infant symptoms in osteomyelitis
failure thrive, drowsy, irritable, tender swelling, decreased ROM, position change, knee.
child symptoms in osteomyelitis
severe pain, reluctance to move, tender fever, malaise
adult signs in osteomyelitis
backache, immunocompromised
investigations for osteomyelitis
FBC + diff WBC ESR CRP blood cultures 3* U+E’s
X-Ray, US, isotope bone scan, labelled white cell scan, MRI, aspiration
treatment for osteomyelitis
Supportive
rest + splintage
4-6 weeks empirical initially antibiotics
surgery for aspiration, drainage, debridement, replacing joint replacements
if chronic eradicate surgically, consider amputate
differential diagnosis for osteomyelitis
Consider synovitis or septic arthritis, or soft tissue infection
acute septic arthritis neonate symptoms and signs
irritable, resistant to movement, ill
child acute septic arthritis symptoms and signs
acute pain in single joint, reluctant to move, fever, pulse, tender
child acute septic arthritis investigations
FBC, WBC, ESR, CRP, blood cultures, US, aspirate
treatment for child acute septic arthritis
Supportive
antibiotics 3-4 weeks, surgical drainage and lavage
failure thrive, drowsy, irritable, tender swelling, decreased ROM, position change, knee. symptoms of
osteomyelitis in child
TB joint manifestation symptoms
Insidious onset
TB contact
night pain, Weight loss, swelling, pyrexia, decreased ROM, ankylosis, deformity
investigations for TB joint manifestation
FBC, ESR, Mantoux, sputum, urine culture, X-ray, joint aspiration and biopsy
treatment for TB joint manifestation
8 weeks
rifampicin
isoniazid
ethambutol
6-12months
rifampicin
isoniazid
rheumatoid arthritis symptoms
Morning stiffness, 3 or more joints, symmetric, nodules. Pain, immobility, poor function, systemic. Swelling, tenderness, redness and heat. Fatigue, weight loss, anaemia
RA investigations
RF
anti CCP
X-Ray
US doppler
gout treatment flare
NSAIDS, colchicine, steroids
gout repeated attacks
symptomatic
xanthine oxidase inhibitor, febuxostat, uricosuric agents, canakinumab, lifestyle
pseudogout symptoms
Elderly female, knee, erratic flares, triggers
pseudogout treatment
NSAIDS, steroids
polymyalgia rheumatica symptoms
Correlates with GCA. Sudden onset of shoulder and pelvic girdle stiffness, malaise, weight loss, fever, depression, arthralgia occasional synovitis
> age of 50
Paget’s disease symptoms and signs
Deformity and fracture >40yrs with bone pain excess heat neurological comp. deafness osteosarcoma
biochemical signs of Pagets
raised ALK P
treatment of Paget’s disease
Treat symptomatic with IV bisphosphonate therapy 1 off IV zoledronic acid
acute pain in single joint, reluctant to move, fever, pulse, tender symptoms of
acute septic arthritis in a child
Morning stiffness, 3 or more joints, symmetric, nodules. Pain, immobility, poor function, systemic. Swelling, tenderness, redness and heat. Fatigue, weight loss, anaemia symptoms of
Rheumatoid arthritis
Insidious onset
night pain, Weight loss, swelling, pyrexia, decreased ROM, ankylosis, deformity symptoms of
TB joint manifestation
Correlates with GCA. Sudden onset of shoulder and pelvic girdle stiffness, malaise, weight loss, fever, depression, arthralgia occasional synovitis
> age of 50 - symptoms of
polymyalgia rheumatica
Elderly female, knee, erratic flares, triggers - symptoms of
pseudogout
Deformity and fracture >40yrs with bone pain excess heat neurological comp. deafness osteosarcoma - symptoms of
Paget’s disease
Progressive deforming bone defective tooth formation hearing loss blue sclera scoliosis barrel chest ligamentous laxity easy bruising symptoms of
Osteogenesis imperfecta
treatment for osteogenesis imperfecta
Treat fractures
IV bisphosphonates to prevent
education
genetic counselling
investigation of osteoporosis
DXA bone scan
osteogenesis imperfecta symptoms
Progressive deforming bone defective tooth formation hearing loss blue sclera scoliosis barrel chest ligamentous laxity easy bruising
osteoporosis treatment
Fall prevention stragety ensure good calcium and Vit D, HRT, SERM main Bisphosphonates biologic Denosumab teriparatide
SLE symptoms
Butterfly rash, fever depression vasculitis, purpura urticaria, pleurisy pleural effusion fibrosis Raynaund’s aseptic necrosis of hip, arthritis, alopecia, fits ataxia, hemiplegia P. neuropathy CN lesions pericarditis endocarditis aortic valve lesions myopathy, anaemia leukopenia thrombocytopenia
investigations for SLE
Anti-ds DNA, SM, cardiolupin, lupus anticoagulant, low complement low WCC U+E’s dipstix biopsy kidney if haematuria ANA
mild SLE treatment
hydroxychloroquine
moderate SLE treatment
azathioprine, methotrexate, mycophenolate
severe SLE treatment
cyclophosphamide, rituximab
scleroderma symptoms
Morphea local systemic limited oesophageal disability Sclerodactyly telangiectasia Calcinosis Raynauds distal to the elbows and knees systemic diffuse fixed flexion deformities of fingers, feel encased
scleroderma investigation
Regular monitoring of RH function and lung function
ANA
scleroderma mild treatment
mild – hydroxychloroquine
moderate scleroderma treatment
azathioprine, methotrexate, mycophenolate
severe scleroderma tx
cyclophosphamide, rituximab
Sjorgren’s syndrome symptoms
GS dysphagia, altered motility, interstitial lung disease, fits, hemiplegia, ataxia, CN lesions, renal tubular acidosis, palpable purpura, Raynaud’s syndrome, arthralgia, dryness, fatigue, myalgia, fever
investigations for Sjogren’s syndrome
Schirmer’s test
Biopsy of minor saliva gland below lip
mild Sjogren’s syndrome tx
hydroxychloroquine
moderate Sjogren’s syndrome Tx
azathioprine, methotrexate, mycophenolate
severe Sjogren’s syndrome Tx
cyclophosphamide, rituximab
auto-immune myositis symptoms
Muscle weakness
symmetrical diffuse, proximal, polymyositis, dermatomyositis Gottron’s papules, heliotrope rash.
no pain
Shawl’s sign
auto-immune myositis mild Tx
hydroxychloroquine
auto-immune myositis moderate Tx
azathioprine, methotrexate, mycophenolate
auto-immune myositis severe Tx
cyclophosphamide, rituximab
GCA symptoms
> 50
new headache
Temporal tenderness
Butterfly rash, fever depression vasculitis, purpura urticaria, pleurisy pleural effusion fibrosis Raynaund’s aseptic necrosis of hip, arthritis, alopecia, fits ataxia, hemiplegia P. neuropathy CN lesions pericarditis endocarditis aortic valve lesions myopathy, anaemia leukopenia thrombocytopenia - symptoms of
SLE
Morphea local systemic limited oesophageal disability Sclerodactyly telangiectasia Calcinosis Raynauds distal to the elbows and knees systemic diffuse fixed flexion deformities of fingers, feel encased - symptoms of
scleroderma
GS dysphagia, altered motility, interstitial lung disease, fits, hemiplegia, ataxia, CN lesions, renal tubular acidosis, palpable purpura, Raynaud’s syndrome, arthralgia, dryness, fatigue, myalgia, fever - symptoms of
Sjogren’s syndrome
Muscle weakness
symmetrical diffuse, proximal, polymyositis, dermatomyositis Gottron’s papules, heliotrope rash.
no pain
Shawl’s sign - symptoms of
auto-immune myositis
> 50
new headache
Temporal tenderness - symptoms of
GCA
GCA mild treatment
hydroxychloroquine
GCA investigation
ESR > 50
Biopsy of temporal artery
GCA moderate treatment
azathioprine, methotrexate, mycophenolate
GCA severe treatment
cyclophosphamide, rituximab
Ankylosing Spondylitis symptoms
Axial, back pain, limited movements anteriorly, posteriorly and laterally, limited chest expansion, bilateral sacroiliitis, erosions or sclerosis
peripheral joints, uveitis, tendonitis, cardiac, pulmonary, GI, osteoporosis, cauda equina, renal amyloidosis
ankylosing spondylitis investigation
HLA B27 positive
modified Schober for spinal mobility
X-ray
ankylosing spondylitis Tx
Physiotherapy, NSAIDs, sulfasalazine, anti TNF, anti IL-17
treat osteoporosis, surgery rarely
psoriatic arthritis symptoms
Distal inter pharyngeal changes with nail changes and psoriasis affecting knees, toes, ankle, base of spine, elbow, wrist, hand, neck and shoulder
Tx psoriatic arthritis treatment
Sulfasalazine methotrexate leflunomide cyclosporine anti TNF Anti IL 17 +23 physio + OT
reactive arthritis symptoms
Mono or oligoarthritic, may be systemic, dactylitis and enthesis be also be seen
skin and mucous involvement keratoderma blennorrhagia, iritis, urethritis, Reighte’r syndrome
reactive arthritis treatment
NSAID, sulfasalazine, methotrexate
reactive arthritis acute treatment
Acute NSAID, joint injections, treat underlying infection
enteropathy arthritis Tx
Sulfasalazine, steroids, methotrexate, anti TNF, bowel resection
meniscal tear symptoms
Pain clicking locking intermittent swelling effusion, tender, mechanical block, fail deep squat, McMurray’s positive, Thassaly’s positive
meniscal tear investigations
X-Ray
MRI
meniscal tear treatment
Rest
NSAIDS
physiotherapy
Arthroscopy for repair or resection
Axial, back pain, limited movmeents anteriorly, posteriorly and laterally, limited chest expansion, bilateral sacroiliitis, erosions or sclerosis
peripheral joints, uveitis, tendonitis, cardiac, pulmonary, GI, osteoporosis, cauda equina, renal amyloidosis - symptoms of
ankylosing spondylitis
Distal inter pharyngeal changes with nail changes and psoriasis affecting knees, toes, ankle, base of spine, elbow, wrist, hand, neck and shoulder - symptoms of
psoriatic arthritis
Mono or oligoarthritic, may be systemic, dactylitis and enthesis be also be seen
skin and mucous involvement keratoderma blennorrhagia, iritis, urethritis, Reighte’r syndrome - symptoms of
reactive arthritis
Pain clicking locking intermittent swelling effusion, tender, mechanical block, fail deep squat, McMurray’s positive, Thassaly’s positive - symptoms of
meniscal tear
osteoarthritis symptoms
pain and stiffness
anterior cruciate ligament tear symptoms
Pop/crack immediate swelling deep pain anterior draw pivot shift Lachmanns test
ACL investigations
X-ray
MRI
ACL Tx
Focused Quadricep programme
ACL reconstruction, partial menisectomy, hamstring graft, ligament repair or augmentation
MCL symptoms
Pop/crack
painful
unable to continue playing
localised swelling, bruising medial knee
lock, tender medially and at femoral insertion, painful full extension, opening on valgus stress
MCL investigations
X-Ray
MRI – modality of choice
MCL treatment
Rest, NSAIDS, brace for comfort, physiotherapy
operative only for failed non operative, or severe with repair or reconstruction
osteochondritis dissecans symptoms
Activity related pain recurrent effusion locking block to full movement tender stiffness Wilson’s test
osteochondritis dissecans investigations
X-ray
MRI
osteochondritis dissecans Tx
Restricted weight bearing, ROM brace
operative Arthroscopy or open fixation
Hallux Valgus symptoms
Pressure from shore wear
pain from crossing over of toes
metatarsalgia
Hallux Valgus investigation
X-ray
clinical
Hallux Valgus non-operative treatment
shoe wear modification
orthotics
analgesia
activity modification
Hallux Valgus operative TX
release lateral soft tissues, osteotomy of 1st metatarsal
Hallux Rigidus symptoms
Asymptomatic
pain at extreme of dorsiflexion
limited ROM
Hallux Rigidus Tx
Activity modification rigid sole analgesia Cheilectomy arthrodesis arthroplasty gold standard is a 1st MTPJ fusion
Pain and stiffness of joint - symptoms of
OA
Pop/crack immediate swelling deep pain anterior draw pivot shift Lachmanns test - symptoms
ACL tear
Pop/crack
painful
unable to continue playing
localised swelling, bruising medial knee
lock, tender medially and at femoral insertion, painful full extension, opening on valgus stress - symptoms
MCL
Activity related pain recurrent effusion locking block to full movement tender stiffness Wilson’s test - symptoms of
Osteochondritis dissecans
Pressure from shore wear
pain from crossing over of toes
metatarsalgia - symptoms of
Hallux Valgus
Asymptomatic
pain at extreme of dorsiflexion
limited ROM - symptoms of
Hallux Rigidus
Lesser Toe deformity symptoms
Deformity
pain from dorsum
metatarsalgia
treatment for Lesser Toe deformity
Activity modification flat shoes with high toes box orthotic insoles operative flexor to extensor transfer fusion of interphalangeal joint release of metatarsophalangeal joint shortening osteotomy of metatarsal
Morton’s Neuroma symptoms
Affects 3rd followed by 2nd webspace toes
neuralgic burning pain
intermittent
altered sensation
Morton’s Neuroma investigation
Mulder’s click
US best
clinical
MRI
Morton’s Neuroma treatment
injection and excision
Dorsal foot ganglia symptoms
Pain from pressure from shoe wear
pain from underlying problem
dorsal foot ganglia treatment
Aspiration and excision
plantar fibromatosis treatment
Avoid pressure/ orthotics
excisions
RT+/- surgery
achilles tendinopathy symptoms
Pain during excersise, following exercise, recurrent, difficult fitting shoes
achilles tendinopathy investigations
Tenderness
check for rupture simmond’s test
US
MRI
achilles tendinopathy treatment
Weight loss activity modification shoe wear modification physiotherapy extra corporeal shockwave treatment immobilise operative debridement and release Gastrocnemius resection
plantar fasciosis symptoms
Pain first thing in morning, pain on weight bearing following rest, pain located at origin of plantar fascia, long lasting
Plantar fasciosis investigations
Clinical
x-Ray
US
MRI
Plantar fasciosis Tx
Rest stretching Ice NSAIDS orthoses heel pads physio weight loss injections of corticosteroids night splinting
diabetic foot ulcer Tx
Prevention
modify the main detriments; smoking, diabetic, vascular, external and internal pressure, infection, nutrition
surgical debride, correct deformity, amputation
Charcot neuroarthropathy symptoms
Acute swollen erythematous foot with neuropathy
greater than 3-degree difference between limbs
not painful
Affects 3rd followed by 2nd webspace toes
neuralgic burning pain
intermittent
altered sensation - symptoms
Morton’s Neuroma
Pain from pressure from shoe wear
pain from underlying problem - symptoms
Dorsal foot ganglia
Pain during exercise, following exercise, recurrent, difficult fitting shoes - symptoms
achilles tendinopathy
Pain first thing in morning, pain on weight bearing following rest, pain located at origin of plantar fascia, long lasting - symptoms
plantar fasciosis
plantar fasciosis differentials
Nerve entrapment syndrome
arthritis
calcaneal pathology
Acute swollen erythematous foot with neuropathy
greater than 3-degree difference between limbs
not painful - symptoms
charcot neuroarthropathy
Sarcoma symptoms
Deep
>5cm
rapid hard craggy, non-tender growth
ma be painless
sarcoma investigations
MRI
Bone tumour symptoms
Pain – progressive, rest, night, activity
mass
malignant may be deep seated and boring pain, difficulty weight bearing and deep swelling
bone tumour investigations
X-ray CT isotope bone scan MRI scan of choice PET for response to chemo Biopsy after other investigations
osteosarcoma symptoms
Pain, loss of function, warm swelling, pathological fractures, effusion, deformity, neurovascular effects, systemic effects. Analgesia not effective, not related to exercise, worse at night
osteosarcoma investigation
MRI
pathological fractures from bone tumours treatment
Early chemo DXT prophylactic internal fixation bone cement aim for early painless weight bearing + mobilisation
spinal central cord
hyperextension injury
weakness of arms > legs
perianal sensation and lower extremity power preserved
spinal anterior cord hyperflexion,
fine touch and proprioception preserved but profound weakness
Brown Sequard
paralysis of affected side ,
Brown Sequard
paralysis of affected side , loss of proprioception and fine discrimination, pain and temperature loss of opposite side below lesion
treatment of spinal cord injury
Prevent secondary insult in-field stabilization ATLS resus pharmacologic agents prompt medical care
posteriorly pedicle screws
long term
physio
OT
psychological support
urological
investigation for spinal cord injury
ASIA classification
X-rays
CT
MRI
Tibialis posterior tendon dysfunction investigation
Clinical diagnosis double and single heel raise
MRI
treatment for Tibialis posterior tendon dysfunction
Orthoses or surgery
tendon reconstruction
triple fusion
IV disk prolapse symptoms
Nerve root pain – limb pain worse than back, nerve distribution
cauda equina symptoms
Bladder and anal sphincter dysfunction and incontinence
bilateral buttock and leg pain, and dysesthesia, weakness
treatment for cervical and lumbar spondylosis
Lateral recess stenosis
nerve root injection, epidural injection
surgery
central stenosis
epidural steroid
surgery
foraminal stenosis
non-operative
epidural injection
surgery
spinal claudication symptoms
Bilateral Sensory dysesthesia poss weakness takes several minutes to ease after stopping walking worse walking down hills
Deep
>5cm
rapid hard craggy, non-tender growth
ma be painless - symptoms
sarcoma
Pain – progressive, rest, night, activity
mass
malignant may be deep seated and boring pain, difficulty weight bearing and deep swelling - symptoms
bone tumours
Pain, loss of function, warm swelling, pathological fractures, effusion, deformity, neurovascular effects, systemic effects. Analgesia not effective, not related to exercise, worse at night - symptoms
osteosarcoma
weakness of arms > legs
perianal sensation and lower extremity power preserved - symptoms
central cord
hyperextension injury
loss of proprioception and fine discrimination, pain and temperature loss of opposite side below lesion
Brown Sequard
paralysis of affected side
, fine touch and proprioception preserved but profound weakness
anterior cord hyperflexion
Bladder and anal sphincter dysfunction and incontinence
bilateral buttock and leg pain, and dysesthesia, weakness
cauda equina
Bilateral Sensory dysesthesia poss weakness takes several minutes to ease after stopping walking worse walking down hills
spinal claudication
Dupuytren’s disease symptoms
Not painful
loss of finger extension
difficulty with hand in pocket, gripping things, washing face
Dupuytren’s treatment
Operative partial fasciectomy dermo-fasciectomy arthrodesis amputation collagenase percutaneous needle fasciotomy
Trigger finger symptoms
Clicking
lump in hand under pulley
may unlock
trigger finger treatment
Splintage, steroid, percutaneous release, open surgery
De Quervain’s syndrome symptoms
Localised swelling
pain localised to radial side of wrist
aggravated by movement of the thumbs , localised tenderness over tunnel
de Quervain’s investigation
Finklestein’s test
resisted thumb extension
De Quervain’s treatment
Splint
steroids
decompression
ganglia symptoms
Lump, firm, non -tender, change in size, smooth, lobulated, not fixed
OA treatment
Manage social, occupation, mood, sleep, support network, comorbidity, pain, exercise
thermotherapy,
electrotherapy, aids and devices, manual therapy
analgesia, NSAIDS, capsaicin, steroids
Erb-Duchenne sign
Arm-Porter’s tip
ulnar nerve symptoms and signs
Claw hand, hypothenar wasting, 1st dorsal interosseous wasting, sensory deficit little finger
median nerve signs and symptoms
Thenar wasting, pointing finger, volar aspect thumb sensory loss
radial nerve signs and symptoms
Wrist drop, sensory deficit 1st web space dorsally
Not painful
loss of finger extension
difficulty with hand in pocket, gripping things, washing face - symptoms
dupuytren’s disease
Clicking
lump in hand under pulley
may unlock - symptoms
trigger finger
Lump, firm, non -tender, change in size, smooth, lobulated, not fixed - symptoms
ganglia
45+ years, activity related joint pain plus no morning related stiffness or morning stiffness that lasts no longer than 30 minutes - symptoms
OA
Wrist drop, sensory deficit 1st web space dorsally
radial nerve injury
Thenar wasting, pointing finger, volar aspect thumb sensory loss
median nerve
Claw hand, hypothenar wasting, 1st dorsal interosseous wasting, sensory deficit little finger
ulnar nerve