Rheumatology and musculoskeletal Flashcards
What is Reiter’s syndrome?
urethritis + conjunctivitis + arthritis
young males usually
buttock/sacroiliac pain worse in the morning, relieved by exercise
syndesmophytes, bamboo spine
ankylosing spondylitis
What conditions are associated with ankylosing spondylitis?
4 A’s
arthritis
anterior uveitis
apical lung fibrosis
aortic regurgitation
arthritis in IBD patients
enteropathic arthropathy
usually asymmetrical, mainly affectes lower limbs
features of systemic sclerosis
Calcinosis (nodules)
Raynaud’s phenomenon
Oesophageal dysmotility
Sclerodactyly
Telangiectasia
What is polymyositis?
proximal muscle weakness, pain and tenderness
elevated serum CK
if purple rash -> dermatomyositis
Churg-Strauss syndrome features
middle aged men
asthma + rhinitis + systemic vasculitis
+++ eosinophils
What disease is anti-dsDNA antibodies associated with?
SLE
What disease is anti-Jo 1 antibodies associated with?
polymyositis
What disease is anti-centromere antibodies associated with?
limited systemic sclerosis
What disease is anti-topoisomerase antibodies associated with?
diffuse systemic sclerosis
What disease is cANCA and anti-PR3 antibodies associated with?
wegener’s granulomatosis
What disease is anti-mitochondrial antibodies associated with?
primary biliary cirrhosis
What disease is alpha-endomysial antibodies associated with?
coeliac disease
What are the radiological findings of osteoarthritis?
loss of joint space
subchondral sclerosis
sybchondral cysts
osteophytes
What are the radiological findings of rheumatoid arthritis?
loss of joint space
juxta-articular osteoporosis
erosions, subluxation joints
What are the radiological findings of ankylosing spondylitis?
syndesmophytes
bamboo spine appearance
malignant bone disease
malignant
- osteosarcoma
- Ewing sarcoma
- chrondrosarcoma
- metastatic disease (secondary)
- haematopoietic
what abnormal bone growth response very well to aspirin to relieve pain?
osteoid osteoma (benign)
features of osteosarcoma
- RF: Paget’s, radiation
- most sporadic
- around knee, proximal humerus, femur
- sclerosis/lytic areas, cortical destruction, Codman triangle (elevation of periosteum), sunray spicules (calcification within tumour but outside of bone)
features of osteosarcoma
- RF: Paget’s, radiation
- most sporadic
- around knee, proximal humerus, femur
- sclerosis/lytic areas, cortical destruction, Codman triangle (elevation of periosteum), sunray spicules (calcification within tumour but outside of bone)
features of chondrosarcoma
- lytic lesion with cortical destruction and central calcification
- growth in pelvis and hip commonly
Ewing sarcoma
- small cell sarcoma
- flat bones (long, femur or tibia, pelvis or vertebra)
- unwell, swelling, fever, warm area
- lytic lesion with laminated periosteal reaction
- onion skinning
pseudogout aspirate features
- calcium pyrophosphate crystals
- positive birefringent
- rhomboid crystals
what is this:
- calcium pyrophosphate crystals
- positive birefringent
- rhomboid crystals
pseudogout
features of gout on aspirate
- monosodium urate crystals
- need shaped
- negatively birefringent
what is this:
- monosodium urate crystals
- need shaped
- negatively birefringent
gout
Musculocutaneous nerve:
- origin
- sensory
- motor
Musculocutaneous nerve:
- origin - C5, C6, C7
- sensory - lateral forearm
- motor - BBC (biceps brachii, brachialis, coracobrachilis)
Axillary nerve:
- origin
- sensory
- motor
Axillary nerve:
- origin - C5/C6
- sensory - sergeant’s patch over lower deloit
- motor - deltoid, teres minor
muscles of the rotator cuff
supraspinatus
infraspinatus
teres minor
subscapularis
Radial nerve:
- origin
- sensory
- motor
Radial nerve:
- origin - C5, C6, C7, C8, T1
-
sensory
- lower posterior arm
- posterior forearm
- lateral ⅔ dorsum (back)
- proximal dorsal aspect of lateral 3 ½ fingers
-
motor
- triceps brachii (posterior compartment arm)
- posterior compartment of forearm
- wrist + finger extensors
- brachioradialis
- supinator
Median nerve:
- origin
- sensory
- motor
Median nerve:
- origin - C5-8, T1
-
sensory
- thenar eminance
- lateral ⅔ of palm of the hand
- palmar aspect of lateral 3 ½ fingers
- distal dorsal aspect of lateral 3 ½ fingers
-
motor
- all muscles in anterior compartment except flexor carpi ulnaris and medial 2 parts of flexor digitorum profundus
- wrist + finger flexers
- pronator teres and quadratus
- LOAF muscles of hand
- lateral 2 lumbrical
- opponens pollicis
- abductor pollicis brevis
- flexor pollicis brevis
- all muscles in anterior compartment except flexor carpi ulnaris and medial 2 parts of flexor digitorum profundus
Ulnar nerve:
- origin
- sensory
- motor
Ulnar nerve:
- origin - C8, T1
- sensory
- hypothenar eminence
- medial ⅓ of palm of hand
- palmar aspect of medial 1 ½ fingers
- whole dorsal aspect of medial 1 ½ fingers
- medial ⅓ dorsum of hand
- motor
- anterior arm - flexor carpi ulnaris, medial 2 parts of flexor digitorum profundus
- HILA hand mucles
- hypothenar eminence
- interossei
- lumbricals (medial 2)
- adductor pollicis
Median nerve:
- common injuries
- results of injury
Median nerve:
- common injuries
- rare
- stab to upper arm
- results of injury
- S - numb lateral fore arm
- M - weak elbow flexion + supination, absent biceps reflex
- wasting of biceps
Axillary nerve:
- common injuries
- results of injury
Axillary nerve:
- common injuries
- # surgical neck of humerus
- stab wound to posterior shoulder
- compression by shoulder dislocation/crutches
- results of injury
- S - numb sergeant’s patch
- M
- very weak shoulder abduction 15-90 degrees
- weak shoulder flexion, extension, external rotation
- wasting of deltoid
radial nerve:
- common injuries
- results of injury
Radial nerve:
- common injuries
- # proximal humerus, humeral shaft or proximal radius
- stab to ACF/forearm/wrist
- compression - crutches, sleep on arm, tight cast, long tourniquet
- results of injury
- S - number posterior arm + forearm, numb hand in radial distrubition
- M
- weak elbow extension
- absent triceps reflex
- weak wrist + finger MCPJ extension
- absent supinator
- wrist drop
nerve for each colour
what is this? nerve injury ?
wrist drop
radial nerve
what is this sign?
nerve injury?
hand of benediction on attempting finger flexion
median nerve
what is this sign?
what nerve associated?
claw hand
ulnar nerve injury
median nerve:
- common injuries
- results of injury
median nerve:
- common injuries
- supracondylar humerus #
- stab wounds ACF, forearm, wrist
- compression at carpal tunnel
- results of injury
- S
- numb thenar eminence and median hand area
- M
- weak pronation
- weak wrist flexion + abduction
- weak finger flexion (ring + little preserved)
- weak grip strength
- wasting of thenar eminence and anterior foreman
- hand of benediction
- S
ulnar nerve:
- common injuries
- results of injury
radial nerve:
- common injuries
- # supracondylar humerus, medial epicondylar
- stab to forearm or wrist
- compression at cubital tunnel in elbow or Guyon’s canal in wrist
- results of injury
- S
- numb hypothenar eminence
- numb ulnar hand distribution
- M
- weak wrist flexion
- weak wrist adduction
- weak flexion of ring + little fingers MCPJs and DIPJs + extension of IPJs
- weak finger abduction, adduction + opposition
- wasting of intrinsic hand muscle
- claw hand
- S
describe common peroneal injury
- L4, L5, S1, S2
- damage around neck of fibula
- causes
- foot drop
- inversion of foot
- anaesthesia over anterior + lateral leg + foot
features of femoral nerve injury
- weak thigh flexion
- no leg extension
- no knee reflex
- anterior thigh + medial leg anaesthesia
features of obturator nerve injury
- loss of thigh adduction
- sensory loss of medial thigh
features of superior gluteal nerve
- waddling gait
- positive trendelenburg sign
features of inferior gluteal nerve injury
- lose ability to rise from seated, climb stairs, incline or jump
- walk leaning back at heel strike
features of common fibular injury
- blow to lateral aspect of leg or # neck of fibula
- no foot eversion or dorsiflexion
- no toe extension
- anterolateral leg and dorsum foot anaesthesia
- can’t stand on heels
antibody for SLE
ANA +ve
dsDNA +ve
ENA +ve - any of Ro, La, Sm, RNP
what disease is this?
ANA +ve
dsDNA +ve
ENA +ve - any of Ro, La, Sm, RNP
SLE
antibodies for Sjogrens
ANA +ve
ENA +ve for anti-Ro and anti-La
what disease?
ANA +ve
ENA +ve for anti-Ro and anti-La
Sjogren’s
what Ab in diffuse cutaneous systemic sclerosis?
scl70
what bloods are used to monitor SLE?
C4 and C3 complement
ESR
ds-DNA
what disease with scl70?
diffuse cutaneous systemic sclerosis
what Ab in CREST?
limited cutaneous systemic sclerosis
limited cutaneous systemic sclerosis
anti-centromere
anti-centromere Ab - what disease?
limited cutaneous systemic sclerosis
CREST
antibodies for mysoitis
anti-jo1
t-RNA synthetase
what drugs are used to manage Raynaud’s?
- avoid cold, keep whole body warm, heated gloves
- CCB - nifedipine or amlodipine
- specialised
what drugs are used to manage Raynaud’s?
- avoid cold, keep whole body warm, heated gloves
- CCB - nifedipine or amlodipine
- specialised
what are the types of epiphyseal injuries? (SALTER HARRIS)
- I - S - straight across
- II - A - above
- III - L - Lower
- IV - TE - Throughout everything
- V - R - cRush
- II most common
- I has the lowest risk and V the highest risk of growth plate injury, in turn altering prognosis what i
how can you describe fractures?
- Descriptive classifications
- Transverse - fracture at 90 degrees to bone longitudinal axis. Usually due to direct force at fracture site
- Oblique - fracture diagonal to bone longitudinal axis
- Spiral - fracture where bone has been twisted
- Comminuted - bone broken into several placed, direct force, high energy
-
Avulsion - fragment of bone tears away from the main mass of bone as a result of physical trauma
- Associated with ligament and tendon insertion sites
- Greenstick fracture - fracture in children, incomplete fracturing across a bone
- Crush fracture - result of compression
- Burst fracture - usually seen in vertebrae due to disc impaction
-
Fracture dislocation or subluxation - involvement of joint resulting in misalignment of joint surfaces
- Dislocation = complete loss of
- Associated features
- Complicated - damage to nerves, vessels or internal organs
- Displacement - relationship of bone fragments to normal alignment of bone. Can be described as un-displaced, <50%, > 50%
what are the types of fracture healing?
primary - direct contact, uses cone-cutter pathway of osteoclast-osteoblast layers
secondary - some gap. occurs in stages
what are the stages of secondary bone healing?
- Haematoma formation - bleeding makes haematoma, neutrophils recruit macrophage via cytokines
- Injury - 48 hours after
- Soft callous formation
- 2 days - 2 weeks
- Hard callous formation - aim for by 3 months
- Remodelling - over 18 months to form lamellar bone from woven bone
what is varus?
distal part is more medial than the proximal
VARUS
what is valgus?
when the distal part is more Lateral than the proximal
what are the requirements for bone healing?
- minimal # gap
- no movement if primary, some movement if indirect
- patient physiology - age, DM, smoking, nutritional status
what are the principles of fracture management?
- reduce
- hold
- rehabilitate (move)
what are the main causes of non or mal union?
- Ischaemia - poor vascular supply or AVN
- Infection
- ↑ interfragmentary strain
- too much movement, large gap
- Interposition of tissue between fragments
- Intercurrent disease e.g. malignancy or malnutrition, smoking
what are the management principles of open #?
-
6As of management
- Analgesia
- Assess - NV status, soft tissue, photograph
- Anti-sepsis - wound swab, copious irrigation, cover with betadine soaked dressing
- Alignment - align and splint
- Anti-tetanus - check status, booster lasts 10 years
- Antibiotics - within 1 hour of injury
- Flucloxacillin 500mg IV/IM with benzylpenicillin 600mg IV/IM
- Definitive - debridement and fixation in theatre, aim for within 24 hours of injury
complications of fractures (general)
- early
- neurovascular damage, DVT, PE, fat embolism, crush, compartment syndrome
- late
- late wound sepsis, failure of fixation, malunion, joint stiffness or contracture, AVN, regional pain syndrome
specific fracture associated palsies
-
Anterior shoulder dislocation + Humeral surgical neck #
- Axillary nerve
- Numb chevron
- Weak abduction
- Axillary nerve
-
Humeral shaft #
- Radial nerve - Waiter’s tip sign
-
Elbow dislocation
- Ulnar nerve - Claw hand
-
Hip dislocation
- Sciatic nerve - Foot drop
-
# neck of fibula + Knee dislocation
- Fibular nerve - Foot drop
summary of OA treatmetn
- conservative
- analgesia
- physio
- walking aids
- avoid exacerbating activity
- injection - steroid
- operative
- replace joint
- realign
- excise
- fuse
- synovectomy (more for RA)
- denervate (wrist)
describe the salter harris classification
causes of Dupuytrens contractures
- idiopathic
- age
- alcoholic liver disease
- trauma
- familial (AD)
- drugs - phenytoin
- epilepsy
normal ROM shoulder
- flexion 180, extension 50
- abduction - 180, adduction 45
- internal rotation and external rotation - 90
RF for adhesive capsuliti
surgery
immobility
trauma
key features of axillary nerve palsy
loss of lateral deltoid sensation (regimental patch)
weak abduction of shoulder and weak elbow flexion
what to always check before a hip examination
native or prosthetic hip
RF for septic arthritis
age, DM, joint prosthesis, IVDU
causes of foot drop
- Common peroneal nerve injury (# or op)
- Sciatic nerve injury, L4 , L5 disc herniation with L5 nerve root compression
- Central causes – MND, MS, stroke, brain tumour, Parkinsonism
- Diabetes, Vit. B12 deficiency, alcohol
what are the 3 questions for GALS?
-
Do you have pain/stiffness in muscles, joint or back?
- Osteoarthritis, rheumatoid arthritis, ankylosing spondylitis
-
Do you need help dressing?
- Fine motor impairment, restricted joint movement
-
Do you have problems going up and downstairs?
- Gross muscle wasting/lower motor lesions, restricted joint movement
Fore arm fracture - Galleazi and Monteggia
GRUM G - Radial # distal + distal radio-ulnar dislocation M - ulna # proximal + proximal radio-ulnar dislocation
What drugs cause drug induced lupus?
Procainamude Hydralazine Isoniazid Phenytoin
What is the antibody seen in drug induced lupus?
Anti histone ANA + Anti dsDNA -ve
management of NOF
