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Flashcards in Module 4 Deck (86):
1

Investigations for RUQ pain

FBC with differentials

EUC, BGl

Aminotransferase, ALP, bulirubin

Lipase and amylase

Abdominal u/s

2

Visceral Pain

 

  • Generalised Pain
  • Vague and diffuse
  • nauseating
  • Strech mechanoreceptors
  • via slow conducting c-fibers 
  • non myelinated 

3

Somatic pain

  • Localised
  • shap pain associated with movement 
  • mainly chemo-receptors that respond to inflammatory cytokines and blood 
  • Fast conducting A-delta fibers
  • large myelinated 

4

Classification of hip fractures

Intracapsular (subcapital) : edge of femoral head to insertion of capsule of hip joint

Extracapsular - can be trochanteric or substrochanteric (greater trocanter is driving line) 

5

What hip fracture classification (according to Garden system) is associated with disrupted blood supply

Type III and Type IV 

6

What are the Garden system classification of hip fractures

  1. Type I = stable fracture with impaction in valgus
  2. Type II = complete fracture but undisplaced
  3. Type III = displaced fracture, usually rotated and angulated but still has bony contact 
  4. Type IV = complete bony disruption 

7

Repair of intracapsular hip fracture 

  • Undisplaced = internal dixation or hemiarthroplasty if unfit
    • Hemiarthroplasty = replaces one half of the hip joint (femor) without the other 
  • Displaced
    • young and fit (<70) = reduction and internal fixation
    • older and reduced mobility = hemiarthroplasty or total hip replacement 

 

8

Repair of extracapsular hip fracture

  • dynamic hip screw
  • if reverse oblique, transverse or subtrochanteric : intramedullary device 

9

What is a Buckle fracture

  • Blucke or torus fracture are incomplete fractre of the shaft of long bone that are characterised by bulging of the cortex 
  • typically in 5-10 years old 

10

What is an oblique fracture

Fracture that lies obliquely to long axis of bone 

11

Comminuted fracture

>2 fractions

A image thumb
12

Segmental fracture

More than one fracture along the bone

A image thumb
13

Transverse Fracture 

Perpendicular to long axis of bone 

A image thumb
14

Spiral fracture

Severe oblique fracture with rotation along long axis of bone 

15

Fracture grading open fracture

Grade 1 - low energy wound < 1cm

Grade 2 - Greater than 1 cm with moderate soft tissue damage

Grade 3 - high energy wound > 1 cm with extensive soft tissue damage 

16

Key points for fracture mangement 

  • Immobalise the fracture inc the proximal and distal joints
  • carefully monitor and document neurovascular status, particularly following reduction and immobalisation 
  • Manage infection inc tetanus prophylaxsis
  • IV broad spectrum antibiotics for open injury 
  • As a general principle all open fracture should be thoroughly debrided (internal fixation should be avoided and used with caution)
  • Open fractures constitute an emergency and should be debrided and lavaged within 6 hours of injury 

17

What  nerve supplies the supraspinatus muscle

Suprascapular nerve

18

What nerve supplies the infraspinatous muscle

suprascapular nerve

19

What nerve supplies the teres minor muscles

Axillary nerve

20

What nerve supplies the subscapularis

Superior and Inferior subscapular nerve 

21

Weight bearing status after hip surgery

Immediate post-op weight bearing 

  • dynamic hip screw requires weight beating so that the compression is achieved across the fractured site 

22

What is a galeazzi fracture

dislocation of the distal radioulnar joint with associated fracture of the radius 

23

What is a Monteggia fracture

Uber high mountains- fracture of the proximal ulna and dislocation of the proximal radioulnar joint 

24

What is a Colles' fracture?

Distal radial fracture with dorsal displacement

25

What is a Smith's fracture

Distal radial fractre with volar displacement

26

What is a boxer's fracture

Fracture ofthe neck of the fourth or fith metacarpal with volar displacement of the metacarpal head 

27

A 22 year old man sustains an open tibial fracture after an accident with farmyard machinary. He has a gaping 8cm and ragged wound overlying a simple oblique fracture of his distal tibia. The limb is neurovascularly intact. What is the most appropriate initial management?

Immediate wound debriedment and application of spanning external fixation device. 

Definitive management of open fracture should be delayed until soft tissues have recovered 

 

should be debrided and lavaged within 6 hours 

28

weak finger abduction and adduction with reduced sensation over ulnar border of the hand. also clawing of the 4th and 5th digits. Where is the damage

Ulnar at the 

29

30

X-ray features of Osteoarthritis

LOSS

L= loss of joint space

O = osteophytes

S = subarticular sclerosis

S= suncondral cyst

31

X-ray features of RA

SOLE

S = soft tissue swelling

0 = osteopenia

L = loss of joint space

E = erosion

32

X-ray features of gout

normal joint space

periarticular erosion 

soft tissue swelling 

33

Causes of anterior uveitis

  1. Reiter's syndrome
  2. Aklyosing spondylitis (HLA-b27)
  3. MS
  4. Inflmmatory bowel diseasee
  5. Rheumatoid arthritis (more scleritis) 
  6. Herpes simplex/zoster/STI
  7. Sarcidosis/TB 

34

Joint affected in OA vs RA

OA

  • DIP (Hebedon's nodes)
  • PIP (Bourchard's)
  • Carpo-metacarpal joints
  • Knee

RA

  • MCP + MTP
  • PIP
  • Wrist
  • monoarthritis of large joints 
  • inter-thumb

35

Hand signs of RA

Patient presents with the following

  • Swollen MCP, PIP joints, tenosynovitis (tenderness of tendon sheath)
  • Swan neck deformity, boutonniere's deformity, ulnar deviation, z-deformity of thumbs, wrist subluxation
  • Nodules of elbow
  • Raynauds
  • Carpal tunnel 

36

Ix confirming RA

Anticyclic citrullinated peptide Antibody = ACPA/Anti-CCP 

37

Is RA severity assessed 

Poor prognosis =

  • High RF titire and/or positive anti-CCP antibody test
  • sustained raised inflammatory marker (CRP or ESR)
  • swelling in more than 20 joints
  • impaired function early in disease
  • bony erosions evident on X-ray early in disease
  • smoking 

38

Involvement of which two joint does NOT indicate RA

carpometacarpal joint

distal interphalangeal joint 

39

What do the following features suggest

  • Early morning stiffness lasting longer than 1 hr
  • swelling of five or more joints
  • symmetry
  • bilateral compression tenderness of metatarsophalangeal joint 

RA

40

What features suggest RA (11)

  1. family history of inflammatory arthritis
  2. early morning stiffness lasting longer than 1 hour
  3. swelling in five or more joints
  4. symmetry of the areas affected
  5. bilateral compression tenderness of the metatarsophalangeal joints
  6. RF positivity
  7. anti-CCP antibody test positivity
  8. symptoms present for longer than 6 weeks
  9. bony erosions evident on X-rays of the wrists, hands or feet (uncommon in early disease)
  10. raised inflammatory markers, such as CRP or ESR, in the absence of infection
  11. presence of rheumatoid nodules

41

What are some of the complication of RA

  1. Atherosclerosis
  2. osteoporosis
  3. depression
  4. vasculitis 
  5. peptic ulcer disease
  6. lung disease 
  7. neuropathy
  8. atlanto-axial involvement 

42

manamgent of RA 

Methotrexate + Folic acid (on days methorexate isn't taken) 

43

Acute management of RA 

Corticosteroids - rapid while waiting on disease-modifying drugs work 

methypredisolone

44

Managing Symptoms in RA  

  • Pain - NSAID
  • Fish oil (3 months to work)
  • Fatigue - physical activity 
  • Exercise - land or water based 
  • Diet - strict vegan, gluten free and mediterranean 
  • Smoking cessation 

45

What scale is used to measure the severity of RA

DAS28

  • count number of swollen joint (out of 28)
  • count number of tender joints (out of 28)
  • take ESR and CRP
  • Global assessment of health 

46

When do you consider biological dMARDs for RA

  1. Failure to respond to DMARDs after 6 months
  2. DAS28 score of >5.1

high risk of infection on biological dMARDs

47

4 categories used to dx RA

Joint involvement

serology (RF and anti-CCP)

acute phase reactant CRP and ESR

duration 6wk +

dx = >6/10

48

Causes of monoarthritis 

Septic arthritis

Crystal arthritis (gout or pseudogout)

Osteoarthritis

trauma - haemoarthritis 

49

Causes of oligoarthritis (<5)

  1. Reactive arthritis (salmonella,  yersinia, campylobacter)
  2. Osteoarthritis
  3. Crystal arthritis 
  4. Psoriatic arthritis 
  5. Ankylosing spondylitis 

 

50

Causes of symmetrical polyarthritis

  • RA
  • OA
  • Virus (hepatitis, A, B, C, mumps)

 

  • Connective tissue disease, Behcet's, leukemia, sickle cell, familialn mediterranean fever
  • endocarditis, sarcoid, haemochromatosis

51

Fevers + abdo pain + arthritis

Recurrent peritonitis + pleurisy

 

Familial Mediterranean fever

Colchicine 

52

Causes of asymmetrical polyarthritis

 

  1. Reactive arthritis (yersinia, salmonella, campylobacter)
  2. Psoriatic arthritis 

53

Factors contributing to gout

  1. dietary purines
  2. alcohol
  3. diuretics
  4. cytotoxins
  5. leukaemia 

54

Factors contributing to pseudogout

  1. Age
  2. hyperparathyroidism
  3. haemochromatosis
  4. hypophosphataemia

55

Ix for gout

joint aspiration - presence of needle shaped negatively birefringent urate crystals of polarised light microscopy

56

Ix for pseudogout

joint aspiration - presence of positively birefringent rhomboid crystals on polarised light microscopy

calcium deposits on x-ray 

57

enthesitis of which tendons is a problem with ankylosing spondylitis

Achiles Tendonitis

Planter fascitis tibia

ischial tuberosities 

iliac creast 

58

bamboo spine on x-ray is characteristic of what

Ankylosing spondylitis

calcification of spinal ligament due to ongoing inflammation 

 

59

"pencil in cup" x-ray finding

severe psoriatic arthritis 

60

Infections implicated in reactive arthritis

  1. following urethritis - chlamydia, ureaplasma sp 
  2. dysentery - campylobacterm salmonella, shigella, yersinia 

61

Urethritis + arthritis + conjuctivitis 

is a triad for what condition

Reiter's syndrome 

ESR and CRP will be raised 

check for GU infection (STI)

check for GI infection (stool culture, serology) 

62

Features of sytemic sclerosis

CREST

C= calcinosis (subcutaneous tissue)

R = raynaud's 

E = esophagel + gut dismotility

S = sclerodactyly (swollen tight digits

T = telangiectasis 

63

SLE investigation

Anti-dsDNA 

64

Ab Ix in drug induced SLE and common drugs responsible

Anti-histone Ab

  • Hydralazine (vasodilator)
  • Isoniazid
  • Phenytoin 

65

Ab test positive in Sjogren's

  • RF
  • Anti nuclear Ab
  • Anti-Ro 
  • Anti La 
  •  

66

Positive c-ANCA vs p-ANCA

c-ANCA

  • Granulamatosis with polyangitis (Wegner's)
  • Polyangitis (microscopic)
  • polyangitis nodosa

p-ANCA 

  • Polyangitis (microscopic)
  • Churg-strauss pulmonary renal vasculidies 

67

Montioring of SLE

  1. Anti dsDNA titire
  2. C3 + C4 drop (complement) 
  3. C3d + C3d rise
  4. ESR 

68

Raised ESR 

normal CRP

multisystem disorder

SLE (systemic lupus erythematosus)

69

Criterias for dx of SLE

  1. malar rash
  2. Discoid rash
  3. photosensitivity 
  4. oral ulcer
  5. arthritis 
  6. serosistis (pleurisy or pericarditis)
  7. Renal - proteinuria or cellular cast 
  8. Neurological/neuropsyh - seizures or psychosis 
  9. Haem features = haemolytic anemia, leucopenia, lymphopenia, throbocytopenia
  10. immune features = anti dsDNA, anti-Sm (smith) ab, antiphospholipid antibody
  11. ANA positive 

Need 4/11

70

Muscoskeletal symptoms + rash + fatigue

SLE 

71

What should be testing in women on OCP and with SLE

after 3 months test

  1. ESR
  2. CRP
  3. ds-DNA 

72

Rheumatic causes of 

  1. Anterior uveitis
  2. conjuctivitis
  3. episcleritis
  4. scleritis 

  1. Anterior uveitis = ankylosing spondylitis + Reiters
  2. Conjuctivitis = Reiters
  3. Episcleritis = SLE, polyarhtiritis nodosa, rheumatic fever, RA
  4. Scleritis = vasculitis, RA

73

Conditions associated with keratoconjuctivitis sicca

  1. Sjogrens 
  2. RA
  3. SLE
  4. Sarcoidosis 

74

Headache + visual disturabnces

Bp - >200/>130

Eye exam - hard exudate, macular oedema, flame hemorrhoages + papilloedema

What is the dx?

Accelerated (malignant) hypertension 

75

40 year old woman has pain on moving the thumb and tenderness over the 1st extensor compartment. What test could confirm the most likely diagnosis?

De Quervains tenosynovitis 

Test = Grip thumb in palm (Finkelsteins)

76

Imaging for Ankylosing spondylosis

Clinical dx 

MRI = most sensitive (sacroilitis, irregularities, erosion, sclerosis, vertebral syndesmophytes)

77

Spinal involvement, HLA-B27 positive. What needs to be assessed on echo

Aortic valve 

Aortic valve incompetence is associated with spondyloarthropathies 

78

Acute SLE flare Rx?

IV cyclosphosphamide 

(I want SLEep on my cycles)

79

Blood vessel size and Rx in vasculitis

  • Large vessel (Takayasu's, GCA) = steriods
  • Medium vessel (PAN + kawasaki) or small (Wegner's, Henoch Schonlein) = Steriods + IV cyclophosphamide 

80

Risk factors for OA

  • Age
  • gender
  • obesity
  • injury
  • occupation - farmer (hip), lifitng (knee), manual labour (hand)
  • low education, SES, psychological = greater pain and disability 

81

What investigation is needed to confirm OA

None- its a clnical dx 

inflammatory marker = usually minimally raised 

82

Management of OA

  • Physical exericse 
  • weight loss 
  • psycholoical therapy
  • physical treatments - walking stick etc 
  • topical - topical NSAId 4x or capsaicin 3-4 times 
  • oral analgeia (NSAID first and paracetamol) 
  • intra-articular injection - corticosteriods (4-12 wks) or hyaluronan (3-5 wks)
  • psych drugs - Duloxetine 

83

Indication of joint replacement surgery 

  1. Pain (sleep interruption and while resting)
  2. limitation in daily activities (walking and self-care)
  3. Psyhosocial health ([psycholigcal wellbeing and carer role)
  4. economic impact
  5. recent deterioration

use the hip and knee questionnarie (11 items) 

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