Investigating and Managing Common Orthopaedic Presentations

Question 1

Broadly describe the differentiation between inflammatory and non-inflammatory arthritis.

Answer 1

Question 2

What are the different causes of inflammatory arthritis?

Answer 2

Question 3

What are the different causes of non-inflammatory arthritis?

Answer 3

Question 4

Which questions should you ask a patient presenting with joint pain?

Answer 4

• Exact location of pain
• When is the pain / swelling / stiffness in the joints worst?
• Do the joint symptoms improve with activity?
• Do you have morning stiffness? Does it last for < / > 60 minutes?

Question 5

Which specific question would you ask if querying rotator cuff impingement / tear?

Answer 5

Do you have pain in the front of your shoulder / side of your arm on activities such as brushing your hair?

Question 6

Which specific question would you ask if querying medial epicondylitis (Golfer’s elbow / pitcher’s elbow)?

Answer 6

Pain in medial elbow with wrist flexion such as shaking hands or carrying suitcase?

Question 7

Which specific question would you ask if querying lateral epicondylitis (tennis elbow)?

Answer 7

Pain in lateral elbow with wrist extension (using screwdriver, turning doorknobs)?

Question 8

Which specific question would you ask if querying DeQuervain tenosynovitis?

Answer 8

Pain on dorsal thumb tendons with grasping?

Question 9

Which specific question would you ask if querying prepatellar bursitis (Clergyman’s knee or Housemaid’s knee)?

Answer 9

Pain on patella with kneeling?

Question 10

Which specific question would you ask if querying trochanteric bursitis?

Answer 10

Pain on lateral thigh while sleeping on that side?

Question 11

Which specific question would you ask if querying achilles tendonitis?

Answer 11

Pain along the back of the heel and foot with stretching of ankle or standing on toes?

Question 12

Which specific question would you ask if querying plantar fasciitis?

Answer 12

Pain in bottom of feet with first steps in the morning?

Question 13

Pain on which actions would indicate that the most likely cause is the hip joint?

Answer 13

• Pain in the groin area / outer thigh when:
  
  • ​Getting into or out of the car
  • Getting into the bath tub
  • Difficulty in bending over while sitting to tie shoe laces

Question 14

Pain on which actions would indicate that the most likely cause is the knee joint?

Answer 14

• Pain in the front of the knee while:
  
  • ​Walking up- or down-stairs
  • Getting up from a chair
  • Kneeling
  • Squatting

Question 15

Pain in which area would indicate that the most likely cause is the back (spinal stenosis)?

Answer 15

• Pain in buttock or leg with standing and walking that improves with rest and leaning forward on a grocery cart.

Question 16

Describe the physical examination of a patient with joint pain.

Answer 16

• Look - for redness, swelling or deformity
• Touch - for heat or warmth
• Palpate - for tenderness or effusion / swelling
• Move - to assess tenderness and limitation of ROM in the joint
• The presence of any one of these - swelling, warmth or erythema is diagnostic or arthritis, but the absence of all of these is diagnostic or arthralgia.

Question 17

What are the typical findings on examination of a patient with OA?

Answer 17

• Bony enlargement
• Heberden nodes
• Bouchard nodes
• Crepitus on motion

Question 18

What are the typical findings on examination of a patient with gout / septic arthritis / injury / trauma?

Answer 18

Acute onset erythema and warmth

Question 19

What are the typical findings on examination of a patient with rheumatoid arthritis?

Answer 19

• Ulnar deviation
• Boutonniere deformities

Question 20

What are the typical findings on examination of a patient with psoriatic arthritis / spondyloarthritis?

Answer 20

Dactylitis

Question 21

Which joints are affected by Heberden’s node and which by Bouchard’s node?

Answer 21

• Proximal interphalangeal joint - Bouchard’s node.
• Distal interphalangeal joint - Heberden’s node.

Question 22

Explain how different types of arthritis can present based on pattern of presentation?

Answer 22

Monoarthropathies tend to be specific to trauma or OA.

Question 23

What are the 4 signs of osteoarthritis?

KNOW THESE

Answer 23

• Joint space narrowing
• Osteophytes
• Subchondral cysts
• Bony sclerosis

Question 24

What are the other findings to note on X-ray of an OA joint?

Answer 24

• Bone loss / AVN
  
  • Loss of shape of femoral head
• Previous surgery / implants
• Deformity / alignment

Question 25

What are the X-ray changes in knee OA?

Answer 25

Question 26

What are the non-operative management options for OA?

Answer 26

* Analgesia * Optimise * Activity modification * Change job * Less golf? * **Walking aids** * **Physiotherapy** * Intra-articular injection * Cortisone * Lubricant

Question 27

What are the operative management options for OA?

Answer 27

* Osteotomy * Re-align the joint / limb * **Arthrodesis** * **​**Make a stiff, painless joint * Mostly smaller joints * Excision arthroplasthy * Remove arthritis * Leaves a shorter joint with less mobility * **Replacement arthroplasty** * **​**Large joints * But also small joints!

Question 28

What are the indications for joint replacement?

Answer 28

* Disabling pain - despite analgesia * Functional restrictions - walking distance * Quality of life - night pain * Radiographic significant arthritis

Question 29

What are the complications of joint replacement?

Answer 29

* Infection - 1-3% * DVT / PE * Peri-prosthetic fracture * Loosening * Knee \>90% 15y survival * Hip \>95% 15y survival * Knee * Limited ROM * ~15% residual pain & stiffness * Hip * Dislocation 1-5% * Dissatisfaction * 20% of patients are not happy with joint replacement even if function and pain are better

Question 30

What are the investigations you should do if querying rheumatoid arthritis?

Answer 30

* Imaging * X-ray * USS * MRI * FBC and ESR * Other tests * RhF * Anti-CCP (antibodies)

Question 31

What is the first stage in management of rheumatoid arthritis?

Answer 31

* Lifestyle - maintain where possible. * This is an MDT effort. * Physiotherapy * Occupational therapy * Podiatry * NSAIDs * More effective than simple analgesics * Variation in response * Balance efficacy and toxicity * Related to dose and diration of therapy * GI * Renal * CV * Elderly are at greater risk

Question 32

What are the principles of using NSAIDs as pain relief in rheumatoid arthritis?

Answer 32

* Use the lowest dose compatible with symptom relief. * Use gastroprotection in 'at-risk' patient. * Reduce and, if possible, withdraw when good response from DMARD.

Question 33

What are the benefits of using COX-2 inhibitors as pain relief in rheumatoid arthritis? Is there any risk?

Answer 33

* Selectively block COX-2 isoenzyme. * Provide pain relief (as efficacious as NSAIDs). * Less GI bleeding than NSAIDs (less significant GI symptoms remain e.g. dyspepsia). * **CV risk??**

Question 34

What is the second stage in the management of rheumatoid arthritis?

Answer 34

* NSAIDs * COX-2 inhibitors

Question 35

What is the third stage in the management of rheumatoid arthritis?

Answer 35

Long-term suppressive drug therapy with disease modifying anti-rheumatic drugs (DMARDs).

Question 36

What are the benefits of using an early DMARD in rheumatoid arthritis?

Answer 36

* Stabilise joint function as early as possible = better outcome. * Greater awareness of NSAID toxicity. * DMARDs slow disease progression.

Question 37

Which DMARDs have the best efficacy : toxicity ratio?

Answer 37

* Methotrexate and Sulfasalazine * Increased use of combination therapy because it is better than sequential monotherapy.

Question 38

Which score can be used as a measure of disease activity in rheumatoid arthritis? What does it assess?

Answer 38

* DAS28 * Swollen joints * Tender joints * ESR * Patient's general health score

Question 39

What monitoring should a patient undergo while on a DMARD?

Answer 39

* FBC * LFTs * U&E * BP * Urinalysis

Question 40

Describe the use of systemic corticosteroids in rheumatoid arthritis.

Answer 40

* Not recommended for routine use * If necessary, use lowest dose for shortest time * Monitor due to side effect profile

Question 41

Describe the use of intra-articular corticosteroids in rheumatoid arthritis.

Answer 41

* Give in 'target' joint (i.e. 1/2 large joints affected), can avoid systemic steroid. * Maximum number per joint / time - but no evidence for this theory. * Evidence is lacking for this practice, but patients report benefit.

Question 42

What are the TNF α blockers used as DMARDs in rheumatoid arthritis?

Answer 42

* Infliximab (human antichimeric antibody) * Etanercept (fusion protein) * Adalimumab (fully humanised monoclonal antibody) * Golimumab (human monoclonal antibody)

Question 43

What are the effects of blocking TNFα?

Answer 43

* Immunological * ↓ Rheumatoid factor * T cell function restored * Inflammation * ↓ Cytokine production in joints (IL1, IL6, TNF) * Angiogenesis * ↓ levels of angiogenesis * Joint destruction * ↓ damage to bone and cartilage * Haematology * ↓ Platelets . fibrinogen, restoration of Hb

Question 44

What do each of these suffixes mean: * ximab? * zumab? * umab? * cept? Describe their immunogenicity.

Answer 44

* Ximab - chimeric antibody * Zumab - humanised antibody * Umab - human antibody * Cept - fusion protein * **Immunogenicity -** the ability to provoke an inflammatory response.

Question 45

What are the eligibility criteria for biological therapy?

Answer 45

* DAS28 \>5.1 * At least 2 previous DMARDs * Adequate response at 3 months * 3-monthly monitoring

Question 46

What effect should infection have on prescribing biologic therapy?

Answer 46

* Do not initiate in the presence of serious active infection or in patients at high risk. * Discontinue in presence of serious infection.

Question 47

Describe the use of biologic therapies in patients with malignancy.

Answer 47

* No increased risk of solid tumours or lymphoproliferative disease. * Investigate / stop the therapy in patients with active malignancy. * Exercise caution in pre-malignant conditions. * Remember preventative skin care / ongoing surveillance.

Question 48

How do you describe an X-ray of a fracture?

Answer 48

* **Say what you see** * Location of fracture * Features of fracture: * Shape * Displacement description * Comminution * Intra-articular * Any dislocation of associated joint

Question 49

Why are paediatric fractures different to adult fractures?

Answer 49

* Open physes - growth may be affected * Remodelling potential as they grow * The younger they are, the faster they heal

Question 50

What is a greenstick fracture?

Answer 50

* Like breaking a root vegetable - it breaks on one side but not the other. * This is what paediatric bones do.

Question 51

What is a buckle fracture?

Answer 51

* Looks like a buckle on the cortex. * Very stable. * Usually treat with just a cast or splint

Question 52

Describe each stage of the Salter Harris classification.

Answer 52

Question 53

Describe basic fracture management.

Answer 53

* **First of all:** * **ABC approach to emergency care of entire patient then ensure limb is neurovascularly intact.** * Analgesia * Splintage - provides pain relief and resuces internal blood loss. * Open wounds - dressings and ABx. * X-rays in 2 planes. * Definitive treatment: * **Stable** - treatment without surgery - hold in correct position until heals (cast / splint / traction). * **Unstable** - surgical fixation with metalwork - usually allows quicker mobilisation of the affected limb.

Question 54

Define acute compartment syndrome.

Answer 54

* Intracompartmental pressure is elevated (relative to the end-capillary pressure) to a level and for such a duration that perfusion of intracompartmental structures is compromised and decompression is nevessary to prevent muscle necrosis. * **Pressure increases to such a level that blood cannot flow in.** * **If blood cannot flow in - the tissue dies.**

Question 55

What are the criteria for clinical diagnosis of acute compartment syndrome?

Answer 55

* Pain * Pain on passive stretch * Paraesthesia * Paralysis * **Pulses present** * **Palpation** * Pain in 95% of conscious patients * 35% unconscious or under anaesthetic at time of diagnosis * Stretch pain 49% * Neurological abnormality 53%

Question 56

What is the single cause of a poor outcome in acute compartment syndrome?

Answer 56

**Delay is the single cause of a poor outcome in acute compartment syndrome.** Compartment syndrome for \>8 hours causes tissue death which will result in amputation.

Question 57

What is the ideal outcome for a patient with acute compartment syndrome?

Answer 57

* Normal function of the extremity * Absence of deformity * Minimal cosmetic deformity

Question 58

What are the outcomes to avoid in acute compartment syndrome?

Answer 58

* Contracture * Sensory deficit * Paralysis * Infection * Nonunion * Amputation

Question 59

Describe how acute compartment syndrome is diagnosed.

Answer 59

* Compartment monitoring - catheter in to monitor intra-compartment pressure. * Need perfusion pressure of ~13mmHg to maintain a compartment. * Continuous 24 hour monitoring. * Delta p (diastolic - tissue pressure) \<30mmHg.