Rheumatology and Orthopaedics Flashcards
1
Q
What are the red flags for back pain?
A
Age <20 or >50 history of previous malignancy night pain history of trauma systemically unwell e.g. weight loss, fever
others- thoracic pain, immunosuppression, structural deformity, neuro signs
2
Q
What are back pain emergencies?
A
infection, malignancy, nerve compromise and fracture
3
Q
What features of back pain point towards a prolapsed disc?
A
leg pain usually worse than back
pain often worse when sitting
4
Q
What features are of a L3 nerve compression?
A
sensory loss over anterior thigh
weak quads
reduced knee reflex
+ve femoral stretch test
5
Q
What features are of a L4 nerve compression?
A
sensory loss over anterior knee
weak quads
reduced knee reflex
+ve femoral stretch test
6
Q
What features are of a L5 nerve compression?
A
sensory loss over dorsum of foot
weakness in foot and big toe dorsiflexion
reflexes intact
+ve sciatic nerve stretch test
7
Q
What features are of a S1 nerve compression?
A
sensory loss posterolateral leg and foot
weakness in plantar flexion
reduced ankle reflex
+ve sciatic nerve stretch test
8
Q
What features of back pain point towards peripheral arterial disease?
A
pain on walking, relieved by rest
absent or weak foot pulses
smoking history or other vascular disease
9
Q
What syndromes are associated with HLA-B27?
A
ankylosing spondylitis
reiter’s syndrome
acute anterior uveitis
10
Q
What is ankylosing spondylitis?
A
ankylosing= stiffness in a joint spondylitis= inflammation of the spine
11
Q
What are associations of ankylosing spondylitis?
A
IBD
Chlamydial urethritis
psoriasis
12
Q
features of ankylosing spondylitis?
A
lower back pain and stiffness
worse in morning and improves with exercise
reduced lateral and forward flexion
reduced chest expansion
13
Q
‘A’ features of ank spond?
A
Apical fibrosis Anterior uveitis Aortic regurg Achilles tendonitis AV node block Amyloidosis Peripheral arthritis
14
Q
Ix of ank spond?
A
ESR/CRP
HLA-B27
Xray of sacroiliac joints- later findings are bamboo spine, subchondrial erosions, sclerosis, squaring of the lumbar vertebrae, syndesmophytes
15
Q
Tx of ank spond?
A
encourage regular exercise
NSAIDs
DMARDs
Anti-TNF if persistently high disease activity (must have failed 2 NSAIDs first)
16
Q
What are features of spinal cord compression?
A
back pain- may be worse on lying down and coughing
lower limb weakness
sensory loss and numbness
nocturnal
lesions above L1-> UMN signs in legs and a sensory level
lesions below L1->LMN signs in the legs and perianal numbness
17
Q
Mx if you suspect spinal cord compression?
A
Whole spine MRI
high dose dexamethasone
urgent oncological assessment for consideration of radiotherapy or surgery
18
Q
What is cauda equina syndrome?
A
Damage to the cauda equina- peripheral nerves protruding from the bottom of the spinal cord
19
Q
What is the structure of the spinal cord?
A
31 spinal nerves C8 T12 L5 S5 1 coccygeal L5 onwards travel together to form the cauda equina
20
Q
What are causes of cauda equina syndrome?
A
lumbar disc herniation spinal stenosis AS spondylolisthesis- vertebra displaced by trauma, surgery or degeneration e.g. anterolisthesis Trauma to spine
21
Q
features of cauda equina syndrome?
A
incontinence due to decreased tone of anal sphincter and muscles of bladder wall decreased sexual function saddle anaesthesia leg weakness sciatic pain
22
Q
Diagnosis of cauda equina syndrome?
A
MRI/CT
23
Q
Tx of cauda equina syndrome?
A
surgical decompression within 48 hours of sudden onset (tumour,trauma)
corticosteroids and Abx of gradual onset (degeneration)
24
Q
What are general features of rheumatoid arthritis?
A
swollen,painful joints in hands and feet stiffness worse in mornings and hot weather gradual larger joint involvement positive squeeze test- metacarpals rheumatoid nodules
25
What are hand signs of rheumatoid arthritis?
```
swan necking
Z-thumb
subluxtion of the MCP
muscle wasting
ulnar deviation
fixed flexion deformity- Boutonniere deformity
```
26
Name some eye signs of rheumatoid arthritis?
keratoconjunctivitis sicca
episcleritis/scleritis
corneal ulceration
27
Name some pulmonary signs of rheumatoid arthritis?
pulmonary fibrosis, pleural effusion, pulmonary modules, pleurisy, caplan's syndrome, infection secondary to immunosuppression
28
Name some systemic signs of rheumatoid arthritis?
```
swollen bursea
anaemia
vasculitis
lymphadenopathy
splenomegaly
Raynaud's Sjogren's syndrome
septic arthritis
amyloidosis
pericarditis
depression
```
29
Ix of rheumatoid arthritis?
```
RF circulating antibody
anti-CCP antibody
ESR/CRP
Joint aspiration
MRI
XR
```
30
XR findings of rheumatoid arthritis?
Loss of joint space
Erosions (periarticular)
Soft tissue swelling
Soft bones (osteopenia)
31
Tx of rheumatoid arthritis?
1st line= DMARD monotherapy +/- a short course of bridging prednisolone
DMARDS- methotrexate, sulfasalazine, leflunomide, hydroxychloroquine
Can add TNF-inhibitors after 2 failed DMARDS e.g. etanercept, infliximab
Rituximab
anti-CD20 monoclonal antibody, results in B-cell depletion
two 1g intravenous infusions are given two weeks apart
infusion reactions are common
32
monitoring and SEs of methotrexate?
Monitor FBC and LFT due to risk of liver cirrhosis and myelosuppression
SE- pneumonitis, liver toxicity, bone marrow suppression, GI toxicity e.g. stomatitis
33
SEs of sulfasalazine?
Increased risk of allergy if also allergic to aspirin
| SE- rashes, oligospermia, interstitial lung disease, staining of contact lenses, steven-johnson syndrome
34
SEs of leflunomide?
Liver impairment, hypertension, interstitial lung disease
35
SEs of hydroxychloroquine?
retinopathy, corneal deposits
36
SEs of TNF inhibitors?
reactivation of TB
37
What is felty's syndrome?
RA + splenomegaly + low WCC
38
what causes gout?
deposition of uric acid in the synovium
39
causes of gout?
decreased excretion of uric acid- diuretics, aspirin, CKD, lead toxicity
increased production of uric acid- myeloproliferative disorder, cytotoxic drugs, severe psoriasis
Diet- red meat, alcohol, high sat fats
40
What is primary gout?
may result from an inherited gene#excess de novo purine
| synthesis or reduced renal excretion of uric acid
41
What is secondary gout?
increased lysis of cells e.g. chemo
| diuretics or chronic renal disease
42
features of acute gout?
70% 1st MTP- pain,swelling, erythema
43
features of chronic (tophaceous) gout?
```
occurs after many attacks
asymmetrical polyarthritis
cartilage and bone 'punched out' lesions
deposition of urate crystals- resulting in tophi
restriction of joint movements
```
44
Ix of gout?
serum urate
WCC
ESR
synovial fluid aspiration- negatively birefringent under polarised light (needle shaped)
45
Tx of gout?
1st line: NSAIDs and colchicine (PPI needed)
prednisolone 15mg/day in contraindicated
intra-articular steroid injection
Urate lowering therapy- allopurinol (xanthene oxidase inhibitor)
- delayed starting
-100mg OD then titrated every few weeks until serum uric acid <300umol/L
-lower initial dose if reduced eGFR
can use febuxostat instead of allopurinol
lifestyle advice- diet and alcohol
46
What is pseudogout?
caused by deposition of calcium pyrophosphate in the synovium
It usually presents as a monoarthritis in the elderly
knee, wrist and shoulder most commonly affected
47
RFs for pseudogout?
```
hyperparathyroidism
hypothyroidism
haemochromatosis
acromegaly
low Mg, low phosphate
Wilson's disease
```
48
Ix of pseudogout?
joint aspiration- weakly positive birefringent rhomboid shaped crystals
X-ray- chondrocalcinosis
49
Tx of pseudogout?
aspiration of joint fluid to exclude septic arthritis
| NSAIDs or intra-articular, IM or oral steroids as per gout
50
What is enteropathic arthropathy?
associated with IBD and coeliac disease
HLA-B27 associated
seronegative therefore ANA and ANCA negative
51
types of psoriatic arthritis?
```
Rheumatoid-like polyarthritis
Asymmetrical oligoarthritis: hands and feet typically
Sacroilitis
DIP joint disease
Arthritis mutilans
```
52
Nail changes in psoriatic arthritis?
```
psoriatic nail dystrophy
discolouration of nails
oncholysis
pitting nails
subungal hyerkeratosis
ridging
```
53
Ix of psoriatic arthritis?
synovial biopsy- not routinely performed
| XR-pencil-in-cup deformity
54
Tx of psoriatic arthritis?
treat as RA
DMARDS- methotrexate and leflunomide
hydroxychloroquine is avoided as it exacerbates skin disease
55
Causes of reactive arthritis?
follow an infection (usually an STI) where the organism can't be recovered from a joint
STIs- chlamydia (more common in men)
Dysentry- shigella, salmonella, E.coli, campylobacter
56
features of reactive arthritis?
typically develops 4 weeks after infection
asymmetrical oligoarthritis, dactylitis, urethritis, eyes: conjunctivitis, anterior uveitis
skin: blennorrhagia (waxy yellow/brown apules on palms and soles), circunate balanitis (painless vesicles on prepuce), keratoderma
57
Ix for reactive arthritis?
bloods- ESR/CRP
stool sample
test for STIs
58
Tx for reactive arthritis?
symptomatic- analgesia, NSAIDs, intra-articular steroids
sulfasalazine and methotrexate are sometimes used for persistent disease
symptoms may last for up to 12 months
59
causes of septic arthritis?
most common organism overall is Staphylococcus aureus
in young adults who are sexually active Neisseria gonorrhoeae should also be considered
in adults, the most common location is the knee
60
RFs for septic arthritis?
```
immunocompromised
DM
prosthetic joint
RA/OA
steroids
IVDU
unprotected sex
```
61
features of septic arthritis?
acute onset, singular joint
gets progressively worse
concurrent infection e.g. UTI
constitutional symptoms (febrile, hypotensive, tachycardic)
62
Kocher criteria for the diagnosis of septic arthritis?
fever >38.5 degrees C
non-weight bearing
raised ESR
raised WCC
63
Mx of septic arthritis?
synovial fluid should be obtained before starting treatment
intravenous antibiotics which cover Gram-positive cocci are indicated. The BNF currently recommends flucloxacillin or clindamycin if penicillin allergic
antibiotic treatment is normally be given for several weeks (BNF states 6-12 weeks)
needle aspiration should be used to decompress the joint
arthroscopic lavage may be required
64
epidemiology of SLE?
```
black africans and indian Asians
peak incidence is 25-35 years
female
genetic predisposition
UV light exposure
can be caused by chlorpromazine, hydralazine, isoniazid, procainamide
```
65
diagnostic criteria of SLE
4/11 needed for diagnosis from American College of Rheumatology-
1- Malar rash
2- Oral ulceration
3- Discoid rash (oval or round) seen in areas exposed to sunlight
4- Arthritis
5- Photosensitivity
6-Serositis
7- Neuro disorders- seizures, psychosis
8- Renal disease- proteinuria, red cell casts in urine
9- Haematological disorder- leucopenia, lymphopenia, haemolytic anaemia, thrombocytopenia
10- immunological disorder- antibodies to DsDNA, Anti-SM
11- ANA positive
66
Ix of SLE?
Urine dipstick- proteinuria, red cell casts
ESR is often raised but CRP is normal
ANA positive in >95%
dsDNA +ve in 65%-highly specific for SLE- used for disease monitoring
67
tx of acute flare ups of SLE?
IV cyclophosphamide and high-dose prednisolone
68
maintenance tx of SLE?
NSAIDs
Hydroxychloroquine- Useful for skin lesions, arthralgia, myalgia and malaise
Cyclophosphamide is reserved for treatment of life-threatening disease
DMARDS as steroid sparing agents
69
What is antiphospholipid syndrome associated with?
SLE
70
Features of antiphospholipid syndrome?
```
CLOTS
Coagulation defect (thrombosis)
Livedo reticularis
Obstetric (recurrent miscarriage)
Thrombocytopenia
SLE
```
71
antibody for antiphospholipid syndrome?
anti-cardolipin
72
Tx for antiphospholipid syndrome?
warfarin for VTE risk
73
what is systemic sclerosis? (scleroderma)
vascular damage within skin and organs leads to fibrosis
74
what are the different types of scleroderma?
1. Limited cutaneous scleroderma
| 2. Diffuse cutaneous scleroderma
75
What is Limited cutaneous scleroderma?
```
CREST
Calcinosis
Raynaud's
oesophageal dysmotility
Sclerodactyly- thickening of the skin
Telangiectasia
```
76
what is diffuse cutaneous scleroderma?
affects trunk and proximal limbs predominantly and there is multi-system involvement
Can be life-threatening
77
What antibodies are associated with which type of scleroderma?
scl-70 antibodies associated with limited cutaneous Anti-centromere associated with diffuse cutaneous
78
mx of scleroderma?
no cure
IV cyclophosphamide for organ involvement and progressive skin disease
Monitor BP and renal function
79
what is Sjogren's syndrome?
autoimmune disorder affecting exocrine glands resulting in dry mucosal surfaces
80
causes of Sjogren's syndrome?
primary or
secondary to RA and other CNDs
females
81
features of Sjogren's syndrome?
```
dry mouth
dry eyes(keratoconjunctivitis sicca)
vaginal dryness
arthralgia
Raynaud's, myalgia
sensory polyneuropathy
recurrent episodes of parotitis
renal tubular acidosis
```
82
antibodies associated with Sjogren's syndrome?
RF +ve
ANA +ve in 70%
anti-Ro
Anti-la
83
what is Schirmer's test?
measures tear infiltration
84
tx of Sjogren's syndrome?
artificial saliva and tears
| pilocarpine may stimulate saliva production
85
what does polymyalgia rheumatica overlap with?
temporal arteritis/GCA
86
what is polymyalgia rheumatica?
vasculitis with giant cells
87
features of polymyalgia rheumatica
```
aching, morning stiffness in proximal limbs
NO WEAKNESS
mild polyarthralgia
lethargy
depression
low-grade fever
anorexia
night sweats
```
88
core criteria for diagnosis of polymyalgia rheumatica
```
bilateral shoulder or pelvic girdle pain
morning stiffness >45 mins
age >50 years
duration of symptoms >2 weeks
raised ESR or CRP
```
89
tx of polymyalgia rheumatica?
prednisolone- should have dramatic response
| oral alendronate and calcium and Vit D replacement
90
what is an important SE of prednisolone?
avascular necrosis
91
what is dermatomyositis?
an inflammatory disorder caused symmetrical, proximal muscle weakness and characteristic skin lesions
(connective tissue disorder)
92
features of dermatomyositis?
```
photosensitive
macular rash over back and shoulders
helitrope rash in the periorbital region
Gottron's papules- roughened red papules over extensor surfaces of fingers
nail fold capillary dilatation
resp muscle weakness
interstitial lung disease
dysphaghia, dysphonia
```
93
Ix for dermatomyositis?
```
ANA positive
Anti-Mi-2 positive in 25%
bloods- CK, AST, LDH
skin biopsy
muscle biopsy
EMG testing
MRI
```
94
tx of dermatomyositis?
oral prednisolone
hydroxychloroquine may reduce the photosensitive rash
immunosuppressive drugs- methotrexate, mycophenolate, azathioprine, cyclophosphamide
Diltiazem may reduce calcinosis
avoid sun exposure
95
what is polymyositis?
a variant of the disease where skin manifestations are not prominent
96
features of polymyositis?
diffuse weakness in proximal muscles
(distal muscles spared)
pharyngheal weakness can cause dysphagia
97
Ix of polymyositis?
CK >50 times normal
20% have anti-Jo-1 antibodies
muscle biopsy and EMG are diagnostic
98
tx of polymyositis
same as dermatomyositis
99
what are causes of primary vs secondary raynauds?
```
primary- Raynaud's disease
secondary:
- CTD- scleroderma, SLE, RA
- leukaemia
- type 1 cryoglobulinaemia, cold agglutinins
- use of vibrating tools
- drugs- OCP, ergot
- cervical rib
```
100
mx of raynauds
```
1st line- CCBs e.g. nifedipine
IV prostacyclin (epoprostenol) infusions: effects may last severeal weeks/months
```
101
what is vasculitis?
inflammation of the blood vessel walls
102
what is Takayasu's arteritis?
vasculitis causing occlusion of the aorta
103
RFs for Takayasu's arteritis?
female and asian
104
features of Takayasu's arteritis?
systemic features- malaise, headache
unequal blood pressure in the upper limbs
carotid bruit
intermittent claudication
aortic regurgitation
ESR often affected during the acute phase
105
association with Takayasu's arteritis?
renal artery stenosis
106
tx of Takayasu's arteritis?
steroids
107
what is buerger's disease?
large artery vasculitis associated with smoking
108
features of buerger's disease?
extremely ischaemic, superficial thrombophlebitis
Raynaud's phenomenon
tortuous corkscrew vessels seen on angiography
109
what is polyarteritis nodosa?
systemic necrotising granulomatous vasculitis
| RFs- middle aged men, hep B infection
110
What is Granulomatosis with polyangiitis?
| medium sized arteries
prev known as Wegener's granulomatosis
autoimmune condition associated with a necrotising graumlomatous vasculitis affecting both the upper and lower resp tract as well as the kidneys
111
features of Granulomatosis with polyangiitis
upper resp tract- epistaxis, sinusitis, nasal crusting
lower resp tract- dyspnoea, haemoptysis
rapidly progressing glomerulonephritis
saddle-shaped nose deformity
vasculitic rash
eye involvement e.g. proptosis, cranial nerve lesions
112
Ix of Granulomatosis with polyangiitis?
cANCA +ve in >90%
pANCA +ve in 25%
CXR- cavitating lesions
renal biopsy- epithelial crescents in Bowman's capsule
113
tx of Granulomatosis with polyangiitis?
median survival 8-9 years
steroids
cyclophosphamide
plasma exchange
114
what is ANCA-associated small vessel vasculitis?
```
prev Churg-Strauss syndrome
asthma
blood eosinophilia
paranasal sinusitis
mononeuritis multiplex
```
115
what is Henoch- schonlein purpura?
IgA-mediated small vessel vasculitis
| overlaps with berger's disease
116
when is HSP commonly seen?
in children following an infection
117
features of HSP?
Palpable purpuric rash (with localised oedema) over buttocks and extensor surefaces of arms and legs
abdo pain
polyarteritis
IgA nephropathy- haematuria, renal failure
118
tx for HSP?
analgesia for arthralgia
self-limiting in children, esp without renal involvement
around 1/3 of patients have a relapse
119
what makes up cartilage?
```
75% water
collagen (type II)
chondrocytes
fibroblasts
proteoglycans
```
120
what is osteoarthritis?
loss of cartilage at synovial joints
121
RFs for OA?
```
genetics
prev trauma
obesity
hypermobile joints
manual labourers
female ,increasing age
DDH
```
122
features of OA?
```
Joint pain and stiffness- pain provoked by movement, stiffness after inactivity
joint instability
muscle wasting
audible joint crepitus
squaring of the hand
```
123
what are heberden's and bouchard's nodes in OA
heberden's nodes (DIP)
| bouchard's nodes (PIP)
124
most common joints for OA?
Knee
| hip
125
XR feature of OA?
Loss of joint space
Osteophyte formation
Subchondral cysts
Subchondral sclerosis
126
other investigations for OA?
bloods
MRI
arthroscopy
127
mx for OA?
Weight loss, exercise, supports and braces
paracetamol and topical NSAIDs first line
intra-articular cortocisteroids
PT
joint replacement
128
What is a type 1 hypersensitivity reactions?
IgE bound to mast cells
| anaphylactic, atopy
129
What is a type 2 hypersensitivity reactions?
IgG or IgM cell bound
| autoimmune haemolytic anemia, ITP, goodpasture's etc
130
What is a type 3 hypersensitivity reactions?
free antigen complex immune bound
| SLE, post-strep GN, extrinsic allegic alveolitis
131
What is a type 4 hypersensitivity reactions?
delayed hypersensitivity, T-cell mediated
| TB, allergic contact dermatitis, MS, GBS
132
What is a type 5 hypersensitivity reactions?
antibodies that bind to cell surface receptors
| grave's disease, myasthenia gravis
133
what is ehler-danlos syndrome?
AD connective tissue disease affecting type III collagen results in tissue becoming more elastic
134
features of ehler-danlos syndrome?
elastic,fragile skin
joint hyperbility- recurrent joint dislocation
east bruising
aortic regurg, mitral valve prolapse, aortic dissection
SAH
135
What muscles are involved in the rotator cuff?
supraspinatus- abduction
infraspinatus-rotates arm laterally
teres minor- adducts and lateral rotation
subscapularis- adducts and rotates arm medially
136
what length of rotator cuff tear needs surgical repairal?
>2cm
| With rotator cuff tears the pain may be in the first 60 degrees.
137
what are signs of impingement syndrome?
painful arc of abduction. With subacromial impingement, this is typically between 60 and 120 degrees.
tenderness over anterior acromion
138
what is a colles' fracture?
FOOSH
distal radial fracture with dorsal displacement of fragments
dinner fork type deformity
139
what is a smith's fracture?
falling backwards onto palm
volar angulation of distal radium fragment
garden spade deformity
140
what are features of a hip fracture?
pain, shortened and externally rotated leg
141
what is the classification of hip fractures?
gardner's classification
intracapsular- can be displaced or undisplaced
extracapsular- subtrochanteric or intertrochanteric
142
what is management of a intracapsular fracture?
undisplaced-
young and fit- internal fixation
old- hemiarthroplasty
displaced-
young and fit- reduced and internal fixation
old but good mobility- total hip replacement
old with bad mobility- hemiarthroplasty
143
mx of extracapsular hip fracture?
intertrochanteric- dynamic hip screw
| extratrochanteric- intramedullary nail
144
mx of fall patient
```
A-E assessment
rule out head injury
cardiac symptoms- pain, SOB, palpitations- ECG
stroke
infection- urine dip
lying and standing BP (sigf if SBP drops by 20 or DBP drops by 10)
BM
c-SPINE
```
145
Criteria for immediate head CT?
GCS < 13 on initial assessment
GCS < 15 at 2 hours post-injury
suspected open or depressed skull fracture.
any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign).
post-traumatic seizure.
focal neurological deficit.
more than 1 episode of vomiting
more than 30 minutes' retrograde amnesia of events immediately before the head injury
146
what happens if patient on warfarin with head injury but no other symptoms?
CT head within 8 hours
147
mx of an open fracture?
```
broad spec abx e.g. coamoxiclav
tetanus booster
analgesia
IVI/ transfusion
imaging- XR
bloods- pre-op bloods: FBC, U&E, group and save, renal function, clotting
ECG
Cannula
specialist- reduce and splint, surgical debridement, then fixation later
```
148
what is adhesive capsulitis
frozen shoulder
149
RFs for adhesive capsulitis?
female, DM
150
features of adhesive capsulitis?
external rotation affected most
both active and passive movement affected
painful freezing stage -> adhesive stage -> recovery stage
lasts 6 months- 2 years
151
mx of frozen capsulitis
`NSAIDs
PT
oral corticosteroids
intra-articular corticosteroids
152
what is Bechet's syndrome?
oral ulcers, genital warts and anterior uveitis
153
what is compartment syndrome?
can occur following fractures
| raised pressure within a closed anatomical space -> compromised tissue perfusion -> necrosis
154
causes of compartment syndrome?
supracondylar fractures
| tibial shaft injuries
155
features of compartment syndrome?
pain, paraesthesia, pallor, paralysis
| arterial pulsation may still be felt
156
diagnosis of compartment syndrome?
measurement of intracompartmental pressure
>40mmHg is diagnostic
no pathology seen on XR
157
tx of compartment syndrome?
fasciotomy
| aggressive IV fluids due to myoglobinuria risk
158
what is Ottawa ankle rules?
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
inability to walk four weight bearing steps immediately after the injury and in the emergency department
159
what is weber classification for an ankle fracture
Type A is below the syndesmosis
Type B fractures start at the level of the tibial plafond and may extend proximally to involve the syndesmosis
Type C is above the syndesmosis which may itself be damaged
160
mx of an ankle fracture
unstable (proximal)- surgical repair
| stable- cast
161
what is carpal tunnel syndrome?
compression of median nerve in the carpal tunnel
162
causes of carpal tunnel syndrome?
```
idiopathic
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis
```
163
features of carpal tunnel syndrome?
pains/ pins and needles in the thumb, index and middle finger
shakes hand to obtain relief
weakness of thumb abduction
tinels and Phalen's sign
164
mx of carpal tunnel syndrome?
corticosteroid injection
wrist splints at night
surgical decompression
165
what is involved in a myeloma screen?
```
FBC with film
U+Es including calcium
Urinary bence-jones proteins
serum electrophoresis
XR of painful bones
```
166
what are common organisms for osteomyelitis?
staph aureus
| salmonella if sickle-cell anaemia
167
predisposing conditions for osteomyelitis?
```
diabetes mellitus
sickle cell anaemia
intravenous drug user
immunosuppression due to either medication or HIV
alcohol excess
```
168
mx of osteomyelitis?
MRI
flucloxacillin for 6 weeks
clindamycin if allergic
169
how does power change in UMN lesions in upper and lower limbs?
UMN lesions- flexors>extensors in upper limbs, extensors >flexors in lower limbs
170
what signs do lesions above and below L1 present with?
above- UMN signs in legs and a sensory level
| below- LMN signs and perianal numbness
171
how doe a NOF appear on clinical examination?
leg shortened and externally rotated
172
how does an anterior and posterior dislocation present on clinical examination?
anterior- abducted and externally rotated. No leg shortening
| posterior- leg is shortened, adducted, and internally rotated
173
complications of hip dislocation?
Sciatic or femoral nerve injury
Avascular necrosis
Osteoarthritis: more common in older patients.
Recurrent dislocation: due to damage of supporting ligaments
174
what is a fat embolism?
hypoxic, neurological (confused), petechial rash, pyrexic
175
what is FRAX?
10 year risk of fragility score
176
what is marfan's syndrome?
mutation in protein fibrollin-1
| tall, high-arched palate, pectus excavatum, heart problems, pes planus
177
mx of a subtrochanteric femoral fracture?
intramedullary nail
| weight bear immediately after operation
178
what is a monteggia fracture?
fracture of proximal ulna and dislocation of proximal head of radius
commonly seen in children
179
SE of steroids?
```
impaired glucose tolerance
OP
avascular necrosis
cushing's syndrome
hypertension
dyspepsia
cataracts
increased risk of infections
```
180
Ottawa rules for ankle fracture?
ankle/foot XR only required if there is tenderness in:
-lateral malleolus
-medial malleolus
- base of 5th metatarsal head
- navicular bone (medial)
OR inability to walk more than 4 steps in ED
181
how to describe fractures?
```
AABCS
Adequacy
Alignment
Bones
Cartilage
Soft tissue
```
OLD ACID
Open/closed
Location- proximal/mid/distal
Degree- complete/incomplete
Articular involvement (joint)/ angulation
Communication and pattern
Intrinsic bone quality
Displacement/rotation
182
what to send joint aspiration for in septic arthritis?
glucose
gram stain
MC&S
183
atraumatic causes of avascular necrosis?
```
lupus
steroids
diabetes
pregnancy-related
perthes
```
184
sign of anterior shoulder dislocation on XR?
light bulb sign
| more medial
