MSK + Ortho Flashcards
(266 cards)
1
Q
How does antiphospholipid syndrome present?
A
- Venous and arterial thromboses
- Recurrent fetal loss
- Thrombocytopenia
- Mottled discolouration of skin (Livedo reticularis)
- PARADOXICAL RISE in APTT
2
Q
Anti phospholipid syndrome
Associations
A
- SLE
- Lymphoproliferative disorders
3
Q
Anti phospholipid syndrome
Management
A
- Low-dose aspirin (primary thromboprophylaxis)
- Lifelong warfarin with target INR 2-3
- If VTE occurred on warfarin, add low-dose aspirin and increase INR target to 3-4
4
Q
Anti phospholipid syndrome
Complications in pregnancy
A
- Recurrent miscarriage
- Intrauterine growth restriction (IUGR)
- Pre-eclampsia
- Placental abruption
- Pre-term delivery
- VTE
5
Q
Anti phospholipid syndrome
Management in pregnancy
A
- Low-dose aspirin once pregnancy test confirmed on urinary testing
- LMWH once foetal heart seen on US
6
Q
Antiphospholipid syndrome
Antibodies
A
- Lupus anticoagulant
- Anticardiolipin antibodies
- Anti-beta-2 glycoprotein I antibodies
7
Q
What is livedo reticularis?
A
A purple lace-like rash that gives a mottled appearance to the skin
8
Q
What is Libmann-Sacks endocarditis?
A
- Non-bacterial endocarditis where there are growths on the valves of the heart
- Mitral valve most commonly affected
- Associated with SLE and antiphospholipid syndrome
9
Q
Osteoarthritis
Risk factors
A
- Local trauma or previous injury
- Hypermobility
- Congenital hip dysplasia
- Obesity
- Increased age
- Gender - females (after menopause)
- Genetics - polyarticular disease
- Occupation - manual labour (hands), farming (hips), football (knees)
10
Q
Osteoarthritis
Presentation
A
- Early morning stiffness < 30 mins
- Pain after exercise/at end of day
- Functional impairment, e.g. walking, ADLs
- Alteration in gait
- HARD joint swelling
- Crepitus
- Synovitis
- Effusion
- Locking of knee = loose body
- NO extra-articular manifestations
- HEBERDENS NODES - DIP joints
- BOUCHARDS NODES - PIP joints
- SQUARING at base of thumb
- Weak/reduced grip
11
Q
Osteoarthritis
XR findings
A
LOSS
L: Loss of joint space
O: Osteophyte formation
S: Subchondral sclerosis
S: Subchondral cysts
12
Q
Osteoarthritis
Diagnosis
A
Can be made w/o investigations IF:
- Over 45 yrs
- Typical activity-related pain
- No morning stiffness (or < 30 mins)
XRs can be helpful for checking severity or for confirming diagnosis, but not always necessary
13
Q
OA
Lifestyle management
A
- Patient education
- Lifestyle changes - weight loss
- PT and OT
- Local muscle strengthening exercises and general aerobic fitness
- Orthotics
14
Q
OA
Pharmacological management
A
- First line = Paracetamol and TOPICAL NSAIDs
2. Capsaicin cream
3. Oral NSAIDs/COX-2 inhibitors (PPI if NSAIDs/COX-2, avoid these if on aspirin)
4. Opioids - use cautiously
5. Intra-articular steroid injections - temporary symptom reduction
15
Q
OA
Surgical management
A
Joint replacement
16
Q
Joint replacement
Criteria
A
Primarily based on function and impacts on QoL
17
Q
Joint replacement
Advice for post-replacement
A
- Avoid flexing hip > 90 degrees
- Avoid low chairs
- Do not cross legs
- Sleep on back for first 6 weeks
- May need stick/crutches for 6 weeks after hip/knee
- Will receive PT and home exercises
- Weight bear asap
18
Q
Joint replacement
General complications
A
- Wound and joint infection
- VTE
- Dislocation
19
Q
Red flag features of OA joint pain that suggest alternative diagnosis
A
- Rest pain
- Night pain
- Morning stiffness > 2 hours
20
Q
Joint replacement - HIP
Complications
A
- Leg length discrepency
- Posterior dislocation
- Aseptic loosening (most common reason for revision)
21
Q
RA
Patho
A
Autoimmune disease causes chronic inflammation of synovial lining on the joints, tendon sheaths and bursa
- Inflammation of the tendons increases risk of tendon rupture
22
Q
RA
Genetic associations
A
HLA DR4
HLA DR1
23
Q
RA
Antibodies
A
- Rheumatoid factor (70%)
- Cyclic citrullinated peptide antibodies (anti-CCP) - more sensitive and specific, and often predate RA presentation
24
Q
Rheumatoid factor
MoA
How to detect
A
- Targets Fc portion of IgG antibodies
- Causes activation of immune system against the patients own IgG –> systemic inflammation
- Detect by Rose-Waaler test: sheep cell agglutination OR latex agglutination test
25
RA
General presentation
- SYMMETRICAL
- Distal polyarthropathy
- Pain, swelling
- Morning stiffness > 30 mins
- Eases with use of joints
- Typically: WRIST, ANKLE, MCP, PIP
- BARELY EVER DIP
- Can be very rapid onset or over months to years
- Fatigue
- Weight loss
- Flu-like illness
- Muscles aches and weakness
26
What is palindromic rheumatism
- Short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints
- The episodes only last 1-2 days and then completely resolve
- Having positive antibodies (RF and anti-CCP) may indicate that it will progress to full rheumatoid arthritis.
27
RA
Signs in hands
- Z thumbs
- Ulnar deviation
- Swan neck deformity (flexed DIP, hyper-extended PIP)
- Boutonniere deformity (flexed PIP, extended DIP)
- Rheumatoid nodules - ELBOWS
28
RA
Extra-articular manifestations
Lungs:
- Pulmonary fibrosis
- Bronchiolitis obliterans
- Nodules
- Caplan's syndrome - RA and pneumoconiosis - intrapulmonary nodules!
Eyes:
- Sjogren's syndrome
- Episcleritis
- Scleritis
- Sicca
Cardiac:
- CVS disease
- Anaemia of chronic disease
- Carpal tunnel syndrome (bilateral)
- Lymphadenopathy
- Amyloidosis
FELTY'S SYNDROME:
- RA
- Splenomegaly
- Neutropenia
29
RA
Diagnosis
- Clinical if features of RA
- Check rheumatoid factor
- If RF negative - check anti-CCP
- CRP and ESR
- XR of hands and feet
- US to look for synovitis
30
RA
XR changes
LESS
- L: Loss of joint space
- E: Erosion (boney)
- S: Soft-tissue swelling
- S: Soft bones (osteopenia)
31
RA
Referral
- Refer any adult with persistent synovitis, even if negative RF, anti-CCP and inflammatory markers
- Urgent if small joints of hands, feet or multiple joints or symptoms > 3 months
32
RA
American College of Rheum criteria
JOINTS:
0: 1 large joint
1: 2-10 large joints
2: 1-3 small joints
3: 4-10 small joints
4: 10 joints (incl 1 small)
SEROLOGY
0: Negative RF and ACPA
2: Low-positive RF or ACPA
3: High-positive RF or ACPA
INFLAMM MARKERS
0: Normal CRP + ERS
1: Abnormal CRP or ESR
DURATION
0: < 6 weeks
1: > 6 weeks
33
Other conditions with raised RF
- Felty's syndrome (around 100%)
- Sjogren's syndrome (around 50%)
- Infective endocarditis (around 50%)
- SLE (= 20-30%)
- Systemic sclerosis (= 30%)
- General population (= 5%)
- Rarely: TB, HBV, EBV, leprosy
34
RA
Poor prognostic fatcors
- RF positive
- anti-CCP positive
- Poor functional status at presentation
- XR: early erosions
- Extra-articular features, e.g. nodules
- HLA DR4
- Insidious onset
35
RA
Long-term management
1st line = DMARD ASAP !!!
- Short-course bridging prednisolone
2nd line = x2 DMARDS
3rd line = biological therapy (TNF-inhibitor)
4th line = rituximab
36
RA
Monitoring
Disease activity --> DAS28
| - Based on swollen joints, tender joints, ESR/CRP result
37
RA
Flare management
- Managed with corticosteroids - oral or IM
38
RA
Most common DMARD
Methotrexate:
| - Monitor FBC and LFTs (risk of myelosuppression and liver cirrhosis)
39
RA
Other DMARDs
- Sulfasalazine
- Leflunomide
- Hydroxychloroquine (mildest)
40
RA
2nd line pharmacological management
- TNF-inhibitor
| - If inadequate response to at least 2 DMARDs (including methotrexate)
41
RA
TNF-Inhibitor examples
ETANERCEPT:
- Recombinant human protein
- Acts as decoy receptor for TNF-alpha
- SC administration
- Can cause demyelination
- Risks: reactivation of TB
INFLIXIMAB:
- Monoclonal antibody
- TNF-alpha
- IV administration
- Risks: reactivation of TB
42
RA management in pregnancy
- Pregnant women tend to have an improvement in symptoms during pregnancy, probably due to the higher natural production of steroid hormones
- Sulfasalazine and hydroxychloroquine are considered as DMARDs in pregnancy
43
SEs of methotrexate
Methotrexate: Bone marrow suppression and leukopenia and highly teratogenic
44
SEs of leflunomide
Leflunomide: Hypertension and peripheral neuropathy
45
SEs of Sulfasalazine
Sulfasalazine: Male infertility (reduces sperm count)
46
SEs of Hydroxychloroquine
Hydroxychloroquine: Nightmares and reduced visual acuitys
47
SEs of Anti-TNF meds
Anti-TNF medications: Reactivation of TB or hepatitis B
48
SEs of rituximab
Rituximab: Night sweats and thrombocytopenia
49
Septic arthritis
Common causes
- Most common = S.aureus
- In young adults who are sexually active --> NEISSERIA GONORRHOEA
- Hematogenous spread - may be from distant bacterial infection, e.g. abscess
- Other causes: Group A Strep (strep pyogenes), H. influenza, E.coli
50
Septic arthritis
Features
- Most common location = knee
- Usually only one joint
- Fever
- Acute, hot, swollen joints with restricted movement
51
Septic arthritis
Ix
- SYNOVIAL FLUID sampling = obligatory, prior to Abx therapy
- Send for gram staining, crystal microscopy, culture and antibiotic sensitivities
- Blood cultures
- Joint imaging
52
Septic arthritis
Management
'hot joint policy'
IV Abx with gram +ve cocci cover
- Flucloxacillin
- Clindamycin if PA
- for 6-12 weeks
Needle aspiration to decompress joint (US)
May need arthroscopic lavage
53
Psoriatic arthritis
Patterns
- Symmetrical polyarthritis, similar to RA (but DIPs!!), more common in women
- Asymmetrical oligoarthritits (only a few joints, hands/feet)
- Spondylitic pattern (more common in men): Sacroiliitis, back stiffness, atlanto-axial joint
- Arthritis mutilans
54
Psoriatic arthritis
Other signs
- Psoriatic skin lesions
- NAIL CHANGES - pitting, onycholysis
- Periarticular disease (tenosynovitis, dactylitis, enthesitis - inflammation of entheses - tendons meet bone)
- Eye disease (conjunctivitis, anterior uveitis)
- Aortitis
- Amyloidosis
55
Psoriatic arthritis
Ix
- Psoriasis epidemiological screening tool (PEST): refer if high score
XR:
- Periostitis
- Ankylosis (bones fuse)
- Osteolysis (destruction of bone)
- Coexistence of erosive changes and new bone formation
- Pencil-in-cup appearance due to central erosions
56
Psoriatic arthritis
When does it occur
- Within 10 years of psoriatic skin changes (unlikely to occur if not developed arthritis within this time)
- Can present before skin changes
- Typically middle-aged
57
Arthritis mutilans
- Severe form of psoriasis
- Occurs in phalynxs
- Destruction of bones at either end of phalynx's --> occurs fingers to shorter, skin folds in on self
- TELESCOPIC FINGER
58
Psoriatic arthritis
Management
Similar to RA
- NSAIDs
- DMARDs
- Anti-TNF meds
59
Enteropathic arthritis
Association?
- IBD
- GI bypass
- Coeliac
- Whipple's disease
60
Enteropathic arthritis
Increases risk of what?
- Pyodermic gangrenosum
| - Erythema nodosum
61
Spondyloarthropathies
Common features
- HLA B27
- Rheumatoid factor NEGATIVE (seronegative)
- Peripheral arthritis, usually asymmetrical
- May have Achilles tendonitis, plantar fasciitis
62
Ankylosing spondylitis
Features
- Young male
- Lower back pain
- Stiffness
- Stiffness: worse in morning and improves with exercise, worsens with rest
- May experience pain at night
63
Ankylosing spondylitis
Clinical examination
- Reduced lateral flexion
- Reduced forward flexion (Schober's test - draw line 10cm above and 5cm below back dimples, distance between the lines should increased by > 5cm)
- Reduced chest expansion
64
Ankylosing spondylitis
Ix
- Inflammatory markers (typically raised)
- HLA B27
- Plain XR of sacroiliac joint --> sacroiliitis
- SQUARING of lumbar vertebrae
- Bamboo spin (late and uncommon)
- Syndesmophytes
- CXR: apical fibrosis!
- MRI if XR negative and still highly suspect AS
65
Ankylosing spondylitis
Management
- NSAIDs
- Steroids for flares
- Anti-TNF
- Monoclonal antibodies against interleukin-17
66
Reactive arthritis
Patho
- Synovitis occurs in joints due to recent infective trigger
- Immune system is responding to previous infection --> causes antibodies that affect the joints
- Used to be known as Reiter syndrome
67
Reactive arthritis
Presentation
- Acute monoarthritic
- Usually in lower limb, most often knee
- NO JOINT INFECTION (in comparison to septic arthritis)
- Common triggers: STIs or gastroenteritis
68
Reactive arthritis
Causes
- STIS: Chlamydia = most common (gonorrhoea = septic)
69
Reactive arthritis
Associations
- Bilateral conjunctivitis
- Anterior uveitis
- Circinate balanitis
"Can't see, pee or climb a tree"
70
Reactive arthritis
Management
'hot joint policy' = presume septic arthritis until proven otherwise
71
Reactive arthritis
Management
'hot joint policy' = presume septic arthritis until proven otherwise
- Abx
- Aspirate and send for gram stain, C&S, crystal examination
After excluding septic arthritis:
- NSAIDs
- Steroid injection
- Systemic steroids if multiple joints
- May need DMARDS or anti-TNF if recurrent!
72
Small vessel vasculitis
ANCA-aaosicated:
- Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
- Microscopic polyangiitis
- Granulomatosis with polyangiitis (Wegener's)
Immune complex:
- Goodpasture's (anti-GBM disease)
- Henoch-Schonlein purpura
- Cryoglobulinaemic
- Hypocomplementeric urticarial vasculitis
73
Medium vessel vasculitis
- Polyarteritis nodosa
- Kawasaki Disease
- Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)
74
Large vessel vasculitis
- Giant cell arteritis
| - Takayasus arteritis
75
Features that should make you think about a vasculitis
- Purpura (non-blanching)
- Joint and muscle pain
- Peripheral neuropathy
- Renal impairment
- GI disturbances
- Anterior uveitis and scleritis
- HTN
76
Systemic manifestations of a vasculitis
- Fatigue
- Fever
- Weight loss
- Anorexia
- Anaemia
77
Vasculitis
Ix
- CRP/ESR
- Anti-neutrophil cytoplasmic antibodies (ANCA)
- p-ANCA and c-ANCA
78
Vasculitis
Tx
- Steroids
- Cyclophosphamide (or methotrexate, azathioprine, rituximab)
- BUT kawasaki or HSP is different Tx
79
ANCA types and conditions
cANCA - granulomatosis with polyangiitis
pANCA - eosinophilic granulomatosis with polyangiitis + others (see below)
80
pANCA associated conditions
- Ulcerative colitis (70%)
- Primary sclerosing cholangitis (70%)
- Anti-GBM disease (25%)
- Crohn's disease (20%)
81
Common findings in ANCA vasculitis
- Renal impairment
- Respiratory symptoms
- Systemic symptoms
- Vasculitis rash
- ENT symptoms (sinusitis)
82
ANCA vasculitis
Ix
- Urinalysis for haematuria and proteinuria
- FBC normocytic anaemia
- CRP raised
- ANCA testing
- CXR: nodular, fibrotic, infiltrative lesions
83
Takayasu's arteritis
Epidemiology
- Younger females
84
Takayasu's arteritis
Features
- Systemic features
- Unequal BP in upper limbs
- Carotid bruit and tenderness
- Absent or weak peripheral pulses
- Upper and lower limb claudication on exertion
- Aortic regurgitation
85
Takayasu's arteritis
Association
Renal artery stenosis
86
Takayasu's arteritis
Management
Steroids
87
Polyarteritis nodosa
Epidemiology
- More common in middle-aged men
| - Associated with hepatitis B infection
88
Anti-GBM disease
Biopsy
- Linear IgG deposits along basement membrane
| - Raised transfer factor secondary to pulmonary haemorrhage
89
Buerger's Disease
- Small and medium vessel vasculitis
- Associated with smoking
- Features: intermittent claudication, ischaemic ulcers, superficial thrombophlebitis, Raynauds
90
Churg strauss syndrome
- Eosinophilic granulomatosis with polyangiitis (EGPA)
- p-ANCA-associated
- Asthma, blood eosinophils, paranasal sinusitis, mononeuritis multiplex, pANCA positive
- Tx with leukotriene receptor antagonists
91
Granulomatosis with polyangiitis vs Churg-Strauss
Both:
- Vasculitis
- Sinusitis
- Dyspnoea
GwP:
- Renal failure
- Epistaxis/haemoptysis
- cANCA
CS:
- Asthma
- Eosinophilia
- pANCA
92
Kawasaki
Features
- High grade fever for > 5 days
- Resistant to antipyretics
- Conjuncitval inkection
- Bright red, cracked lips
- Strawberry tongue
- Cervical lymphadenopathy
- Red palms and soles of feet that later peel
93
Kawasaki
Management
- ASPIRIN (one of few used of aspirin in children)
- IV immunoglobulin
- ECHO - screen for coronary artery aneurysm
94
Kawasaki
Complications
Coronary artery aneurysm
95
Why do you not usually use aspirin in children?
Reye's Syndrome
| encephalopathy accompanied by fatty infiltration of liver, kidneys, pancreas
96
Septic arthritis
RFs
- Pre-existing joint disease
- DM
- Immunosuppression
- CKD
- Recent joint surgery
- Prosthetic joints
- IVDU
- > 80 yrs
97
SLE
Antibody
Anti-nuclear antibodies (protect a persons own cell nucleus)
98
SLE
Features
SOAP BRAIN MD
S: Serositis
O: Oral ulcers
A: Arthritis/synovitis
P: Photosensitivity
B: Blood/haem disorders - haemolytic anaemia
R: Renal disorder - proteinuria or red cell casts
A: ANA positive
I: Immunological disorder
N: Neurological disorders (optic neuritis, transverse myelitis (inflammation of the spinal cord) or psychosis)
M: Malar rash
D: Discoid rash
Main cause of death = CVS disease
99
SLE
Investigations
- Autoantibodies - ANA and anti-double stranded DNA (anti-dsDNA) = more specific!!
- May also find antiphospholipid antibodies (40%) - increase VTE risk
- FBC
- C3 and C4 levels decreased (but C3d and C4d increased)
- Raised ESR, normal CRP
- Immunoglobulins
- PCR (protein creatinine ratio)
- Renal biopsy or PCR for lupus nephritis
100
Types of anti-nuclear antibodies and their conditions
- Anti-Smith (highly specific to SLE but not very sensitive)
- Anti-centromere antibodies (most associated with limited cutaneous systemic sclerosis)
- Anti-Ro and Anti-La (most associated with Sjogren’s syndrome)
- Anti-Scl-70 (most associated with systemic sclerosis)
- Anti-Jo-1 (most associated with dermatomyositis)
101
SLE
Epidemiology
- More common in WOMEN (90%)
- Typically child-bearing age
- More common in HLA B8, DR2, DR3
102
SLE
Diagnostic criteria
- SLICC Criteria
| - ACR Critera
103
SLE
Lifestyle management
- F50 suncream
- Assessment of lupus activity in clinic
- Patient education
- Screen for major organ involvement
- Assessment of damage
104
SLE
Pharmacological management
- NSAIDs
- Steroids
- Replace steroids for long term use: Methotrexate, azathioprine, ciclosporin
- Anticoagulants if increased clotting risk
105
SLE
Tx of mild flares (no organ involvement)
Hydroxychloroquine or low-dose steroids
106
SLE
Tx of moderate flares (organ involvement)
- May require DMARDs or mycophenolate
107
SLE
In medication resistant
Stem cell transplant
108
Gout
Patho
- Purine are broken down into uric acid
- Uric acid is then excreted by kidney
- If increase in uric acid or it is not excreted --> hyperuricaemia
- At 7.4 pH, uric acid loses a proton and becomes a urate ion, which binds to SODIUM --> MONOSODIUM URATE CRYSTALS
- These deposit in the joints (most commonly 1st metatarsal joint = big toe)
109
Gout causes
- Increased consumption of purines (shellfish, anchovies, red meat, organ meat)
- Increased production of purines (high fructose corn syrup-containing beverages)
- Decreased clearance of uric acid (dehydration, CKD, thiazide diuretics, alcohol consumption)
- Cell damage or cell death (chemo, radio, surgery)
- Genetic predisposition (LESCH-NYAN)
110
Gout
Presentation
- Hot, tender, swollen joint
- Toe on fire
- WCCs
111
Gout
Ixs
- Hot joint policy
- Synovial fluid aspirate - polarised light microscopy: NEGATIVELY BIREFRINGENT needles - yellow
- Hyperuricaemia in blood
- Raised WCC and ESR
112
Gout
Management of acute attacks
- NSAIDs = 1st line
- Colchicine
- Steroids 3rd line
113
Gout
XR findings
- Space between joint is maintained
- Lytic lesions
- Punched out lesions
- Erosions have sclerotic borders with overhanging edges
114
Gout
Prophlyaxis
- Allopurinol (xanthine oxidase inhibitor)
- Lifestyle changes
- Do not initiate during acute attack, wait until after it has settled
- Once initiated can continue through acute attacks
- Can be used down to eGFR of 30
115
Pseudogout
Deposit?
Calcium pyrophosphate deposition
116
Pseudogout
Most common joint?
Knee
117
Pseudogout
Risk factors
- Hypo/hyperthyroidism
- Diabetes
- Hyperparathyroidism
- Haemochromatosis
- Mg levels
118
Pseudogout
Polarised light microscopy
- Rhomboid shaped crystals
| - POSITIVE birefringent
119
Pseudogout
XR changes
- Similar to OA (LOSS)
120
Pseudogout
Tx
- Symptomatic - rest/cool
- NSAIDs/colchicine
- Joint aspiration
- Steroid injections
- Oral steroids
- Joint washout (arthrocentesis) if severe
121
Discoid lupus erythematosus
What is it?
Non-cancerous chronic skin condition
122
Discoid lupus erythematosus
Epidemiology
- More common in women
| - More common in darker-skinned patients and smokers
123
Discoid lupus erythematosus
Relationship with SLE
- Slightly more likely to develop SLE though still < 5%
124
Discoid lupus erythematosus
Presentation
- Typically face, ears, scalp
- Photosensitive
- Scarring alopecia
- Hyper-pigmented or hypo-pigmented scars
125
Discoid lupus erythematosus
Management
- Sun protection
- Topical steroids
- Intralesional steroid injections
- Hydroxychloroquine
126
Discoid lupus erythematosus
Ix
Skin biopsy can confirm
127
CTD
Marfans
Features
- Tall
- Long fingers and toes
- Long arms
- Long legs
- Span > height
- High arched palate
- Skeletal abnormalities
- Hypermobility
- Pectus carinatum
- Pectus excavatum
- Downward sloping palpable fissures
- Can present with joint pain
128
CTD
Ehler Danlos
- Hypermobile, hyper elastic skin and ligaments
129
CTD - Systemic sclerosis
AKA scleroderma
130
CTD - Systemic sclerosis
Type of CTD
- Autoimmune
- Inflammatory
- Fibrotic
131
Systemic sclerosis
Patterns of disease
1. Limited systemic sclerosis
- CREST symptoms
C: Calcinosis - deposits under skin
R: Raynauds
E: Oesophageal dysmotility (connective tissue dysfunction - reflux, oesophagitis)
S: Sclerodactyly
T: Telangiectasia
2. Diffuse systemic sclerosis
- CREST PLUS internal organs
- CVS: HTN, CAD
- Resp: fibrosis and pulm HTN
- Kidney: glomerulonephritis, scleroderma renal crisis (severe HTN, AKI)
132
Limited systemic sclerosis
Autoantibody
Anti-centromere
| type of ANA
133
Diffuse systemic sclerosis
Autoantibody
Anti-scl-70 (type of ANA) - associated with more severe disease
134
Systemic sclerosis
Investigation
Nailfold capillaroscopy: looks at health of peripheral capillaries
In systemic sclerosis:
- Microhaemorrhage
- Avascular areas
- Abnormal capillaries
Also done in Raynauds to exclude underlying SS (will have normal capillaries)
135
Systemic sclerosis
Diagnostic criteria
- EULAR
| - ACR
136
Systemic sclerosis
Lifestyle management
- No standardised Tx
- Avoid smoking
- Gentle skin stretching routines
- Emollients
- Avoid cold
- PT and OT
137
Systemic sclerosis
Pharmacological management
- May need steroids or immunosuppressants
- Raynauds: nifedipine
- Oesophageal dysmobility: PPI, ranitidine, metoclopramide
- Analgesia for joitn pain
- Abx for skin infections
- Anti-hypertensives for HTN (ACE-I)
138
Sjogrens syndrome
What is it
- Autoimmune condition affecting exocrine glands - due to lymphocytic infiltration and fibrosis
- Leads to dry mucous membranes (eyes, mouth, vagina)
139
Primary sjogrens
Condition occurs in isolation
140
Secondary sjogrens
Occurs related to SLE or RA
141
Sjogren's antibodies
anti-Ro and anti-La
142
Sjogren's
Ix
- SCHIRMER TEST: litmus paper on eye for 5 mins, measure moist strip
- Normally tears should travel 15 mm in healthy young adult
- < 10 mm = significant
143
Sjogren's
Management
- Artificial tears
- Artificial saliva
- Vaginal lubricants
- Hydroxychloroquine to halt progressions of disease
144
Sjogren's
Complications
- Eye: conjunctivitis and corneal ulcers
- Oral: dental cavities, candida infection
- Vagina: candiasis, sexual dysfunction
- Higher risk of lymphoma (40-60 fold)
145
Marfans
Test for arachdactyly
- Cross thumb over palm: will overhang
| - Wrap thumb and fingers round wrist: will overlap
146
Marfans
Genetics
- Autosomal dominant
| - Affects gene responsible for creating fibrillin
147
Marfans
Associated conditions
- Lens dislocation in eye
- Joint dislocation and pain due to hypermobility
- Scoliosis
- Pneumothorax
- GORD
- Mitral valve prolapse
- Aortic valve prolapse
- Aortic aneurysms
148
Marfans
Management
- Biggest risk - CVS: may need surgical assessment
- Avoid caffeine and stimulants
- Beta-blockers, ARBs
- Pregnancy must be carefully considered due to risk of aortic aneurysms
- PT
- Genetic counselling
- Echo and opthalmology
149
Ehler Danlos
Score for hypermobilkity
Beighton score
One point for each side of body (max 9)
- Palms flat on floor w straight legs (score 1)
- Elbows hyperextend
- Knees hyperextend
- Thumb can bend to touch forearm
- Little finger hyperextends past 90 degrees
150
Ehler Danlos
Presentation
- Joint dislocations
- Hypermobility
- Joint pain after exercise/inactivity
- Easy bruising
- Poor healing of wounds
- Bleeding
- Headaches
- GORD
- Abdo pain
- IBS
- Menorrhagia/dysmenorrhea
- PROM
- Incontinence
151
Dermatomyositis / Polymyositis
Patho
- Autoimmune disorders
- Inflammation within the muscles
- Polymyositis = chronic inflammation of muscles
- Dermatomyositis = connective tissue disorder, inflammation of skin and muscles
152
Dermatomyositis / Polymyositis
Mainstay invesitgation?
CK !!!
- Inflammation of muscles leads to release of CK
- Usually less than 300 U/L
- In this disease, often > 1000
153
Other causes of raised CK? (other than muscle inflammation)
- Rhabdomyolysis
- AKI
- MI
- Statins
- Strenuous exercise
154
Which cancers can cause dermatomyositis / polymyositis
- Lung
- Breast
- Ovarian
- Gastric
155
Dermatomyositis / Polymyositis
Presentation
- Muscle pain, fatigue, weakness
- BILATERAL
- Typically proximal muscles
- Mostly shoulder and pelvic girdle
- Develops over weeks
- May have malignancy
Dermatomyositis = rash too
156
Dermatomyositis
Skin lesions
- Gottron lesions - scaly, erythematous patches on knuckles, elbows, knees
- Photosensitive erythematous rash on back, shoulders, neck
- Purple rash on face/eyelids
- Periorbital oedema
- SC calcinosis
157
Dermatomyositis / Polymyositis
Autoantibodies
- Anti-Jo-1
- Anti-Mi-2
- ANA
158
Dermatomyositis / Polymyositis
Diagnosis
- Clinical
- Elevated CK
- Autoantibodies
- Electromyography (EMG)
MUSCLE BIOPSY = definitive
159
Dermatomyositis / Polymyositis
Management
- Corticosteroids = 1st line in both
- Immunosuppressants
- IV immunoglobulins
160
Behcet's Disease
What is it
- Complex inflammatory condition
| - Presents as oral and genital ulcers
161
Behcet's Disease
Genetics
Link with HLA B51
Prognostic indicator of severe disease
162
Behcet's Disease
Features
- Mouth ulcers - 3x episodes a year, painful, circumscribed with a RED HALO, heal over 2-4 weeks
- Genital ulcers
- Skin: erythema nodosum, papules and pustules, vasculitis rashes
- Eyes: anterior/posterior uveitis, retinal vasculitis, retinal haemorrhage
- MSK: arthralgia, morning stiffness, oligoarthritis
163
Behcet's Disease
Ix
- Pathergy test: uses sterile needle to create SC abrasion on forearm, reviewed 24-48 hrs later for a weal > 5mm in size
- Tests for non-specific hypersensitive reaction
164
Behcet's Disease
Management
Relapsing remitting condition
- Topical steroids to mouth ulcers
- Systemic steroids
- Colchicine
- Topical anaesthetics for genital ulcers
- Immunosuppressants
- Biologic therapy, e.g. infliximab
165
Osteoporosis
Patho
- Reduction in density of the bones
- Low bone mass and microarchitectural deterioration of bone tissue
- Loss of coupling in the bone remodelling process --> osteoclasts start to outwork the osteoblasts
- Can be due to increased bone resorption, decreased bone formation or both
- Results in overall net loss of bone volume
- Spongy bone becomes increasingly porous
- Increased fracture risk
166
Risk factors for osteoporosis
- Older age
- Female
- Reduced mobility
- Low BMI
- RA
- Alcohol and smoking
- Long-term steroids (cortico)
- SSRIs, PPIs, anti-eplieptics, anti-oestrogens
- Post-menopausal women (oestrogen is protective against OP)
167
FRAX tool
What does it do?
It gives results as a percentage 10-year probability of a:
- Major osteoporotic fracture
- Hip fracture
168
DEXA scan
What is it and what does it measure?
- A brief XR scan that measures radiation absorbed by the bone
- Measures bone mineral density
- Must be measured at the hip for classification and management of OP
169
Bone density scores
Types of score and which is more important
Z-score: number of standard deviations the patients bone density falls below the MEAN FOR THEIR AGE
T score: the number of standard deviations below the mean for a healthy young adult's bone density
T score of hip = most clinically important outcome
170
Bone density scores
Classification
Using T scores from hip:
> 1 = Normal
-1 to -2.5 = Osteopenia
< -2.5 = Osteoporosis
< -2.5 + fracture = Severe osteoporosis
171
Osteoporosis
Management - lifestyle changes
- Activity and exercise
- Maintain a healthy weight
- Adequate calcium intake
- Adequate vit D
- Avoiding falls
- Stop smoking
- Reduce alcohol consumption
172
Osteoporosis
Management - pharmacological
- Vit D and calcium (Calcichew-D3)
- Bisphosphonates
- HRT if menopause
173
When to remeasure FRAX and DEXA in bisphosphonate Tx?
- After 3-5 years
- Treatment holiday if BMD has improved and no fragility fractures
- Break = 18 months to 3 years before repeating the assessment
174
Changes in trabecular architecture with age?
1. Decrease in trabecular thickness, more pronounced for non-load bearing trabecular
2. Decrease in connection between horizontal trabeculae
3. Decrease in trabecular strength and increased susceptibility to fractures
175
HRT benefits
- Reduce fracture risk by 50%
| - Stop bone loss
176
Osteomalacia
What is it?
- Defective bone mineralisation causing 'soft' bones
- Resulting from Vit D deficiency
- In children when it occurs prior to growth plates closing it is called RICKETS
177
Which autoantibody is associated with drug-induced SLE?
Anti-histone
178
Osteomalacia
Patho
- Low Vit D also causes low calcium and phosphate
- Calcium and phosphate are required for the construction of the bone
- Therefore, low levels results in defective bone mineralization
- Low calcium causes a secondary hyperparathyroidism as the parathyroid gland tries to raised calcium levels --> higher levels of PTH lead to increased resorption from the bone, causing further problems for the bone
179
Osteomalacia
Causes
- Vit D deficiency: malabsorption (IBD), lack of sunlight, diet, darker skin (requires longer periods of sunlight for same level of Vit D)
- CKD
- Drug-induced (anticonvulsants)
- Inherited (hypophosphatemic rickets)
- Liver disease, e.g. cirrhosis
180
Osteomalacia
Presentation
- Fatigue
- Bone pain
- Muscle weakness - proximal myopathy, waddling gait
- Muscle aches
- Pathological or abnormal fractures - especially femoral neck
- 'Looser zones' - fragility fractures that go part way through the bone
181
Osteomalacia
Investigations
- Serum-25-hydroxyvitamin D
- < 25 nmol/L is deficient
- 25-50 nmol/L = insufficient
- > 75 nmol/L = optimal, but > 50 considered enough for most
- Raised ALP
- Low calcium and low phosphate
- PTH (may be high)
- XR: more RADIOLUCENT bones, translucent bands, looser zones, pseudofractures
182
Osteomalacia
Treatment
Vit D supplementation (CHOLECALCIFEROL) if DEFICIENT:
- 50, 000 once weekly for 6 weeks
- 20,000 twice weekly for 7 weeks
- 4000 once daily for 10 weeks
If INSUFFICIENT, start on maintenance dose:
- Maintenance dose = 800 IU+ a day
- If deficient, should be continued after initial treatment
183
Paget's Disease of the bone
Patho
Increased bone turnover due to excessive activity of both osteoblasts and osteoclasts
- This is not coordinated, so leads to patchy areas of high density (sclerosis) and low density (lysis)
- Results in enlarged and misshapen bones with structural problems
- Increase risk of pathological fractures
- Particularly affects axial skeleton (head and spine) and long bones of lower limb
184
Causes of raised alkaline phosphatase (ALP)?
```
ALKPHOS
A: Any fracture
L: Liver damage - cholestatis, hepatitis, fatty liver, neoplasia and renal failure
K: K for Kancer (bone mets) + (K)Children - growing)
P: Paget's Disease + Pregnancy
H: Hyperparathyroidism
O: Osteomalacia
S: Surgery
```
Raised calcium: bone mets, hyperparathyroidism
Low calcium: Osteomalacia, renal failure
185
Paget's Disease of the bone
Predisposing factors
- Increasing age
- Male sex
- Northern latitude
- Fx
186
Paget's Disease of the bone
Presentation
Symptomatic in 1 in 20 (5%)
- Bone pain
- Bone deformity - bowing of tibia, bossing of skull
- Fractures
- Hearing loss (if bones of ear affected)
Typical patient = older male with bone pain and isolated raised ALP
187
Paget's Disease of the bone
Investigations
- Raised ALP (other LFTs normal)
- Normal calcium and phosphate
XR:
- Osteoporosis circumscripta (osteolytic lesions that appears dense compared to normal bone)
- Cotton wool appearance of skull - poorly defined patchy areas of increased density (sclerosis) and decreased density (lysis)
- V-shaped defect within normal bone in the long bones
188
Paget's Disease of the bone
Management
- BISPHOSPHONATES (risedronate or IV zolendronate)
- NSAIDs for bone pain
- Calcium and Vit D supplements
- Surgery for fractures - rare
Monitoring = check the ALP and review symptoms
189
Paget's Disease
Complications
- Osteosarcoma
- Spinal stenosis and spinal cord compression
- Deafness (cranial nerve entrapment)
- Fractures
- High-output cardiac failure
190
What is felty's syndrome
- RA
- Splenomegaly
- Neutropenia
191
Osteosarcoma
- Type of bone cancer
- Mesenchymal cells with osteoblastic differentiation
- Very poor prognosis
- Presents with focal bone pain, bone swelling or pathological fractures
- Risk is increased in Paget's - patients need to be followed up to detect it early, usually seen on plain XR
192
Spinal stenosis of Pagets
- Deformity in spine leads to spinal canal narrowing
- If presses on spinal nerves --> neuro symptoms
- Diagnosed with MRI
- Treated with bisphosphonates
- Surgical intervention may be considered
193
Polymyalgia rheumatica
Presentation
Inflammatory condition that cause:
- Pain and stiffness in shoulders, pelvic girdle and neck
- Bilateral shoulder pain, may radiate to elbow
- Bilateral pelvic girdle pain
- Worse with movement
- Interferes with sleep
- Stiffness for at least 45 mins in morning
- Systemic: weight loss, fatigue, low-grade fever, low mood
- Upper arm tenderness
- Carpal tunnel syndrome
- Pitting oedema
NO WEAKNESS
194
Polymyalgia rheumatica
Epidemiology
- Usually aged > 60 yrs
- Rapid onset (< 1 month)
- More common in women
- More common in caucasians
195
Polymyalgia rheumatica
Investigations
- Raised ESR > 40 mm/hr
| - Normal CK and EMG
196
Polymyalgia rheumatica
Management
- Prednisolone - 15 mg OD to start
- Assess after 1 week - if not response, consider alternative diagnosis
- Assess after 3-4 weeks, should see 70% improvement in symptoms and inflammatory markers to be normal
197
Additional measures for patients on steroids
DON'T STOP:
- DON’T – Make them aware that they will become steroid dependent after 3 weeks of treatment and should not stop taking the steroids due to the risk of adrenal crisis if steroids are abruptly withdrawn
- S – Sick Day Rules: Discuss increasing the steroid dose if they become unwell (“sick day rules”)
- T – Treatment Card: Provide a steroid treatment card to alert others that they are steroid dependent in case they become unresponsive
- O – Osteoporosis prevention: Consider osteoporosis prophylaxis whilst on steroids with bisphosphonates and calcium and vitamin D supplements
- P – Proton pump inhibitor: Consider gastric protection with a proton pump inhibitor (e.g. omeprazole)
198
Types of sarcoma
Bone sarcoma:
- Osteosarcoma (most common)
- Chondrosarcoma (cartilage)
- Ewing sarcoma (most affecting children/young adults)
Soft-tissue sarcoma:
- Liposarcoma (adipose tissue)
- Rhabdomyosarcoma (skeletal muscle)
- Leiomyocarcoma (smooth muscle)
- Synovial sarcoma (soft tissues around the joints)
- Angiosarcoma (blood and lymp)
- Kaposi's sarcoma (HHV 8, seen in HIV)
199
Sarcoma
Presentation
- Soft tissue lump (> 5cm) - particularly if growing, painful, large
- Bone swelling
- Persistent bone pain
200
Sarcoma
Investigations
- XR for bone
- US for soft tissue
- CT or MRI to visualise lesion and look for mets (particularly thorax as spreads to lungs)
- Biopsy required to look at histology
201
Sarcoma
Staging
TNM staging
| Most common to metastasise to lungs
202
Sarcoma
Management
- Surgery
- Radiotherapy
- Chemotherapy
- Palliative care
203
Kaposi's sarcoma
- Caused by human herpes virus (HHV) 8
- Presents as purple papules or plaques to skin or mucosa (e.g. GI tract, resp tract)
- Skin lesions may later ulcerate
- Resp involvement may cause massive haemoptysis and pleural effusion
- Radiotherapy and resection
204
Which bones have vulnerable blood supplies? (fracture can lead to avascular necrosis, non-union and impaired healing)
- Scaphoid bone
- Femoral head (hip)
- Humeral head (shoulder)
- Talus, navicular and fifth metatarsal in the foot
205
Pathological fractures
Bone mets - which?
PoRTaBLe
```
P: Prostate
R: Renal
T: Thyroid
B: Breast
L: Lung
```
206
Pathological fractures
Bone diseases
- Osteogenesis imperfecta
- Osteoporosis
- Metabolic bone disease
- Paget's disease
207
Pathological fractures
Benign conditions
- Chronic osteomyelitis
| - Solitary bone cyst
208
Pathological fractures
Primary malignant tumours
- Chondrosarcoma
- Osteosarcoma
- Ewing's tumour
209
Complications of fractures
- Damage to local structures (e.g., tendons, muscles, arteries, nerves, skin and lung)
- Haemorrhage leading to shock and potentially death
- Compartment syndrome
- Fat embolism (see below)
- Venous thromboembolism (DVTs and PEs) due to immobility
210
What is a fat embolism?
- Can occur following fracture of long bones
- Fat globules released into cirulcation
- Become lodged in blood vessels
- Can cause a systemic inflammatory response --> fat embolism syndrome
- Typically 24-72 hrs after fracture
- Operating early reduces risk of fat embolism
211
Compartment syndrome
Patho
- The pressure within a fascial compartment is abnormally high
- Cuts off blood flow to contents of that compartment
212
Compartment syndrome
Causes
- Bone fractures
- Crush Injuries
(Oedema and tissue swelling creates high pressure)
213
Compartment syndrome
Most common fractures associated with it?
- Supracondylar fractures (humerus, above elbow)
| - Tibial shaft fractures (shin)
214
Compartment syndrome
Presentation
5 P's:
- P: Pain - disproportionate to underlying injury, worse on Passive stretching of muscle - pain meds are not effective
- P: Paraesthesia
- P: Pale
- P: Pressure = high
- P: Paralysis (late and worrying feature)
- P: Presence of Pulse (because necrosis is due to microvascular compression)
215
Compartment syndrome
Diagnosis
- Measure intracompartmental pressure (> 20 mmHg = abnormal, > 40 mmHg = diagnostic) = needle manometry
- Won't show on XR
216
Compartment syndrome
Management
- Escalate to ortho reg/consultant
- Remove any external dressings/bandages
- Elevate leg to heart level
- Maintain good blood pressure (avoid hypotension)
- Emergency fasciotomy (within 6 hrs of injury)
- Explore compartment and debride any necrotic muscle tissue
- Leave wound open and cover with dressing
- May require repeated surgery every few days for necrotic tissue
- Skin graft may be required if skin can never close
217
Compartment syndrome
Chronic
- Usually associated with exertion
- During exertion, pressure rises, blood flow is restricted and symptom start
- During rest, pressure falls and symptoms resolve
- Not an emergency
- Symptoms are usually isolated to specific location
- Pain, numbness, paraesthesia
- Needle manometry before, during, after exertion
- Tx = fasciotomy
218
Osteomyelitis
Types
Metastatic haematogenous spread
- Most common in children
- Vertebral is most common in adults
- Pathogen is carried through blood and seeded in the bone
- Usually monomicrobial
- RFs: sickle cell, IVDU, immunosuppression, infective endocarditis
Direct/local infection
- Most common adults
- Spread of infection from adjacent soft tissues or direct trauma/injury
- Often polymicrobial
- RFs: diabetic foot ulcers/pressure sores, DM, PAD
219
Osteomyelitis
Causes
STAPH AUREUS
- H. influenza
- Salmonella (in SICKLE CELL)
220
Osteomyelitis
Symptoms
- Fever
- Local pain and erythema
- Sinus formation - if chronic
221
Osteomyelitis
Investigations
- MRI = BEST
- XR often does not show changes, can not be used to exclude osteomyelitis
- Blood tests - ESR, CRP, WBC
- Blood cultures
- Bone cultures
222
Osteomyelitis
Management of acute
- Surgical debridement
- Abx: 6 weeks of FLUCLOXACILLIN +/- fusidic acid or rifampicin for first 2 weeks
- If PA: clindamycin
- If MRSA: Vancomycin or teicoplanin
223
Osteomyelitis
Management of chronic
- 3 months of Abx
| - If associated with prosthetic joints --> may need complete revision
224
Fibromyalgia
What is it?
A syndrome characterized by widespread pain throughout the body, with tender points at specific anatomical sites.
Cause is unknown.
225
Fibromyalgia
Epidemiology
- 5x more commin women
| - Typically between 30 and 50 yrs
226
Fibromyalgia
Features
- Chronic pain: at multiple sites, sometimes 'pain all over'
- > 3 months
- Lethargy
- Cognitive impairment: fibro fog
- Sleep disturbances
- Headaches
- Dizziness
- Low mood
- NO inflammation
227
Fibromyalgia
Diagnosis
Clinical using classification criteria of 9 pairs of tender points. If pain in at least 11 of 18 points, diagnosis is more likely
228
Fibromyalgia
Management
- Education of patient and family
- Explain - relapsing and remitting
- Reassure - Pain is not damaging the body/joints
- CBT
- Graded aerobic exercise programmes
- Drugs: rarely respond to NSAIDs and steroids (if so, reconsider diagnosis)
- Tricyclic antidepressants - amytryptilline! pregablin, duloxetine
229
Red flag causes of back pain
- Spinal fracture (e.g., major trauma)
- Cauda equina (e.g., saddle anaesthesia, urinary retention, incontinence or bilateral neurological signs)
- Spinal stenosis (e.g., intermittent neurogenic claudication)
- Ankylosing spondylitis (e.g., age under 40, gradual onset, morning stiffness or night-time pain)
- Spinal infection (e.g., fever or a history of IV drug use)
230
Abdo and thoracic causes of back pain
- Pneumonia
- Ruptured aortic aneurysms
- Kidney stones
- Pyelonephritis
- Pancreatitis
- Prostatitis
- Pelvic inflammatory disease
- Endometriosis
231
Sciatica
Which nerves is it formed from?
Spinal nerves L4 - S3 come together to form sciatic nerve
232
Sciatica
Path of sciatic nerve?
- Exits posterior part of pelvis through GREATER SCIATIC FORAMEN in buttock area
- Travels down BACK of leg
- Divides at knee into TIBIAL NERVE and COMMON PERONEAL NERVE
233
Sciatic nerve
What does it supply?
motor and sensory
Motor - posterior thigh, lower leg and foot
| Sensory - lateral lower leg and foot
234
Sciatica
Presentation
- Unilateral pain from buttock, down back of thigh to below knee or feet
- Electric or shooting pains
- Paraesthesia
- Numbness
- Motor weakness
- Reflexes may be affected depending on affect nerve root
235
Sciatica
Main causes?
Lumbosacral nerve root compression:
- Herniate disc
- Spondylolisthesis (anterior displacement of a vertebra out of line with one below)
- Spinal stenosis
236
Sciatica
Red flag?
Bilateral - red flag for cauda equina !!
237
Key symptoms of back pain history
- Major trauma (spinal fracture)
- Stiffness in the morning or with rest (ankylosing spondylitis)
- Age under 40 (ankylosing spondylitis)
- Gradual onset of progressive pain (ankylosing spondylitis or cancer)
- Night pain (ankylosing spondylitis or cancer)
- Age over 50 (cancer)
- Weight loss (cancer)
- Bilateral neurological motor or sensory symptoms (cauda equina)
- Saddle anaesthesia (cauda equina)
- Urinary retention or incontinence (cauda equina)
- Faecal incontinence (cauda equina)
- History of cancer with potential metastasis (cauda equina or spinal metastases)
- Fever (spinal infection)
- IV drug use (spinal infection)
238
Key examination findings with back pain?
- Localised tenderness to the spine (spinal fracture or cancer)
- Bilateral neurological motor or sensory signs (cauda equina)
- Bladder distention implying urinary retention (cauda equina)
- Reduced anal tone on PR examination (cauda equina)
239
Sciatica
Management
- Do NOT use gabapentin, pregabalin, diazepam, oral corticosteroids, pioids
- DO USE amitriptyline, duloxetine
Specialist management:
- Epidural corticosteroid injections
- Local anaesthetic injections
- Radiofrequency denervation
- Spinal decompression
240
Tronchanteric bursitis
Patho
- Bursa = sacs created by synovial membrane, filled with small amount of synovial fluid (also found at knee, shoulder, elbow)
- Inflammation of the bursa over the greater trochanter of hip
- Causes thickening of synovial membrane and increased production of synovial fluid causing swelling of bursa
241
Tronchanteric bursitis
Presentation
- Middle-aged
- Gradual onset
- Pain over the lateral side of thigh/hip
- May radiate to the outer thigh
- Aching/burning
- Worse on activity, standing after sitting for a prolonged time, sitting cross-legged
- May disrupt sleep, struggle to find a comfortable position
- Tenderness on palpation of greater trochanter
- No visible swelling (unlike other bursitis)
242
Tronchanteric bursitis
Causes
- Friction from repetitive movement
- Trauma
- Inflammatory conditions (RA)
- Infection (septic bursitis) - rare
243
Tronchanteric bursitis
Special tests
- Trendelenburg test: stand one legged on affected leg. Other side will drop down, suggesting weakness in hip.
- Worse pain on: resisted abduction, internal and external rotation of hips
244
Tronchanteric bursitis
Management
- Rest
- ICE
- Analgesia - NSAIDs
- PT
- Steroid injections
- If infected (warmth, erythema, swelling, pain, fever) --> Abx
- Can take 6-9 months to fully recover
245
Which drugs can cause achilles tendon rupture?
- Ciprofloxacin (fluoroquinolones) - can occur spontaneously within 48 hrs of starting Tx
- Steroids
246
Frozen shoulder
What is the main risk factor?
Diabetes
247
What is anterior shoulder dislocation associated with?
| anterior glenohumeral
- Greater tuberosity fracture
- Bankart lesion
- Hill-Sachs defect
248
What is inferior shoulder dislocation associated with?
| inferior glenohumeral
- Luxatio erecta
249
What is posterior shoulder dislocation associated with?
| posterior glenohumeral
- Rim's sign
- Light bulb sign
- Trough sign
250
When might you see an acromioclavicular fracture? How might it present?
- Clavicle loses all attachment
- Secondary to direct injury to superior aspect of acromion
- Loss of shoulder contour and prominent clavicle
E.g. A 23-year-old rugby player falls directly onto his shoulder. There is pain and swelling of the shoulder joint. The clavicle is prominent and there appears to be a step deformity
251
Achilles tendon rupture
Imaging of choice
USS
252
Achilles tendon rupture
What examination shoudl be performed?
Simmonds triad
- Ask patient to lie prone with feet over bed
- Look for an abnormal angle of declination (may lead to greater dorsiflexion of foot compared to other foot)
- Feel for a gap in the tendon
- gently squeeze calf muscle - if rupture, the foot will stay in neutral position
253
What is charcot joint?
- Neuropathic joint
- Joint becomes badly disrupted and damaged due to loss of sensation
- not necessarily painful
- Swollen, red and warm joint
- Seen in peripheral neuropathy (DM, alcoholics)
254
Posterior hip dislocation
Presentation
- Internally rotated
- Shortened leg
- Adducted
255
Posterior hip dislocation
Management
- ABCDE
- Analgesia
- Reduction under GA within 4 hours to reduce risk of avascular necrosis (anterior)
- Long term PT
256
Posterior hip dislocation
Complications
- Sciatic nerve injury
257
Anterior hip dislocation
Presentation
- Externally rotated
- Abducted
- NO shortening of leg
258
Anterior hip dislocation
Complications
Avascular necrosis
259
What can you not prescribe allopurinol with? Why?
Azathioprine
| Bone marrow suppression!
260
Which hip dislocation is most common?
Posterior
261
Presentation of a fat embolism?
- Respiratory
- Neurological
- Petechial rash !! (usually after first 2 symptoms)
262
SEs of azathioprine
- Bone marrow suppression
- N+V
- Pancreatitis
- Increased risk of non-melanoma skin cancer
- Interacts with allopurinol
- SAFE in pregnancy
263
What blood supply supplies the scaphoid?
Dorsal carpal branch of radial artery
264
Which drugs can induce SLE?
- procainamide
- hydralazine
Less common:
- isoniazid
- minocycline
- phenytoin
265
What can be used to monitor active flares of SLE?
Complement factor - levels drop in active disease due to the formation of complexes leads to consumption of complement
266
Causes of dupytrens
- manual labour
- phenytoin treatment
- alcoholic liver disease
- diabetes mellitus
- trauma to the hand
