MSK

Question 1

RHEUM PHYSIOLOGY
Give 3 causes of inflammatory joint pain?

Answer 1

1. Autoimmune (RA, connective tissue disease, spondyloarthropathy, vasculitis)
2. Crystal arthritis
3. Infection

Question 2

RHEUM PHYSIOLOGY
Give 2 causes of non-inflammatory joint pain?

Answer 2

1. Degenerative (OA)

2. Non-degenerative (fibromyalgia)

Question 3

RHEUM PHYSIOLOGY
What are the 5 main signs of inflammation?

Answer 3

1. Red (rubor)
2. Heat (calor)
3. Pain (dolor)
4. Swelling (tumour)
5. Loss of function

Question 4

RHEUM PHYSIOLOGY
How does inflammatory pain differ from degenerative non-inflammatory pain?

Answer 4

Inflammatory pain eases with use

Degenerative pain increases with use

Question 5

RHEUM PHYSIOLOGY
Are you more likely to see swelling in inflammatory or degenerative pain?

Answer 5

In inflammatory pain = synovial swelling

Often no swelling in degenerative

Question 6

RHEUM PHYSIOLOGY
What is bone pain?

Answer 6

Pain at rest and at night

Can be due to tumour, infection, fracture

Question 7

RHEUM PHYSIOLOGY
What is inflammatory joint pain?

Answer 7

Pain and stiffness in joints in the morning, at rest and with use
Can be inflammatory or infective

Question 8

RHEUM PHYSIOLOGY
Name 2 inflammatory markers that can be detected in blood tests

Answer 8

1. ESR (erythrocyte sedimentation rate)

2. CRP

Question 9

RHEUM PHYSIOLOGY
Explain why ESR levels are raised in someone with inflammatory joint pain

Answer 9

Inflammation leads to increased fibrinogen –> RBC’s clump together –> RBC’s fall faster = increased ESR

Question 10

RHEUM PHYSIOLOGY
Explain why CRP levels are raised in someone with inflammatory joint pain

Answer 10

Inflammation leads to increased IL-6 levels –> CRP produced in response to IL-6 –> CRP raised

Question 11

RHEUM PHYSIOLOGY
Describe the ESR and CRP levels in someone with lupus

Answer 11

ESR raised

CRP low

Question 12

RHEUM PHYSIOLOGY
Other than inflammatory markers, might be seen in blood tests when investigating joint pain?

Answer 12

Auto-antibodies = immunoglobulins that bind to self antigens

Question 13

SPONDYLARTHRITIS
With what tissue type are all spondyloarthropathies conditions associated?

Answer 13

HLA B27 tissue type

Question 14

SPONDYLARTHRITIS
Give 5 conditions that fall under the term spondyloarthritis

Answer 14

1. Ankylosing spondylitis
2. Reactive arthritis
3. Psoriatic arthritis
4. Enteropathic arthritis
5. Juvenile idiopathic arthritis

Question 15

SPONDYLARTHRITIS
Give the 3 main clinical features of spondyloarthritis

Answer 15

1. Seronegative and HLAB27 association
2. Axial arthritis
3. Asymmetrical large joint arthritis

Question 16

SPONDYLARTHRITIS
Give 6 signs of spondyloarthritis

Answer 16

SPINE ACHE

1. Sausage digits = dactylics
2. Psoriasis
3. Inflammatory back pain
4. NSAID responsive
5. Enthesitis
6. Arthritis
7. Crohn’s/UC
8. HLAB27
9. Eye - uveitis

Question 17

SPONDYLARTHRITIS
What is the general treatment for all spondyloarthritis?

Answer 17

Initially DMARDs and then biological agents if DMARDS fail (TNF blockers)

Question 18

ANKYLOSING SPONDYLITIS
what is it?

Answer 18

a chronic, multi-system inflammatory disorder characterised inflammation of the sacroiliac joints and axial skeleton

Question 19

ANKYLOSING SPONDYITIS
Describe the pathophysiology of ankylosing spondylitis

Answer 19

Inflammatory arthritis of spine + rib cage → leads to new bone formation + fusion of joints (syndesmophytes)

Question 20

ANKYLOSING SPONDYLITIS
what is the epidemiology of ankylosing spondylitis?

Answer 20

● More common and severe in men
● Usually presents in young adults – 16-30yrs
● 90% are HLA-B27 positive
● Women present later and are underdiagnosed
● Low incidence in Africa and Japan
● Native North Americans have high incidence

Question 21

ANKYLOSING SPONDYLITIS
what is the clinical presentation of ankylosing spondylitis

Answer 21

pain + stiffness → worse with rest/at night + improves with movement

SYMPTOMS
- back pain
- reduced spinal movement
- dyspnoea
- peripheral arthritis + dactylitis
- painful red eye

SIGNS
- pain in buttock or along axial spine
- reduced lumbar flexion (when patient tries to touch toes)
- loss of lumbar lordosis
- reduced chest expansion
- asymmetrical peripheral joint pain (oligoarthritis)
- anterior uveitis

Question 22

ANKYLOSING SPONDYLITIS
What investigations might you do in someone who you suspect to have ankylosing spondylitis?

Answer 22

CRP + ESR - raised
HLA B27 genetic test
X-ray of spine + sacrum
- Bamboo spine
- Squaring of vertebral bodies
- dagger sign
- Subchondral sclerosis + erosions
- Syndesmophytes
- Ossification of ligaments, discs + joints
- Fusion of facet, SI + costovertebral joints
MRI spine - bone marrow oedema in early disease before x-ray changes

Question 23

ANKYLOSING SPONDYLITIS
What is the diagnostic criteria for ankylosing spondylitis?

Answer 23

1. > 3 months back pain
2. Aged <45 at onset
3. Plus one of the SPINE ACHE symptoms

Question 24

ANKYLOSING SPONDYLITIS
What is the treatment for ankylosing spondylitis?

Answer 24

1st line
- regular exercise regimes
- NSAIDs
- corticosteroid injections
- DMARD (if NSAIDs not tolerated/ineffective) = ADALINUMAB, ETANERCEPT or INFLIXIMAB

2nd line
- surgery

Question 25

ANKYLOSING SPONDYLITIS what are the complications?

Answer 25

- osteoporosis - spinal fractures - ischaemic heart disease - cauda equina - pulmonary involvement

Question 26

PSORIATIC ARTHRITIS Give 3 locations that psoriasis commonly occurs at

Answer 26

1. Elbows 2. Knees 3. Fingers

Question 27

PSORIATIC ARTHRITIS what are the clinical features of psoriatic arthritis

Answer 27

- Asymmetrical oligoarthritis (60%) - affects DIP joints - Large joint arthritis (15%) - Enthesitis - inflammation of entheses - Dactylitis - inflammation of full finger - Nail changes (pitting, onycholysis) - inflammatory joint pain - plaques of psoriasis

Question 28

PSORIATIC ARTHRITIS What investigations might you do in someone you suspect to have psoriatic arthritis?

Answer 28

X-ray - Erosion in DIPJ + periarticular new-bone formation - Osteolysis - Pencil-in-cup deformity Bloods - ESR + CRP - normal or raised - Rheumatoid factor -ve - anti-CCP - negative Joint aspiration - no bacteria or crystals

Question 29

PSOROIATIC ARTHRITIS what is the diagnostic criteria?

Answer 29

CASPAR criteria - history of psoriasis (+2) - psoriatic nail changes (+1) - RF negative (+1) - history of dactylitis (+1) - radiological evidence = juxta-articular peristitis (+1) score >2 = positive diagnosis

Question 30

PSORIATIC ARTHRITIS How do you treat psoriatic arthritis?

Answer 30

MILD DISEASE - NSAIDS + physiotherapy - intra-articular steroids PROGRESSIVE DISEASE - DMARDs (1st line = methotrexate, sulfasalazine is alternative) - biologic agents (etanercept or infliximab)

Question 31

REACTIVE ARTHRITIS What is reactive arthritis?

Answer 31

sterile arthritis occurring after an infection typically GI or GU infection occurs 1-4 weeks following infection

Question 32

REACTIVE ARTHRITIS what are the risk factors?

Answer 32

- sexual intercourse - young adults - male sex - genetic susceptibility - HIV positivity

Question 33

REACTIVE ARTHRITIS What GI infections are associated with causing reactive arthritis?

Answer 33

Salmonella Shigella Yersinia campylobacter

Question 34

REACTIVE ARTHRITIS What GU infections are associated with causing reactive arthritis?

Answer 34

Chlamydia trachomatis Neisseria gonorrhoea

Question 35

REACTIVE ARTHRITIS What is the classic triad of symptoms for reactive arthritis?

Answer 35

1. Arthritis 2. Conjunctivitis 3. Urethritis(can't see, can't pee, can't climb a tree)

Question 36

REACTIVE ARTHRITIS what are the clinical features?

Answer 36

SYMPTOMS - joint pain and swelling - urethral discharge + dysuria - painful red eyes - rash - rectal discharge SIGNS - asymmetrical oligoarthritis (painful joints, affecting <5 joints, most likely to affect knee) - urethritis +/- epididymo-orchitis or mucopurulent cervicitis - conjunctivitis - cutaneous lesions on genitals + feet - proctitis and/or anal discharge

Question 37

REACTIVE ARTHRITIS What investigations might you do in someone you suspect to have reactive arthritis?

Answer 37

swab from infected site - urethral, cervical or rectal stool sample joint aspiration (to rule out septic arthritis) full screening for STIs HLA-B27 serology x-rays of affected joints ophthalmological evaluation

Question 38

REACTIVE ARTHRITIS How is reactive arthritis treated?

Answer 38

1st line - NSAIDs - intra-articular corticosteroids - antibiotics if active STI 2nd line - oral corticosteroids - DMARD (methotrexate or sulfalazine) - infliximab

Question 39

SPONDYLOARTHRITIS What type of spondyloarthritis occurs in 20% of patients with IBD?

Answer 39

Enteropathic arthritis

Question 40

PSORIATIC ARTHRITIS Psoriatic arthritis commonly involved swelling of what joint?

Answer 40

DIP joint

Question 41

PSORIATIC ARTHRITIS Describe a psoriatic plaque

Answer 41

Pink, scaling lesion | Occurs on extensor surfaces of limbs

Question 42

PSORIATIC VS RA Give 3 differences between RA and psoriatic arthritis

Answer 42

``` Psoriatic = psoriatic lesions, sausage like swelling around DIP joint, pencil in cup erosion on XR, HLAB27 associated. RA = hands and wrists typically affected, peri-articular erosion on XR, rheumatoid nodules ```

Question 43

OSTEOPOROSIS Define osteoporosis

Answer 43

reduction in trabecular bone mass/density and disruption of bone architecture Increase in bone fragility and fracture susceptibility Defined as bone mineral density more than 2.5 standard deviations below the young adult mean

Question 44

OESTEOPOROSIS Describe the epidemiology of osteoporosis

Answer 44

50% of women and 20% of men over 50 are affected ● Over 50, females > males as women lose trabeculae with age ● More common in Caucasians and Asians ● Increased risk with age

Question 45

OESTEOPOROSIS What 2 factors are important for determining the likelihood of osteoporotic fracture?

Answer 45

1. Propensity to fall --> trauma | 2. Bone strength

Question 46

OESTEOPOROSIS Give 4 properties of bone that contribute to bone strength

Answer 46

1. Bone mineral density 2. Bone size 3. Bone turnover 4. Bone micro-architecture 5. Mineralisation 6. Geometry

Question 47

OESTEOPOROSIS Name a hormone that can control osteoclast action and so bone turnover

Answer 47

Oestrogen

Question 48

OESTEOPOROSIS Why are so many women over 50 affected by osteoporosis?

Answer 48

Likely to post-menopausal --> less oestrogen --> osteoclast action isn't inhibited High rate of bone turnover --> bone loss and deterioration --> increased fracture risk

Question 49

OESTEOPOROSIS What happens to bone micro-architecture as we get older that leads to a reduction intone strength?

Answer 49

Trabecular thickness decreases and horizontal connection decrease --> lowers trabecular strength --> increase risk of fracture

Question 50

OSTEOPOROSIS what is the pathophysiology?

Answer 50

caused by an imbalance of bone remodelling where resorption (osteoclastic activity) exceeds bone formation (osteoblastic activity)

Question 51

OESTEOPOROSIS Why can RA cause osteoporosis?

Answer 51

RA is an inflammatory disease | High levels of IL-6 and TNF --> increase bone resorption

Question 52

OESTEOPOROSIS What is the affect of high cortisol levels on bone turnover?

Answer 52

Cortisol increases bone turnover --> increase bone resorption and induces osteoblast apoptosis

Question 53

OESTEOPOROSIS Give 5 risk factors for osteoporosis

Answer 53

- old age, women, FHx, previous fracture, smoking, alcohol, Asian/Caucasian ‘SHATTERED’ - Steroid use - Hyperthyroidism, hyperparathyroidism, hypercalciuria - Alcohol + tobacco use - Thin (BMI < 18.5) - Testosterone (low) - Early menopause - Renal or liver failure - Erosive/inflammatory bone disease (e.g. myeloma or RA) - Dietary low calcium /malabsorption or Diabetes type 1

Question 54

OESTEOPOROSIS which endocrine diseases can be responsible for causing osteoporosis?

Answer 54

1. Hyperthyroidism and primary hyperparathyroidism - TH and PTH increase bone turnover 2. Cushing's syndrome - cortisol leads to increase bone resorption and osteoblast apoptosis 3. Early menopause, male hypogonadism - less oestrogen/testosterone to control bone turnover

Question 55

OESTEOPOROSIS which medications can cause osteoporosis?

Answer 55

- glucocorticoids (steroids - phenytoin - heparin - ciclosporin - PPIs - pioglitazone - SSRIs - Aromatase inhibitors

Question 56

OESTEOPOROSIS Give the clinical presentation of osteoporosis

Answer 56

- asymptomatic - evidence of acute fracture (pain, acute bony deformity, inability to weight bare) - evidence of previous fractures (kyphosis, chronic bony deformity)

Question 57

OESTEOPOROSIS What investigations might you do in someone who you suspect to have osteoporosis

Answer 57

- DEXA scan = bone mineral density scan - gives you a T score - bone profile (calcium + ALP) - vitamin D levels - renal function to consider - PTH screening - testosterone - x-ray (if fracture suspected) - TFTs

Question 58

OESTEOPOROSIS Name 2 areas of the skeleton commonly affected by osteoporosis that the DEXA scan focuses on

Answer 58

o Thoracic and lumbar vertebrae o Proximal femur o Colles fracture of the wrist (distal radius)

Question 59

OESTEOPOROSIS What is a T score?

Answer 59

Is a standard deviation that is compared to a gender-matched young adult mean

Question 60

OESTEOPOROSIS What is a normal T score?

Answer 60

> -1.0

Question 61

OESTEOPOROSIS What T score signifies that a patient has osteopenia?

Answer 61

-2.5 < t < -1

Question 62

OESTEOPOROSIS What T score signifies that a patient has osteoporosis?

Answer 62

T < -2.5

Question 63

OESTEOPOROSIS What tool can be used to assess someones risk of osteoporotic fracture?

Answer 63

FRAX = predicts 10 year fracture chance

Question 64

OESTEOPOROSIS Give 2 examples of anti-resorptive treatments used in the management of osteoporosis

Answer 64

Decrease osteoclast activity and bone turnover 1. Bisphosphonates - alendronate, risedronate 2. HRT - oestrogen 3. Denosumab - monoclonal Ab that blocks activity of osteoclasts – binds to RANK-ligand

Question 65

OESTEOPOROSIS what is the treatment for osteoporosis?

Answer 65

CONSERVATIVE - weight-bearing exercise - vitamin D + calcium intake - smoking cessation - reduce alcohol consumption MEDICAL (DEXA <-2.5) - 1st line = bisphosphonates (alendronic acid or zoledronic acid) + calcium and vit D supplement (adcal D3) - 2nd line = denosumab or raloxifene (post-menopausal women) or PTH receptor agonist (teriparatide)

Question 66

OESTEOPOROSIS Give 3 advantages of HRT

Answer 66

1. Reduces fracture risk 2. Stops bone loss 3. Prevent menopausal symptoms

Question 67

OESTEOPOROSIS Give 3 disadvantages of HRT

Answer 67

1. Increased risk of breast cancer 2. Increased risk of stroke and CV disease 3. Increased risk of thrombo-embolism

Question 68

OESTEOPOROSIS How do bisphosphonates work?

Answer 68

Inhibit cholesterol formation --> osteoclast apoptosis

Question 69

OESTEOPOROSIS Define osteopenia

Answer 69

Pre-cursor to osteoporosis characterised by low bone density

Question 70

VASCULITIS What is vasculitis?

Answer 70

Inflammation and necrosis of blood vessel walls with subsequent inspired blood flow

Question 71

VASCULITIS What cells might you see on a histological slide taken form someone with vasculitis?

Answer 71

Neutrophils | Giant cells

Question 72

VASCULITIS Describe the pathophysiology of of vasculitis

Answer 72

Vessel wall destruction --> perforation and haemorrhage | Endothelial injury --> thrombosis and infarction

Question 73

VASCULITIS Give an example of large vessel vasculitis

Answer 73

Giant cell arteritis

Question 74

VASCULITIS Give an example of medium/small vessel vasculitis

Answer 74

Wegner's granulomatosis (Granulomatosis polyangitis)

Question 75

GIANT CELL ARTERITIS What is Giant cell arteritis?

Answer 75

Granulomatous inflammation of large cerebral arteries as well as other large vessels (aorta) which occurs in association with Polymyalgia rheumatica

Question 76

GIANT CELL ARTERITIS Describe the epidemiology of giant cell arteritis

Answer 76

Affects those > 50 years old Incidence increases with age Twice as common in women

Question 77

GIANT CELL ARTERITIS Describe the pathophysiology of giant cell arteritis

Answer 77

Arteries become inflamed, thicken and can obstruct blood flow

Question 78

GIANT CELL ARTERITIS what are is the clinical presentation of giant cell arteritis?

Answer 78

1. Headache, typically unilateral over temporal area 2. Temporal artery/scalp tenderness 3. Jaw claudication 4. Visual symptoms - vision loss (painless) 5. Systemic symptoms - fever, malaise, lethargy

Question 79

GIANT CELL ARTERITIS How does giant cell arteritis present in a medical emergency?

Answer 79

Stroke and blindness

Question 80

GIANT CELL ARTERITIS What are the investigations for giant cell arteritis?

Answer 80

- ↑ESR and/or CRP (=highly sensitive) ESR >50 mm/hr - Halo sign on US of temporal and axillary artery - Temporal artery biopsy = gold standard for Dx (show giant cells, granulomatous inflammation)

Question 81

GIANT CELL ARTERITIS What is the diagnostic criteria for giant cell arteritis?

Answer 81

1. Age >50 2. New headache 3. Temporal artery tenderness 4. Abnormal artery biopsies

Question 82

GIANT CELL ARTERITIS Describe the treatment for giant cell arteritis

Answer 82

1. High dose corticosteroids - prednisolone ASAP 2. DMARDs - methotrexate (sometimes) 3. Osteoporosis prophylaxis is important - lansoprazole, alendronate, Ca2+, vit D

Question 83

GIANT CELL ARTERITIS Give 2 complications of giant cell arteritis

Answer 83

1. Increased CVA risk | 2. Visual loss

Question 84

What does ANCA stand for?

Answer 84

Anti-neutrophil cytoplasmic antibodies

Question 85

GRANULOMATOSIS WITH POLYANGIITIS what is it?

Answer 85

systemic vasculitis characterised by granulomatous inflammation, necrotising vasculitis affecting small-to-medium vessels it is an ANCA-associated vasculitis

Question 86

GRANULOMATOSIS WITH POLYANGIITIS What is the pathophysiology of granulomatosis with polyangiitis?

Answer 86

Necrotising granulomatous vasculitis affecting arterioles and venules ANCAs can activate primed circulating neutrophils which leads to fibrin deposition in vessel walls and deposition of destructive inflammatory mediators

Question 87

GRANULOMATOSIS WITH POLYANGIITIS where in the body can be affected?

Answer 87

ears sinuses lungs kidneys

Question 88

GRANULOMATOSIS WITH POLYANGIITIS What are the clinical features?

Answer 88

SYMPTOMS - epistaxis - sinus congestion - cough +/- haemoptysis - haematuria - joint pain - paraesthesia and numbness SIGNS - nasal crusting or bleeding - nasal or oral inflammation - saddle nose deformity - crackles or wheeze - tender, swollen joints - signs of peripheral neuropathy - vasculitic rash (purpura)

Question 89

GRANULOMATOSIS WITH POLYANGIITIS What investigations might you do in someone you suspect to have granulomatosis with polyangiitis?

Answer 89

ANCA testing - c-ANCA CRP/ESR = raised renal function tests urine dipstick + microscopy CXR/CT chest renal biopsy (gold standard) = necrotising glomerulonephritis FBC - high eosinophils

Question 90

GRANULOMATOSIS WITH POLYANGIITIS What is the treatment for granulomatosis with polyangiitis?

Answer 90

1st line - corticosteroids (prednisolone) - cyclophosphamide - maintenance therapy (azathioprine or methotrexate) 2nd line - rituximab (may be used instead of cyclophosphamide) - plasma exchange

Question 91

OSTEOARTHRITIS Define osteoarthritis

Answer 91

A non-inflammatory degenerative disorder of moveable joints characterised by the deterioration of articular cartilage and the formation of new bone

Question 92

OSTEOARTHRITIS Why does the prevalence of OA increase with age?

Answer 92

Due to the cumulative effect of trauma and a decrease in neuromuscular function

Question 93

OSTEOARTHRITIS what are the risk factors for developing OA?

Answer 93

NON-MODIFIABLE - genetic - increasing age - female sex - high bone density MODIFIABLE - obesity - joint injury + damage - occupation

Question 94

OSTEOARTHRITIS What are the most important cells responsible for OA?

Answer 94

Chondrocytes

Question 95

OSTEOARTHRITIS Describe the pathophysiology of osteoarthritis

Answer 95

Mechanical stress --> progressive destruction and loss of articular cartilage exposed subchondral bone becomes sclerotic cytokine mediated TNF/IL/NO involved deficiency in growth factors

Question 96

OSTEOARTHRITIS Name the 2 main pathological features of osteoarthritis

Answer 96

1. Cartilage loss | 2. Disordered bone repair

Question 97

OSTEOARTHRITIS Name the 3 joints of the hand that are commonly affected in osteoarthritis

Answer 97

1. Distal interphalangeal joint 2. Proximal interphalangeal joint 3. Carpal metacarpal joint

Question 98

OSTEOARTHRITIS Which surface of the knee is most commonly affected by OA?

Answer 98

Medial surface

Question 99

OSTEOARTHRITIS What are the symptoms of OA?

Answer 99

SYMPTOMS - Joint pain worsened by movement and relieved by rest - Stiffness after rest – gelling - Only transient (<30 minute) morning stiffness - joint locking SIGNS - heberdens nodes (nodes at DIP joint) - bouchards nodes (nodes at PIP joint) - thenar muscle wasting - first carpometacarpal joint most affected - crepitus in knees - joint tenderness - antalgic gait - restricted internal rotation when hip flexed

Question 100

OSTEOARTHRITIS What is the primary investigation used to make a diagnosis of OA?

Answer 100

X-ray to consider - ESR and CRP - WBC - rheumatoid factor + anti-CCP

Question 101

OSTEOARTHRITIS Give 5 radiological features associated with OA

Answer 101

LOSS 1. Loss of joint space - articular cartilage destruction 2. Osteophyte formation - calcified cartilaginous destruction 3. Subchondral sclerosis - exposed 4. Subchondral cysts 5. Abnormalities of bone contour

Question 102

OSTEOARTHRITIS Describe the non-medical management of osteoarthritis

Answer 102

1. Education 2. Weight loss 3. Activity and exercise 4. Physiotherapy and occupational therapy 5. Walking aids/podiatry

Question 103

OSTEOARTHRITIS Describe the pharmacological management of OA

Answer 103

1st line - simple analgesia (paracetamol) - topical NSAIDs 2nd line - oral NSAIDs with PPI - weak opioids (codeine) - topical capsaicin - intra-articular corticosteroid injection

Question 104

OSTEOARTHRITIS Give 3 indications for surgery in OA

Answer 104

1. Significant limitation of function 2. Uncontrolled pain 3. Waking at night from pain

Question 105

OSTEOARTHRITIS A patient complains of 'locking', what is the most likely cause?

Answer 105

A loose body - bone or cartilage fragment

Question 106

OSTEOARTHRITIS Nodal osteoarthritis can affect the DIP and PIP joints. What are the 2 terms sued for nodes on these joints?

Answer 106

1. PIP = Bouchard's nodes | 2. DIP = Heberden's nodes

Question 107

OSTEOARTHRITIS what are the complications?

Answer 107

BIOLOGICAL - joint effusion - NSAID related complications (nephrotoxicity, GI bleeding) PSYCHOLOGICAL - low mood - chronic pain SOCIAL - functional decline - reduction on ADLs - falls

Question 108

Give an example of an inherited connective tissue disease

Answer 108

1. Marfan's syndrome = abnormal fibrillar production | 2. Ehlers Danlos syndrome = abnormal collagen production

Question 109

Give an example of an autoimmune connective tissue disease

Answer 109

1. SLE 2. Systemic sclerosis (scleroderma) 3. Sjogren's syndrome 4. Dermatomyositis/Polymyositis

Question 110

SLE What is SLE?

Answer 110

Systemic lupus erythematous = inflammatory multi-system disease characterised by the presence of serum anti-nuclear antibodies (ANA)

Question 111

SLE Describe the epidemiology of SLE

Answer 111

1. 90% of cases are in young women 2. More common in afro-caribbean 3. Genetic association 4. peak onset = 20-40yrs

Question 112

SLE Describe the pathogenesis of SLE

Answer 112

Type 3 hypersensitivity reaction = immune complex mediated | Autoantibodies to a variety of auto antigens result in formation and deposition of immune complexes

Question 113

SLE What can cause thrombosis in SLE?

Answer 113

The presence of antiphospholipid antibodies

Question 114

SLE What autoantibody is specific to SLE?

Answer 114

Anti-double stranded DNA

Question 115

SLE what are the clinical features of SLE?

Answer 115

GENERAL - fatigue - fever - lymphadenopathy DERMATOLOGICAL - malar 'butterfly' rash - photosensitivity - discoid rash - livedo reticularis - non-scarring alopecia - raynauds phenomenon MSK - arthralgia - non-erosive arthritis PULMONARY - pleurisy - interstitial lung disease - PE CARDIOVASCULAR - pericarditis/myocarditis GI - lupus peritonitis - mesenteric artery occlusion RENAL - lupus nephritis (diffuse proliferative glomerulonephritis) OPHTHAMOLOGICAL - keratoconjunctivitis - sjogrens syndrome HAEMATOLOGICAL - warm autoimmune haemolytic anaemia - thrombocytopaenia - antiphospholipid syndrome OTHER - mouth + nose ulcers

Question 116

SLE What investigations might you do in someone who you suspect has SLE?

Answer 116

- FBC = anaemia, neutropenia, thrombocytopenia, - CRP/ESR = RAISED ESR and NORMAL CRP - U&Es - renal function - clotting screen = prolonged APTT in antiphospholipid syndrome - complement (C3+4) = low in active disease - Serum autoantibodies = ANA, anti-dsDNA to consider - urinalysis = proteinuria + haematuria in lupus nephritis - joint x-rays

Question 117

SLE Describe the non medical treatment for SLE

Answer 117

Patient education and support UV protection Screening for end organ damage Reduce CV risk factors - smoking cessation

Question 118

SLE Describe the pharmacological treatment for SLE

Answer 118

ACUTE FLARE - mild = prednisolone + hydroxychloroquine + NSAIDs - moderate/severe = prednisolone + hydroxychloroquine + immunosuppressant (azathioprine or ciclosporin) - refractory cases = biologics (rituximab) MAINTENANCE - hydroxychloroquine

Question 119

SYSTEMIC SCLEROSIS What is systemic sclerosis (scleroderma)?

Answer 119

autoimmune disease characterised by fibrosis of the skin and visceral organs

Question 120

SYSTEMIC SCLEROSIS Describe the pathophysiology of scleroderma

Answer 120

Various factors cause endothelial lesion and vasculopathy Excessive collagen deposition --> inflammation and auto-antibody production

Question 121

SYSTEMIC SCLEROSIS what are the different types?

Answer 121

- limited systemic sclerosis = anti-centromere antibodies - diffuse systemic sclerosis = anti-Scl 70 antibodies

Question 122

SYSTEMIC SCLEROSIS what are the general clinical features?

Answer 122

DERMATOLOGICAL - sclerodactyly (prayer sign) - skin tightening + fibrosis - digital ulcers - calcinosis (lumpy calcium deposits) - telangiectasia - perioral furrowing (skin wrinkling around mouth) - beaked nose - microstomia (tightening skin around mouth) CARDIOVASCULAR - raynauds - hypertension RESPIRATORY - interstitial lung disease - pulmonary hypertension GI - oesophageal dysmotility RENAL - renal crisis (acute renal failure with hypertension)

Question 123

SYSTEMIC SCLEROSIS what are the features of limited scleroderma?

Answer 123

CREST 1. Calcinosis - skin calcium deposits 2. Raynauds 3. Esophageal reflux/stricture 4. Sclerodactyly - thick tight skin on fingers/toes 5. Telangiectasia - dilated facial spider veins Pulmonary arterial hypertension - skin thickening distal to elbows + knees - raynauds phenomenon often precedes skin changes -

Question 124

SYSTEMIC SCLEROSIS what are the features of diffuse scleroderma?

Answer 124

Skin changes develop more rapidly and are more widespread than inlimited cutaneous scleroderma/CREST 1. Proximal scleroderma 2. interstitial lung disease 3. Bowel involvement 4. hypertension 5. Renal crisis - skin thickening extends proximally, affecting trunk + proximal limbs predominantly - raymauds phenomenon occurs before or after skin changes - early visceral involvement

Question 125

SYSTEMIC SCLEROSIS what are the investigations?

Answer 125

BLOODS - FBC = anaemia (microcytic) - U&Es = may demonstrate renal failure - CRP + ESR = elevated ANTIBODIES - ANA = positive - anti-centromere = limited systemic sclerosis - anti-Scl 70 = diffuse systemic sclerosis to consider - ECG + echo - CXR - pulmonary function tests - -barium swallow

Question 126

SYSTEMIC SCLEROSIS Describe the management of scleroderma

Answer 126

SKIN - emollient - methotrexate (for skin thickening) - prednisolone (for pruritus) RAYNAUDS - avoid cold + wear gloves - nifedipine - topical nitrate (if poor response) - sildenafil (if ulcers present) PULMONARY ARTERY HTN - bosentan INTERSTITIAL LUNG DISEASE - cyclophosphamide RENAL CRISIS - ACE inhibitor - dialysis (if required) GI - PPI

Question 127

SJOGRENS what is it?

Answer 127

systemic autoimmune disorder that affects the joints and the lacrimal + minor salivary glands

Question 128

SJOGRENS What is the pathophysiology of sjögren's syndrome?

Answer 128

T-lymphocyte mediated type 4 hypersensitivity reaction

Question 129

SJOGRENS What does sjögren's syndrome often occur secondary to?

Answer 129

Other autoimmune disease --> SLE, RA, scleroderma, primary biliary cirrhosis

Question 130

SJOGRENS what are the risk factors?

Answer 130

- age (40-60) - female sex - family history - concurrent autoimmune conditions (RA, SLE, scleroderma and primary biliary cholangitis)

Question 131

SJOGRENS what are the clinical features of sjögren's syndrome?

Answer 131

SYMPTOMS - dry eyes (keratoconjunctivitis) - dry mouth (xerostomia) - dry skin - fatigue - vaginal dryness - dyspareunia SIGNS - parotid gland swelling - photosensitivity - corneal ulcers - periodontal disease + dental caries - symmetrical + non-erosive joint inflammation - Jaccoud's deformity (reducible nodules in MCP joints)

Question 132

SJOGRENS Why does someone with sjögren's syndrome have dry eyes and a dry mouth?

Answer 132

There is immunologically mediated destruction of epithelial exocrine glands meaning the lacrimal and salivary glands produce fewer secretions

Question 133

SJOGRENS What investigations might you do in someone who you suspect to have sjögren's syndrome?

Answer 133

- lip biopsy - schirmers test (measure tears produced) - antibodies = anti-Ro and anti-La - ESR/CRP = elevated to consider - occular surface staining - unstimulated salivary flow rate - total protein - MRI - joint x-ray

Question 134

SJOGRENS What is the treatment for sjögren's syndrome?

Answer 134

- Artificial tears, artificial saliva, vaginal lubricants - Hydroxychloroquine - NSAID - M3 agonist - pilocarpine

Question 135

DERMATOMYOSITIS What is dermatomyositis?

Answer 135

A rare disorder of unknown aetiology Inflammation and necrosis of skeletal muscle fibres and skin

Question 136

DERMATOMYOSITIS what are the clinical features of dermatomyositis?

Answer 136

SYMPTOMS - symmetrical muscle weakness - difficulty walking, lifting arms + standing up - myalgia - joint pains - dysphagia - feeling depressed SIGNS - muscle tenderness (around pelvic + pectoral girdle) - shawl sign (red rash over shoulders, arms + upper back in v-shape) - heliotrope rash (dusky red rash on hands or face) - Gottrons papules (red/purple hardened or eroding areas of skin on upper surface of finger joints/knees and elbows) - periungual telangiectasia (dilated capillaries at skin folds around nail bed - photosensitivity

Question 137

DERMATOMYOSITIS What investigations might you do in someone who you suspect has dermatomyositis?

Answer 137

- CRP/ESR = raised - LFTs = ALT/AST raise - TFTs - CK, LDH + ANA = raised - myositis-specific auto-antibodies = anti-jo 1 and anti-Mi 2 - electromyogram to consider - muscle biopsy - skin biopsy

Question 138

DERMATOMYOSITIS What is the treatment for dermatomyositis?

Answer 138

1st line - exercise + physio - sun protective measures 2nd line - immunosuppressants (methotrexate, azathioprine or cyclophosphamide) - immunoglobulin therapy - biologic (rituximab)

Question 139

What is the name given to inflammation of an entire digit?

Answer 139

Dactylitis

Question 140

RAYNAUDS What class of drugs can cause Raynaud's?

Answer 140

Beta blockers

Question 141

RAYNAUDS What are the 3 phases of Raynaud's?

Answer 141

White (vasoconstriction) --> Blue (tissue hypoxia) --> red (vasodilation)

Question 142

RAYNAUDS What class of drugs does Nifedipine fall into and why can is be used to treat Raynaud's?

Answer 142

Nifedipine - CCB Relaxes blood vessels and stops vasospasm

Question 143

SEPTIC ARTHRITIS Describe the pathophysiology of septic arthritis

Answer 143

Infection produces inflammation in joints Knee > Hip > Shoulder

Question 144

SEPTIC ARTHRITIS what are the causes of septic arthritis?

Answer 144

- staph.aureus = most common in all age groups - staph.epidermidis = prosthetic joints - strep.pyogenes = children <5yrs - n.gonorrhoea = young sexually active - pseudomonas aeruginosa = immunosuppressed, elderly + IVDU

Question 145

SEPTIC ARTHRITIS what are the risk factors for septic arthritis?

Answer 145

Pre-existing joint disease (OA or RA) Joint prostheses IVDU Immunosuppression Alcohol misuse Diabetes Intra-articular corticosteroid injection Recent joint surgery

Question 146

SEPTIC ARTHRITIS what are the clinical features of septic arthritis

Answer 146

SYMPTOMS - difficulty weight bearing - fever SIGNS - hot, tender, erythematous, swollen joint - very limited range of movement

Question 147

SEPTIC ARTHRITIS What investigation would you do to someone you suspect has septic arthritis?

Answer 147

- joint aspiration MS + C (ideally prior to antibiotics) - blood cultures - FBC = leukocytosis - CRP + ESR = elevated - plain x-ray to consider - USS or MRI

Question 148

SEPTIC ARTHRITIS what is the diagnostic criteria?

Answer 148

Kocher criteria - non-weight bearing = 1 - temp >38.5 = 1 - ESR > 40mm/hr = 1 - WCC >12x10 9/L = 1 score of 2 = 40% probability score of 3 = 93% probability

Question 149

SEPTIC ARTHRITIS Describe the treatment for septic arthritis

Answer 149

ANTIBIOTICS - IV for 2 weeks followed by oral for 4 weeks - empirical = flucloxacillin (clindamycin in penicillin allergy) - suspected MRSA = vancomycin - gonococcal = cefotaxime or ceftriaxone SURGERY - arhtroscopic washout - srugical debridement

Question 150

OSTEOMYELITIS Define osteomyelitis

Answer 150

Bone inflammation secondary to infection

Question 151

OSTEOMYELITIS Describe the epidemiology of osteomyelitis

Answer 151

Increasing incidence of chronic OM Bimodal age distribution (children and elderly) ● Predominantly occurs in children ● Increasing incidence of chronic osteomyelitis ● Adolescents and adults tend to get osteomyelitis due to infection secondary to direct trauma ● Elderly get it due to risk factors ● Majority of haematogenous acute osteomyelitis occurs in children

Question 152

OSTEOMYELITIS What organisms can cause osteomyelitis?

Answer 152

1. Staph. aureus = most common 2. Coagulase negative staph (s. epidermidis) 3. Aerobic gram negate bacilli (salmonella) 4. haemophilus influenza 5. Mycobacterium TB

Question 153

OSTEOMYELITIS Name 2 predisposing conditions for osteomyelitis

Answer 153

1. Diabetes 2. PVD

Question 154

OSTEOMYELITIS Describe the 3 routes of infection into bone

Answer 154

1. Direct inoculation of infection to bone (trauma, surgery) 2. Contagious spread of infection from adjacent tissues to bone 3. Hematogenous seeding (e.g. due to cannula infection)

Question 155

OSTEOMYELITIS Who is most likely to be effected by contagious spread of infection?

Answer 155

Affects older adults, those with DM, chronic ulcers, vascular disease, arthroplasties

Question 156

OSTEOMYELITIS What bones are likely to be affected by hematogenous seeding in adults?

Answer 156

Vertebrae

Question 157

OSTEOMYELITIS What bones are likely to be affected by hematogenous seeding in children?

Answer 157

Long bones

Question 158

OSTEOMYELITIS Why do vertebrae tend to be affected by hematogenous seeding in adults?

Answer 158

With age, the vertebrae become more vascular meaning bacterial seeding is more likely

Question 159

OSTEOMYELITIS Why do long bones tend to be affected by hematogenous seeding in children?

Answer 159

In children the metaphysis of long bones has a high but slow blood flow and basement membrane are absent meaning bacteria can move from the blood to bone

Question 160

OSTEOMYELITIS Name a group of people who are at risk of hematogenous osteomyelitis

Answer 160

IVDU and other groups at risk from bacteraemia

Question 161

OSTEOMYELITIS what changes to bone might you see histologically in acute osteomyelitis?

Answer 161

1. Inflammatory cells 2. Oedema 3. Vascular congestion 4. Small vessel thrombosis

Question 162

OSTEOMYELITIS what changes to bone might you see histologically in chronic osteomyelitis?

Answer 162

1. Necrotic bone - 'squestra' 2. New bone formation 'involucrum' 3. Neutrophil exudates 4. Lymphocytes and histiocytes

Question 163

OSTEOMYELITIS Why does chronic osteomyelitis lead to sequestra and new bone formation?

Answer 163

- Inflammation in BM increase intramedullary pressure exudate into bone cortex which rupture through periosteum - this causes interruption of periosteum blood supply which results in necrosis and sequestra - therefore new bone forms

Question 164

OSTEOMYELITIS What is acute osteomyelitis associated with?

Answer 164

Associated with inflammatory bone changes caused by pathogenic bacteria

Question 165

OSTEOMYELITIS What is chronic osteomyelitis associated with?

Answer 165

Involves bone necrosis

Question 166

OSTEOMYELITIS what is the clinical presentation of osteomyelitis?

Answer 166

SYMPTOMS - fatigue - pain - fever - reduced ROM SIGNS - puncture wound - limp/reluctance to weight bear - local inflammation - local erythema - swelling - ulceration/charcot foot (in diabetes)

Question 167

OSTEOMYELITIS what are the signs of acute osteomyelitis?

Answer 167

1. Tender 2. Warm 3. Red swollen area around OM

Question 168

OSTEOMYELITIS what are the signs of chronic osteomyelitis?

Answer 168

1. Acute OM signs 2. Draining sinus tract 3. Non-healing ulcers/fracture

Question 169

OSTEOMYELITIS What is the differential diagnosis of osteomyelitis?

Answer 169

1. Cellulitis 2. Charcot's joints (sensation loss --> degeneration) 3. Gout 4. Fracture 5. Malignancy 6. Avascular bone necrosis

Question 170

OSTEOMYELITIS What investigations might you do on someone who you suspect may have osteomyelitis?

Answer 170

1. Bloods - raised inflammatory markers (CRP, ESR) and WCC 2. X-rays (cortical erosion, sequestra, sclerosis) and MRI (delineates inflammatory layers, marrow oedema) 3. wound swab 4. Blood cultures to consider - MRI - bone biopsy - urine microscopy, culture + sensitivities

Question 171

OSTEOMYELITIS Describe the usual treatment for osteomyelitis

Answer 171

ACUTE PERIPHERAL OM/ACUTE OM IN PATIENT WITH DIABETIC FOOT - 1st line = IV flucloxacillin - if MRSA suspected = vancomycin - if pseudomonas = piperacillin/tazobactam - supportive = analgesia, hydration - 2nd line = surgical debridement VERTEBRAL OM - referral to infectious diseases - if neuro involvement = surgery - no neuro involvement = vancomycin + ceftriaxone - supportive = analgesia + hydration CHRONIC OM - MDT referral - consideration for surgery - optimise contributing co-morbidities - treat acute flares with IV antibiotics

Question 172

OSTEOMYELITIS How is the stopping of antibiotics determined in osteomyelitis?

Answer 172

Guided by ESR and CRP

Question 173

OSTEOMYELITIS Give 4 ways in which TB osteomyelitis is different to other osteomyelitis

Answer 173

1. Slower onset 2. Epidemiology is different 3. Biopsy is essential - caseating granuloma 4. Longer Treatment = 12 months

Question 174

OSTEOMYELITIS Why is osteomyelitis difficult to treat?

Answer 174

Antibiotics struggle to penetrate bone and bone has a poor blood supply

Question 175

OSTEOMYELITIS What is bacteraemia?

Answer 175

Bacteria in the blood

Question 176

OSTEOMYELITIS What is debridement?

Answer 176

The removal of damaged tissue

Question 177

OSTEOMYELITIS What condition must always be rules out in an acutely inflamed joint?

Answer 177

Septic arthritis --> aspirate the joint

Question 178

RHEUMATOID ARTHRITIS What is rheumatoid arthritis?

Answer 178

An auto-inflammatory synovial joint disease causing symmetrical polyarthritis

Question 179

RHEUMATOID ARTHRITIS Name 3 risk factors of RA

Answer 179

1. Smoking 2. Women 3. family history 4. Other AI conditions 5. genetic factors - HLA-DR4 and HLA-DRB1

Question 180

RHEUMATOID ARTHRITIS Describe the pathophysiology of RA

Answer 180

1. Chronic inflammation - B/T cells and neutrophils infiltrate 2. Proliferation --> pannus formation (synovium grows out and over cartilage) 3. Pro-inflammatory cytokines --> proteinases --> cartilage destruction

Question 181

RHEUMATOID ARTHRITIS what are the symptoms of RA?

Answer 181

1. Early morning stiffness (>60 mins) 2. Pain eases with use 3. Swelling 4. General fatigue, malaise 5. Extra-articular involvment

Question 182

RHEUMATOID ARTHRITIS what are the signs of RA?

Answer 182

1. Symmetrical polyarthorpathy (typically small joints of hands and feet (MCP, PIP, MTP) + progresses to larger joints) 2. boutonniere deformity (PIP flexion + DIP hyperextension) 3. swan-neck deformity (PIP hyperextension + DIP flexion) 4. Z-thumb deformity (hyperextension of thumb IP joint with flexion of MCP joint) 5. ulnar deviation 6. rheumatoid nodules

Question 183

RHEUMATOID ARTHRITIS RA extra-articular involvement: describe the effect on soft tissues

Answer 183

Nodules Bursitis Muscle wasting

Question 184

RHEUMATOID ARTHRITIS RA extra-articular involvement: describe the effect on the eyes

Answer 184

Dry eyes Scleritis Episcleritis

Question 185

RHEUMATOID ARTHRITIS RA extra-articular involvement: describe the neurological effects

Answer 185

Sensory peripheral neuropathy Entrapment neuropathies (carpal tunnel syndrome) Instability of cervical spine

Question 186

RHEUMATOID ARTHRITIS RA extra-articular involvement: describe the haematological effects

Answer 186

Felty's syndrome (RA + splenomegaly + neutropenia) Anaemia

Question 187

RHEUMATOID ARTHRITIS RA extra-articular involvement: describe the pulmonary effects

Answer 187

Pleural effusion Fibrosing alveolitis

Question 188

RHEUMATOID ARTHRITIS RA extra-articular involvement: describe the effects on the heart

Answer 188

Pericardial rub Pericardial effusion

Question 189

RHEUMATOID ARTHRITIS RA extra-articular involvement: describe the effects on the kidney

Answer 189

Amyloidosis

Question 190

RHEUMATOID ARTHRITIS RA extra-articular involvement: describe the effects on the skin

Answer 190

Vasculitis - infarcts in nail bed

Question 191

RHEUMATOID ARTHRITIS What investigations might you do in someone you suspect has rheumatoid arthritis?

Answer 191

- Blood for inflammatory markers - ESR and CRP raised - RF and Anti-CCP X-ray- Synovial fluid is sterile with high neutrophil count

Question 192

RHEUMATOID ARTHRITIS What is seen on an X-ray of someone with RA?

Answer 192

LESS: - Loss of joint space (due to cartilage loss) - Erosion - Soft tissue swelling - Soft bones = osteopenia - subluxation - periarticular osteoporosis

Question 193

RHEUMATOID ARTHRITIS Describe the treatment for rheumatoid arthritis

Answer 193

PRIMARY CARE - NSAIDs - refer to specialist - physiotherapy + occupational therapy SECONDARY CARE - DMARD (methotrexate, sulfasalazine or hydroxychloroquine) - steroids can be given whilst DMARDs take effect - biologics (abatacept, rituximab) MANAGING FLARES - NSAIDs - intra-articular steroid injection

Question 194

RHEUMATOID ARTHRITIS What joints tend to be affects in RA?

Answer 194

MCP PIP Wrist (DIP often spared)

Question 195

GOUT What is gout?

Answer 195

Crystal arthritis Inflammatory arthritis caused by hyperuricaemia and intra-articular sodium urate crystals

Question 196

GOUT Describe the epidemiology of gout?

Answer 196

● 5x more common in men ● Occurs rarely before young adulthood ● Rarely occurs in pre-menopausal females ● Often a family history

Question 197

GOUT What joint does gout most commonly affect?

Answer 197

Big toe metatarsophalangeal joint

Question 198

GOUT Describe the pathophysiology of gout

Answer 198

Purine --> (by xanthine oxidase) xanthine --> uric acid --> monosodium rate crystals OR excreted by kidneys Urate blood/tissue imbalance --> rate crystal formation --> inflammatory response through phagocytic activation Overproduction/under excretions of uric acid causes build up and precipitated out in joints

Question 199

GOUT Give 3 causes of gout

Answer 199

= Hyperuricaemia 1. Impaired excretion - CKD, diuretics, hypertension 2. Increased production - hyperlipidaemia 3. Increased intake - high purine diet = red meat, seafood, fructose, alcohol

Question 200

GOUT Name 3 common precipitants of a gout attack

Answer 200

1. Aggressive introduction of hypouricaemic therapy 2. Alcohol or shellfish binges 3. Sepsis, MI, acute severe illness 4. Trauma

Question 201

GOUT Name 4 diseases that someone with gout might have an increased risk of developing

Answer 201

1. Hypertension 2. CV disease - e.g. stroke 3. Renal disease 4. Type 2 diabetes

Question 202

GOUT what is the clinical presentation of gout?

Answer 202

SYMPTOMS - rapid onset severe joint pain - joint stiffness SIGNS - joint inflammation (tenderness, erythema + swelling) - 1st MTP most common (ankle, knee + wrist common) - gouty tophi

Question 203

GOUT What are tophi?

Answer 203

Onion like aggregates of urate crystals with inflammatory cells. Proteolytic enzymes are released --> erosion

Question 204

GOUT What investigations might you do in a patient you think has gout?

Answer 204

- U&E and eGFR - renal failure - Uric acid levels - 4-6 weeks after to confirm hyperuricaemia - gold standard = joint aspiration

Question 205

GOUT How would you treat acute gout?

Answer 205

ACUTE FLARE - 1st line = NSAIDs or colchicine with PPI - 2nd line = intra-articular steroids PREVENTION - 1st line = allopurinol - 2nd line = febuxostat - may require colchicine to help cover first couple of weeks as allopurinol + febuxostat can cause gout

Question 206

GOUT You see a patient with gout who is taking bendroflumethiazide. What drug might you replace this with to help treat their gout?

Answer 206

You would switch bendroflumethiazide to cosartan as bendroflumethiazide is a diuretic and so impairs urate excretion

Question 207

GOUT Name 6 factors that can cause an acute attack of gout

Answer 207

1. Sudden overload 2. Cold 3. Trauma 4. Sepsis 5. Dehydration 6. Drugs

Question 208

GOUT A patient presents with an acute mono-arthropathy of their big toe. What are the two main differential diagnoses?

Answer 208

1. Gout 2. Septic arthritis

Question 209

PSEUDOGOUT Describe the pathophysiology of pseudogout

Answer 209

Calcium pyrophosphate crystals are deposited on joint surfaces - produces the radiological appearance of chondrocalcinosis Crystals elicit an acute inflammatory response

Question 210

PSEUDOGOUT What can cause pseudogout?

Answer 210

1. Hypo/hyperthyroidism 2. Haemochromatosis 3. Diabetes 4. Magnesium levels

Question 211

PSEUDOGOUT what is the clinical presentation of pseudogout?

Answer 211

SYMPTOM hot, swollen, tender joint, usually knees SIGNS recent injury to the joint in the history Typically the wrists and knees

Question 212

PSEUDOGOUT What investigations might you do in someone you suspect might have pseudogout?

Answer 212

Joint aspiration --> fluid for crystals and blood cultures = positive birefringent rhomboid crystals X-rays --> can show chondrocalcinosis

Question 213

PSEUDOGOUT What is the most likely differential diagnosis for pseudogout?

Answer 213

Infection

Question 214

PSEUDOGOUT Describe the treatment for pseudogout

Answer 214

- anti-inflammatory = NSAIDs or colchicine - corticosteroid = intra-articular steroids

Question 215

PSEUDOGOUT How can you distinguish OA from pseudogout?

Answer 215

Pattern of involvement --> Pseudo = wrists, shoulders, ankle, elbows Marked inflammatory component --> Elevated CRP and ESR Superimposition of acute attacks

Question 216

PSEUDOGOUT What kind of crystals do you see in pseudogout?

Answer 216

Positive birefringent calcium pyrophosphate rhomboid crystals

Question 217

GOUT What kind of crystals do you see in gout?

Answer 217

Monosodium urate crystals = negatively birefringent

Question 218

FIBROMYALGIA What is the diagnostic criteria for fibromyalgia?

Answer 218

Chronic widespread pain lasting for > 3 months with other causes excluded Pain is at 11/18 tender point sites for 6 months

Question 219

FIBROMYALGIA Name 4 diseases that fibromyalgia is commonly associated with

Answer 219

1. Depression 2. Choric fatigue 3. IBS 4. Chronic headache

Question 220

FIBROMYALGIA Give 4 symptoms of fibromyalgia

Answer 220

1. Neck and back pain 2. Pain is aggravated by stress, cold and activity 3. Generalised morning stiffness 4. Paraesthesia of hands and feet 5. Profound fatigue 6. Unrefreshing sleep 7. poor concentration, brain fog

Question 221

FIBROMYALGIA Give 3 disease that might be included in the differential diagnosis for fibromyalgia

Answer 221

1. Hypothyroidism 2. SLE 3. Low vitamin D

Question 222

FIBROMYALGIA How is fibromyalgia diagnosed?

Answer 222

Everything seems normal 11/18 trigger points | Exclude other diagnoses

Question 223

FIBROMYALGIA Describe the management of fibromyalgia

Answer 223

1st line - patient education + explanation - physical therapy 2nd line - CBT +/- antidepressants - analgesia = amitriptyline, pregabalin or duloxetine - multi-modal rehab programmes

Question 224

PHSIOLOGY Why is the ACL so important?

Answer 224

Important stabiliser of the knee joint, limits anterior translation of the tibia and also contributes to knee rotational starbility

Question 225

SARCOMA Define sarcoma

Answer 225

A rare tumour of mesenchymal origin | A malignant connective tissue neoplasm

Question 226

BONE CANCER What are the red flag symptoms for bone malignancy?

Answer 226

``` Rest pain Night pain Loss of function Neurological problems Weight loss Growing lump Deformity ```

Question 227

BONE CANCER Who are primary bone tumours seen in?

Answer 227

they are rare - are mainly seen in children and young peoplemore common in males

Question 228

BONE CANCER Give 3 primary bone tumours

Answer 228

1. Osteosarcoma 2. Fibrosarcoma 3. Chondrosarcomas 4. Ewings sarcoma

Question 229

BONE CANCER What are secondary bone tumours?

Answer 229

Metastases from: 1. Lungs 2. Breast 3. Prostate 4. Thyroid 5. Kidney

Question 230

BONE CANCER What investigations might you do in someone you suspect has bone cancer?

Answer 230

1st line → x-ray Gold standard → biopsy Bloods → FBC, ESR, ALP, lactate dehydrogenase, Ca, U+E CT chest/abdo/pelvis

Question 231

BONE CANCER What might you seen on an X-ray of someone with bone cancer?

Answer 231

Onion skin/sunburst appearance = Ewings Colman's triangle = osteosarcoma, Ewings, GCT, Osteomyelitis, metastasis

Question 232

BONE CANCER What staging is used for bone cancers?

Answer 232

Enneking grading

Question 233

BONE CANCER How are malignant bone cancers staged using Enneking grading?

Answer 233

``` G1 = Histologically benign G2 = Low grade G3 = High grade ``` ``` A = intracompartmental B = extracompartmental ```

Question 234

BONE CANCER How are benign bone cancers staged using Enneking grading?

Answer 234

``` G1 = Latent G2 = Active G3 = Aggressive ```

Question 235

BONE CANCER How are bone cancers treated?

Answer 235

``` MDT management Benign - NSAIDS - Bisphosphonates (alendronate) - symptomatic help ``` Malignancy = surgical excision --> limb sparing/amputation radio/chemotherapy

Question 236

BONE CANCER Give 4 local complications with surgery for bone cancers

Answer 236

1. Haematoma 2. Loss of function 3. Infection 4. Local recurrence

Question 237

SARCOMA Where do osteosarcomas usually present?

Answer 237

Knee - distal femur, proximal humerus

Question 238

SARCOMA What is an osteosarcoma?

Answer 238

Malignant tumour of bone Spindle cell neoplasm that produce osteoid rapidly metastases to the lung

Question 239

SARCOMA Give 3 features of osteosarcoma

Answer 239

1. Fast growing 2. Aggressive - Destroys bone and spreads into surrounding tissues, rapidly metastasises to lung 3. Typically affects 15-19 year olds 4. often relatively painless

Question 240

SARCOMA What is a chondrosarcoma?

Answer 240

A malignant neoplasm of cartilage

Question 241

SARCOMA Name a boney sarcoma that responds well to chemotherapy

Answer 241

Ewings sarcoma

Question 242

SARCOMA Where does Ewings sarcoma arise from?

Answer 242

mesenchymal stem cells

Question 243

SARCOMA Boney sarcomas make up what percentage of overall sarcomas?

Answer 243

``` 20% = boney 80% = soft tissue ```

Question 244

SARCOMA Name 3 soft tissue sarcomas

Answer 244

1. Liposarcoma = malignant neoplasm of adipose tissue 2. Leiomyosarcoma = malignant neoplasm of smooth muscle 3. Rhabdomyosarcoma = malignant neoplasm of skeletal muscle

Question 245

SARCOMA If it not possible to get a wide margin when resecting a sarcoma what might you do?

Answer 245

Give adjuvant radiotherapy

Question 246

PHARMACOLOGY Name 2 NSAIDs

Answer 246

1. Ibuprofen | 2. Naproxen

Question 247

PHARMACOLOGY Give 3 side effects of NSAIDs

Answer 247

1. Peptic ulcer disease 2. Renal failure 3. Increased risk of MI and CV disease

Question 248

PHARMACOLOGY What can you do to reduce the risk of gastric ulcers and bleeding in someone taking NSAIDs?

Answer 248

1. Co-prescribe PPI | 2. Prescribe low doses and short courses

Question 249

PHARMACOLOGY Give 5 potential side effects of steroids

Answer 249

1. Diabetes 2. Muscle wasting 3. Osteoporosis 4. Fat redistribution 5. Skin atrophy 6. Hypertension 7. Acne 8. Infection risk

Question 250

PHARMACOLOGY How do DMARDs work?

Answer 250

Non-specific inhibition of inflammatory cytokines cascade = reduces joint pain, stiffness and swelling

Question 251

PHARMACOLOGY Give an example of a DMARD

Answer 251

Methotrexate = gold standard Hydroxychloroquine Sulfasalazine

Question 252

PHARMACOLOGY How often should methotrexate be taken?

Answer 252

Once weekly

Question 253

PHARMACOLOGY Give 3 potential side effects of methotrexate

Answer 253

1. Bone marrow suppression 2. Abnormal liver enzymes 3. Nausea 4. Diarrhoea 5. Teratogenic

Question 254

PHARMACOLOGY What can be co-prescribed with methotrexate to reduce the risk of side effects?

Answer 254

Folic acid

Question 255

PHARMACOLOGY What are cytokines?

Answer 255

Short acting hormones

Question 256

PHARMACOLOGY Name a TNF blocker

Answer 256

InfliximabAdalimumab

Question 257

PHARMACOLOGY Name a monoclonal antibody that binds to CD20 on B cells

Answer 257

Rituximab - binds to CD 20 --> B cell depletion

Question 258

PHARMACOLOGY Describe the mechanism of action of infliximab

Answer 258

Inhibits T cell activation

Question 259

PHARMACOLOGY How does alendronate work?

Answer 259

Reduces bone turnover by inhibiting osteoclast mediated bone resorption

Question 260

PHARMACOLOGY What class of drug is alendronate?

Answer 260

Bisphosphonate

Question 261

PHARMACOLOGY Name 2 drugs that act on the HMGcoA pathway

Answer 261

1. Bisphosphonates - alendronate | 2. Statins - simvistatin

Question 262

OSTEOARTHRITIS what are the signs of osteoarthritis?

Answer 262

● Deformity and bony enlargement of the joints ● Limited joint movement ● Muscle wasting of surrounding muscle groups ● Crepitus (grafting) due to disruption of normally smooth articulating surfaces of joints ● May be joint effusion ● Heberden’s nodes are bony swellings at DIPJs ● Bouchard’s nodes occur at proximal interphalangeal joints

Question 263

OSTEOARTHRITIS what is the epidemiology of osteoarthritis?

Answer 263

● Most common form of arthritis & most common condition affecting synovial joint ● Prevalence increases with age ● Most people over 60 have some radiological evidence of it – only a fraction have symptoms ● Women > men ● Familial tendency to develop nodal and generalised OA

Question 264

OSTEOARTHRITIS what are the investigations for osteoarthritis?

Answer 264

● FBC and ESR normal ● Rheumatoid factor is negative but positive low titre tests may occur incidentally in elderly ● XRs abnormal in advanced disease

Question 265

RHEUMATOID ARTHRITIS what are the complications of rheumatoid arthritis?

Answer 265

Cervical spinal cord compression- weakness and loss of sensation Lung involvement- interstitial lung disease, fibrosis.

Question 266

SEPTIC ARTHRITIS what is the difference between the presentation of early and late septic arthritis

Answer 266

● Early infection presents with inflammation, discharge, joint effusion, loss of function and pain ● Late disease presents with pain or mechanical dysfunction

Question 267

GOUT what are the risk factors for gout?

Answer 267

Middle age overweight males. high purine diet, increased cell turnover

Question 268

GOUT what are the complications of gout?

Answer 268

Infection in the tophi | Destruction of the joint

Question 269

OSTEOMYELITIS what are the risk factors for osteomyelitis?

Answer 269

``` Previous osteomyelitis Penetrating injury IVDU Diabetes HIV Recent surgery Distant or local infection Sickle cell disease RACKD Children → upper resp tract or varicella infection ```

Question 270

OSTEOMYELITIS what is the pathophysiology of osteomyelitis?

Answer 270

● Pathogen has to get into bone – many routes o Direct inoculation of infection via trauma/surgery – easy o Contagious spread without skin breaking – infection of adjacent tissue spreading into bone, seen in elderly who have DM, chronic ulcers, vascular disease, joint replacements and prostheses o Haematogenous seeding – infection from skin spreading to bone

Question 271

ANKYLOSING SPONDYLITIS what are the risk factors for ankylosing spondylitis?

Answer 271

HLA-B27 | environment - klebsiella, salmonella, shigella

Question 272

ANKYLOSNG SPONDYLITIS what is ankylosing spondylitis?

Answer 272

● Chronic inflammatory disorder of the spine, ribs and sacroiliac joints ● Ankylosis is abnormal stiffening and immobility of a joint due to new bone formation

Question 273

PSORIATIC ARTHRITIS what is psoriatic arthritis?

Answer 273

Inflammatory arthritis associated with psoriasis | 1 in 5 patients with psoriasis have psoriatic arthritis

Question 274

ARTHRITIS what is arthritis mutilans?

Answer 274

Most severe form of psoriatic arthritis Occurs in phalanxes Osteolysis of bones around joints in digits → leads to progressive shortening Skin then folds as digit shortens → telescopic finger

Question 275

PSORIATIC ARTHRITIS what are the different types of psoriatic arthritis?

Answer 275

● Distal interphalangeal arthritis – most typical pattern of joint involvement – dactylitis is characteristic ● Mono- or oligoarthiritis ● Symmetrical seronegative polyarthritis – resembling RA ● Arthritis mutilans – a severe form with destruction of the small bones in the hands and feet ● Sacroiliitis – uni- or bilateral

Question 276

REACTIVE ARTHRITIS what is the clinical presentation of reactive arthritis?

Answer 276

Begin 1-4 weeks after onset of infection Asymmetrical oligoarthritis Painful, swollen, warm, red + stiff joints Dactylitis Classic triad → conjunctivitis, urethritis + arthritis (can’t see, can’t pee, can’t climb a tree)

Question 277

REACTIVE ARTHRITIS what treatment should be used if reactive arthritis relapses?

Answer 277

methotrexate or sulfasalazine

Question 278

REACTIVE ARTHRITIS what is the epidemiology of reactive arthritis?

Answer 278

● Males who are HLA-B27 positive have a 30-50 fold increased risk ● Women less commonly affected

Question 279

REACTIVE ARTHRITS what is the pathophysiology of reactive arthritis?

Answer 279

● Bacterial antigens or DNA have been found in the inflamed synovium of affected joints – suggests persistent antigenic material is driving the inflammatory response

Question 280

SLE what are the complications for SLE?

Answer 280

Cardiac, lung, kidney involvement. Widespread inflammation causing damage.

Question 281

FIBROMYALGIA what is the epidemiology of fibromyalgia?

Answer 281

women, poor socioeconomic status, 20-50 year old

Question 282

FIBROMYALGIA what is the the pathophysiology of fibromyalgia?

Answer 282

Unknown, possibly pain perception/hyper excitability of pain fibres

Question 283

FIBROMYALGIA what are the complications of fibromyalgia?

Answer 283

- can really affect quality of life - anxiety, depression, insomnia - opiate addiction

Question 284

FIBROMYALGIA what is fibromyalgia?

Answer 284

Also known as chronic persistent pain ● Widespread msk pain after other diseases have been excluded ● Symptoms present at least 3 months and other causes have been excluded ● Characterised by central (non-nociceptive) pain o Due to a central disturbance in pain processing o Biopsychosocial factors important ● Not easily diagnosed as there is no specific pathology

Question 285

RICKETS what is rickets?

Answer 285

Rickets: inadequate mineralization of the bone and epiphyseal cartilage in the growing skeleton of CHILDREN.

Question 286

SJOGRENS what is the difference between primary and secondary sjogren's syndrome?

Answer 286

- primary = syndrome on it's own | - secondary = associated with connective tissue disease e.g. RA, SLE

Question 287

SJOGRENS what are the complications of Sjogren's syndrome?

Answer 287

- eye infections- oral problems (dental cavities, candida infections) - vaginal problems (candidiasis, sexual dysfunction) RARE - pneumonia and bronchiectasis - non-hodgkin's - vasculitis - renal impairment - peripheral neuropathy

Question 288

GIANT CELL ARTERITIS which arteries are particularly affected by giant cell arteritis?

Answer 288

- aorta and vertebral arteries - Cerebral arteries affected in particular e.g. temporal artery - Opthalmic artery can also be affected potentially resulting in permanent ortemporary vision loss

Question 289

GIANT CELL ARTERITIS what is found on physical examination of giant cell arteritis?

Answer 289

temporal arteries may be tender on palpation and thickened. Pulses may be diminished.

Question 290

ANTIPHOSPHOLIPID SYNDROME what is antiphospholipid syndrome?

Answer 290

- Syndrome characterised by thrombosis (arterial or venous) and/or recurrentmiscarriages with positive blood tests for antiphospholipid antibodies (aPL) - hypercoagulable state

Question 291

ANTIPHOSPHOLIPID SYNDROME what is the epidemiology of antiphospholipid syndrome?

Answer 291

- 20-30% are associated with SLE- more common in females- more often primary disease

Question 292

ANTIPHOSPHOLIPID SYNDROME what are the risk factors for antiphospholipid syndrome?

Answer 292

- diabetes - hypertension - obesity - female - underlying autoimmune condition - smoking - oestrogen therapy

Question 293

ANTIPHOSPHOLIPID SYNDROME what is the clinical presentation of antiphospholipid syndrome?

Answer 293

- thrombosis - miscarriage - livedo reticularis - purple lace rash - ischaemic stroke, TIA, MI - DVT, budd-chiari syndrome - thrombocytopenia - valvular heart disease, migraines, epilepsy

Question 294

ANTIPHOSPHOLIPID SYNDROME what is the pathophysiology of antiphospholipid syndrome?

Answer 294

- Antiphospholipid antibodies (aPL) play a role in thrombosis by binding tophospholipid on the surface of cells such as endothelial cells, platelets andmonocytes - Once bound, this change alters the functioning of those cells leading tothrombosis and/or miscarriage - Antiphospholipid antibodies (aPL) cause CLOTs: * Coagulation defect * Livedo reticularis - lace-like purplish discolouration of skin * Obstetric issues i.e. miscarriage * Thrombocytopenia (low platelets)

Question 295

ANTIPHOSPHOLIPID SYNDROME what are the investigations for antiphospholipid syndrome?

Answer 295

Hx of thrombosis/ pregnancy complications + Antibody screen with raised: - anticardiolipin antibodies - lupus anticoagulant - anti-beta-2 glycoprotein I antibodies

Question 296

ANTIPHOSPHOLIPID SYNDROME what is the treatment for antiphospholipid syndrome?

Answer 296

- long term warfarin - Pregnant women on low molecular weight heparin (e.g. enoxaparin) + aspirin - lifestyle - smoking cessation, exercise, healthy diet

Question 297

ANTIPHOSPHOLIPID SYNDROME what are the complications of antiphospholipid syndrome?

Answer 297

- Venous thromboembolisms (e.g. DVT, pulmonary embolism) - Arterial thrombosis (stroke, MI, renal thrombosis) - Pregnancy complications (recurrent miscarriage, pre-eclampsia,…)

Question 298

GRANULOMATOSIS WITH POLYANGIITIS what are the complications of granulomatosis with polyangiitis?

Answer 298

Glomerulonephritis

Question 299

BONE CANCER what is the most common primary bone malignancy in children?

Answer 299

osteosarcoma

Question 300

SARCOMA what condition is osteosarcoma associated with?

Answer 300

Paget's disease

Question 301

SARCOMA what is the appearance of osteosarcoma on x-rays?

Answer 301

bone destruction and formation, | soft tissue calcification produces a sunburst appearance

Question 302

SARCOMA what is the clinical presentation of ewing's sarcoma?

Answer 302

● Presents with mass/swelling, most commonly in long bones of the o Arms, legs, pelvis, chest o Occasionally skull and flat bones of the trunk ● Painful swelling, redness in surrounding area, malaise, anorexia, weight loss, fever, paralysis and/or incontinence if affecting the spine, numbness in affected limb

Question 303

SARCOMA what is the epidemiology of Ewing's sarcoma?

Answer 303

● Very rare | ● Average age of onset 15

Question 304

SARCOMA where is Ewing's sarcoma commonly found?

Answer 304

Presents with mass/swelling, most commonly in long bones of the o Arms, legs, pelvis, chest o Occasionally skull and flat bones of the trunk

Question 305

SARCOMA where does chrondosarcoma commonly present?

Answer 305

Common sites are pelvis, femur, humerus, scapula and ribs

Question 306

SARCOMA what is the clinical presentation of chrondrosarcoma?

Answer 306

Associated with dull, deep pain and affected area is swollen and tender

Question 307

SARCOMA which is the most common sarcoma in adults?

Answer 307

chondrosarcoma

Question 308

BONE CANCER which types of malignancy cause bone pain?

Answer 308

- multiple myeloma - lymphoma - primary bone tumours - metastases - secondary bone tumour

Question 309

BONE CANCER other than bone pain, what other symptoms can indicate bone tumours?

Answer 309

- Mobility issues → unexplained limp, joint stiffness, reduced ROM - Inflammation + tenderness over bone - Systemic symptoms

Question 310

ANTIPHOSPHOLIPID SYNDROME what is the prophylactic treatment for antiphospholipid syndrome?

Answer 310

aspirin or clopidogrel for people with aPL

Question 311

SYSTEMIC SCLEROSIS what is the epidemiology of scleroderma?

Answer 311

- more common in females - peak incidence = 30-50yrs - rare in children

Question 312

SYSTEMIC SCLEROSIS what are the risk factors for scleroderma?

Answer 312

- exposure to vinyl chloride, silica dust, rapeseed oil, trichloroethylene - bleomycin - genetic

Question 313

POLYMYOSITIS what is polymyositis?

Answer 313

a rare muscle disorder of unknown aetiology in which there is inflammation and necrosis of skeletal muscle fibres

Question 314

DERMATOMYOSITIS what is dermatomyositis?

Answer 314

polymyositis with skin involvement

Question 315

what is the epidemiology of polymyositis/dermatomyositis?

Answer 315

- Very rare - Both affect adults and children - More common in FEMALES than males

Question 316

what is the clinical presentation of polymyositis?

Answer 316

- symmetrical progressive muscle weakness and wasting - affects proximal muscles of shoulder and pelvic girdle - difficulty squatting, going upstairs, rising from chair and raising hands above head - involvement of pharyngeal, laryngeal and respiratory muscles = dysphagia, dysphonia and respiratory failure - pain and tenderness = uncommon

Question 317

what is the clinical presentation of dermatomyositis?

Answer 317

- heliotrope (purple) discolouration of eyelids - scaly erythematous plaques over knuckles (Gotton's papules) - arthralgia, dysphagia and raynauds

Question 318

what are the investigations for polymyositis/dermatomyositis?

Answer 318

Muscle Biopsy Bloods - serum creatine kinase, aminotransferases, lactate dehydrogenase (LDH) and aldolase all raised Immunology ANA, Anti jo1, anti mi2

Question 319

what is the treatment for polymyositis/dermatomyositis?

Answer 319

- bed rest + exercise plan - oral prednisolone - steroid sparing immunosuppressive - azathioprine, methotrexate, ciclosporin - hydroxychloroquine for skin disease

Question 320

OSTEOPOROSIS what factors are used in the FRAX score calculation?

Answer 320

- age - sex - height and weight - previous fractures - smoking - parent fractured hip (FHx) - steroid (glucocorticoid use) - RA - secondary osteoporosis - alcohol consumption (>3 units) - femoral neck bone mineral density

Question 321

RHEUMATOID ARTHRITIS what is the diagnostic criteria for RA?

Answer 321

RF RISES - >6 weeks and >4 of following: - RF positive - Finger/hand/wrist involvement - Rheumatoid nodules present - Involvement of >3 joints - Stiffness in morning >1 hr - Erosions on x-ray - Symmetrical involvement

Question 322

RAYNAUDS what is the treatment for raynauds phenomenon?

Answer 322

Lifestyle - protect the hands, stop smoking | Medications - CCB

Question 323

SYSTEMIC SCLEROSIS what is limited scleroderma?

Answer 323

- skin involvement limited to hands, face, feet and forearms - characteristic ‘beak’-like nose and small mouth - Microstomia - small mouth

Question 324

SYSTEMIC SCLEROSIS what is diffuse scleroderma?

Answer 324

skin changes develop more rapidly and are more widespread Raynaud’s phenomenon coincident with skin involvement GI, Renal, Lung involvement

Question 325

PAGETS DISEASE what is paget's disease?

Answer 325

localized disorder of bone remodelling ↑ osteoclastic bone resorption followed by ↑ formation of weaker bone Leads to structurally disorganized mosaic of bone (woven bone)

Question 326

PAGETS DISEASE what is the pathophysiology of paget's disease?

Answer 326

↑ osteoclastic bone resorption followed by ↑ formation of weaker bone Leads to structurally disorganized mosaic of bone (woven bone)

Question 327

PAGETS DISEASE what is the epidemiology of paget's disease?

Answer 327

incidence ↑ with age, rare under 40 y.o - affects up to 10% of individuals by the age of 90

Question 328

PAGETS DISEASE what are the clinical features of paget's disease?

Answer 328

can be asymptomatic SYMPTOMS - bone pain (femur/pelvis, skull) - facial pain (if skull disease with CN V involvement) - hearing loss (if skull disease with CN VIII involvement) SIGNS - bony deformities (skull bossing, bone bowing, prognathism) - pathological fracture - reduced visual acuity (if CN II involvement) - local temperature rise (due to increased metabolic activity)

Question 329

PAGETS DISEASE what are the investigations for paget's disease?

Answer 329

plain film x-ray radionucleotide bone scan LFTs = raised ALP bone profile = calcium normal vitamin D level = normal to consider - urinalysis - bone biopsy

Question 330

PAGETS DISEASE what is the management for paget's disease?

Answer 330

ASYMPTOMATIC - observation SYMPTOMATIC/HIGH RISK - 1st line = bisphosphonates (alendronic acid or zolendronic acid) - 2nd line = calcitonin - supportive measures = education, analgesia, orthoses, walking aids SEVERE DISEASE - surgery

Question 331

OSTEOMALACIA what is osteomalacia?

Answer 331

Defective mineralization of newly formed bone matrix or osteoid in adults, due to inadequate phosphate or calcium, or due to ↑ bone resorption (hyperPTH)

Question 332

OSTEOMALACIA what are the causes of osteomalacia?

Answer 332

malnutrition (most common) vitamin D deficiency drug induced defective 1-alpha hydroxylation Liver disease

Question 333

OSTEOMALACIA what are the risk factors?

Answer 333

- limited exposure to sunlight - dark skin - dietary vitamin D deficiency (fish, cheese, eggs) - CKD - liver dysfunction - malabsorption (IBD) - anticonvulsant use (phenytoin, carbamazepine + phenobarbital use)

Question 334

OSTEOMALACIA what is the clincial presentation of osteomalacia?

Answer 334

SYMPTOMS - generalised bone pain (rib, hip, pelvis, thigh and foot pain) - proximal muscle weakness - difficulty walking upstairs - fracture (secondary to mild trauma) SIGNS - waddling gait - signs of hypocalcaemia e.g. Chvostek sign - skeletal deformities

Question 335

RICKETS what is the clincial presentation of rickets?

Answer 335

leg-bowing and knock knees - tender swollen joints - growth retardation - bone and joint pain dental deformities – delayed formation of teeth, enamel hypoplasia - enlargement of end of ribs (‘rachitic rosary’)

Question 336

OSTEOMALACIA what are the investigations for Osteomalacia / rickets?

Answer 336

- serum calcium + phosphate - serum 25-hydroxyvitamin D - PTH level - serum ALP - renal and liver function to consider - plain x-rays (pseudofractures, osteopenia, coarsened trabeculae) - DEXA scan - iliac bone biopsy with double tetracycline labelling

Question 337

OSTEOMALACIA what is the management for osteomalacia/rickets?

Answer 337

depends on vitamin D levels VITAMIN D DEFICIENCY - loading regimen followed by maintenance dose of vitamin D - increased oral calcium intake VITAMIN D INSUFFICIENCY - only treat if pt has concomitant risk factors - same as above ADEQUATE VITAMIN D - vitamin D supplementation

Question 338

POLYMYALGIA RHEUMATICA what is it?

Answer 338

systemic inflammatory disease characterised by shoulder and hip girdle pain

Question 339

POLYMYALGIA RHEUMATICA what are the clinical features?

Answer 339

- bilateral shoulder +/- pelvic girdle pain for >2 weeks - stiffness lasting >45 mins after walking/resting - systemic symptoms (low-grade fever, weight loss, fatigue, depression) - bilateral pitting oedema - carpal tunnel syndrome

Question 340

POLYMYALGIA RHEUMATICA what are the investigations?

Answer 340

bloods - ESR +/- CRP - FBC, U&Es, LFT, calcium, TFTs, CK, RF

Question 341

POLYMYALGIA RHEUMATICA what is the management?

Answer 341

1st line - steroids (15mg prednisolone), should be reduced by 2.5mg every 3 weeks - bone protection (bisphosphonates) 2nd line - specialist referral - relapses may require increasing doses of steroids

Question 342

POLYMYALGIA RHEUMATICA what most commonly confirms diagnosis?

Answer 342

improvement of symptoms when steroids are started

Question 343

POLYMYALGIA RHEUMATICA what other condition is it commonly associated with?

Answer 343

giant cell arteritis (40-60% of patients with GCA have PMR)

Question 344

BURSITIS what is it?

Answer 344

is the inflammation of the synovium-lined, sac-like structures (bursa ) found throughout the body, usually between bones, muscles, tendons or ligaments

Question 345

BURSITIS what are the most common locations?

Answer 345

Prepatellar bursitis Infrapatellar bursitis Anserine bursitis Olecranon bursitis Trochanteric bursitis Subacromial bursitis Retrocalcaneal bursitis

Question 346

BURSITIS what are the risk factors?

Answer 346

- occupation causing repeated mechanical stress - autoimmune conditions (RA, psoriatic arthritis) - gout/pseudogout - abnormal gait

Question 347

BURSITIS what are the clinical features?

Answer 347

SYMPTOMS - pain - reduced range of movement - swelling SIGNS - tenderness on palpation - altered gait - erythema

Question 348

BURSITIS what are the investigations?

Answer 348

- clinical diagnosis investigations to rule out other causes - bloods - FBC, CRP - fluid aspiration - x-ray - MRI

Question 349

BURSITIS what is the management?

Answer 349

1st line - conservative = rest, ice, compression - analgesia = paracetamol, ibuprofen 2nd line - corticosteroid injection 3rd line - bursectomy

Question 350

COMPARTMENT SYNDROME what is it?

Answer 350

increased interstitial pressure within a closed osteofascial compartment compromises blood flow leading to tissue necrosis

Question 351

COMPARTMENT SYNDROME what are the most common causes?

Answer 351

- fractures - soft tissue injuries - reperfusion injury - penetrating trauma

Question 352

COMPARTMENT SYNDROME what is a compartment?

Answer 352

groupings of muscles, nerves and blood vessels in the upper and lower limbs, which are separated by a fascial layer

Question 353

COMPARTMENT SYNDROME what is acute compartment syndrome?

Answer 353

surgical emergency with sudden onset compression, often as a result of traumatic injury, requires prompt diagnosis and management to prevent muscle ischaemia and rhabdomyolysis

Question 354

COMPARTMENT SYNDROME what is chronic compartment syndrome?

Answer 354

typically affects young athletes and is caused by strenuous exercise, with symptomatic relief upon ceasing the activity

Question 355

COMPARTMENT SYNDROME what are the clinical features?

Answer 355

6Ps of acute ischaemia - pain - pallor - perishingly cold - pulseless - parasthesia - paralysis - muscle swelling

Question 356

COMPARTMENT SYNDROME what are the investigations?

Answer 356

- intracompartmental pressure monitoring - serum CK + urinary myoglobin - U&Es - USS with doppler

Question 357

COMPARTMENT SYNDROME what is the management of acute compartment syndrome?

Answer 357

- remove all constrictive bandages/casts - elevate limb to hear level - analgesia - fasciotomy (within 6hrs) - amputation if delayed presentation or evidence of necrosis

Question 358

COMPARTMENT SYNDROME what is the management of chronic compartment syndrome?

Answer 358

- massage + stretching - physio - orthotics - anti-inflammatories (NSAIDS) - surgical fasciotomy

Question 359

COMPARTMENT SYNDROME what are the complications?

Answer 359

- acute limb ischaemia - infection - renal failure from rhabdomyolysis

Question 360

PATHOLOGICAL FRACTURE what is it?

Answer 360

abnormally weakened bone breaks from a force that would typically be insufficient to cause a fracture

Question 361

PATHOLOGICAL FRACTURE what are the causes?

Answer 361

GLOBAL - osteoporosis - CKD-metabolic bone disease - hyperparathyroidism FOCAL - metastatic cancer - infection - primary bone tumours - bone biopsies

Question 362

PATHOLOGICAL FRACTURE what scoring system can be used?

Answer 362

Mirels scoring system - used to guide the need for prophylactic fixation

Question 363

PATHOLOGICAL FRACTURE what are the risk factors?

Answer 363

- increasing age - primary bone disease (osteoporosis, malignancy, pagets) - chronic steroid use - pervious radiation therapy to a bone

Question 364

PATHOLOGICAL FRACTURE what are the clinical features?

Answer 364

- pain without clear causes - pain disproportionate to injury - increased pain with weight bearing - localised tenderness - localised swelling - abnormal movement - bone deformity

Question 365

PATHOLOGICAL FRACTURE what are the investigations?

Answer 365

- x-ray - MRI

Question 366

PATHOLOGICAL FRACTURE what is the management?

Answer 366

- orthopaedic stablisation - treatment for osteoporosis - radiation therapy for malignancy - chemotherapy/hormonal therapy

Question 367

LOWER LIMB FRACTURES what are the different types of femur fracture?

Answer 367

- shaft - distal are typically high energy injuries e.g. motorbike crash

Question 368

LOWER LIMB FRACTURES what are the key features of a patella fracture?

Answer 368

- inability to straight leg raise - tenderness of the kneecap

Question 369

LOWER LIMB FRACTURES what are the most common mechanisms of injury for patella fractures?

Answer 369

- direct blow to knee e.g. dashboard injury - rapid contraction of quadriceps against flexed knee

Question 370

LOWER LIMB FRACTURES what are the different types of tibial fracture?

Answer 370

- segond fracture - tibial plateau fracture - tibial shaft fracture - toddler's fracture - tibial plafond fracture

Question 371

LOWER LIMB FRACTURES what is a segond fracture of the tibia?

Answer 371

- small avulsion fracture of lateral tibial plateau - caused by internal rotation + varus stress - typically caused by sporting injuries - associated with ACL injury

Question 372

LOWER LIMB FRACTURE what is the mechanism of injury for Segond fracture of tibia?

Answer 372

internal rotation + varus stress (sporting injuries)

Question 373

LOWER LIMB FRACTURE what are tibial plateau fractures?

Answer 373

- periarticular injuries of proximal tibia - divided into 6 types based on Schatzker classification

Question 374

LOWER LIMB FRACTURES what is the mechanism of injury for tibial plateau injuries?

Answer 374

varus or valgus injuries causing medial or lateral involvement respectively

Question 375

LOWER LIMB FRACTURE what are common features of tibial shaft fractures?

Answer 375

- open fractures and compartment syndrome - due to lack of fascial compartment + subcutaneous tissues of shin

Question 376

LOWER LIMB FRACTURE what is the mechanism of injury for tibial shaft fractures?

Answer 376

direct blows, falls or indirectly (through twisting motions)

Question 377

LOWER LIMB FRACTURE what is a toddlers fracture?

Answer 377

- spiral fracture without injury to fibula - stable fracture without displacement - requires no intervention other than monitoring

Question 378

LOWER LIMB FRACTURE what is a tibial plafond fracture?

Answer 378

fracture of distal tibia often presents with severe ankle pain + inability to weight bear

Question 379

LOWER LIMB FRACTURE what is the mechanism of injury for a tibial plafond fracture?

Answer 379

high energy axial load (e.g. fall from height or car crash) talus is driven into plafond causing #

Question 380

LOWER LIMB FRACTURES what are the different types of fibula fractures?

Answer 380

- maisonneuve fracture - lateral malleolar fracture

Question 381

LOWER LIMB FRACTURES what is a maisonneuve fracture of the fibula?

Answer 381

- spiral fracture of proximal fibula associated with ankle instability - caused by pronation-external rotation mechanism e.g. stepping off curb awkwardly

Question 382

LOWER LIMB FRACTURE what is the mechanism of injury for a maisonneuve fracture?

Answer 382

- caused by pronation-external rotation mechanism e.g. stepping off curb awkwardly

Question 383

LOWER LIMB FRACTURE how are lateral malleolar fractures of the fibula typically sustained?

Answer 383

rolling the ankle

Question 384

LOWER LIMB FRACTURE what is the classification system for lateral malleolar fractures?

Answer 384

Weber classification type A = # distal to syndesmosis type B = # at level of syndesmosis type C = # proximal to syndesmosis

Question 385

LOWER LIMB FRACTURES what are the different types of foot fractures?

Answer 385

- jones fracture - lisfranc injury - calcaneal fracture - talar neck fracture

Question 386

LOWER LIMB FRACTURES what is a jones fracture of the foot?

Answer 386

- fracture of 5th metatarsal base - can be caused by repetitive strain in athletes

Question 387

LOWER LIMB FRACTURE what is the mechanism of injury for Jone's fracture?

Answer 387

- inversion injury to foot - repetitive stress or overuse (e.g. in athletes)

Question 388

LOWER LIMB FRACTURES what is a lisfranc injury of the foot?

Answer 388

-tarsometatarsal fracture + dislocation where 1st + 2nd metatarsals articulate with tarsals - caused by falling from height

Question 389

LOWER LIMB FRACTURE what is the mechanism of injury for a Lisfranc injury?

Answer 389

axial load applied to hyperplantarflexed foot (e.g. falling from a height)

Question 390

LOWER LIMB FRACTURE what is the most commonly fractured tarsal in the foot?

Answer 390

calcaneus

Question 391

LOWER LIMB FRACTURE what is the mechanism of injury for a calcaneal fracture?

Answer 391

traumatic axial loading (e.g. falling from a height) to heel bone

Question 392

LOWER LIMB FRACTURE what is the mechanism of injury for a talar neck fracture?

Answer 392

forced dorsiflexion with axial loading (carries high risk of avascular necrosis)

Question 393

LOWER LIMB FRACTURES what are the clinical features of a hip fracture?

Answer 393

- inability to weight bear - shortened + externally rotated leg

Question 394

LOWER LIMB FRACTURES what is a complication of hip fractures?

Answer 394

- avascular necrosis (most commonly occurring with neck of femur fractures)

Question 395

LOWER LIMB SOFT TISSUE INJURIES what are the different types?

Answer 395

- greater trochanteric pain syndrome - ACL tear - meniscal tear - osgood-schlatter syndrome - achilles tendinopathy - achilles tendon rupture - plantar fasciitis

Question 396

LOWER LIMB SOFT TISSUE INJURIES what is the clinical presentation of greater trochanteric pain syndrome?

Answer 396

- gradual onset - lateral hip + buttock pain - worse with activity, prolonged standing or sitting - tenderness over greater trochanter - trendelenberg gait

Question 397

LOWER LIMB SOFT TISSUE INJURIES what is the mechanism of injury for greater trochanteric pain syndrome?

Answer 397

- repetitive movement

Question 398

LOWER LIMB SOFT TISSUE INJURIES what is the clinical presentation of ACL tear?

Answer 398

- popping sound - pain, swelling, instability + reduced range of movement - tenderness on palpation - positive drawer + lachnman tests

Question 399

LOWER LIMB SOFT TISSUE INJURIES what is the mechanism of injury for ACL and meniscal tears?

Answer 399

twisting injury - sudden change in direction or deceleration

Question 400

LOWER LIMB SOFT TISSUE INJURIES what is the clinical presentation of meniscal tear?

Answer 400

- pain - swelling - reduced range of movement - locking + instability - localised joint line tenderness - McMurrays test positive

Question 401

LOWER LIMB SOFT TISSUE INJURIES what is the clinical presentation of achilles tendinopathy?

Answer 401

- gradual onset - heel pain - worse with activity - swelling + stiffness - tenderness on achilles tendon - may have nodularity

Question 402

LOWER LIMB SOFT TISSUE INJURIES what are the clinical features of achilles tendon rupture?

Answer 402

- sudden onset - pain/snapping sensation - positive Simmonds test - plantarflexion weakness

Question 403

LOWER LIMB SOFT TISSUE INJURIES what are the clinical features of planar fasciitis?

Answer 403

- inferior heel pain on pressure - tenderness on palpation

Question 404

LOWER LIMB SOFT TISSUE INJURIES what are the common investigations?

Answer 404

- x-ray - USS - MRI - arthroscopy (gold standard for meniscal + cruciate ligament ruptures)

Question 405

LOWER LIMB SOFT TISSUE INJURIES what is the management for lower limb soft tissue injuries?

Answer 405

1st line - RICE (rest, ice, compression, elevation) - analgesia (paracetamol, ibuprofen) - physio 2nd line - surgery

Question 406

UPPER LIMB SOFT TISSUE INJURIES what are the different types?

Answer 406

- frozen shoulder - supraspinatus tendinopathy - rotator cuff tear - medial epicondylitis (golfers elbow) - lateral epicondylitis (tennis elbow) - de quervains tenosynovitis - dupuytrens contracture

Question 407

UPPER LIMB SOFT TISSUE INJURIES what are the clinical features of frozen shoulder?

Answer 407

- painful phase followed by stiffness - stiffness on active + passive movement, particularly external rotation - subsequent thawing to resolution - total duration is 1-3 years

Question 408

UPPER LIMB SOFT TISSUE INJURIES what is the mechanism of injury for frozen shoulder?

Answer 408

- primary - secondary to trauma, surgery or reduced mobilisation

Question 409

UPPER LIMB SOFT TISSUE INJURIES what are the clinical features of supraspinatus tendinopathy?

Answer 409

- positive empty can test - painful arc on shoulder abduction between 60-120 degrees

Question 410

UPPER LIMB SOFT TISSUE INJURIES what is the mechanism of injury for supraspinatus tendinopathy?

Answer 410

- overhead activities compounded by narrowing joint space

Question 411

UPPER LIMB SOFT TISSUE INJURIES what muscles make up the rotator cuff?

Answer 411

- supraspinatus - infraspinatus - teres minor - subscapularis

Question 412

UPPER LIMB SOFT TISSUE INJURIES what are the clinical features of rotator cuff tear?

Answer 412

- shoulder pain + weakness - special tests = gerbers lift off, neers and hawkins

Question 413

UPPER LIMB SOFT TISSUE INJURIES what is the mechanism of injury for rotator cuff tears?

Answer 413

- trauma - repetitive strain - associated with overhead activities - chronic degeneration

Question 414

UPPER LIMB SOFT TISSUE INJURIES what are the clinical features of medial epicondylitis?

Answer 414

- pain at medial epicondyle - radiates down forearm - pain on wrist flexion + pronation - paraesthesia in ulnar nerve distribution

Question 415

UPPER LIMB SOFT TISSUE INJURIES what is the mechanism of injury for medial epicondylitis?

Answer 415

repetitive use - golfers elbow

Question 416

UPPER LIMB SOFT TISSUE INJURIES what is the clinical presentation of lateral epicondylitis?

Answer 416

pain on resisted wrist extension

Question 417

UPPER LIMB SOFT TISSUE INJURIES what is the mechanism of injury for lateral epicondylitis?

Answer 417

repetitive use - tennis elbow

Question 418

UPPER LIMB SOFT TISSUE INJURIES what is the clinical presentation of de quervains tenosynovitis?

Answer 418

- radial wrist pain over radial styoid process - pain on resisted thumb abduction - finkelsteins test positive

Question 419

UPPER LIMB SOFT TISSUE INJURIES what is the mechanism of injury for de quervains tenosynovitis?

Answer 419

repetitive strain injury

Question 420

UPPER LIMB SOFT TISSUE INJURIES what are the clinical features of dupuytrens contracture?

Answer 420

- hand palmar nodules - fixed finger flexion - most commonly ring finger

Question 421

UPPER LIMB SOFT TISSUE INJURIES what are the risk factors for dupuytrens contracture?

Answer 421

- increasing age - family history - male - diabetes - use of vibrating tools

Question 422

UPPER LIMB SOFT TISSUE INJURIES what are the common investigations?

Answer 422

- x-rays - USS - MRI

Question 423

UPPER LIMB SOFT TISSUE INJURIES what is the management of upper limb soft tissue injuries?

Answer 423

1st line - RICE (rest, ice, compression, elevation) - analgesia (paracetamol, ibuprofen) - physio 2nd line - surgery

Question 424

LYME DISEASE what is it?

Answer 424

a bacterial infection caused by Borrelia burgdorferi that are transmitted to humans following a bite from an infected tick

Question 425

LYME DISEASE what is it caused by?

Answer 425

infection by borrelia burgdorferi from tick bites

Question 426

LYME DISEASE what are the stages of infections?

Answer 426

1. early localised disease (<30days) - red ring-expanding 'bulls-eye' rash (erythema migrans) 2. early disseminated disease (>30 days) - multiple erythema migrans rashes - lymphadenopathy - myalgia - heart block - cranial nerve palsy 3. late disease (several years after) - acrodermatitis chronic atrophicans + arthritis

Question 427

LYME DISEASE what are the clinical features of early disease?

Answer 427

erythema migrans rash (bulls-eye)

Question 428

LYME DISEASE what are the clinical features of early disseminated disease?

Answer 428

- multiple bulls eye rashes - weakness of facial muscles (CN VII palsy)

Question 429

LYME DISEASE what are the clinical features of late disease?

Answer 429

- arthritis (oligoarthritis with synovitis) - unilateral discolouration of extensor surfaces (acrodermatitis chronica atrophicans)

Question 430

LYME DISEASE what are the investigations?

Answer 430

- clinical diagnosis if presenting with erythema migrans (bulls eye rash) without rash - ELISA antibodies to borrelia burgdorferi - immunoblot test

Question 431

LYME DISEASE what is the management?

Answer 431

1st line - doxycycline BD for 21 days - if unsuitable, use amoxicillin instead 2nd line - if not managed by 1st antibiotics a second course of antibiotics is considered

Question 432

LYME DISEASE what are the complications?

Answer 432

- Jarisch-Herxheimer reaction - neurological (facial nerve palsy, meningitis, peripheral neuropathy) - 1st degree heart block - myocarditis - lyme arthritis - acrodermatitis chronica atrophicans

Question 433

BACK PAIN what are the causes of mechanical back pain?

Answer 433

- muscle or ligament sprain - facet joint dysfunction - sacroiliac joint dysfunction - herniated disc - spondylolithesis - scoliosis - degenerative changes (arthritis)

Question 434

BACK PAIN what are the risk factors for mechanical back pain?

Answer 434

- physical work involving heavy lifting, bending or twisting - sedentary lifestyle with lack of physical activity - obesity - smoking - depression/anxiety - stressful life events (including physical or emotional trauma)

Question 435

BACK PAIN what are the red flag causes of back pain?

Answer 435

- spinal fracture (major trauma) - cauda equina (saddle anaesthesia, urinary retention, incontinence etc) - spinal stenosis (intermittent neurogenic claudication) - ankylosing spondylitis (gradual onset, morning stiffness) - spinal infection (fever or IVDU)

Question 436

BACK PAIN what are the clinical features of mechanical back pain?

Answer 436

- dull or sharp pain in area between lower ribs + buttocks - restricted movement - sleep disturbance - distress + low mood - stiffness - muscle spasms

Question 437

BACK PAIN what are the investigations for mechanical back pain?

Answer 437

can be diagnosed from history if suspicion of other pathology: - x-ray - MRI spine (for cauda equina) blood tests - inflammatory markers - blood cultures - HIV testing - HbA1c - myeloma screen (FBC, calcium, ESR, serum electrophoresis, serum-free light-chain assay + urine Bence-Jones protein) - vitamin D, bone profile + PTH

Question 438

BACK PAIN what is the management of mechanical back pain?

Answer 438

CONSERVATIVE - reassurance + patient education - regular exercise +/- physio MEDICAL - 1st line = NSAIDs (IBUPROFEN) +/- PPI - 2nd line = codeine +/- paracetamol - 3rd line = benzodiazepines (DIAZEPAM) if maximum 5 days for muscle spasm) do not use opioids or antidepressants for low back pain

Question 439

UPPER LIMB FRACTURES what is the typical mechanism of a Colle's fracture?

Answer 439

fall onto outstretched hands

Question 440

UPPER LIMB FRACTURES what are the features of a Colle's fracture?

Answer 440

- transverse fracture of radius - 1 inch proximal to radio-carpal joint - dorsal displacement + angulation

Question 441

UPPER LIMB FRACTURES how is the deformity described in a Colle's fracture?

Answer 441

dinner fork type deformity

Question 442

UPPER LIMB FRACTURES what is the mechanism of injury for a Smith's fracture?

Answer 442

falling backwards onto the palm of outstretched hand or falling with wrists flexed (reverse Colle's)

Question 443

UPPER LIMB FRACTURES what are the features of Smith's fracture?

Answer 443

volar angulation of distal radius fragment

Question 444

UPPER LIMB FRACTURES how is the deformity described in Smith's fracture?

Answer 444

garden spade deformity

Question 445

UPPER LIMB FRACTURES what is the mechanism of injury for Bennett's fracture?

Answer 445

- impact on flexed metacarpal, caused by fist fights

Question 446

UPPER LIMB FRACTURES what are the features of Bennett's fracture?

Answer 446

- intra-articular fracture at the base of the thumb metacarpal (triangle fragment at the base of metacarpal)

Question 447

UPPER LIMB FRACTURES how is the deformity described in Bennett's fracture

Answer 447

triangular fragment at base of metacarpal on x-ray

Question 448

UPPER LIMB FRACTURES what is the mechanism of injury for a Monteggia's fracture?

Answer 448

fall onto outstretched hand with forced pronation

Question 449

UPPER LIMB FRACTURES what are the features of a Monteggia's fracture?

Answer 449

- dislocation of proximal radioulnar joint in association with ulnar fracture

Question 450

UPPER LIMB FRACTURES what is the mechanism of injury for Galeazzi fractures?

Answer 450

fall onto the hand with rotational force superimposed

Question 451

UPPER LIMB FRACTURES what are the features of a Galeazzi fracture?

Answer 451

- radial shaft fracture with dislocation of distal radioulnar joint - bruising over lower forearm

Question 452

UPPER LIMB FRACTURES what is a barton's fracture?

Answer 452

distal radius fracture (Colles/Smiths) with associated radiocarpal dislocation

Question 453

UPPER LIMB FRACTURES what is the mechanism of injury for a Barton's fracture?

Answer 453

fall onto extended and pronated wrist

Question 454

UPPER LIMB FRACTURES what is the most common carpal fracture?

Answer 454

scaphoid fractures

Question 455

UPPER LIMB FRACTURES what is the mechanism of injury for a scaphoid fracture?

Answer 455

fall onto outstretched hand

Question 456

UPPER LIMB FRACTURES what are the clinical features of a scaphoid fracture?

Answer 456

swelling + tenderness in anatomical snuffbox pain on wrist movements + longitudinal compression of thumb

Question 457

UPPER LIMB FRACTURES what imaging is required for a scaphoid fracture?

Answer 457

ulnar deviation AP x-ray

Question 458

UPPER LIMB FRACTURES what is the mechanism of injury for a radial head fracture?

Answer 458

fall onto outstretched hand

Question 459

UPPER LIMB FRACTURES what are the clinical features of a radial head fracture?

Answer 459

- tenderness at head of radius - impaired movement at elbow - sharp pain at lateral side of elbow at extremes of rotation (supination + pronation)

Question 460

VERTEBRAL DISC DEGENERATION what is it?

Answer 460

vertebral discs wear away leading to vertebral bones rubbing against each other

Question 461

VERTEBRAL DISC DEGENERATION what is the pathophysiology?

Answer 461

- drying out of the disc with age - tears in the outer portion of the disc due to daily activities + sports

Question 462

VERTEBRAL DISC DEGENERATION what are the clinical features?

Answer 462

- neck/lower back pain - pain extends to arms and hands - radiates to buttocks - worse when sitting or after bending, lifting or twisting - pain comes and goes - can cause weakness in leg muscles or foot drop

Question 463

VERTEBRAL DISC DEGENERATION what are the investigations?

Answer 463

- history and physical examination - x-ray - MRI or CT scan

Question 464

VERTEBRAL DISC DEGENERATION what is the management?

Answer 464

- physical therapy - NSAIDs or paracetamol - corticosteroid injections into disc space - surgery = artificial disc replacement, spinal fusion