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Flashcards in MBChB Deck (285):
1

Seropositive arthritis

Lupus
Rheumatoid arthritis
Scleroderma
Vasculitis
Sjogrens

2

Seronegative Arthritis

Ankylosing Spondylitis
Psoriatic Arthritis
Reactive arthritis
Inflammatory bowel disease arthritis

3

Most common form of arthritis?

Osteoarthritis

4

Second degree causes of OA

Congenital dislocation of the hip
Perthes
SUFE
Previous intra‐articular fracture
Extra‐articular fracture with malunion
Osteochondral / hyaline cartilage injury
Crystal arthropathy
Inflammatory arthritis (can give rise to mixed pattern arthritis)
Meniscal tears
Genu Varum or Valgum

5

What is perthes?

A disease where the top of the thigh bone in the hip softens and breaks down

6

SUFE

Slipped upper femoral epiphyses
(the growth plate is weak and the ball slips down and backwards)

7

Radiographical findings of osteoarthritis?

L (loss of joint space)
O (osteophytes)
S (sclerosis)
S (subchondral cysts)

8

Diagnosis of rheumatoid arthritis

Clinical presentation, radiographic findings and serological analysis
The ACR/EULAR Rheumatoid Arthritis Criteria scoring system assists in the diagnosis.

9

Which internal organs can be affected in rheumatoid arthritis?

Rheumatoid Lung
Ischaemic heart disease

10

Operations performed for rheumatoid arthritis

Synovectomy
Joint replacement
Joint excision
Tendon transfers
Arthrodesis (fusion)
Cervical spine stabilisation

11

Synovectomy

Removes inflamed synovium

12

Most likely places to get joint involvement in SLE?

Hands and knees
Avascular necrosis can also occur in the hip and knee

13

How would you treat tendon ruptures and severe symptomatic joint damage in SLE?

Surgery
(but remember that they try to treat everything with drugs primarily)

14

Which gender is more commonly affected in ankylosing spondylitis?

Males 3:1
chronic inflammatory disease of the spine and sacro‐iliac joints which leads to eventual fusion of the intervertebral joints and SI joints
May often develop knee and hip arthritis aswell

15

Conditions associated with ankylosing spondylitis

aortitis, pulmonary fibrosis and amyloidosis

16

Xrays show bony spurs from the vertebral bodies known as syndesmophytes which can bridge the intervertebral disc resulting in fusion producing a “bamboo spine”

Ankylosing Spondylitis

17

Treatment for ankylosing spondylitis

Treatment consists of physiotherapy, exercise, simple analgesia and DMARDs for more aggressive disease

18

onycholysis

Lifting of the nail from the nail bed

19

In psoriatic arthritis, some patients have a predilection for arthritis in which joints?

DIP

20

In psoriatic arthritis, 5% of patients with DIP arthritis develop a more aggressive and destructive form of this. What is this condition called?

Arthritis Mutilans

21

Enteropathic arthritis

Enteropathic arthritis refers to an inflammatory arthritis involving the spine and peripheral joints occurring in patients with inflammatory bowel disease (Crohn’s disease and Ulcerative Colitis), coeliac disease, patients with extensive bowel resections and patients with a reactive arthritis from bacterial or parasitic infection of the GI tract (Shigella, Salmonella, Yersinia, Campylobacter, Cryptosporidium, Giardia and others)

22

Treatment for Enteropathic Arthritis

10‐20% of IBD sufferers will experience spine or joint problems. Treatment includes treating the underlying condition (corticosteroids, antibiotics) and DMARDs can help. Any peripheral arthritis is usually self‐limiting and orthopaedic surgery is not required but steroid injection can help.

23

Some patients have a triad of symptoms of urethritis, uveitis and arthritis known as Reiter’s syndrome

Reactive Arthritis

24

What is gout usually due to?

Gout is a crystal arthropathy caused by deposition of urate crystals within a joint which is usually due to high serum uric acid levels (hyperuricaemia)

25

Gouty tophi

Painless white accumulations of uric acid can occur in the soft tissues and erupt through the skin

26

What can chronic gout result in?

Destructive erosive arthritis

27

How to diagnose gout

A definitive diagnosis can be made by analysing a sample of synovial fluid with polarised microscopy (the fluid is also analysed with Gram stain and culture to exclude infection). Uric acid crystals are needle shaped and display negative birefringence (change from yellow to blue when lined across the direction of polarization).

28

Treatment for Gout

Treatment for acute attacks includes NSAIDs, corticosteroids, opioid analgesics and colchicine for patients who cannot tolerate NSAIDs (though it can have GI side effects and interfere with other medications). For sufferers of recurrent attacks or those with joint destruction or tophi, allopurinol or probenecid can prevent attacks but they should not be started until an acute attack has settles as theoretically they could potentiate an acute attack.

29

What is Chondrocalcinosis

The term chondrocalcinosis is used when calcium pyrophosphate deposition occurs in cartilage and other soft tissues in the absence of acute inflammation

30

Treatment of Pseudogout

Treatment of acute attacks includes NSAIDs, corticosteroids (systemic and intra‐articular) and occasionally colchicine. There are no medications used as prophylaxis to prevent recurrence.

31

Where does gout tend to affect?

Knee, wrist and ankle

32

What can pseudogout coexist with?

Pseudogout can coexist with hyperparathyroidism, hypothyroidism, renal osteodystrophy, haemochromatosis and Wilson’s disease. It can also occur in some cases of OA however chronic CPPD can also result in osteoarthritic change

33

Which bacteria can infect osteocytes intracellularly and make osteomyelitis very hard to get rid of?

Staph. aureus

34

In which age group would you usually see an acute osteomyelitis in the absence of surgery?

Children
Also seen in immunocompromised

35

Brodie's Abscess

Children can develop a subacute osteomyelitis with a more insidious onset where the bones react by walling off the abscess with a thin rim of sclerotic bone. This is known as a Brodie's abscess

36

Where does chronic osteomyelitis tend to occur in adults?

Chronic osteomyelitis tends to be in the axial skeleton (spine or pelvis) with haematogenous spread from pulmonary or urinary infections, or from infection from the intervertebral discs.
Chronic OM in adults/children can be peripheral from previous open fracture or internal fixation

37

What might suppress chronic osteomyelitis?

Antibiotics

38

What well known historical disease could cause osteomyelitis?

Tuberculosis (particularly in spine from haematogenous spread from the primary lung infection)

39

Where might you see osteomyelitis occurring if you've had TB?

Spine

40

In which patients might you see an osteomyelitis caused by salmonella?

Sickle cell anaemia patients

41

Which groups of people are particularly susceptible to osteomyelitis of the SPINE?

Diabetics, intravenous drug users and other immunocompromised patients

42

What can be used to determine extent of infection in osteomyelitis?

MRI

43

Organism which usually causes osteomyelitis?

Staph aureus but atypical in immunocompromised

44

Which heart condition should you check for in osteomyelitis

Endocarditis should be considered (look for clubbing, splinter haemorrhages, murmur, consider ECHO

45

Indications for surgery in osteomyelitis

Indications for surgery include inability to obtain cultures by needle biopsy, no response to antibiotic therapy, progressive vertebral collapse and progressive neurological deficit. Surgery involves debridement, stabilization and fusion of adjacent vertebrae.

46

Doughy Swelling?

Synovitis
You would see this in rheumatoid arthritis ;)

47

Synovectomy?

Surgery to remove inflamed synovium

48

Predominant feature of inflammatory arthritis?

Synovium inflammation

49

Which non-articular diseases would suggest spondyloarthritis?

psoriasis, iritis, inflammatory bowel disease, non-specific urethritis, recent dysentery

50

Anticyclic citrullinated peptide antibodies

Marker for erosive disease in RA
(ESR and CRP raised in RA. You may also see normochromic normoctytic anaemia)

51

Complications of Rheumatoid Arthritis

Bakers cysts (joint rupture)
Ruptured tendons
Joint infection
Spinal cord compression
AMYLOIDOSIS

52

Most common cause of secondary AA amyloidosis?

Rheumatoid Arthritis

53

Which procedure can excise all metatarsal heads in end stage rheumatoid foot?

Excision arthroplasty

54

What is arthrodesis gold standard for?

1st MTPJ OA

55

Which surgical procedure was originally used for TB hip and young OA hip?

Arthrodesis say whuuuut

56

Name a way in which you could fix malunion following a fracture?

Osteotomy

57

What is gold standard for hallux valgus?

Osteotomy

58

What is osteotomy?

Surgical realignment of bone

59

Antibodies in RA?

Antibodies to the Fc fragment of IgG (rheumatoid factor)
Antibodies to citrullinated cyclic peptide

60

Allele associated with RA?

HLA-DR4

61

Which type of RA is smoking an environmental risk factor for?

Seropositive RA

62

What drives the overproduction of TNF-a in RA?

The interaction between macrophages, B & T lymphocytes
(interleukin 6 is also involved in RA)

63

How does the pannus of inflamed synovium damage the underlying cartilage?

Blocks normal route for nutrition and it is also damaged through the direct effects of cytokines on the chondrocytes

64

Histological appearance of RA synovium?

Hypertrophy of the tissues with infiltration by lymphocytes and plasma cells

65

What is a useful predictor of prognosis of RA?

Rheumatoid factor
(persistently high titre in early disease implies more persistently active synovitis, more joint damage and a greater disability eventually)

66

Carpal tunnel syndrome

Carpal tunnel syndrome (CTS) is a median entrapment neuropathy that causes paresthesia, pain, numbness, and other symptoms in the distribution of the median nerve due to its compression at the wrist in the carpal tunnel
(10% of people with RA could present with this)

67

When is pain and stiffness worse in RA?

In the morning

68

Complications of RA

Ruptured tendons,
Ruptured joints (Baker's cysts)
Joint Infection
Spinal cord compression (atlantoaxial or upper cervical spine)
Amyloidosis (rare)

69

What cells might you see in septic arthritis?

Neutrophil leucocytosis
(abnormally high number of neutrophils)

70

Finger deformities in RA?

Ulnar deviation
Boutonniere deformity
Swan-neck deformity

71

Foot deformities in RA?

-Foot becomes broader and hammer-toe deformity develops
-Exposure of metatarsal heads to pressure by forward migration of the protective fibrofatty pad causes pain
-Ulcers&calluses may develop under the metatarsal heads and over the dorsum of the toes
-flat medial arch and loss of flexibility
-ankle often assumes a valgus position

72

Soft tissue non-articular manifestations of RA

Rheumatoid nodules
(typically elbow, finger joints and achilles tendon)

73

Non-articuar manifestations of rheumatoid arthritis

Scleritis
Atlantoaxial subluxation rarely causing spinal compresison
Pleural effusion
Fibrosing alveolitis
Caplans syndrome
Small airways disease
Nodules
Anaemia
Carpal tunnel syndrome
Nail fold lesions of vasculitis
Splenomegaly
Leg ulcers
Ankle oedema
Amyloidosis
Tendon sheath swelling
Bursitis/nodules
Pericarditis
Lymphadenopathy
Sjogrens syndrome (dry eyes, dry mouth)

74

Poorly controlled RA with a persistently raised CRP and high cholesterol is a risk factor for premature what? (<3)

Premature coronary artery and cerebrovascular atherosclerosis

75

Most common cause of secondary osteoporosis?

Corticosteroids

76

Can sulfasalazine be used during pregnancy?

Yes

77

What must you monitor for when on steroids?

Hypertension and diabetes

78

Side effects when using sulfasalazine?

Leucopania
Thrombocytopenia
Nausea
Skin rashes and mouth ulcers

79

"Gold standard" drug in RA

Methotrexate

80

If nausea/poor absorption limit the efficacy of methotrexate, how might you administer it?

Subcutaneously

81

What could you give in combination with methotrextae to minimise side effects?

Oral folic acid

82

Side effects of leflunamide?

Diarrhoea
(leflunamide works in some patients who have failed to respond to methotrexate)
Neutropenia and thrombocytopenia
Alopecia
Hypertension

83

Leflunamide and pregnancy?

Should avoid in pregnancy due to long half life

84

Anti-TNF is usually given in combo with..?

Methotrexate

85

List 5 anti-TNFs

Adalimumab
Etanercept (s/c)
Infliximab (IV)
Certolizumab
Golimumab (s/c) for severe RA

86

Side effects of methotrexate?

Nausea, mouth ulcers, diarrhoea
Neutropaenia and/or thrombocytopenia
Renal impaitment
Pulmonary fibrosis

87

Etanercept side effects?

Injection site reactions
Infections e.g. TB and septicemia

88

Adalimumab side effects?

Hypersensitivity reactions
Heart failure
Demyelination and autoimmune syndromes
Reversible lupus-like syndromes

89

Rituximab side effects?

Hypo/hypertension
Skin rash
Nausea
Pruritis
Back pain
Rare: toxic epidermal necrolysis

90

Side effects of Tocilizumab?

Headache, skin eruption, stomatitis, fever, anaphylactic reactions

91

RA drugs to avoid in pregnancy?

Leflunamide, methotrexate, Gold, CYCLOPHOSPHAMIDE, penicillamine (women must not conceive when on leflunamide or methotrexate)

92

When can oral NSAIDS and selective COX-2 inhibitors be used during pregnancy?

Oral NSAIDS and selective COX-2 inhibitors can be used after implantation up until the 3rd trimester

93

Can corticosteroids be used during pregnancy?

Yes, they can be used to control disease flares (the main maternal risks are hypertension, glucose intolerance and osteoporosis)

94

Which DMARDS can be used during pregnancy?

Sulfasalazine, hydroxychloroquine, aziathioprine, cyclosporin A
These can be used if required to control inflammation

95

Drugs that can induce SLE

Hydralazine
Procainamide
Penicillamine
Isoniazid
(SLE is mild though, kidneys and CNS are not affected)

96

What kind of light can trigger flares of SLE?

Ultrviolet

97

Pathology of SLE

SLE of the skin is characterised by deposition of complement and IgG antibodies and influx of neutrophils and lymphocytes

98

Most common clinical feature of SLE?

Joint problems
Patients often present with similar features to RA

99

Hypocalcaemia Symptoms

Parasthesia
Muscle cramps
Irritability
Fatigue
Seizures
Brittle nails

100

What is a psuedofracture?

A dignostic form of osteomalacia
A condition seen in the radiograph of a bone as a thickening of the periosteum and formation of new bone over what looks like an incomplete fracture.

101

Hypercalcemia Symptoms

fatigue, depression, bone pain, myalgia, nausea, thirst, polyuria, renal stones, osteoporosis

102

Test for Carpal Tunnel

Tinel's Test: tapping nerve in carpal tunnel
Phalen's Test: holding wrist in flexion position

103

Treatment for carpal tunnel syndrome?

Splint wrist in dorsiflexion overnight. This should resolve in a couple of weeks. If this doesn't then you can try a corticosteroid injection (avoid the nerve!!)

104

Carpal tunnel symptoms

numbness
altered sensation
dysaesthesia
clumsiness
night awakening
pain

105

Investigations for Carpal Tunnel

Nerve conduction studies
PV
X-ray
T4
blood glucose

106

Results (carpal tunnel) Free distribution, ulnar or radial?

Ulnar

107

Indications for Carpal Tunnel Syndrome decompression

Failed conservative treatment
Constant numbness
Weakness

108

What is the surgical treatment for carpal tunnel syndrome?

Standard open carpal tunnel release
Arthroscopic
endoscopic carpal tunnel release
mini-open carpal tunnel release

109

Which gender does cubital tunnel syndrome affect more?

Men

110

Symptoms of Cubital Tunnel Syndrome

Symptoms include numbness, tingling and/or pain in arm/hand/fingers
Symptoms often felt during the night or during the day when you've had your elbow bent for long periods of time
May have noticed clumsiness/weaker grip when using hand

111

Which fingers are likely to tingle in cubital tunnel syndrome?

Ring and little fingers :) aw little

112

Test shown in lecture slide that you could use when assessing cubital tunnel syndrome?

Trying to get patient to hold paper between fingers

113

Froment's Sign?

(thumb super bent when you try to get them to pinch stuff, because with ulnar nerve palsy, the patient will experience difficulty maintaining a hold and will compensate by flexing the FPL (flexor pollicis longus) of the thumb to maintain grip pressure causing a pinching effect.
Clinically, this compensation manifests as flexion of the IP joint of the thumb (rather than extension, as would occur with correct use of the adductor pollicis).
The compensation of the affected hand results in a weak pinch grip with the tips of the thumb and index finger, therefore, with the thumb in obvious flexion )

114

Treatment for Cubital Tunnel Syndrome

Splint
Neurolysis
Anterior transposition
subcutaneous
submuscular
intra-muscular
medial epicondylectomy

115

Causes of mechanical back pain

Causes implicated include obesity, poor posture, poor lifting technique, lack of physical activity, depression, degenerative disc prolapse, facet joint OA and spondylosis. Spondylosis is where the intervertebral discs lose water content with age resulting in less cushioning and increased pressure on the facet joints leading to secondary OA.

116

Explain disc degeneration and prolapse

The spinal disc tends to lose its water content during compressive loading – this is replaced during rest periods (when we are non weight-bearing) by absorbing tissue fluid from the adjacent vertebrae. In addition, as we age, the disc becomes less hydrated and loses its elasticity - ageing of the disc occurs early and can often be seen in the late teens or early twenties.

Everyday neck movements can squeeze a brittle disc, which forces the gel-like nucleus against the sides of the disc’s fibrous outer wall, the pulp material extrudes into the spinal nerve root or spinal canal causing a herniated or prolapsed disc – similarly this can occur due to a traumatic injury.

117

What is instability?

excessive motion caused by a degenerate disc, diagnosed typically on MRI

118

What type of motor neurone signs are reflexes?

Lower motor neurone

119

Commonest site for sciatica/lumbar radiculopathy

The commonest site for this to occur in the spine is the lower lumbar spine with the L4, L5 and S1 nerve roots contributing to the sciatic nerve and pain radiating to the part of the sensory distribution of the sciatic nerve (hence the term “sciatica”).

120

Prolapse in lumbar spine and resulting signs

L3/4 prolapse > L4 root entrapment > pain down to medial ankle (L4), loss of quadriceps power, reduced knee jerk
L4/5 prolapse > L5 root entrapment > pain down dorsum of foot, reduced power Extensor Hallucis Longus and tibialis anterior
L5/S1 prolapse > S1 root entrapment > pain to sole of foot, reduced power planarflexion, reduced ankle jerks

121

Treating an open fracture

ABx, tetanus, early debridement and operative stabilisation

122

Treating compartment syndrome

fasciotomy & operative stabilisation

123

Vascular injury # treatment

reduction, stabilisation and reassess circulation. May need revscularisation procedure

124

Pilon fracture

Inter-articular fracture of the distal tibia

125

Distal tibia fractures associated injuries

Spine, pelvis, calcaneus

126

Distal tibia fracture is a surgical emergency, how could you fix it?

Urgent bridging,
External fixation
(allows soft tissues to settle)
-Limited internal fixation
-CT scan to determine personality of fracture
-Internal fixation once soft tissues settle

127

Colles Fracture

A Colles' fracture, also raikar's fracture, is a fracture of the distal radius in the forearm with dorsal (posterior) and radial displacement of the wrist and hand

128

Galeazzi fracture dislocation

If the radius is fractured in isolation, suspect a dislocation of the DRUJ

129

Monteggia fracture dislocation

If the ulna is fractured in isolation, suspect a dislocation of the radial head

130

What is polytrauma?

>1 fracture (long bones +/- pelvis)

131

Causes/associations of patella dislocation

Hypermobility
Under-developed (hypoplastic) lateral femoral condyle
Increased Q-angle
Genu valgum
Increased femoral neck anteversion
Lateral quads insertions or weak vastus medialis

132

Treatment for repeat Patella dislocations

Surgery
(Lateral release / medial reefing
Patella tendon realignment)

133

Medial Reefing

A surgical procedure to tighten the tissues on the medial aspect of the patella

134

Lateral Release? (Patella dislocation treatment)

Loosening the tissues on the lateral side of the patella

135

What should you be aware of in patella dislocation spontaneous relocation?

Lateral collateral ligament injury and peroneal nerve injury

136

Nerve that could be damaged in knee dislocation?

Peroneal nerve

137

Associated fractures of hip dislocation

Posterior acetabular wall
Femoral #'s

138

Hip dislocation presentation

Flexed, internally rotated and adducted knee

139

Nerve that could be damaged in hip dislocation

Sciatic nerve

140

Hip Dislocation Complications

Sciatic nerve palsy
Avascular necrosis of the femoral head
Secondary osteoarthritis of hip
Myositis ossificans

141

What may cause an olecranon fracture?

Usually an avulsion fracture from triceps contraction

142

If you dislocate your elbow, which bone might you fracture?

The head of the radius

143

What is a nightstick fracture?

Isolated fracture of the Ulna

144

How might you fix a colles fracture?

K-wiring

145

Complications of Distal Radial Fracture

Median nerve compression, EPL rupture, CRPS, loss grip strength

146

Distal Radius Fractures: how would you fix a comminuted intra-articular fracture with small fragments?

External fixation +/- K-wires

147

How would you fix a Smith's fracture?

ORIF

148

When might you consider looking for endocarditis in septi arthritis?

When you have multiple bones/joints affected by septic arthritis (septic emboli)

149

Who might get E.coli septic arthritis?

The elderly, IV drug users and seriously ill

150

Organisms which can cause a "low grade" infection in surgical implants (i.e. not the most common organism but the one that is most likely to be picked up later than should be)

Staph epidermidis

151

Useful blood tests for bone and joint infection?

CRP and Plasma viscosity
(Occasionally useful: blood cultures, white cell count, ESR)

152

Most common causative organism in osteomyelitis?

Staph aureus
(haemophilus in children)

153

What antibiotics does our lecturer use for cellulitis?

He uses Flucloxacillin and benzylpenicillin

154

In cellulitis, what is crepitis a sign of?

Crepitus is a sign of infection most commonly observed with anaerobic organisms

155

Which cells produce granulation tissue in secondary cone healing?

Fibroblasts

156

Which cells form cartilage?

Chondroblasts

157

Which cells lay down bone matrix (collagen type 1)

Osteoblasts

158

Which process produces immature woven bone?

Calcium mineralisation

159

By what week is the soft callus usually formed?

2-3 weeks

160

How long does it take the hard callus to appear?

6-12 weeks

161

Why can smoking impair healing of a fracture?

It causes vasospasm (bones need good blood supply for nutrients, oxygen and stem cells etc)

162

Aside from smoking, what else can impair fracture healing?

Chronic ill health
Malnutrition

163

When do oblique fractures occur?

Obliques fractures occur with a shearing force (e.g. fall from a height, deceleration)

164

Why do oblique fractures have a slight advantage?

You can fix these with an interfragmentary screw.
Remember also, oblique fractures tend to shorten and may angulate

165

Why are spiral fractures most unstable?

They can rotate, may also angulate

166

Why do spiral fractures occur?

Spiral fractures occur due to torsional forces

167

Are segmental fractures stable or unstable?

Segmental fractures are very unstable and require stablisation with long rods or plates

168

Clinical signs of a fracture

Localised bony tenderness (not mild diffuse tenderness)
Swelling
Deformity
Crepitus (from bone ends grating with an unstable fracture)

169

Guidelines used for ankle injury?

Ottowa guidelines

170

Investigation for mandibular fracture?

Tomogram

171

Which fractures can an oblique x-ray be good for?

-Scaphoid
-Acetabulum
-Tibial plateau

172

When are technetium bone scans useful?

Technetium bone scans can be useful to detect stress fractures (e.g. hip, femur, tibia, fibula, 2nd metatarsal) as these may fail to show up on x-ray until hard callus begins to appear

173

Analgesia usually given for long bone fracture?

IV morphine

174

Initial management of long bone fracture

S (splintage/immobilisation)
I (investigation e.g. x-ray)
A (analgesia)

175

Another name for temporary plaster slab

Backslag

176

When might you consider reducing fracture before waiting for x-rays?

If a fracture is grossly displaced, if there is an obvious fracture dislocation (e.g. of the ankle) or if there is a risk of skin damage
(x-ray will still be seen on x-ray post-reduction)

177

Anaesthetic that can be used for reducing an unstable fracture

GA
Spinal
Peripheral nerve block
Bier's block

178

When is a Bier block indicated?

For fractures of the forearm, wrist and hand (not appropriate for elbow)

179

Early complications of fractures

Compartment syndrome
Vascular injury with ischaemia
Nerve compression or injury
Skin necrosis

180

Early systemic complications of fractures

Hypovolaemia
Fat embolism
Shock
ARDS
Acute renal faiure
Systemic Inflammatory Response Syndrome
Multi-organ Dysfunction Syndrome
Death

181

Volkmann's Ischaemic Contracture

Volkmann's ischaemic contracture, is a permanent flexion contracture of the hand at the wrist, resulting in a claw-like deformity of the hand and fingers

182

The main late systemic complication of a fracture

Pulmonary embolism
(deep vein thrombosis is a late LOCAL complication of a fracture)

183

Why does secondary ischaemia occur in compartment syndrome?

Rising pressure compresses the venous system which results in congestion within the muscle. This means that oxygenated arterial blood cannot supply the congested muscle

184

What characterises muscle ischaemia in compartment syndrome?

Severe pain
Pressure rises can also compress nerves resulting in parasthesia and sensory loss.
THE CARDINAL CLINICAL SIGNS ARE (1) INCREASED PAIN ON PASSIVE STRETCHING OF THE INVOLVED MUSCLE AND (2) SEVERE PAIN OUTWITH THE ANTICIPATED SEVERITY IN THE CLINICAL CONTEXT
(loss of pulses is a feature of end stage ischaemia)

185

What happens if ischaemic muscle is left untreated?

If left untreated ischaemic muscle will necrose resulting in fibrotic contracture known as Volkmann's ischaemic contracture and poor function

186

What artery is at risk if a child sustains an elbow fracture?

Brachial artery injury

187

Which artery can be affected in shoulder trauma

Axillary artery

188

Which fracture may be associated with life threatening haemorrhage from arterial or venous bleeding?

Pelvic fractures

189

How might you localise the site of arterial occlusion?

Urgent angiography

190

How could you control ongoing haemorrhage from arterial injury in the pelvis?

Ongoing haemorrhage from arterial injury in the pelvis can be controlled by angiographic embolization performed by interventional radiologists

191

Where does the triceps insert at the elbow and what elbow movement does it produce?

The triceps is responsible for elbow extension and inserts at the olecranon process

192

Where do the brachialis and biceps insert and which elbow movement do they produce?

Brachialis inserts at the coronoid process and biceps inserts at the BICIPITAL TUBEROSITY of the radius. They produce flexion at the elbow. (the biceps also produces supination along with the supinator muscles)

193

Painful and tender lateral epicondyle with resisted middle finger and wrist extension?

Lateral epicondylitis (tennis elbow)

194

Which nerve could be damaged in a total hip replacement?

The sciatic nerve

195

Causes of avascular necrosis of the hip?

AVN of the hip may be primary/idiopathic
-It can also be secondary to alcohol abuse, steroids, hyperlipidemia or thrombophilia

196

Why would queen victoria get AVN of the hip?

She was fat (hyperlipidemia)
She had thrombophili

197

Patchy sclerosis of the weight bearing area with lytic lesions underneath formed by granulation tissue of an attempted repair

AVN

198

Hanging rope sign on x-ray?

AVN

199

Pain and tenderness in the region of the greater trochanter with pain on restricted abduction

Trochanteric bursits/gluteal cuff syndrome

200

What is complete knee dislocation?

When you rupture all 4 of the ligaments in your knee

201

In an obese patient, you may not be able to feel the palpable gap in an extensor mechanism, what could you do?

Do an ultrasound to determine the extent of the injury

202

Which way does the patella dislocate?

It dislocates laterally

203

When can patellar dislocation occur?

After a sudden blow to the knee or after a sudden turn

204

Risk factors for patella dislocation

• Ligamentous laxity
• Female gender
• Shallow trochlear groove
• Genu valgum
• Femoral neck anteversion
• High riding patella

205

When would you see a haemarthrosis?

Following dislocation of the patella

206

The word that is associated with bunions but I always forget?

Hallux valgus

207

Hallux valgus?

Medial deviation of the 1st metatarsal and lateral deviation of the toe itself

208

Mulder's click test?

Squeezing the forefoot to produce a click (will happen if mortons neuroma is present)
-Ultrasound may be used for diagnosis

209

Can you use steroid and local anaesthetic injections in mortons neuroma?

Yes you can

210

Where do metatarsal fractures most commonly occur?

The 2nd metatarsal followed by the 3rd
(Mortons neuroma most commonly occurs in the 3rd interspace nerve, and then the 2nd)

211

Pain "like being kicked in the back of the leg"

Achilles tendon rupture

212

Gottron's sign

-Erythematous, scaly eruption over the MCPs and interphalngeal joints
-Seen in dermatomyositis

213

Diagnosis of polymyositis- history

Muscle weakness in symmetrical proximal muscles
May also have muscle pain
Weight loss, breathlessness, FEVER, RAYNAUDS PHENOMENON, polyarthritis
Other medical problems: DM, thyroid
Medications: steroids, statins
Family history
Social history: alcohol, illicit drugs

214

How to diagnose polymyositis?

MUSCLE BIOPSY IS THE DEFINITIVE TEST
Raised CK
(check electrolytes, calcium, PTH, TSH to exclude other causes)
Inflammatory markers
ANA, Anti-Jo-1
Electromyography (EMG): increased fibrillations, abnormal motor potentials, complex repetitive discharges

215

Electromyography in polymyositis?

Increased fibrillations, abnormal motor potentials, complex repetitive discharges

216

What would you find in a muscle biopsy in polymyositis?

Perivascular inflammation and muscle necrosis

217

Polymyositis MRI?

Muscle inflammation, oedema, fibrosis and calcification

218

Treatment for polymyositis/dermatomyositis?

Glucocorticoids
Azathioprine
Methotrexate
Ciclosporin
IV immunoglobulin

219

Drugs that can cause polymyositis?

Statins, steroids

220

Differences between polymyositis and inclusion myositis?

-CK lower in inclusion myositis than polymyositis
-Inclusion bodies in biopsy of inclusion myositis (perivascular inflammation and muscle necrosis in polymyositis)
-Inclusion body myositis responds poorly to therapy
-Weakness symmetrical in polymyositis, asymetrical in inclusion myositis
AGE AGE AGE (polymyositis >18 years, dermatomyositis child/adult, Inclusion myositis OVER 50!!!)

221

What is polymyalgia rheumatica associated with?

Temporal arteritis
Giant cell arteritis

222

Clinical findings of fibromyalgia

Tender 11/18 points
No other abnormality of musculoskeletal system
-No diagnostic tests

223

Perimysial inflammation?

Dermatomyositis

224

Endomysial inflammation?

Polymyositis

225

Endomysial inflammation and CD8+ cells?

Polymyositis

226

Perimysial inflammation and CD4 cells?

Polymyositis

227

Why does intoeing occur?

Anteversion of femoral head --> internal torsion of tibia --> metatarsus adductus

228

How can you check internal tibial torsion?

Thigh foot angle

229

Bow legs, photographs or x-rays?

Photographs!

230

What causes bow legs?

<2 years, fine
More than two years, think about internal tibial torsion

231

When should you refer for bow legs?

-asymmetry
-painful
-height <2SD

232

When do you refer for knock knees?

If the intermalleolar distance is greater than 8cm at 11 years old

233

Do insoles help knock knees?

No

234

An adolescent girl presents with anterior knee pain and localised patellar tenderness. It is worse when she squats or goes down stairs. What investigations would you like to carry out?

X-ray, check its not her hips!
Give physio.

235

How do you fix curly toes?

With tenotomy (after 6 years old because fairly normal until then)

236

When can a baby sit unsupported?

10 months

237

Congenital vertical talus

Rocker bottom feet

238

Rocker bottom feet

Congenital vertical talus

239

NF diagnosis

-6 or more cafe au lait spots (pigmented birth marks)
>5mm pre puberty
>15 post puberty
-2 or more NF or 1 PNF
-axillary/groin freckling
-osteoporosis/osteomalacia/skeletal dysplasia
-kyphoscoliosis, sphenoid dysplasia
-pseudoarthrosis
-1st degree relative
-known genetic mutation 17q11.2

240

Classifying skeletal dysplasias

The Wynne-Davies classification
(epiphyseal/metaphyseal/diaphyseal, bone density, spinal involvement, storage disease, fibrous disorder, dysplasia with a tumour like appearance)

241

FGF3 gene mutations?

Achondroplasia

242

Frontal bossing
Midface hypoplasia
Rhizomelic disproportion
Genu varum
Trident hand
Normal intelligence
Motor delay

Achondroplasia

243

Which part of the brain is damaged in cerebral palsy?

The encephalon

244

What is the leading cause of childhood disability?

Cerebral palsy

245

Drug treatment for spasticity (BBB)

Benzodiazepines
Botox
Baclofen
Surgery = rhizotomy

246

Features of upper motor neurone syndrome?

-Hyper-reflexia
-Clonus
-Co-contraction
-Spasticity

247

Management of cerebral palsy (grade I-III)
(people who can walk)

-orthothotics
-botox
-physio
-surgery

248

Management of tip-toe walking

Usually idiopathic
Common before 3 years
Physio/observation
Splinting/casting
Botox
Surgery

249

Spinal claudication

• Age 50+
• M:F 2:1
• Limited walking capacity (i.e can’t walk very far)
• Stoop/lean forward/sit to relieve symptoms
• “heavy or tired” legs

250

• Age 50+
• M:F 2:1
• Limited walking capacity (i.e can’t walk very far)
• Stoop/lean forward/sit to relieve symptoms
• “heavy or tired” lefgs

Spinal claudication

251

How do you relieve spinal claudication?

-flexing
(remember in comparison to claudication, going uphill and cycling are not that bad)

252

Spinal stenosis/claudication on x-ray

Hypertrophic spine with narrowing of the interpedicular space and obliteration of the neural foramena

253

Investigation for spinal claudication?

X-ray

254

Deep seated low central back pain that gets worse as the day goes on
-Typically worse on coughing
-made worse by flexing
-worse with activity

Discogenic back pain

255

-Pain in the back (may radiate to buttocks and legs)
-Stiff in the morning, loosening up routine
-Restless --> difficulty sitting, standing, driving
-Worse with extension
-BETTER WITH ACTIVITY

Facet arthropathy

256

Facet Arthropathy

-Stiff in the mornings
-Loosening up routine
-Restless (difficulty sitting, standing, driving)
-WORSE WITH EXTENSION, relieved by activity
-Often radiates to buttocks and legs

257

Worse with extension, better with activity

Facet arthropathy

258

Worse with flexion

Discogenic back pain

259

Relieved by flexion

Spinal claudication/stenosis

260

Feels like 'walking on marbles'

Metatarsalgia

261

Which fracture can be associated with an ankle fracture?

Twisting of the ankle or foot can be associated with an avulsion fracture of the base of the 5th metatarsal

262

Deltoid ligament?

Medial side of the ankle.
Attaches the medial malleolus to multiple tarsal bones

263

The ligament complex on the lateral side of the foot?

The talofibular ligament complex

264

The dorsalis pedis pulse?

Lateral to the flexor hallucis longus

265

The posterior tibialis pulse?

Distal and posterior to the medial maleolus

266

Nerve supply to the foot?

Superficial peroneal nerve and deep peroneal nerve

267

Where does the deep peroneal nerve supply?

The gap between the big toes and he toe next to it

268

What is the tendo-Achilles and what does it do?

Tendinous extension of the gastrocnemius and soleus
-Plantar flexes the foot

269

De Quervain's tenosynovitis affects which tendon sheaths?

Abductor pollicis longus
Extensor pollicis brevis

270

Give an example of when de Quervain's tenosynovitis might hurt?

When you turn your wrist, make a fist, grasp anything etc etc

271

Which fracture causes pain in the snuffbox?

A scaphoid fracture

272

Ligaments of the elbow?

Medial and lateral collateral ligaments

273

Bursa at the elbow?

Olecranon bursa

274

The humero-ulna joint

Flexion/extension of the elbow

275

Radio-capitellar joint

Pronation/supination

276

Pain at insertion of the extensor muscles of the forearm?

Lateral epicondylitis

277

Pain at insertion of the common flexor origin?

Medial epicondylitis

278

Which elbow problem is associated with muscle wasting/weakness, sensory loss and provocation tests?

Cubital tunnel syndrome

279

What does the FDS flex?

The PIPJ

280

What does the FDP flex?

The DIPJ

281

If you see a high arched foot what should you be thinking of?

You should be thinking of neurological conditions e.g. cerebral palsy, spina bifida, stroke, muscular dystrophy, Charcot-Marie tooth disease

282

What could a flat foot mean?

RA
Posterior tibialis dysfunction

283

Where can you use cartilage regeneration techniques?

Knee and ankle

284

When can excision arthroplasty be used?

•1st CMC (trapeziectomy) for OA in hand
•1st MTPJ OA & hallux valgus in frail, elderly patients (Keller’s procedure)
•Can excise all metatarsal heads for end stage rheumatoid foot

285

What is Keller's procedure?

Excision of the 1st MTPJ / hallux valgus
-often used for frail, elderly patients with OA