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MSK and Rheum 🦴 Flashcards

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1
Q

Define Ankylosing Spondylitis:

A

Ankylosing spondylitis is an chronic inflammatory joint disease of the spine.

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2
Q

What are the risk factors of developing Ankylosing Spondylitis?

A
  • Genetic (+HLA-B27)
  • Male
  • Fhx
  • 20s
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3
Q

What are the symptoms Ankylosing Spondylitis?

A
  • back pain- early morning stiffness (better with activity)
  • Enthesitis (Achilles Tendonitis/ Plantar fasciitis)
  • Anterior-uveitis
  • Aortitis => aortic regurgitation
  • upper pulmonary fibrosis
  • IgA nephropathy
  • alternating buttock pain
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4
Q

What are the signs of Ankylosing Spondylitis?

A
  • restriced ROM in spine
  • modified Schober test ++
  • Dorsal thoracic kyphoss
  • reduced chest expansion
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5
Q

How is Ankylosing Spondylitis Investigated?

A
  • FBC, ESR, CRP
  • antibodies + HLA testing
  • 1st line X-ray ( bamboo spine)- MRI if normal
  • Pelvic X-ray = sacroiliitis
  • MRI of sacroiliac joints = GOLD STANDARD
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6
Q

What is the Treatment for Ankylosing Spondylitis?

A
  • exercise, Physiotherapy
  • 1st line NSAIDs and PPI
  • DMARDs
  • steroid injections
  • Biologics
    - 1st Anti TNF if NSAIDs not work
    - 2nd Anti-IL17
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7
Q

Define Spinal stenosis:

A

This is a narrowing of the spinal canal or neural foramina causing spinal compression.

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8
Q

What are the risk factors for developing Spinal stenosis?

A
  • age
  • congenital
  • trauma
  • OA/RA
  • tumour
  • pagets disease
  • surgical hx
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9
Q

What are the symptoms of Spinal Stenosis?

A
  • back pain/ discomfort
  • paraesthesia (better sx supine)
  • bilateral leg pain (better leaning forward/ walking up a hill)
  • lower extremity pain/ numbness
  • LEG PAIN worse than back pain
  • pain worse on activity
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10
Q

What are the investigations to be done for Spinal Stenosis?

A
  • physical exam
  • MRI/CT GOLD STANDARD
  • EMG- assess nerve function
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11
Q

What is the management of Spinal Stenosis?

A
  • analgesia
  • physio
  • weight management
  • lifestyle changes
  • surgical: laminectomy, laminoplasty, spinal fusion
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12
Q

What are the Red Flag symptoms of Back Pain?

A
  • new onset in age <=20 or >= 55
  • thoracic/ cervical pain
  • pain not relieved by rest
  • spinal tenderness
  • fevers, chills, weight loss
  • early morning stiffness > 30 minutes
  • lower limb neurology sx
  • trauma with b/g osteoporosis
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13
Q

What is the investigations for mechanical Back pain?

A
  • diagnosis of exclusion
  • doesn’t usually need scans
  • X-ray if pain >= 6 weeks
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14
Q

What is the treatment for mechanical Back pain?

A

avoid bed rest
* NSAIDS
* Self-limiting

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15
Q

Define Cauda Equina:

A

Medical emergency- compression of spinal nerves L4/ L5 or L5/ S1

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16
Q

What are the causes of Cauda Equina?

A
  • neoplasms
  • Abscess
  • iatrogenic
  • tumours
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17
Q

What are the symptoms of Cauda Equina?

A
  • lower back pain
  • alternating/ bilateral radicular pain
  • saddle anaesthesia
  • bladder/ bowel incontinence
  • laxity of anal sphincter
  • erectile dysfunction
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18
Q

What is the Investigation for Cauda Equina?

A

WHOLE SPINE MRI = GOLD

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19
Q

What is the management of Cauda Equina?

A

Surgical decompression in < 48 hours

If secondary due to malignancy, give dexamethasone 16 mg daily with PPI cover.

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20
Q

What is Herniated Nucleus Pulposus/ Radiculopathy?

A

??

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21
Q

What are the symptoms of Herniated Nucleus Pulposus/ Radiculopathy?

A
  • unilateral leg pain radiating down
  • low back pain
  • leg pain is worse than back pain
  • numbness and tingling
  • weakness/ reflex changes
  • +++ straight leg raise test
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22
Q

What is the Ix of Herniated Nucleus Pulposus/ Radiculopathy?

A

MRI

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23
Q

What is the treatment for Herniated Nucleus Pulposus/ Radiculopathy?

A

NSAIDS

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24
Q

Define Avascular Necrosis:

A

This is the loss of blood supply to the femoral head which causes bone death.

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25
What is the risk factors of developing Avascular Necrosis?
- alcohol - steroids - chemo - immunosuppression - SCA * 30-60 years age
26
What are the causes of Avascular Necrosis?
* trauma * intravascular coagulation * fat emboli * steroid therapy
27
What are the symptoms of Avascular Necrosis?
* groin pain to leg pain * pain worsens when weight bearing * reduced ROM in affected joint * collapsed subchondral bone
28
What are the investigations of Avascular Necrosis?
* X-ray * MRI * Bone scan
29
What is the management of Avascular Necrosis?
* total hip replacement * physio * NSAIDS * Aids
30
Define Slipped Upper Femoral Epiphysis:
??
31
Whom is Slipped Upper Femoral Epiphysis most commonly found in?
10-17 year old children
32
What are the Risk factors of developing Slipped Upper Femoral Epiphysis?
* male * adolescent * Obese * endocrine disorders * black and Hispanic
33
What are the Symptoms of Slipped Upper Femoral Epiphysis?
* hip pain * limp * referred pain to the knee * Reduced ROM upon hip flexion * + ++ Trendelenburg
34
What are the Ix of Slipped Upper Femoral Epiphysis?
Anterolateral X-ray of leg = Frog legs
35
How is Slipped Upper Femoral Epiphysis treated?
Surgical screw
36
Whom is Perthes Disease most commonly found in?
In children aged 4-8 years.
37
Define Perthes disease:
This is the avascular necrosis of the femoral head in children ages 4-8 years.
38
What are the Risk Factors of developing Perthes Disease?
* male * 4-8 years * hypercoagulability
39
What are the symptoms of Perthes Disease?
* usually unilateral * painless limp = gluteal medial lurch * painful hip after activity * reduced ROM * pain better upon rest * limp worse on activity
40
How is Perthes disease Investigated?
X ray and frog leg lateral * sclerosis and fragmentation of the epiphysis
41
How is Perthes Disease Managed?
* if <50% of femoral head affected = bed rest and no weight bearing * if >50% of femoral head affected = plaster, osteotomy
42
What is meant by Developmental dysplasia of the Hip?
This is when the femoral head and acetabulum do not articulate properly.
43
What are the risk factors of Developmental Hip Dysplasia:
5Fs * female * first born * Fhx * Frank Beech Presentation * Fluid- low amniotic fluid
44
What are the symptoms of Developmental Dysplasia of the Hip?
IN INFANTS: * reduced hip abduction * asymmetry of gluteal and thigh infolds * limb length discrepancy IN OLDER CHILDREN * walking difficulty- limp * delayed walking * waddling gait
45
What are the Investigations of Developmental Dysplasia of the Hip?
* Barlow ( posterior dislocation) * Ortolani ( relocation of abduction) * USS CONFIRM * pelvic radiography if older patient
46
What is the treatment of Developmental Dysplasia of the Hip?
* usually self-limiting * Pavlik harness * surgery
47
What causes Trochanteric Bursitis?
* falls/ trauma * strain injuries * obesity * leg length discrepancies * prolonged sitting * excessive running
48
What are the symptoms of Trochanteric Bursitis?
* localised pinpoint tenderness * pain down the thigh * no swelling usually * +++ Trendelenburg * lateral hip pain which is sever at night and worsens on activity
49
What are the investigations of Trochanteric Bursitis?
* MRI/ USS to visualise inflammation
50
What is the management of Trochanteric Bursitis?
* physio * NSAIDs * corticosteroid injection * bursectomy
51
What is Osgood-Schlatter Disease?
Also known as tibial tuberosity apophysitis/ osteochondritis
52
Who is commonly affected by Osgood-Schlatter Disease?
10-14 year old males/ footballers
53
What are the symptoms of Osgood-Schlatter Disease?
* anterior knee pain * worsening pain on activity and better at rest * swelling / tenderness over the tibial tuberosity Lump if severe
54
What is the investigations for Osgood-Schlatter Disease?
- X-ray - USS - MRI
55
What is the treatment for Osgood-Schlatter Disease?
* NSAIDs * stretch and strengthen * immobilise with knee brace
56
What is the management of a Meniscal injury/ tear?
RICE (rest, ice, compress, elevate) Analgesia Physio Surgery
57
What is the Ix of a Meniscal injury/ tear?
* MRI- apley sign/ mcmurry sign * Arthroscopy
58
What are the signs of a Meniscal injury/ tear?
* knee pain * swelling * locking/ buckling of knee * restricted RO * popping sensation at time of injury
59
What are the risk factors of a Meniscal injury/ tear?
* contact sports * aging * trauma * over-use * pre-existing conditions * twisting motion injury
60
What is Chondromalacia Patella?
Also known as runner's knee and is the loss of cartilage under the patella.
61
What are the symptoms of Chondromalacia Patella?
* pain; worse on deep-bending * hypermobile patella with crepitus
62
What are the Ix for Chondromalacia Patella?
Skyline knee X-ray = bone on bone
63
What are the risk factors of developing Pre-patella Bursitis?
* increased frequency kneeling * trauma/ injury/ blow * infection * rheumatology hx
64
What are the symptoms of Pre-patella Bursitis?
* localised pain at the front of knee * swelling and tenderness over the patella * warm and red * reduced knee flexion
65
What are the Ix of Pre-patella Bursitis?
* aspiration * US/MRI
66
What is the Management if Pre-patella Bursitis?
* RICE * NSAIDS * corticosteroid * Antibiotics if septic
67
What is ACL injury usually a result from?
Sudden deceleration e.g., sports/ football
68
What is PCL injury usually a result from?
PCL injury due to direct blow to the proximal tibia when the knee is flexed e.g., motor vehicle accidents
69
Is ACL or PCL injury more common?
ACL injury
70
What are the symptoms of ACL injury?
* sudden, painful popping feeling * rapid swelling of knee * unable to return to activity * knees *gave way*
71
What are the signs of ACL injury?
* lateral knee and joint line tenderness * Anterior drawer test +++ * Lachman test +++ * effusion
72
What are the symptoms of PCL injury?
* asymptomatic * knee pain
73
What are the signs of PCL injury?
* Sag test ++ * Posterior drawer test +++
74
What are the investigations in someone with suspected ACL/ PCL injury?
* X-ray to rule out fracture * MRI DEFINITIVE
75
What is the management in someone with ACL/ PCL injury?
PRICEM (Physio, Rest, Ice, Compress, Elevate) Knee brace Surgery Analgesia
76
What are the symptoms of Achilles Tendon injury?
* Patient feels like they have been struck above the heel * unable to tiptoe * plantar flexion is weak * usually able to walk
77
What is a risk factor for developing Achilles Tendon Rupture?
* frequent use of fluoroquinolone abx
78
What is the Ix for Achilles Tendon Rupture
simmons/ thompson's test
79
Define Plantar fasciitis:
???
80
What are the risk factors for developing Plantar fasciitis?
* repeated microtrauma to soles of foot * repetitive impact activity * prolonged standing * flat/ high arch feet * tight Achilles tendon * calf muscle * obesity
81
What are the Symptoms of Plantar fasciitis?
* sharp/ stabbing pain in heel/ plantar * severe on walking/ after rest * pain worsens AFTER exercise (not during) * Tender to touch over the medial tubercle of calcaneus
82
What are the Ix of Plantar fasciitis?
* clinical diagnosis * Radiograph * USS * MRI
83
What is the management of Plantar fasciitis?
* RICE * NSAIDS * supportive footwear (heel padding insoles) * physio * corticosteroids * surgery
84
Which type of Ankle fracture/ sprain is most common?
Inversion ankle sprain
85
What are the symptoms of an Ankle Fracture?
* recent trauma * ankle pain * swelling * unable to weight bear * tender
86
What are the symptoms of an Ankle Sprain?
* pain * bruising * swelling
87
What are the Ottawa Ankle rules to get an X-Ray?
Malleolar pain and >=1: * bone tenderness as lateral/ medial malleolus * unable to weight bear for 4 steps Midfoot pain and >=1: * bone tender at base of 5th metatarsal or navicular bone * unable to weight bear for 4 steps If none of the rules apply, then it is more likely a sprain.
88
How to investigate an Ankle fracture?
X-ray
89
How to investigate an Ankle Sprain?
MRI/ USS
90
What is the treatment for an Open ankle fracture?
surgical fixation
91
What is the management for an Closed ankle fracture?
reduce and splint
92
Define Dupuytren's Contracture:
Progressive fibrotic thickening of palmar fascia causing permanent flexion of the affected digits (usually 4th and 5th).
93
What are the risk factors of developing Dupuytren's Contracture?
* male over 50 years * Northern european * fhx
94
What are the causes of Dupuytren's Contracture?
* diabetes/ AIDS * alcohol * peyronie's disease
95
What are the symptoms of Dupuytren's Contracture?
* fixed flexion deformity of the 4th and 5th digit * contraction at MCP and IP joints * usually bilateral * no pain * fingers get caught on things * palpable cord on exam
96
What are the Ix of Dupuytren's Contracture?
Clinical diagnosis- table top test
97
What is the management of Dupuytren's Contracture?
* physio * surgery- fasciectomy * steroid injection
98
What is Trigger finger also known as?
Stenosing Tenosynovitis
99
What are the risk factors for developing Trigger Finger?
* 40-60 years * female * DM * RA * carpal tunnel
100
What are the signs and symptoms of Trigger Finger?
* pain at the base of affected finger and thumb * nodule/ swelling at the base of digit * catching/ locking sensation of finger in a bent position * morning stiffness * pop/ snap when moving affecting finger
101
What are the Ix of Trigger Finger?
Clinical diagnosis USS MRI
102
What is the management of Trigger Finger?
* rest and splint * NSAIDS * steroid injection * surgical release if >=3 months of symptoms
103
What is Carpel Tunnel?
Median nerve compression
104
What are the symptoms of Carpel Tunnel?
* pain and paresthesia to the lateral 3.5 digits * wasting of thenar eminence * worse at night and upon wrist flexion * relief by hanging arm out of bed or shaking
105
What are the Ix of Carpel Tunnel:
* Phalen's * Tinnel's * EMG * NCS ???
106
What is the Tx of Carpel Tunnel syndrome?
* NSAIDs * Splints * Steroids * surgery
107
Define De Quervain's Tenosynovitis:
When the tendons at the base of the thumb becomes inflamed/ swollen therefore restricting movement.
108
What are the Risk factors of developing De Quervain's Tenosynovitis?
* jobs requiring repetitive thumb abduction * overuse of wrist
109
What are the symptoms of De Quervain's Tenosynovitis?
* pain at the base of thumb which can extend to forearm * pain worse upon: thumb abduction; unlar deviation; gripping. * tender in snuffbox * hand + thumb weakness * swelling + redness at base of thumb * discomfort
110
What is the Ix of De Quervain's Tenosynovitis?
* Clinical diagnosis * Finkelstein's +++ * USS
111
What is the Tx of De Quervain's Tenosynovitis?
* Splint * Analgesia * Physio * Steroid injection * Surgery
112
Define Subacromial Impingement:
Inflammation and irritation of the shoulder tendons as they pass through the subacromial space.
113
What are the Signs and Symptoms of Subacromial Impingement?
* painful abduction * painful arc of ROM
114
What are the risk factors for developing Rotator Cuff Tendonitis?
* young * increasing age
115
What are the Sx of Rotator Cuff Tendonitis:
* unable to abduct/ hold it * Pain on resisted movement rather than passive
116
What is the Ix for Rotator Cuff Tendonitis?
* clinical * Empty can test ++++
117
What is the Tx for Rotator Cuff Tendonitis:
* Intra-articular steroid injection * Physio
118
What is Supraspinatus Tendonitis?
The most common Rotator Cuff Tendonitis Pain on resisted Abduction
119
What is Infraspinatus Tendonitis?
Pain on resisted external rotation
120
What is Subscapularis Tendonitis?
Pain on resisted Internal Rotation
121
What is Bicipital Tendonitis?
Pain on resisted forearm flexion.
122
When is Dislocation of the Shoulder most common?
After as FOOSH
123
What type of shoulder dislocation is the most common?
Anterior Dislocation
124
What are the signs and sx of an Anterior shoulder dislocation?
* the arm at the side of the body positioned in external rotation * Axillary nerve may be damaged (chesk deltoid)
125
What are the signs and sx of an Posterior shoulder dislocation?
* arm is held in medial rotation
126
What is the management of a Shoulder Dislocation?
* reduction under sedation * sling + immobilisation 1-3 weeks * physio * analgesia
127
Define Adhesive Capsulitis:
(Frozen shoulder); is the slow, progressive loss of passive + active ROM of the shoulder joint, caused by chronic fibrosis.
128
What are the risk factors of developing Adhesive Capsulitis?
* female * 40-60 years * DM * thyroid issues
129
What are the sx of Adhesive Capsulitis?
* gradual onset pain of shoulder * Stiffness of shoulder joint, affecting external rotation * persisting weeks- months
130
What are the Ix of Adhesive Capsulitis?
Clinical Diagnosis X-ray to exclude other pathologies if needed
131
What is the Tx of Adhesive Capsulitis?
1st Physio + NSAIDS 2nd Intra-articular steroid injection
132
What is Tennis Elbow?
This is caused by the overuse of the muscles attached at the epicondyle-extensions.
133
What are the signs and sx of Tennis Elbow?
Point tenderness at the lateral aspect of the Elbow
134
What is the Tx of Tennis Elbow?
* rest * physio * NSAIDs
135
What is the Ix of Tennis Elbow?
Clinical Diagnosis ++ pain on resisted wrist extension
136
What is Golfer's elbow?
Also known as Medial Epicondylitis, which is caused by the overuse of the muscles attached at the epicondyle flexors/ pronators.
137
What are the signs of Golfer's Elbow?
* point tenderness of the medial aspect of the elbow
138
What is the Tx of Golfer's Elbow?
* Rest * Physio * NSAIDs
139
What are the Ix of Golfer's Elbow?
* Clinical Diagnosis * +++ pain of resisted wrist flexion
140
What is Pulled Elbow?
Also known as Nursemaid's Elbow which occurs when swinging children by hands.
141
What are the Ix of Pulled Elbow?
x-ray
142
What are the signs and sx of pulled elbow?
* not using affected arm * pain/ difficulty on extension of elbow and pronation of forearm * distressed only on elbow movement * NO: swelling, bruising, deformity, tenderness
143
What is the Tx of Pulled Elbow?
Reduce and immobilise
144
Define Rheumatoid Arthritis:
Systemic joint inflammatory disorder
145
What are the Risk Factors for developing RA?
* females * age 20-30 * HLA-DR4
146
What are the Sx of RA?
* Affects the peripheral joints * symmetrical joint pain, stiffness, swelling * functional loss * systemic signs
147
What are the Signs of Rheumatoid Arthritis?
* swan-neck deformity * Z shaped deformity of ulnar deviation of thumb
148
What are the Ix of Rheumatoid Arthritis?
* FBC, ESR, CRP * Anti-CCP (specific) * RF (not always reliable) * X-ray: erosions, periarticular osteopenia
149
What is the Management of RA?
Urgent referral if: * small joints affected * >1 joint * more than 3 months of sx Urgent referral within 3 days of presentation if any of the following: - Small joints of the hands or feet are affected. - More than one joint is affected. - There has been a delay of 3 months or longer between the onset of symptoms and the person seeking medical advice. Management: - NSAID at lowest dose for shortest time until rheumatology appointment. - Steroid shouldn’t be prescribed in primary care before specialist assessment is carried out β€” steroids may mask key clinical features of rheumatoid arthritis and delay diagnosis. Treatment: - DMARDs- methotrexate
150
What is the Tx of RA?
* 1st DMARDS * 2nd Hydroxychloroquine * do not give steroids before diagnosis * NSAIDs
151
What is Osteoarthritis?
A disorder of the Synovial Joints, Is a non-inflammatory degenerative joint disorder.
152
What are the causes of OA?
* cartilage loss * remodelling of the adjacent bone * Osteophyte formation * Mild synovitis
153
What are the Risk factors of developing OA?
* Female * obese * reduced bone density * damage
154
What are the symptoms of OA?
* activity related joint pain * morning stiffness lasting less than 30 mins * some functional loss * nil systemic sx * nil swelling/ redness
155
What are the Signs of OA?
* bony swelling * joint deformity * joint effusuion * warm/ tender soft tissue swelling * muscle wasting/ weakness * crepitus * nodes * Joint pain WITHOUT stiffness and disability
156
What is the Ix of OA?
X-ray: * Joint space narrowing * Osteophyte formation * Subchondral sclerosis
157
What is the Tx of OA?
* manage weight * change footwear * physio * NSAIDS/ topical for knee 1st * refer to ortho if no improvement for more than 3 months * Aspiration of joint effusions and joint injections
158
Define Reactive Arthritis:
Usually occurs after exposure to GI/ GU infections. Classic triad of arthritis, uveitis, urethritis (can’t see, can’t pee, can’t climb a tree), but not normally seen as a triad clinically
159
What is the most common cause of reactive arthritis?
Chlamydia Trichomoniasis???
160
What are the Risk Factors of developing Reactive Arthritis?
* male * chlamydia infection 4 weeks ago * HLA-B27
161
What are the symptoms of Reactive Arthritis?
* fever * oligoarthritis * asymmetric * conjunctivitis * urethritis * enthesitis * skin lesions * dactylitis
162
What is the Tx of Reactive Arthritis?
* 1st NSAIDs * 2nd Steroids
163
Define Septic Arthritis:
999- Spread of bacteremia, periarticular osteomyelitis, infection due to diagnostic or therapeutic procedure or from infection elsewhere.
164
What are the common causes of Septic Arthritis:
* kids- staph/ strep * neisseria gonorrhoeae * Staph- most common
165
What are the sx of Septic Arthritis:
* HOT JOINT * acute swelling * Tender * restricted ROM * fever and systemically unwell
166
What is the Ix for Septic Arthritis:
* Aspirate + culture (NEVER on prosthetic joint) * Refer ORTHO as this is an orthopedic emergency
167
What is the Management of Septic Arthritis:
IV abx Gram ++ Cocci * Flucloxacillin 2mg QDS * Clindamycin/ Cephalosporin Gram - * Ceftriaxone MRSA * Vancomycin
168
Define Psoriatic Arthritis:
Chronic, inflammatory joint disease associated with psoriasis
169
What are the sx of Psoriatic Arthritis:
* psoriatic rash * nail changes * enthesopathy * dactylitis * asymmetrical oligoarthritis
170
What are the Ix of Psoriatic Arthritis:
* X-ray of hands and feet – DIP arthritis, β€œpencil in cup deformity” * MRI * USS
171
What are the Treatment of Psoriatic Arthritis:
- Mild = NSAIDs - DMARDs (methotrexate) can help both skin and joint manifestations - Other immunosuppressants (TNF alpha inhibitors) can help both skin and joint manifestations if DMARDs fail.
172
What are the complications of Giant Cell Arteritis:
* permanent monocular blindnes * stroke * aortic aneurysms
173
Define Poly Arteritis Nodosa:
This is a rare form of vasculitis affecting medium/ small arteries causing aneurysms and microaneurysms.
174
What are the risk factors of developing Poly Arteritis Nodosa?
* 40-60 years * HBV
175
What are the sx of Poly Arteritis Nodosa?
* weight loss >=4 kg * livedo reticularis * testicular pain/ tenderness * myalgia/ weakness * tender legs * neuropathy * ++ HBV infection
176
What are the Ix of Poly Arteritis Nodosa?
* diastolic BP >90 mmHg * raised urea/ creatinine * CRP, ESR, Cr * Biopsy showing polymorphonuclear leukocytes * Angiography
177
What is the Tx of Poly Arteritis Nodosa?
* steroids +/- DMARDs
178
Define Giant Cell Arteritis?
Is a Chronic Vasculitis characterised by granulomatous inflammation in the walls of medium and large arteries.
179
What are the risk factors for GCA?
* over 60 years * female * caucasion
180
What are the sx of GCA?
* temporal headache * jaw claudication * amaurosis fugax * systemic features
181
What are the Signs of GCA?
* thick temporal artery (pulsless) * scalp tenderness * asymmetrical BP * absent pulse
182
What are the Ix of GCA?
INITIAL: * ESR, CRP, LFTs, FBC DEFINITE: * Temporal Artery Biopsy showing granulomatous inflammation. Doppler Ultrasonography = Halo sign FQG-PET
183
What is Juvenile RA?
this is an inflammatory arthritis in <16 year olds.
184
What are the Risk Factors of Juvenile RA?
* Fhx * female
185
What are the sx of Juvenile RA?
* joint pain/ swelling (knee) * intermittent spiking fevers (1-2 per day) * Extra articular - uveitis
186
What are the Ix of Juvenile RA?
* raised CRP + ESR * ANA + (maybe) * RA + (maybe)
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What is the management of Juvenile RA?
* 1st NSAIDs * 2nd DMARDS * physio
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Define Sjogren's Syndrome:
This is a chronic, inflammatory autoimmune disorder causing sicca complex by affecting the lacrimal glands and salivary glands. Can be secondary to RA/ SLE.
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What are the sx of Sjogren's Syndrome?
* severe dry eyes * severe dry mouth
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What are the Ix of Sjogren's Syndrome?
* Schirmer test * ++ SSA/RO antibodies * ++ SSB/LA antibodies * ++ ANA (not specific * GOLD IS SALIVARY GLAND BIOPSY
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What is the Tx of Sjogren's Syndrome?
* eye drops * sialogogues * punctal plugs
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Define Scleroderma:
This is a multi-system autoimmune disease, characterised by abnormalities of small blood vessels, fibrosis of skin and internal organs, and production of autoantibodies.
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What are the symptoms of Scleroderma?
CREST Calcinosis Raynauds Esophageal dysmotility Sclerodactyly Telangectasia
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What are the Ix of Scleroderma?
* +ANA * ++SCL-70 * anti-topoisomerase I
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SLE!!!!
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What is a Colles Fracture?
Fracture of the distal radius with dorsal displacement of wrist.
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What are the Risk Factors of getting a Colles Fracture?
- A fall onto outstretched hand (FOOSH injury) - Elderly - osteoporatic
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What are the Signs of a colles fracture?
'dinner fork deformity' with prominence on the back of the wrist and a depression in front.
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What is the management of colles fracture:
- Treatment involves straightening the deformity, and immobilisation in cast for six weeks
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What is a Smiths Fracture?
Also sometimes known as a reverse Colles' fracture is a fracture of the distal radius caused by falling onto flexed wrists.
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What are we worried about identifying a Scaphoid Fracture?
- Lead to avascular necrosis - Because of the precarious blood supply to the bone scaphoid fractures are notorious for complications, such as AVN
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What are the signs of Scaphoid Fracture?
- Local tenderness over the scaphoid bone (in the anatomical snuff box or over the base of the thenar eminence: indicated imaging
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What is the management of a Scaphoid fracture?
- Immobilise and send for MRI - PAIN IN ANATOMIC SNUFFBOX, NORMAL XRAY οƒ  IMMOBILISE - telescoping
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What is a Boxer's Fracture?
Fracture of the 5th metatarsal.
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What is Osteomyelitis?
Osteomyelitis is an inflammatory condition of bone caused by an infecting organism. It usually involves a single bone.
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What is the most common cause of Osteomyelitis
Staphylococcus aureus
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What are the risk factors of developing Osteomyelitis?
* hx of penetrating injuries * intravenous drug misuse, * diabetes, * HIV infection, * surgical contamination * periodontitis
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Sx of Osteomyelitis?
- Non specific pain, fever, malaise/fatigue, inflammation, swelling
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What are the Ix for Osteomyelitis?
- WBC (inc), CRP&ESR (inc), - xray – osteopenia & bone destruction
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What is the Tx of Osteomyelitis?
High dose Abx
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What is Compartment Syndrome?
A orthopedic emergency 999; Elevated interstitial pressure in a closed osteofascial compartment that results in restriction of capillary blood flow & If untreated tissue death.
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What are the Risk Factors to developing Compartment Syndrome?
- Trauma - Bleeding disorder - Compression support - Thermal injury - IV infusion - Venous obstruction - sports
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What are the Symptoms of Compartment Syndrome?
- 7 Ps: Pain out of Proportion to exam, Pallor, Paraesthesias, Pulselessness, Poikilothermia, Paralysis
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What are the Ix for Compartment Syndrome?
- Tissue pressure measurements (elevated) – uncommon in practice - CK raised - Urine myoglobin elevated
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What is the management of Compartment Syndrome?
Immediate Fasciotomy
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Define Bursitis:
Inflammation of a bursa (A bursa is a sac containing a small amount of synovial fluid that lies between a tendon and either skin or bone to act as a friction buffer).
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Define Polymyalgia Rheumatica?
Is a chronic inflammatory condition which presents with stiffness and pain of the proximal large joints.
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What are the Risk factors of delevoping Polymyalgia Rheumatica?
* 70-80 years * women * Northern European
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What are the sx and signs of Polymyalgia Rheumatica?
* The key symptom is bilateral shoulder, neck and pelvic girdle pain * Joints feel stiff, especially after rest or sleep, and movement worsens pain * Pain may radiate to the elbows or knees * Systemic symptoms, B sx, Malaise, Depression * On examination, muscle power is usually preserved (unless there is disuse atrophy from prolonged symptoms) * Active range of motion may be limited by pain and stiffness * unilateral swelling and pain in peripheral joints (e.g. wrists and ankles) * Hands and feet - swollen with pitting oedema * Carpal tunnel syndrome
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What are the Ix of Polymyalgia Rheumatica?
Clinical diagnosis which is supported by resolution of symptoms with steroid treatment.
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What are the management of Polymyalgia Rheumatica?
- Resolves rapidly with steroids- usually taken for 1-2 years - 10-15% will have associated Giant Cell Arteritis/Temporal Cell (Rheum Emergency! Vision loss. Must be treated with steroids
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Define Polymyositis:
Idiopathic inflammatory myopathies characterised by weakness in proximal muscles.
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Who is commonly affected by Polymyositis?
women; > 40 age
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What are the sx of Polymyositis?
* Symmetrical proximal muscle weakness * Patients may complain of difficulty climbing stairs, lifting objects and holding up the head, for example * Severe pain is not present, but there may be myalgia in some patients * Muscle cramps can also occur * Distal muscles are typically spared (meaning fine motor movements are intact) * Facial and external ocular muscles are also not affected * Dysphagia may occur due to pharyngeal weakness * Systemic symptoms include: Weight loss, Fevers, Anorexia, Fatigue, Arthralgia
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What are the signs of Polymyositis?
* Weakness of affected muscle groups * The anterior neck flexors, hip and shoulder girdles are the main muscle groups affected * Muscular atrophy * Reflexes and sensation are intact * Tenderness on palpation of the muscles in some patients
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What is the Ix of Polymyositis?
??? - See if your patient can stand from a chair without using arm rests - CK massively elevated usually, EMG, - Muscle biopsy for definitive diagnosis
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What is the Tx of Polymyositis?
Steroids DMARDs
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Define Gout:
Uric acid crystal deposition in joint causing episodic acute swelling/pain in joint(s).
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Risk factors for Gout:
- FH - obesity, - excess alcohol - high purine diet - Diuretics - acute infection - surgery, - leukemia, - renal failure
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What are the sx of Gout:
Acute - Sudden onset of pain lasting 1-2wks - Spontaneous but may have trigger - Big toe, ankle joint, finger joints, elbow - Skin is red and shiny, swollen and hot, tender - VERY PAINFUL – SHEET CANNOT TOUCH TOE - May have associated skin findings, Tophi - Intermittent attacks
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The Investigations of Gout:
Gold standard diagnosis: Joint aspiration and crystal analysis. Negatively birefringent crystals. - Serum uric acid levels- may be raised - ***PEARL: Patients may have chronic raised uric acid but during an acute attack, uric concentrations may fall and uric acid during a flare is not a good diagnostic test - Leucocytosis, raised ESR and CRP during acute attack - CV risk factors- lipid + glucose
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Tx for Gout:
Acute gout treatment – Resolves <2wk – Exclude infection – Rest, elevate, ice packs – NSAIDS – Colchicine 500mcg bd – Prednisolone – Steroid joint injection- caution need to be certain of diagnosis (cannot give if infection) Prophylactic gout treatment – Allopurinol – given as a daily medication to prevent frequent attacks – If attacks occur frequently/ needing regular doses of steroids/NSAIDs/pain medications PEARL* Never give allopurinol during an acute attack. Will make the acute attack worse
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Define Pseudogout?
Deposition of calcium pyrophosphate crystals (aka CPPD) into joint during acute attacks
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Sx of Pseudogout:
- Very similar presentation to gout, but most common in KNEE joint - Red, hot swollen, episodic attacks.
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Ix of Pseudogout:
Aspiration of joint and crystal analysis shows positively birefringent crystals (think P for pseudogout and positive)
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Tx of Pseudogout:
- IA steroids - NSAIDs
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Define Osteoporosis:
Thinning/weakening of the bones putting patients at risk for fractures.
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What are the risk factors for developing Osteoporosis?
- Post menopausal women - Increasing age - Smoking - Steroid use - Low BMI
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What are the symptoms of Osteoporosis?
ASYMPTOMATIC UNTIL A FRACTURE APPEARS. Osteoporosis does not cause any pain! It leads to fractures which can cause pain
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What are the Ix for Osteoporosis?
DEXA scan - Look at the T score on a DEXA scan. T score = 0, normal bone density. Your bones are as strong as people your sex/age - T score >0, good bone density. Your bones are stronger than people your age/sex - T score between -2.5 and 0, osteopenia - T score <-2.5, osteoporosis
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What is the treatment of Osteoporosis?
- Bisphosphonates - Calcium - Vit D Must be given a ”drug holiday” (time off of the medication) after taking bisphosphonates for 3-5 years
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Define Fibromyalgia?
Fibromyalgia is a syndrome of chronic widespread pain that is not secondary to any other condition, which causes significant functional impairment and/or distress. Fibromyalgia is caused by abnormal processing of pain by the nervous system.
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Define Systemic lupus erythematosus:
SLE is a complex autoimmune disease that may affect a wide variety of organs. The clinical course is commonly a relapsing-remitting one, with intermittent flares of disease activity.
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Risk f. SLE:
* women * Afro-Caribbean * South Asian descent * Mean age at diagnosis is 49 years * Smoking * Ultraviolet light * Silica exposure * Epstein-Barr virus * genetics
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What might trigger SLE flares?
Flares of SLE may be triggered by: * Oestrogen exposure (e.g. pregnancy, COCP) * Infections * Emotional stress * Physical stress e.g. surgery, injury * Excessive ultraviolet light exposure
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What is the Medical Management of SLE:
Refer to Specialist!!! * All patients- treated with hydroxychloroquine * Steroids e.g. oral prednisolone; high-dose IV methylprednisolone is often required for acute severe disease (e.g. renal or neuropsychiatric lupus) * Use of steroid-sparing agents is very important to minimise the long-term effects of prolonged steroid use - options include methotrexate and azathioprine * Severe- biologic agents- belimumab or rituximab * Topical agents for skin disease e.g. topical glucocorticoids or calcineurin inhibitors * Mycophenolate mofetil (MMF) and cyclophosphamide - lupus nephritis, with most patients continuing on either MMF or azathioprine * Cardiovascular risk factors such as hypertension and hyperlipidaemia may require medical treatment * Vitamin D supplementation may be required as well as bone protection in patients on long-term steroids
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Ix for SLE
* C3,C4 - low in active disease * ANA is almost always positive * Anti-dsDNA antibodies are highly specific for SLE * Anti-Smith (anti-Sm) antibodies- highly specific * Antiphospholipid antibodies- tested in all patients * Anti-histone antibodies are found in both SLE and drug-induced lupus * Anti-Ro and anti-La antibodies * Chest X-ray in all patients as a baseline and to screen for pulmonary involvement * CT chest * Ultrasound of the kidney, ureters and bladder (KUB) to exclude other causes of renal impairment e.g. obstruction * X-rays of affected joints looking for arthritis and fractures * CT/ MRI brain if cerebral lupus is suspected * Renal biopsy is the key diagnostic test for lupus nephritis and is important for classification * Skin biopsy may be useful for the diagnosis of dermatological manifestations * Pulmonary function tests if there * Pleural tap if there is an effusion present - exudative * Neurophysiology testing in suspected peripheral neuropathy
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What are the Risk F. of Fibromyalgia?
Women 40-60 years Family history of fibromyalgia Stressful life events or psychological trauma Obesity Socio-economic deprivation Inactive lifestyle Comorbid rheumatological conditions e.g. rheumatoid arthritis, osteoarthritis
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What are the Symptoms and signs of Fibromyalgia?
The cardinal symptom of fibromyalgia is chronic, widespread body pain. This should be in at least 4/5 body regions (left and right upper body, left and right lower body and axial regions). * Fatigue * Unrefreshing sleep * Insomnia * Cognitive issues, such as difficulties with concentration or memory * Mood disturbance, particularly depression and anxiety * Headaches * Abdominal cramping Physical examination is typically normal, and features of synovitis or abnormal neurology should prompt investigations for another underlying condition. There may be tenderness or pain when muscular areas are palpated (although this is no longer part of the diagnostic criteria).
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What are the Ix for Fibromyalgia?
Diagnosis of fibromyalgia is clinical, with the American College of Rheumatology (ACR) criteria used to support this. These require the presence of widespread pain (measured using the widespread pain index or WPI) as well as presence of associated symptoms (measured using the symptom severity scale or SSS). A diagnosis requires presence of symptoms at a similar level for at least 3 months, with a WPI of 7 or more and SSS of 5 or more, OR WPI 4-6 and SSS of 9 or more. * FBC- rule out anaemia as a cause for fatigue * ESR and CRP to rule out inflammatory conditions * Creatine kinase- raised in muscle damage e.g. in myositis * LFTs may be abnormal in some painful conditions e.g. Paget's disease (raised ALP) * U&Es as hyponatraemia may cause symptoms of fatigue, muscle cramps, headache and cognitive difficulties * Bone profile as hypercalcaemia can cause pain, fatigue and mood changes * TFTs to rule out hypothyroidism * Blood glucose as diabetes may cause symptoms of fatigue and headache * Other investigations may be indicated if there are suggestive clinical features, for example MRI brain and spine in suspected multiple sclerosis.
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What is the Management of Fibromyalgia?
Many patients may be managed in primary care, however if there is complexity (e.g. multiple comorbidities, diagnostic uncertainty etc.) referral onto specialist services may be required from either rheumatology or pain teams Non-pharmacological: * Patient education and self-management are crucial * Lifestyle changes: weight and diet, stopping smoking/ alcohol limits * Group exercise is recommended by NICE and some patients may benefit from individual specialist physiotherapy * Psychology input may be helpful, with acceptance and commitment therapy (ACT) and (CBT) * Conventional analgesic medications are usually not effective and NICE recommend that these should not be used * Antidepressant medications such as amitriptyline or fluoxetine may be considered * For patients with severe disability, multimodal rehabilitation programmes may be indicated
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