Orthopedics & Rheumatology Flashcards
What advice should be given to a woman on methotrexate regarding her contraception and when to try for a baby?
Patients using methotrexate require effective contraception during and for at least 3 months after treatment in men or women
What are the features of a common peroneal nerve lesion? (4)
FOOT DROP Weak foot dorsiflexion Weak foot eversion Sensory loss over dorsum of foot Sensory loss over lower, lateral part of leg
A 35-year-old female presents with pain on the radial side of the wrist and tenderness over the radial styloid process. On examination, abduction of the thumb against resistance is painful, and when the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation. What is the most likely diagnosis?
Pain over radial styloid process on forced abduction or flexion of the thumb (+ve Finkelstein test) - De Quervain’s tenosynovitis
A 28-year-old male presents to the emergency room with severe pain in the right knee following an injury during a football match. He states that he was tackled from behind, and then felt a ‘pop’ and severe pain which was followed by rapid swelling of the joint. On examination there is a right sided knee effusion and a positive Lachman test.
What is the most likely diagnosis?
ACL Rupture
Rapid joint swelling is suggestive of haemoarthrosis which can occur due to ACL or PCL rupture. The mechanism of injury suggests rupture of the ACL. A positive Lachman tests is also very suggestive of an ACL injury.
What is the most common treatment of a mobile patient with an extracapsular hip fracture?
DHS
Dynamic Hip Screw
Which type of hip fracture would be treated with an intermedullary device?
Subtrochanteric
A 22-year-old male presents to the emergency room with pain in the left knee following a twisting injury during a rugby match. He states that it has gradually swollen over the past 24 hours, and he is unable to fully extend it. On examination you note tenderness over the medial joint line, a joint effusion, and the joint is held in a flexed position. There is no laxity on valgus stress test.
What is the most likely diagnosis?
Medial meniscus tear
- Gradual swelling of the knee is suggestive of effusion which often occurs due to meniscal injury. Tenderness over the medial joint line suggests a medial meniscus tear.
- Isolated MCL injuries rarely cause a large effusion. In addition, the lack of laxity on the valgus stress test makes an MCL injury less likely.
An 82-year-old woman with long-standing rheumatoid arthritis presents with a history of recurrent chest infections over the past 6 months. On examination she is found to have splenomegaly. Her current medications include methotrexate and sulphasalazine. Blood results demonstrate neutropenia. MLD?
Felty’s syndrome is a condition characterized by splenomegaly and neutropenia in a patient with rheumatoid arthritis.
What is Morton’s neuroma and who does it classically affect?
Benign neuroma, most common in third IMP space
Classically affects females
How should Morton’s neuroma be managed?
Refer if symptoms persist over 3 months
Supportive orthotics
Which clinical test is most suggestive of Ank Spond?
Schobers test < 5cm
Diffuse systemic sclerosis is associated with which antibodies?
Anti-topoisomerase (also known as anti-Scl-70)
Limited cutaneous systemic sclerosis is assocaited with which antibodies?
Anti-centromere antibodies
Name two signs of limited cutaneous systemic sclerosis?
Scleroderma affecting face and distal limbs mainly
Raynauds may be first sign
What is CREST syndrome and what are the 5 signs?
A subtype of limited cutaneous systemic sclerosis C- Calcinosis R- Raynauds E- oEsophageal problems S- Sclerodactyly T- Telangiectasia
A 23-year-old man wakes up on a Sunday morning unable to extend his wrist . He had been drinking heavily the previous night. What is the likely cause of his weakness?
Radial nerve palsy
A 51-year-old woman with a worsening small joint, symmetrical polyarthritis is seen in the rheumatology clinic and diagnosed with rheumatoid arthritis (RA). Her past medical history includes asthma, eczema and a documented severe allergy to co-trimoxazole.
Which of the following treatments for RA is CI in due to this patient’s past medical history?
Sulfasalazine Methotrexate Hydroxychloroquine Leflunomide Azathioprine
Patients with a documented allergy to a sulfa drug (i.e. co-trimoxazole) should not take sulfasalazine
Co-trimoxazole (also called by its brand name, Septrin) is an antibiotic preparation that combines trimethoprim and sulfamethoxazole, a sulfonamide. Some patients that experience an adverse reaction to sulfonamides also display sensitivity to other drugs which contain a similar chemical structure including sulfasalazine.
Methotrexate should never be prescribed with which antibiotic?
Trimethoprim
(Co-trimoxazole contrains trimethoprim)
Increased risk of bone marrow aplasia and pancytopenia
A 35-year-old female presents with pain on the radial side of the wrist and tenderness over the radial styloid process. On examination, abduction of the thumb against resistance is painful, and when the thumb is flexed across the palm of the hand (+ve finklestein test), pain is reproduced by movement of the wrist into flexion and ulnar deviation. What is the most likely diagnosis?
De Quervain’s tenosynovitis
It typically affects females aged 30 - 50 years old
Features
- pain on the radial side of the wrist
- tenderness over the radial styloid process
- abduction of the thumb against resistance is painful
Name two types of intracapsular fractures?
Femoral head #
Femoral neck #
(Tx is with DHS if not displaced and if displaced THR (if fit and well) or hemiarthoplasty if not mobile)
How does Chondromalacia patellae usually present?
(Softening of the cartilage of the patella)
- Common in teenage girls
- Characteristically anterior knee pain on walking up and down stairs and rising from prolonged sitting
- Usually responds to physiotherapy
(May have quad wasting and pseudolocking of knee)
How does osgood-schlatter disease usually present?
Seen in sporty teenagers
Pain, tenderness and swelling over the tibial tubercle
Worse during activity, better with rest
How does Osteochondritis dissecans usually present?
Pain after exercise
Intermittent swelling and locking
What age and presentation for Slipped upper femoral epiphysis?
10-15 years Obese boys most common - Hip, groin, medial thigh or knee pain loss of internal rotation of the leg in flexion - Either acute or chronic
A 24 year old female patient presents after twisting her knee during a football match, her knee buckled and she felt a popping/ tearing sensation in the knee. You examine the joint and see swelling, plus a loss of extension and widespread tenderness. ???
Torn ACL
Hemarthrosis (joint bleed) causing swelling
Treat Anti-inflammatory, ice and possible surgery
(often associated with injury to meniscus or collateral lig)
An athlete presents after running in a downhill race on concrete. He has pain in his medial tibial area with tenderness and swelling. He says it was worst at the start, eased off and then became bad again. ???
Medial tibial stress syndrome (Inflammation due to microfractures) -SHIN SPLITS
Rest for two weeks, possible NSAID/ Icing
A 23yr old male presents with slow onset of back pain, buttock pain, neck pain, especially when moving. They are also very fatigued. What is the first thing you would consider?
Ankylosing spondylitis (Inflammation of spine and sacroiliac joints most common)
A 57yoF presents with pain in her knee, made worse when she tries to get up or walk around, and better when she sits down. Sometimes she hears a crunching sounds when she moves the joint. She says after she gets up the joint is very stiff for around 10mins. She shows you that she can not fully extend her knee when sitting down and trying to do so causes pain. She has no fever or rash. MLD?
A diagnosis of OA can be made clinically without investigations if a person:
- Is aged 45 years or over; and
- Has activity-related joint pain; and
- Has either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes. if this is present send for investigation (Xray/ FBC/ MRI if needed)
What is the most common 3 sites affected by gout?
Big toe
Ankle
Knee
(In that order)
Name 4 differentials for swelling in the hand?
Trauma
Non-inflammatory arthopathy (OA)
Inflammatory arthropathy (RA, seronegative, septic, crystal)
Soft tissue injury
What is de Quervain’s tenosynovitis, how does it present?
Pain on radial side of wrist, aggrevated by lifting the thumb (hitchhiker position)
What are the changes seen in RA on XR?
Loss of joint space
Erosions
Subluxation
Soft tissue swelling
What are the changes in on OA on XR?
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cyts
Name 3 risk factors for Carpel Tunnel?
Pregnancy Obesity RA Diabetes Any cause of oedema Idiopathic
Name two specific antibodies for SLE?
Anti-Smith
Anti-dsDNA
(Both 99% specific, dsDNA is more sensative)
What antibody is most associated with diffuse systemic sclerosis?
Anti-Scl70
What antibody is most assocated with limited systemic sclerosis?
Anti-centromere
Sjogren’s syndrome causes what symptoms?
Autoimmune attacking of exocrine glands
- Dry eyes
- Dry mouth
- Dry vagina
(Anti-Ro and Anti-La)
Heliatrope rash is associated with?
Dermatomyocytis
Anti-Jo1
How does APLS present?
Coagulation defect
Livedoreticularis
Obstetric sequelae
Thrombocytopenia
Name 5 complications of RA?
Lung fibrosis Uveitis IHD Crohns Osteoporosis Depression Infections
What are the key features of gout? (3)
Monoarthropathy
1st MTP most common
What is seen on aspiration of gout?
Needle crystals
-ve birefringent
(Urate crystals)
What is seen on aspiration of pseudogout?
Rhomboid crystals
+ve birefringent
(Calcium crystals)
What organisms cause septic arthritis in a) younger patients and b) older patients?
a) Gonococcal
b) Staph aureus (or IVDU, not just old)
Name 3 examples of seronegative arthritis?
Reactive arthritis (within 1mth of infection)
Ank spond
Psoritic arthritis
Entropathic (if IBD as well)
