MSK

Question 1

Amyloidosis - Management

Answer 1

FL: bortozemib, lenalinomide, dexamethasone (protease inhib, IMD, steroid)
HDM-ASCT is preffered in younger, more fit patients with less severe Dx

Question 2

Amyloidosis disease monitoring

Answer 2

Free light chain

or M-protein

Question 3

Amyloidosis Complications and Management

Answer 3

Nephrotic syndrome: loop diuretic, salt restriction ?human albumin
CKD: monitor function, dialysis if nec. Transplant only if low extra-renal amyloid or clonal remission
Hypertension: ACEi, ARB
CHF: loop diuretic

Question 4

Prognosis of amyloidosis

Answer 4

Untreated is progressive and fatal
Cardiac involvement bad sign
Avg. survival is now years but depends on organs affected

Question 5

Achilles tendinosis Define

Answer 5

Tendon degeneration (not inflammatory state) causing disruption of collagen fibres.

Question 6

Achilles tendinosis epi

Answer 6

200:100,000 annual incidence

Common amongst active people - most commonly middle aged and middle/long distance runners

Question 7

Aetiology/Risk factors for achilles tendinosis

Answer 7

Fluoroquinonlones
DM
Hyperlipidaemia

Question 8

Achilles tendinosis history

Answer 8

Aching (sometimes sharp) in heel made worse on activity
Stiffness in tendon
Mid point: pain 2-6cm proximal to insertion that limits activity
Insertional: pain and swelling at insertion on posterior calcaneus
- Can have both
Risk factors: DM, dyslipidaemia, fluoroquinolone use

Question 9

Achilles tendinosis examination

Answer 9

Examine both legs look for: redness, swelling, asymmetry
Palpate tendon assessing: tenderness, heat, crepitus, thickening, nodularity (is it distal or mid point)
Pain worsens with passive dorsiflexion

Question 10

achilles tendinonsis investigations

Answer 10

VISA-A questionnaire indicates severity
Clincal Dx so imaging not usually indicated
Arrange Ix for lipids/HbA1c if riak factors likely

Question 11

Achilles tendinosis management - primary care

Answer 11

Primary care:
Manage underlying cause (fluoroquinolones, DM, hypercholesterolaemia)
Self care (ice packs, paracetamol, rest, weight bear as tolerated)
Refer to physio if not improved after 7-10 days
NOT CORTICOSTEROIDS
If chronic or fails to respond arrange sports physician/ortho referral

Question 12

Achilles tendinosis management - secondary care

Answer 12

Secondary care:
Exercise programme (eccentric contraction based)
Extracorporeal shock wave therapy - acoustic waves may help diseased tissue - uncertain efficacy
Surgery: if chronic and unresponding, debridement and removal of diseased tendon

Question 13

Achilles tendinosis complications

Answer 13

rupture

irreversible degeneration

Question 14

Achilles tendinosis prognosis

Answer 14

Pain can take weeks-months to resolve

If adequate management not undertaken can go into degenerative tendinopathy which may be irreversible

Question 15

Achilles rupture epi

Answer 15

18:100,000 annual incidence

Mean age 37-44

Question 16

Achilles rupture aetilogy/RF

Answer 16

Activity! - weekend warriors
Age 30-50
Inflexible gastrocsoleus
Cavus foot
Chronic renal failure
DM

Question 17

Achilles rupture diagnosis

Answer 17

Sudden pain in back of leg +/- audible snap
Ache in calf, swelling, bruising, weakness
Difficulty weight bearing

Question 18

Achilles rupture examination

Answer 18

Simonds triad (examined prone with feet dangling off end of bed) - angle of declination (greater dorsiflexion in injured foot), palpation for break in tendon, calf squeeze test (injured will remain in neutral position)

Question 19

Achilles rupture investigations

Answer 19

In trauma: x-ray to exclude fracture

Can confirm Dx w/USS/MRI

Question 20

Achilles tendon rupture management

Answer 20

Arrange same day referral to orthopaedics
Initially: RICE
Can be operative or non-op
Non op: Generally comorbid/sedentary lifestyle. Possible increased risk of re-rupture. Lower complication rate
Op: quicker return to work

Non-op techniques involve serial casting/functional bracing
All operative approaches involve reapproximating torn ends

Rehab is key - strength and ROM

Question 21

achilles tendon rupture complications

Answer 21

Rerupture (v rare if surgically managed)
Wound healing Cx 5-10%
Sural nerve injury

Question 22

Prognosis achilles rupture

Answer 22

Usually full recovery - in some non athletes there is a risk of reduced ROM
Non operative re-rupture rate is up to 40% compared to 0.5% surgically

Question 23

Bunions definition

Answer 23

deformity which occurs when the great toe moves towards the second toe (and may sometimes overlie it). This causes a prominent first metatarsal head, sometimes associated with bursitis

Question 24

Bunions epidemiology

Answer 24

Exact prevalence unknown but is common in elderly

Question 25

Aetiology of bunions

Answer 25

exact cause unknown A/w narrow tight footwear Gout/RA Connective tissue Dx

Question 26

Symptoms of bunions

Answer 26

Pain Deformity (great toe towards second toe leaving prominent metatarsal head) ?bursitis

Question 27

Bunion Ix

Answer 27

clinical diagnosis

Question 28

Bunion management

Answer 28

C: low heeled, wide shoes, soft sole. If DM refer to foot protection M: simple analgesia (para/NSAID). Bunion pad/icepack ?podiatry referral for footwear advice/night splints/orthosis S: only indicated for pain. Refer if deformity worsening/painful or second toe involvement or difficulty finding shoes

Question 29

Complications of bunions

Answer 29

``` Pain, difficulty finding footwear OA of 1st MTP Deformity/dislocation of second toe Increased risk of fall in elderly Surgery: infection, stiffness, pain/tender ball of foot, recurrence, nerve damage ```

Question 30

Bunion prognosis

Answer 30

Only surgical Mx will prevent progression | Improves pain and alignment in 90%

Question 31

#Ankle types

Answer 31

ankle: #tibia, fibula, talus Metatarsal stress: repeated injury to MT bones Lisfranc: tarsometatarsal fracture dislocation. Traumatic (medial cuneiform and base of 2nd MT)

Question 32

#ankle epidemiology

Answer 32

A: most common # in 15-60 MTS: common in athletes Lisfranc: uncommon, M:F 4:1. RTA

Question 33

Aetiology/RF for #ankle

Answer 33

A: usually twisting mechanism MTS: overuse L: RTA

Question 34

Symptoms of #ankle

Answer 34

A: pain, deformity, swelling. ?inability to weight bear. Sudden occurence MTS: swelling/warmth, pain. Progressively worse w/activity Tender top of foot/lateral ankle and #site L: severe midfoot pain, inability to bear weight

Question 35

Examination of #ankle

Answer 35

A: swelling, deformity, ?inability to weight bear MTS: swelling, pain. Palpate for max tenderness (is it bony) L: medial plantar ecchymosis, midfoot swelling. Tender TMT. ?Dorsal subluxation of 2nd metatarsal on applying dorsal force

Question 36

Investigations #ankle

Answer 36

x-ray. AP, Lateral, oblique views of ankle/foot

Question 37

Management #ankle

Answer 37

A: reduce ASAP. Stable = boot w/unrestricted WB. Unstable: ORIF (6wk cast if unfit). think VTE proph for all # MTS: Shaft: supportive shoe and progressive WB. Prox segment: splint and non WB case r/v 7days and if normal x-ray allow WB L: non-op: 8 wk cast (only non-displaced OR unfit for surgery) Op: temp. pinning w/delayed ORIF (skip delay if >2mm instability)

Question 38

Complications #ankle

Answer 38

A: compartment syndrome (fasciotomy), dislocation (surgery) limited ROM (physio). Operative risks MTS: rare. can progress w/o Mx. Deformity, malunion L: Plantovalgus deformity if non-op or non-anatomic ORIF post-traumtic arthritis (if non-anatomically ORIF Mx by arthrodesis) Deep infection (debridemen)

Question 39

Prognosis #ankle

Answer 39

A: non-op: excellent (back to exercise 6-8wks) ORIF: WB 12w but can be 2y return to baseline. Poor prognosis in elderly (12% mortality at 65) MTS: excellent. WB within days/weeks full recovery expected L: variable ~70% full return to exercise. Risk of planovalgus deformity and chronic pain