Rheumatology and Ortho Flashcards
Differentials of hip pain in a child
Septic Arthritis Perches disease Transient synovitis Slipped upper femoral epiphysis Developmental dysplasia of the hip JIA Cancer Fracture Referred pain from knee, back, testes
Transient synovitis
Boys aged 4-8 Limp with or without pain Self limiting Occurs after URTI treat with ibuprofen Resolves after few days Sepsis safeguard!
Slipped upper femoral epiphysis
Boys over age of 10 Usually obese or hypothyroid Sudden onset pain Non weight bearing Limp
Developmental dysplasia of the hip
Girls, usually discovered at birth
Change in leg length
Perthes disease
Boys aged 4-8
Avascular necrosis of head of femur
Can be bilateral
Hip pain in child- Nocturnal pain, night sweats, weight loss
Think ALL!
Treatment of osteoarthritis
Patient education Weight loss Exercise Physio Analgesia- WHO ladder Can escalate to steroid joint injections Joint replacement
X-ray changes in osteoarthritis
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
Osteoarthritis examination findings
Heberdens nodes on DIP
Bouchards nodes on PIP
Boxing of hand
Rheumatoid Arthritis X-ray findings
LESS loss of joint space Erosions Soft tissue swelling Soft bones (osteopenia)
Rheumatoid arthritis clinical examination findings
Ulnar deviation of fingers Subluxation of joints Z thumb Boggy joint swellings Swan neck deformities Boutinierres deformity
Can have nail changes
Negatively birefringent needles under polarised light
Gout - urate crystals
Treatment of gout
Ibuprofen or colchicine if ibuprofen contraindicated
Febuxostat also used
Allopurinol if repeated attacks (be aware of increase in episodes in first 6 months)
Risk factors for gout
High urate intake- red meats, marmite, alcohol
Diuretic use especially thiazides
Metabolic disorders (genetics)
Dehydration
Pseudogout
Calcium pyrophosphate crystals
Weakly positive rhomboid shaped crystals
Treatment- ibuprofen, steroid injections, stay hydrated
Describe a fracture
Simple vs comminuted Transverse, oblique, spiral Site Displaced or not Angulated or not Is the bone normal?
Ask for lateral view
Treatment of intra capsular neck of femur fracture
Hemiarthroplasty if not very active and co morbidities
Full hip replacement if active and healthy or pre existing joint disease
Presentation of hip fracture
Pain especially on greater trochanter and on rotation Usually after fall Leg externally rotated Shortened leg Non weight bearing
Could be referred to knee
Treatment of extra capsular NOF fracture
Dynamic hip screw or intramedullary fixation
Think about bone protection, analgesia, IV access
Secondary causes of OA in young people
Crystal deposition, acromegaly, haemochromatosis, Wilson’s disease, joint injury, surgery, SUFE, diabetes, syphillis, inflammatory arthritis
Hot swollen painful joint
Septic arthritis until proven otherwise!
Gout Rheumatoid arthritis Pseudogout Psoriatic arthritis Haemoarhrosis Reactive arthritis
Symptoms of septic arthritis
Hot painful swollen joint
Systemically unwell
Fevers
Acute onset
Diagnosis of septic arthritis
Joint aspirate and culture!!
Treatment of septic arthritis
Analgesia
Broad spec antibiotics eg ceftriaxone
Usually a stall aureus infection
Look for underlying risks such as immunosuppression
Back pain In 15-30 YOA
Prolapsed disc
Trauma
Fractures
Ankylosing spondylitis
Back pain in 30-50 YOA
Degenerative spinal disease, prolapsed disc, malignancy
Back pain in over 50s
Degenerative, osteoporotic vertebral collapse, pagets, malignancy, myeloma, spinal stenosis
Positive straight leg raise
Sciatica
Under 50s due to prolapsed disc
Over 50 due to spinal stenosis
Symptoms of lupus
Malar rash Discoid rash Photosensitivity Oral ulcers Arthritis Pleuritis Renal involvement Haematological involvement Immune involvement Positive ANA
SLE antibodies
ANA >95%
Anti dsDNA- over 60%
Treatment for SLE
Anti inflammatories eg ibuprofen
Corticosteroids during flare up
Immunosuppression
Symptom control- suncream, kidney treatment if necessary
Positive c-ANCA
Small vessel vasculitis
Microscopic polyangitis
GPA
GPA- granulomatosis polyangitis
Positive c ANCA
Nasal crusting, lung lesions, saddle nose deformities
P ANCA
Church Strauss
Eosinophilia granulomatosis polyangitis EGPA
Linked with asthma
Medium vessel vasculitis
Kawasaki- symptoms in children, fever, strawberry tongue, rash
Giant cell arteritis
Temporal arteritis Give prednisone ASAP Need biopsy within seven days of starting pred to get positive biopsy. Increase ESR!! Jaw claudication Temporal tenderness Headache around eye
Takayasu’s arteritis
Absent pulses
Happens in younger People
PET scan shows activity
Pred and strong DMARDS eg cyclophosphamide
Polyarteritis nodosa
Associated with hep B
Get aneurysms
Control BP as affects kidneys
Symptoms of fibromyalgia
Pain in at least 11 of the 18 pain points- above and below waist, either side of axis and on spine
Difficulty sleeping
Chronic widespread pain lasting over three months
Risk factors of fibromyalgia
Low education, low income, female, FH, traumatic event
Treatment for fibromyalgia
Exercise!
Screen for depression and anxiety
Sleep hygiene
Reactive arthritis
After GU or GI infection
Reiter’s anterior uveitis, arthritis, urethritis
Ankylosing spondylitis
Back pain In young males
HLAB27 positive in 90%
Pain in sacroiliac joints
Associations with ankylosing spondylitis
Aortic regurgitation Apical fibrosis igA nephropathy Anterior uveitis Achilles tendinitis Amyloidosis
Treatment of ankylosing spondylitis
- Exercise
- Ibuprofen
- If necessary anti TNF-a or local steroid injections
Symptoms of rheumatoid arthritis
Boggy swelling in hands
Stiffness and pain worse in morning
Symmetrical usually in wrists, MCP, PIP
Positive for RF and anti CCP
Monitor rheumatoid arthritis
DAS28 helps to monitor disease activity
side effects of methotrexate
Mucositis, penumonitis, oral ulcers, hepatotoxicity
TNF alpha blocker side effects
Serious infection risk including reactivation of TB, hep B
Worsens heart failure
Hypersensitivity
Injection site reaction
Anti Ro and Anti La
Sjogrens
CREST
Anti centromere antibodies
Anti SCL 70
Scleroderma
Anti ds DNA and ANA
SLE
