Rheumatology Flashcards
What is the name given to inflammation of an entire digit?
Dactylitis.
What is the approach used for managing trauma patients?
ATLS - treat the greatest threat to life first (ABCDE).
What is the physis?
The physis is the growth plate in paediatric bone.
What feature of paediatric bone means it can heal rapidly?
The thick periosteum.
Describe the 3 initial steps in the management of fractures.
- Reduce the fracture e.g. restore the length, alignment, rotation.
- Immobilise.
- Rehabilitate.
What is often the first line management option for paediatric fractures?
Non-operative management e.g. traction, casts, splints. This is because paediatric bone heals quickly due to the thick periosteum.
What can happen if the physis is damaged?
Physis damage -> growth arrest -> deformity.
What is the name of the classification used for fractures involving the physis?
Salter-Harris Fracture classification.
Salter-Harris Fracture classification: describe a type 1 fracture.
Transverse fracture through the growth plate.
Salter-Harris Fracture classification: describe a type 2 fracture.
A fracture through the growth plate and metaphysis.
Salter-Harris Fracture classification: describe a type 3 fracture.
A fracture through the growth plate and epiphysis.
Salter-Harris Fracture classification: describe a type 4 fracture.
A fracture through the metaphysis, physis and epiphysis. These fractures often need fixation.
Salter-Harris Fracture classification: describe a type 5 fracture.
Crush injury of growth plate! These fractures have a very poor prognosis and growth arrest is likely.
Give 2 ‘red flag’ signs of non-accidental injury in children.
- Long bone fracture in a child unable to walk.
2. Multiple bruises and fractures.
Describe the management for non-accidental injury in children.
- Admit the child!
- Skeletal survey.
- Referral to paediatric medics and safeguarding services.
What can cause a supracondylar fracture in children?
Falling on an outstretched hand.
What nerve might be affected in a supracondylar fracture?
The median nerve.
What is the treatment for a supracondylar fracture?
K-wires.
Give 5 potential complications of fractures.
- Open fractures.
- Neurovascular compromise.
- Mal union - bone heals with deformity.
- Non union - bone fails to heal.
- Compartment syndrome.
- Cast problems e.g. tightness, compartment syndrome, plaster burns/blisters.
What is the most serious complication of arthroplasty surgery?
Prosthetic joint infection.
Give 2 ways in which prosthetic joint infections can be prevented.
- Aseptic environment and laminar air flow.
2. Systemic prophylactic antibiotics.
What investigations might you do on someone who you suspect might have a prosthetic joint infection.
- Aspirate -> microbiology.
- Bloods for inflammatory markers and FBC.
- X-rays.
What are the three aims of treatment for prosthetic joint infections?
- Eradicate sepsis.
- Relieve pain.
- Restore function.
Prosthetic joint infections: what treatment might you choose for a patient that is unfit for surgery?
Antibiotic suppression.
What is the gold standard treatment for prosthetic joint infections?
Exchange arthroplasty.
- Radical debridement of all infected and dead tissue.
- Systemic and local antibiotic cover.
- Sufficient joint and soft tissue reconstruction.
Name 2 NSAIDs.
- Ibuprofen.
2. Naproxen.
Give 3 side effects of NSAIDs.
- Peptic ulcer disease.
- Renal failure.
- Increased risk of MI and CV disease.
What can you do to reduce the risk of gastric ulcers and bleeding in someone taking NSAIDs?
- Co-prescribe PPI.
2. Prescribe low doses and short courses.
Give 5 potential side effects of steroids.
- Diabetes.
- Muscle wasting.
- Osteoporosis.
- Fat redistribution.
- Skin atrophy.
- Hypertension.
- Acne.
- Infection risk.
How do DMARDs work?
Non-specific inhibition of inflammatory cytokine cascade = reduced joint pain, stiffness and swelling.
Give an example of a DMARD.
Methotrexate = gold standard.
Hydroxychloroquine.
Sulfasalazine.
How often should methotrexate be taken?
Once weekly.
Give 3 potential side effects of methotrexate.
- Bone marrow suppression.
- Abnormal liver enzymes.
- Nausea.
- Diarrhoea.
- Teratogenic.
What can be co-prescribed with methotrexate to reduce the risk of side effects?
Folic acid.
What are cytokines?
Short acting hormones.
Name a TNF blocker.
Adalimumab.
Name a monoclonal antibody that binds to CD20 on B cells.
Rituximab: binds to CD20 -> B cell depletion.
Describe the mechanism of action of abatacept?
Inhibits T cell activation.
With what disease would you associate the ‘pencil-in-cup erosion’ seen on a plain XR with?
Psoriatic arthritis.
With what disease would you associate the Schirmer’s test?
Sjögren’s syndrome.
You do some investigations on a 30 y/o woman who has presented with painful, red and swollen MCP and PIP joints. The XR shows swelling of soft tissues, deformity and loss of joint space. What auto-antibodies would you expect to see in the serum?
Anti-CCP and RF positive.
This patient has rheumatoid arthritis.
How does alendronate work?
Alendronate reduces bone turnover by inhibiting osteoclast mediated bone resorption.
What class of drug is alendronate?
Bisphosphonate.
Name 2 drugs that act on the HMGCoA pathway.
- Bisphosphonates e.g. alendronate.
2. Statins e.g. simvastatin.
What auto-antibodies are often present in people with RA?
RF and anti-CCP.
A patient presents with an acute mono-arthropathy of their big toe. What investigations might you do?
Joint aspirate.
If septic arthritis - high WCC and neutrophilia and bacteria on gram stain.
If gout - urate crystals.
What is polymyalgia rheumatica (PMR)?
A condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips
What disease is giant cell arteritis associated with?
Polymyalgia rheumatica.
What class of drugs can cause Raynaud’s?
Beta blockers.
What class of drugs does Nifedipine fall into and why can it be used to treat Raynaud’s?
Nifedipine - CCB.
It relaxes blood vessels and stops vasospasm.
What condition must be always ruled out in a acutely inflamed joint?
Septic arthritis.
Aspirate the joint!
An elderly man presents with worsening bone pain and is found to have an enlarged and bowed tibia. What is the most likely diagnosis?
Paget’s disease of bone.
What cells secrete RANK ligand?
Osteoblasts.
What is the function of RANK ligand?
It binds to osteoclasts and is essential for their formation, function and survival.
What protein inhibits RANK ligand?
OPG.
What is the function of OPG?
OPG inhibits osteoclast formation, function and survival by binding RANK ligand; it prevents RANK ligand from binding to osteoclasts.
What is the affect of unopposed RANK ligand?
Unopposed RANK ligand leads to increased bone loss. More osteoclasts are stimulated due to a lack of OPG.
What enzyme, expressed by osteoclasts, is responsible for bone resorption?
Cathepsin K.
