced
translational, angulation, rotation, shortening
- comminuted or simple transverse/oblique/spiral
Vertebral fractures in osteoporo
sudden severe pain - radiate around front (ribs abdo)
v tender alog central spinal processes
but 2 in 3 are asympotmatic
get pain from subsequent accumulated mechanical derangement
- increased kyphosis
osteoporosis
loss of normal bone mass/density/architecture
- increase fragility - inc fracture risk
DEXA bone density scan
(dual energy xray absorptiometry)
- give T score - how many SD’s from young healthy adult mean
- give Z score - how many SD’s from age matched normal
Risk factors
- age, female, low bmi, fh
- smoking, steroid, alcohol
- RA, liver, renal, copd
- oestrogen deficiency
- vit D deficiency, hyperparathyroid
osteoporosis causes
early menopause cushings (high steroid) DM chronic renal fail RA coeliac, IBD
treatment and prevent osteoporo
- bisposphonates (inhib osteoclasts)
- w water,uproght, no food for 30 mins
calcium
vit D
smoking cessation
reduce falls
for spinal fractures - bed rest and analgesia
pagets
osteitis deformans
disorder of bone remodelling
excessive resorp then increased formation - structurally abnormal
often asympto (incidental xray finding)later get pain, deform, nerve palsy
commonly pelvis, lumbar spine, femur
not below 40, inc dramatically with age
raised ALP
t: bisphosphonate
skull x ray
think pagets
- inc bone turnover affecting skull and long bones
bisphosphonates
HISTORY: back pain
HPC
- pain tender stiff
- pattern (AS worse in morn, good with exercise)
- location
- wake at night (AS)
- injury or mechanism worse on extension
- radiate to buttock
system: fatigue, fever, wl
assoc w inflammatory disease: peripheral joints (mainly knee hip), rib pain, eyes (AS)
neuro: tingling, shooting pain, saddle anaesth, urinary incont
back pain history
HPC
- pain tender stiff
- pattern (AS worse in morn, good with exercise)
- location
- wake at night (AS)
- injury or mechanism worse on extension
- radiate to buttock
system: fatigue, fever, wl
assoc:
rib pain, eyes (AS)
neuro: tingling, shooting pain, saddle anaesth, urinary incont
back pain red flags
<20 or >50
persistent
worse at night or early morn (AS)
systemic: fever, wl, fatigue
neurology: pain, ting, urinary, saddle
ankylosing spondylitis
young adults (slight male predom) >90% HLA B27
seronegative but
- esr, crp raised
- wcc may be raised
episodic inflam in spine
- lower back pain, tender, stiff
- also in buttocks (alternating)
fatigue
stiffness worse in morning, improve w exercise
waking at night (second half)
AS management
physio: daily, morning exercises
- can prevent accumulative disability
- spinal mobility, chest expan, posture
active inlfamm: NSAIDs
persistent inflam: consider antiTNF
(methotrexate reserved for peripheral arthritis)
consider genetics:
if hla +, 50% chance of passing on, 30% chance of devel
later effects of AS
gradually limit spinal flexion
- reliably measure w Schoeber’s
- fusion - bamboo spine
costochondritis
- may limit chest expansion
uveitis / red eye
not well prevented (w exercises)
- dorsal kyphosis (question mark post), affect gait, chest expan, paraspinal muscle wasting
ank spond xray changes
sacroilitis
squaring of vert
syndesmophytes (calcific of anulus fibrosis)
bamboo fusion
spondylosis
degenerative changes in fibrous intervertebral joints
- dehydration of gel in disc - fissures in outer zone
- prone to prolapse
- sclerosis and spurs at vertebrae
- OA at facet joints
may see
- episodic pain
- stiffening
- disc prolapse: nerve irritation
- stenosis
- spodylolisthesis
disc prolapse
protrusion of nucleus pulposus through fissure in annulus fibrosis
often underlying spondylosis - but also often in young fit adults
can affect cervical, thoracic, lumbar spine
onset w local strain or injury - ie lifting, stooping for lumbar - often less prominent for cervical see local pain, may be worse w coughing/straining may get local muscle spasm, tenderness
then get onset of nerve pain and neuro symptoms (weakness, sensory)
Disc prolapse
Lateral - nerve root compression (also c by root canal stenosis)
Central (less common) - cauda equina (f/u incont, numb weak)
Root compression
- sciatic pain
- paraesthesia
- fem (l2-4) stretch or straight leg raise (l4-s3)
Xrays not helpful
MRI if suspicious
Rest, analgesia. Surgery if severe/persist/neurol
Exclude tumour, inflam (AS)
Muscular - physio
disc prolapse
see leg pain (worse when sitting)
straight leg raise positive
t: analgesia and physio
if no improve consider MRI
L3 - thigh; L4 - knee
- weak quads
- red knee reflex
- femoral stretch positive
L5 - dorsum: S1 - postero-lat
- sciatic stretch positive
acute lumbar disc prolapse
commonly set off by lifting twisting bending
on its own: diffuse pain (often unilat, to buttock) and muscle spasm
nerve irritation: tingling, pain, weakness
- *ask about saddel anaesth, incont
- cauda equina lesion
straight leg raise - sciatic - L4-S3
femoral nerve stretch - L2-L4
treatment disc prolapse
2-3 days bed rest
- flat if lower lumb
- semi-rec if upper lumbar
analgesia and muscle relaxants
once tolerable - mobilise, physio
? may need xray guided nerve root injection
? may require surgery - microdiscectomy
Back pain differential: myeloma
Malignancy of plasma cells
Seen in elderly
In most, will have both..
Blood: monoclonal paraprotein
Urine: bence jones
For diagnosis need one of these plus
- radiolog evidence of lytic bone lesions,
- high plasma cells on bm aspirate
Also raised ESR, and crp
Blood film: rouleux
Features:
- bone destruction: hypercalc and fractures
- marrow infiltration - anaemia and infections
- fatigue, wl, fever
- renal impariment
**Steroids and Chemotherapy** Radiotherapy for local painful lesions Bisphosphonates useful Plasmaphoresis vs viscosity Tranfusion vs anaemia, Abx vs infec
malignant bone pain
nsaids good
then think bisphosphonates and radiotherapy
mechanical lower back pain
on exam - stiffness? spasm? scoliosis?
analgesia, physio, gentle exercise
facet joint syndrome
pain worse on extension (or straightening form flexed)
radiate to buttocks
major relief when anaeastheitc injected under xray
=diagnositc
treat: steroid injec, physio, weightloss
fibrositic nodulosis
low back pain rad to buttock thigh
can pinpoint v tender nodules on buttock and iliac crest
benefit from steroid injection into nodules
spondylolisthesis
- vertebrae slipping out of alignment
can cause cauda equina syndrome
in young adult
- due to congenital bilat pars interarticularis defects
in older
- due to degenerative changes (lumbar spondylosis, facet joint OA)
stenosis: spinal & root canal
caused by:
- loss of disk height
- facet joint OA
- bony spurs
- buckling of ligamentum flavum
present with nerve root pain and spinal claudication
spinal claudication:
- pain and paraesth is brought on by walking - gradually disappears on rest
(unlike vascular claud - immed relief, absent pulses)
- may occur in arms if lesion is cervical
DISH
diffuse idiopathic skeletal hyperstosis
ossification of ligaments and muscle insertions
bony overgrowths
stiffness
occurs in lumbar spine but also pelvis, patella, feet
t: analgesia, nsaids, exercise
dermamyositis and polymyositis
inflammation of striated muscle - proximal muscle weakness
eventually may affect respiratory muscles, swallowing
May see interstitial lung disease
derma- when skin also involved
- heliotrope (purple around eye)
- papules on palms soles
High risk malignancy
Anti-Jo antibody (specific), raised CK
Steroid, immunosup
Calcific tendinosis and bursitis
Often seen at shoulder
Deposition of calcium crystals on tendon visible on xray
Pain (acute or chronic) and restricted range of movement
Steroid injection may help
May resolve, persist or become complicated by crystals shedding into subacromial bursae causing bursitis
Bursitis will be hot red v painful - ie differential of gout, pseudogout and septic arthritis
Dupuytrens
Idiopathic or familial
- onset w age, worse in men
also alcoholic liver disease and DM
also trauma, manual labour
Fibrosis of palmar aponeurosis - thickened palmar fascia
- w flexion of fingers
- skin changes (nodules, pitting)
Can be bilateral
Can affect soles of feet
‘Ectopic manifestations’
- fibrosis also seen at knuckles, feet, penis
‘Dupuytrens diathesis’
- early, severe, bilat, w ectopic manifests
Tx: steroid inject, surgical release
Tenosynovitis
Finger flexors
- may cause trigger finger
De quervains - thumb flexor
T: rest splint nsaids
steroid injection
?therapeutic ultrasound
Golfers elbow
Epicondylitis
Flexors insertion into medial epicondyle
Tennis elbow
Extensors insertion into lateral epicondyle
Epicondylitis
Carpal tunnel
Median nerve
Wake at night with tingling numbness pain
- relieved by shaking
Thenar wasting (abd policis brevis)
Tinnels, Phalens
T: night splint - relief: diagnostic; may see full recovery Steroid inj into tunnel (not nerve!) Decompression
Sjogrens
sicca (dry eyes dry mouth)
- schirmer test
raynauds
vasculitis
parotid or lymph gland swelling (risk lymphoma)
anti La and anti Ro
antiphospholipid syndrome APS
thrombosis
recurrent miscarriage
persistently +ve blood test for antiphospholidi antibodies - mainly anti-cardiolipin (ie on 2 occasions, 6wks apart)
can occur alone or with another ARD (autoimmune rheumatic disease) eg SLE (in 20-30%)
can get cerebral and cardiac probs
clinical features APS
thrombosis
- stroke in 20%, DVT in 40%
of ladies who have 2 spont miscarriages, 27% have APS
other assoc features:
- thrombocytop
- chorea, migraine, epilepsy
- valve disease, livedo reticularis, renal involve (thromboses)
test: antiphospholipid antibodies
1) anti-cardiolipin
2) lupus anticoagulant
treat APS
long term warfarin if had thrombosis
during pregnancy - aspirin, subcut heparin
gout
middle aged man
painful red swollen
commonly DIP’s
also often 1st MTP (big toe)
age, obesity, alcohol, protein
metabolic syndrome (dm, ihd, chol, htn)
family history
overprod: alcohol
impaired excretion: renal, htn, drug (diuretic)
negatively birofringent crystals
gout mgmt
flare up respond well to nsaid (diclofenac, naproxen)
- also colchicine
lifestyle - weight, exercise, smoking, diet
- limit beer and spirits (wine ok)
- fizzy drinks
- offer leaflet on foods
allopurinol
- not within month of attack
- can precip, so cover with nsaids
management septic arthritis
aspirate
- gram stain instantly
- but also culture
blood for culture, wcc, esr/crp
start treatment Abx
- iv 2 weeks, oral 6 weeks
- eg fluclox for staph aureus
pseudogout
calcium pyrophosphate crystals
- positively birofringent
elderly women
knee wrist
heamochromatosis/wilsons (in young)
t: nsaids, colchicine
raynauds
primary
or secondary to SSc, SLE, RA
T: CCB
systemic sclerosis SSc
- epid
- aet
- patho
3:1 f:m
30’s 40’s
environmental factors - silica dust, chloride, rapeseed oil, drugs: bleomycin
? genetic factors
patho:
- inc fibroblast act
- vascular damage, excess collagen + fibrosis in tissues partic skin skin
SSc features
limited cutaneous (ana, anti-centromere)
raynauds
70% have limited cutaneous scleroderma
- 15yrs after raynauds get tightening, thickening of skin in hands face feet forearms
- flexion deform in fingers
- beak nose and small mouth
- painful ulcers on fingers
- telangectasia
CREST
- calcinosis, raynauds, eosophageal, sclerodactyl, telangectasia
also see GI involve, pulmonary hypertension
SSc features
diffuse cutaneous (ana, anti-topoisomerase, anti-scl70)
raynauds is quickly followed or concurrent w oedema and stiffness which turns to sclerosis/skin thickening
may have lethargy, weight loss
oesophaegeal: heartburn, reflux, dysphagia
anal incontinence
poor function of bowel - malabsorption
renal involve - chronic or acute eg acute hypertensive renal crisis (often cause of death)
- may see raised bp as first sign
lung - fibrosis, pulm htn
heart - myocardial fibrosis - arrhyth
SSc investigations
CXR to get baseline of heart and lungs in case involved
?Barium swallow
xray hands - calcium deposits
Echo might show pulm htn
SSc blood
aneamia - normochro, normocyt - or haemolytic
urea and elec rise with renal involve
antibodies: ANA in 90% RhF in 30%
limited: anti centromere ACA 70%
diffuse: anti-topoisomerase (aka anti-SCL-70) 30%
SSc management
organ specific
no cure
corticosteroids and immunosuppressants rarely used (except if have pulm fibrosis)
nifedipine for raynauds exercise skin lubricants ppi for oesophageal sx nutritional suppl for malab abx for bacterial overgrowth ace for kidneys
SSc prognosis
in limited form 70% ten year survival
worse survial in diffuse form
death from pulmonary involvement 50% also renal cardiac
large vessel vasculitides
giant cell arteritis
polymyalgia rheumatica
polymyalgia rheumatica
sudden onset severe pain and stiffness of shoulders, neck, hip, lumbar spine
worst in morning
pt >50yrs
tiredness, fever, weightloss, depression, night sweats
15% have GCA
raised ESR and/or CRP =halllmark
raised ALP, GGT
anaemia
assoc w temporal arteritis
PMR and GCA treat
prednisolone for 18m to 2y
- 10-15mg fro PMR
- 40-60mg for GCA (grad reduced)
Aspirin
- red risk of thromboembolic - ie in opthalmic: visual loss
alongside prednis
vit-D, Ca, do DEXA scan
ppi
giant cell arteritis
inflammatory granulomatous arteritis
often in assoc w polymyalgia rheumatica
often temporal
v tender, headache (stabbing), erythema, jaw claudication
**may get sudden painless loss of vision in one eye (involve opthalmic artery)
systemically tiredness malaise fever
anaemia
raised esr and very high CRP
diagnosis: biopsy
medium vessel vasculitis
polyarteritis nodosa
kawasakis
small vessel vasculitis
ANCA assoc:
microscopic poyangitis
wegeners (granulomatous polyangitis)
churg-straus
other:
henoch-schonlein purp
polyarteritis nodosa
initially fever malaise wl myalgia
then acute features due to organ infarction:
neuro (mononeuritis multiplex), abdo, renal, cardiac, skin, lung
T: prednis and immunosuppress
wegeners primarily affects..
lungs and kidneys
perhaps also skin and nerves
kawasaki
mainly affects children under 5
fever lasting more than 5 days
bilat conjunctival congestion
dry, red lips/mouth
redness, oedema on palms, soles
sle presentation
9:1 f:m
in 20’s 30’s
higher in afro-caribbean
ANA positive
fatigue/malaise, arthralgia, skin probs
fever in exacerbations
also: kidney, lungs, cv, nervous, eyes, GI
sle aetiology
ANA positive
family history relevant
some identified genetic links
premenopausal women (also hormone therapy inc flare risk)
UV light: flare up
drug induced sle (mild)
- isoniazid, hydralazine
management of sle
NSAIDs good for arthralgia, fever, pleuritis, pericarditis
- or consider corticosteroids
Can measure anti-dsDNA as marker of activity
Also urine dipstick to monitor kidneys easily
topical steroids for skin
high dose steroids and immunosupression for renal, cerebral
steroids for haemolytic anaemia, thrombocytopenia
immunosuppression: cyclophosphamide, mycofenolate mofetil, azathioprine, rituximab
w/ steroids - bisphopsh, vitd, calcium, ppi
course/prog of sle
episodic
remission may last for long time
but can also be chronic progressive
early death due to severe renal, cerebral, infective comp. then stroke, ihd
joint muscle skin features in sle
joints >90%
- symmetrical small joint pain, some swelling, deformity rare
(nb jaccoud arthropathy - rare type of major joint deformity)
muscle: myalgia in 50%
skin 85%
- butterfly rash
- fingertip/nail fold vasculitic lesions
- photosensitivity
- other: purpura, urticaria, livedo reticularis, palm/plantar rashes, pigmentation, alopecia
raynauds common
(nb discoid lupus - benign variant - only skin)
kidney lungs and CV in sle
kidneys 30%
- glomerulonephritis
- may present with nephritic or nephrotic syndrome
lungs in 50% - pleurisy, effusions, restrictive changes
heart 25%
- pericarditis (as in RA)
- mild myocarditis – arryth
- rarer: valve
cv
raynauds, vasculitis, thrombosis
- higher risk stroke/ihd (due to systemic inflam, vasculitic involve, steroids=atherogenic)
nervous, GI and eyes in sle
nervous involve 60%
- depression, sometime more severe psychiatry
- epliepsy, migraines, cerebellar ataxia, cranial nerve lesions, stroke, polyneuropathy
eyes
- sjogrens
- episcleritis, conjunctivitis, optic neuritis
GI
- mouth ulcers
- vasculitis can affect bowel (inflam, infarct, perforate)
bloods in sle
low wcc, low platelet (due to autoimmune)
anaemia (normochro, normocyt - or autoimmune haemolytic)
esr raised but crp normal (unless partic cause)
urea and creat rise when renal impair
autoantibodies: ANA, anti-dsDNA (more specific less sensitive), anti-Ro, anti-La (also autoimmune hepatitis), anti-Sm (very specific but only 20%)
low C3 and C4
Sle lymph nodes
Axillary and cervical
Risk glandular fever and lumphoma
pregnancy in sle
fertility normal unless in severe disease
but recurrent miscarriage common (esp w antiphospholipid antibodies)
often see exacerbations post paartum (as with RA)
continue usual treatment in preg
anti-Ro anti-La – 2% risk of neonatal lupus (rash hepatitis heart block)
histology in sle
immune depositions seen in biopsies of skin and kidneys
rheumatoid arthritis
70% seropositive (RF)
anti-CCP more specific
commonly female 30’s 40’s
symmet pain swelling stiffness
small joints of hands/feet (especially MCP)
worse in morning
develop wasting, deformity
typically slowly progressive, relapsing remitting
but may be rapidly progressive, or transient remitting
RA investigations
rasied esr, crp
anaemia (normocyt, normochro)
anti-CCP +/- RF
xray: erosion and periartic osteopenia (in advanced disease)
DAS 28
disease activity score
- considers 28 joints - how many tender, how many swollen
- consider esr and crp
- considr subjective ‘global score’ of health
Xray changes in RA
loss of joint space periarticular osteopenia juxtaarticular erosions subluxation and deformity periarticular soft tissue swelling
may see cysts
management RA
NSAIDs and analgesia
-ppi cover over 65
prednisolone to induce remission
DMARDs: methotrex/sulfasalazine
- then combine
- then consider biolog (antiTNF)
non-articular RA manifestations
anaemia
soft tissue
- nodules, bursitis, tenosynovitis
lung fibrosis
pericarditis
cvd risk
eyes
- dry eyes and mouth (sjogrens)
- scleritis
kidneys
methotrexate counselling
pill taken weekly
long term for disease control
take folic acid also (three days later)
gen se:
- mouth ulcers
- GI upset
more signif: pulmonary liver bone marrow (infection, bruise) renal
> > do bloods and ray before
monitor bloods every month (more initially)
limit alcohol
contraception: avoid pregancy
avoid trimethoprim and septrin (talk to doc)
avoid live vaccines (talk to doc)
sulfasalazine counselling
long term for disease control
gradually increase dose
(od for 1 week, bd fro a week…up to qds)
take daily after food
enteric coated
gen se: mouth ulcer, GI, rash
also: stain urine and contacts
signif:
- thrombocyto (infection, bruising)
- liver
baseline bloods then 4 monthly once stable
osteoarthritis
DIP’s affected most
- heberden’s (may also see bouchard’s)
worse with activity, late in day
big joints also effected
- weight bearing
xray: loss of space, osteophytes, sclerosis
OA on exam
heberden & bouchard no major deformity crepitus tender limited movement ?may see effusion, wasting
Yellow flags - poor psychological prognosis
Think rest good, exercise bad for back
OA xray changes
narrowing of joint space
osteophytes (spurs) - quite specific
sclerosis - quite specific
cysts
?can see erosions in postmenopausal women
management OA
weight loss
exercise
hydrotherapy/massage
paracetamol
NSAIDs - local gel (eltenac)
opioid analgesia
(oral nsaids and aspirin not routinely used)
joint injection +/- aspiration
replacement
osteo vs rheumatoid arthritis
rheum
- systemic sx
- worse in am
- effusions
- nodes on extensors (not heb/bouch)
- symmetrical
osteo
- big joints
- more painful throughout day
- heberden and bouchard nodes on fingers
- asymmet
- less swelling
joint pain history
cardinal Sx: swelling, pain, tender, stiff
- which joints
- when worst (early, late)
other Sx: skin (psoriasis) nails eyes lower back pain (p.a)
family history
pmh
diet (especially alcohol for gout)
Psoriatic arthropathy
arthritis in people w psoriasis (10%) - often just DIP's symmetrically but may be poly - nail changes prominent - also enthesitis and tenosynovitis - sausage fingers/toes (dactylitis) (also in reactive)
5% have arthritis mutilans - telescoping
15% have lower back pain (spondylosis, sacoiliitis)
seronegative (no markers)
but 50% hla-b27
xray: pencil in cup
tx: nsaid, analg, steroid injection, methotrex/sulfa
Nail changes
Psoriatic HOP
- hyperkaratosis
- onycholisis
- pitting
RA
- linear ridging +
behcets disease
polyarthritis
recurrent oral ulceration
ant uveitis
neurological probs - like dementia, ms, parkinsons
steroid, immunosupress
reactive arthritis
sterile synovitis following infection (by days or weeks)
- dysentry, uti, std
higher risk if hla b27
more in men
acute, asymmetrical, lower limb
- knee
- mtp
- dactylitis (sausage toes)
also
- enthesitis (plantar, achilles)
if severe:
- urethritis
- lower back pain (SIJ, spondy)
- foot rash (keratoderma blennorhagica)
- ulcers on glans penis
treat infection if still present
NSAID, joint injec
if relapsing: methotrexate
nsaids
renal impair
gastric irritation
asthma
allopurinol se
skin rash
GI upset
rarely: hypersensitive
steroid side effects
bones (vit-D, Ca, DEXA)
gastric (PPI)
weight gain, sleep disturb, infection
less freq: diabetes, cushings
fibromyalgia
history of widespread pain
multiple widespread points of tenderness
?exercise beneficial
?low dose amitriptyline
knee complaints in kids
chondromalacia patellae
- teen girls
- ant knee pain up and down stairs/ standing up
- > physio
O-S
- sporty teen
- tib tubercle pain tender swell
patellar tendonitis
- sporty boys
- worse w activity
- tender below patellar
osteo chondritis disecans
- pain post exercise
- intermittent welling and LOCKING
patellar subluxation
- med knee giving way
tallipes equinevarus - club foot
inverted plantar flex deform at birth
grad non surgical correction
autoantibodies summary
AMA - prim bil cirr SMA, ANA - auto hep ANA, anti-dsDNA, anti-Smith - SLE RhF, anti CCB - RA ANA, anti centromere - cutaneous SSc ANA, anti topoisomerase - diffuse SSc
