Word 2 Flashcards
Adhesive capsulitis (frozen shoulder)
An important cause of shoulder pain and stiffness, which commonly occurs in patients with diabetes.
Aetiology
• Idiopathic
• Diabetes
• Thyroid disorders
Clinical features
• Begins as progressive shoulder pain over many months → leads to progressive stiffness and deterioration in the range of movement of the shoulder joint
• On examination:
- External rotation is limited more than internal rotation
- Active and passive movement is affected
Investigation
• Clinical diagnosis
Management
• Analgesia → paracetamol, NSAIDs
• Physiotherapy
• Consider corticosteroids
Ankylosing spondylitis
A type of axial spondyloarthritis which typically occurs in males 20-30 years old. The condition is associated with HLA-B27 (positive in 90% of patients).
Clinical features
• Lower back pain and stiffness, worse in the morning and improves with exercise
• On examination:
- Reduced lateral flexion and forward flexion - Schober’s test
• The condition is associated with:
- Anterior uveitis
- AVN block on ECG (1st degree HB)
- Aortic regurgitation - early diastolic murmur
- Amyloidosis A
- Apical lung fibrosis
Investigation
• XRAY of sacroiliac joint → sacroiliitis, squaring of the vertebra, syndesmophytes and a bamboo spine
• If XRAY is negative but clinical suspicion is high - MRI spine
Management
• First-line: NSAIDs
• Physiotherapy
• The disease-modifying drugs which are used to treat rheumatoid arthritis (such as methotrexate) are only really useful if there is peripheral joint involvement
Anterior cruciate ligament injury
Injury of the anterior cruciate ligament which act as the primary constraint preventing anterior displacement of the tibia on the femur
. It also stabilises the knee during rotational and valgus stresses.
Around 70% of injuries occur in people who participate in sports.
Clinical features
Typical injury is seen in noncontact deceleration or change of direction e.g - landing from a jump awkwardly
• Patient may hear a ‘pop’ sound or feel tearing sensation
• Knee giving away → can lead to collapse to the ground
• Severe pain which decreases within minutes
• A rapid onset of swelling within few hours of the injury
• On examination:
- Positive Lachman test
Investigation
• MRI
Management
• Physiotherapy or surgery
Clinical features
• Oral ulcers
• Genital ulcers
• Anterior uveitis
• Arthritis
• Deep vein thrombosis
• Erythema nodosum
Behcet’s disease
A chronic multisystem inflammation of arteries and veins of unknown aetiology.
Management
• The treatment of Behcet’s syndrome can be divided into:
- Topical steroids - for mucocutaneous ulcers and uveitis
- Systemic steroids - usually required in severe disease
Clinical features
• Back pain
• Sciatica pain → shooting pain which radiates into legs and feet
• Lower limb weakness
• Bladder dysfunction → urinary retention, overflow incontinence
• Reduced sensation in the perianal area
• Bowel dysfunction or erectile dysfunction
Cauda equina syndrome
A syndrome which occurs when the bundle of peripheral nerves L1-S5 in the lumbar canal (below the end of the spinal cord), known as the cauda equina, is compressed.
This most commonly occurs due to acute lumbar disc herniation at L4/5 or L5/S1.
Cauda equina is a serious condition and late diagnosis can lead to long term leg weakness and urinary/bowel incontinence.
Investigation
• Urgent MRI
Management
• Emergency referral to spinal surgery service
• Urgent surgical decompression
Clinical features
• Symmetrical, proximal muscle weakness e.g. difficulty getting up from a chair
• Lethargy
• Weight loss
• Cutaneous features:
- A rash with photosensitivity
- Heliotrope periorbital rash → purple rash on eyelids
- Red rash affecting back and shoulders → ‘shawl sign’
- Gottron’s red papules on extensor surfaces - often overlying the knuckles and PIP/DIP joints → ‘Mechanics hands’
Investigation:
• ANA positive
• Raised CK levels
• Antibodies → Anti-MI-2 Antibodies, anti-SRP antibodies and anti-synthetase antibodies
Management:
• Steroids
• All patients should be screened for malignancy
Dermatomyositis
A chronic, inflammatory condition characterised by symmetrical, proximal muscle weakness and skin lesions.
The condition is associated with an underlying malignancy in 25% of cases → ovarian, breast and lung cancer.
A variant of dermatomyositis which is characterised by proximal muscle weakness which NO cutaneous features.
Associated with anti-JO1 antibodies.
Polymyositis
Clinical features
• Localised back pain
• Fever
• Neurological features
• On examination:
- Tenderness on palpation of the infected disc
- Limited range of motion
Discitis
Infection in the intervertebral disc space, typically caused by Staphylococcus aureus.
Investigation
• MRI - the most sensitive test
Management
• 6 - 8 weeks of IV antibiotics
Complications
• Epidural abscess
Clinical features
• Asthma
• Sinusitis
• Mononeuritis multiplex → peripheral neuropathy affecting at least 2 different nerves of the peripheral nervous system
Eosinophilic granulomatosis with polyangiitis
An ANCA associated small-medium vessel vasculitis. Most patients are pANCA positive.
Investigation
• Blood test → eosinophilia
• Antibodies → pANCA
Clinical features
• Fever
• Abdominal pain - the pain usually begins in one quadrant and spreads to affect the whole abdomen. The abdomen may also be distended.
• Chest pain - pleuritic chest pain, with a friction rub, decreased breath sounds, or a pleural effusion.
• Joint pain
• Skin manifestations - painful erythema on the lower legs.
Familial mediterranean fever
An autosomal recessive condition characterised by recurrent fever and serositis,
which results in pain in the abdomen, chest, joints, muscles, etc.
The condition occurs most often in Arabs, Armenians and non-Ashkenazi Jews.
Management
• First-line: colchicine
The association of rheumatoid arthritis with a triad of:
- Splenomegaly
- Neutropenia, anaemia and thrombocytopenia
- Lymphadenopathy
It occurs in less than 1% of RA patients.
Felty syndrome
Clinical features
The most commonly affected joint is the 1st metatarsophalangeal joint. Other joints affected → ankle, wrist, knee.
• Acute pain, redness and swelling of the joint
Gout
An inflammatory arthritis caused by deposition of monosodium urate monohydrate crystals into the synovium of the joints.
Investigation
• Blood test:
- High uric acid levels
• Joint aspirate:
- Needle shaped negatively birefringent monosodium urate crystals under
polarised light
• Joint XRAY:
- Well-defined ‘punched-out’ erosions with sclerotic margins
Management
• For acute flares of gout:
- 1st Line: NSAID OR colchicine (renal impairment) OR a short course of oral corticosteroids
• For chronic management:
- Urate-lowering therapy to all patients after their first attack of gout
- First-Line: Offer Allopurinol
- Colchicine cover should be considered when starting allopurinol.
• Second-line agent is febuxostat
Clinical features
• URT: sinusitis, epistaxis, saddle nose, nasal crusting
• LRT: haemoptysis, dyspnoea
• Renal: crescentic glomerulonephritis, leading to a nephritic syndrome (hypertension, haematuria, AKI)
• Vasculitis rash
Granulomatosis with polyangiitis
An autoimmune condition causing granulomatous vasculitis, which affects the upper respiratory tract, the lower respiratory tract and the kidneys.
Investigations
• cANCA positive
• Renal biopsy: Epithelial crescents affecting Bowman’s capsule
Management
• Steroids
• Cyclophosphamide
Clinical features
• Fever which lasts for > 5 days
• Bright red, cracked lips
• Strawberry tongue
• Conjunctival injection
• Red palms of the hands and the soles of the feet which later peel
Kawasaki disease
A vasculitis of unknown aetiology which affects children < 5 years of age.
Investigation
• Clinical diagnosis
• ECHO is required to rule out coronary artery aneurysm (complication of the condition)
Management
• High dose aspirin
• Intravenous immunoglobulin
Clinical features
• Pain and tenderness localised to the lateral epicondyle, radiating into the forearm
• Pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended
• On examination:
- Localised tenderness on palpation of the lateral epicondyle
Management
• Analgesia
• Physiotherapy
Lateral epicondylitis
An attachment point disease of the origin of the extensor carpi radialis brevis (an extensor muscle of the forearm) on the lateral epicondyle of the humerous.
The condition is caused by repetitive use of the extensor muscles e.g. playing tennis
Clinical features
• Pain and tenderness localised to the medial epicondyle
• Pain is aggravated by wrist flexion and pronation against resistance
Medial epicondylitis
An attachment point disease causing inflammation of the medial common flexor tendon at the point of attachment to the medial epicondyle.
It is caused by repetitive use of the flexor muscles of the forearm e.g. golfing.
Clinical features
• Knee pain
• Knee swelling
• Joint locking
• On examination:
- McMurray test may be positive
Meniscal tear
Typically occurs in rotational sporting injuries.
Clinical features
In the upper lateral aspect of the thigh:
• Burning pain, tingling, numbness, or shooting pain in the anterolateral and lateral regions of the thigh
• Symptoms are aggravated by standing, and relieved by sitting
• Associated with pain
• On examination:
- Symptoms are reproduced on deep palpation just below the ASIS (pelvic compression) and also by extension of the hip
- Altered sensation over the upper lateral aspect of the thigh
- No motor weakness
Meralgia paraesthetica
A syndrome of paraesthesia in the distribution of the lateral femoral cutaneous nerve (LFCN), which occurs due to entrapment of the LFCN.
Investigation
• The pelvic compression test → highly sensitive
Management
• Injection of the nerve with local anaesthetic will improve the pain
