MSK- orthopaedics and rheumatology

Question 1

What are the seronegative spondyloarthropathies

Answer 1

Ankylosing spondylitis
Psoriatic arthritis
IBD related arthritis
Reactive arthritis

Question 2

Most common primary malignant bone tumour

Answer 2

Osteosarcoma
Seen mostly in children and adolescents
Sunburst pattern on xray

Question 3

Ewing’s sarcoma sign on xray

Answer 3

Onion skin appearance

Severe long bone pain

Question 4

Differentials for polyarteritis

Answer 4

Rheumatoid arthritis 
SLE
Seronegative spondyloarthropathies 
Henoch-Schonlein purpura
Sarcoidosis
Tuberculosis
Pseudogout
Viral infection: EBV, HIV, hepatitis, mumps, rubella

Question 5

Classical Colle’s fracture

Answer 5

Fall onto an extended outstretched hand
Transverse fracture of the radius
1 inch proximal to the radio-carpal joint
Dorsal displacement and angulation

Question 6

Bennett’s fracture

Answer 6

Intra-articular fracture of the first carpometocarpal joint

Caused by fist fights

Question 7

Pott’s fracture

Answer 7

Bimalleolar ankle fracture

Question 8

Blood results in PMR

Answer 8

Raised ESR and CRP

Normal CK and anti-CCP

Question 9

Typical features of PMR

Answer 9

Usually patient >60
Association with GCA
Usually rapid onset
Aching, morning stiffness in proximal limb muscles (which may present as weakness but is not true weakness)
Mild polyarthralgia
Lethargy and depression
Low grade fever
Anorexia 
Night sweats

Question 10

Schober’s test

Answer 10

A line is drawn at the level of the ASIS
10cm above and 5cm below
Gap should increase on lumbar flexion by more than 5cm

Question 11

Management of De Quervain’s tenosynovitis

Answer 11

Analgesia
Steroid injection
Immobilisation with a thumb splint
Surgical treatment may be required

Question 12

Signs of ank spon on Xray

Answer 12

Sacroilitis- subchondral erosions and sclerosis (most useful in establishing diagnosis)
Squaring of lumbar vertebrae
Syndesmophytes due to ossification of the annulus fibrosus
Bamboo spine (late stages)
‘Shiny corners’ on MRI

Question 13

Felty’s syndrome

Answer 13

RA
Splenomegaly
Low WCC

Question 14

Sulfasalazine

Answer 14

5-ASA- decreases neutrophil chemotaxis and suppresses lymphocytic prophylaxis

Allergy to sulphonamides

S/E: oligospermia, Stevens-Johnson, pneumonitis/ fibrosis, myelosuppression, anaemia

Considered safe in pregnancy and breast-feeding

Question 15

Anterior compartment of the lower leg

Innervated by

Answer 15

Tibialis anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis longus

Deep peroneal nerve

Question 16

Superficial posterior compartment of the lower leg

Innervated by

Answer 16

Gastrocnemius
Soleus

Tibial nerve

Question 17

Deep posterior compartment of the lower leg

Innervated by

Answer 17

Flexor digitorum longus
Flexor hallucis longus

Tibialis posterior

Question 18

Still’s disease in adults

Answer 18

Arthralgia 
Elevated serum ferritin
Salmon-pink, maculopapular rash
Pyrexia in a daily pattern- rises in the late afternoon 
Lymphadenopathy 
RF and ANA negative

Question 19

Most common cause of mitral stenosis

Answer 19

Rheumatic fever

Question 20

Erythema marginatum

Answer 20

Pathognomonic for rheumatic fever
Annular erythematous rash that commonly affects the trunk and inner surfaces of arms and legs and can persist for several months
Non-pruritic rings that are barely raised
Generally spares the face

Question 21

Clinical features of ankylosing spondylitis

Answer 21

Young caucasian man in teens or 20s
Sacroiliitis- MRI can show early oedema
Back pain in the night or early morning, especially on inactivity
Unilateral buttock pain that radiates to the groin

Question 22

Complications of ankylosing spon

Answer 22

Enphysitis- inflammation between tendon and bone
Costochondritis
Rarely jaw pain
Apical interstitial fibrosis
Fusing of syndesmophytes late stage causes bamboo spine

Question 23

Treatment of ankylosing spondiliitis

Answer 23

NSAIDs- ibuprofen and/or naproxen
Exercise
Physiotherapy
If this isn’t successful then biologics can be used- infliximab

Question 24

Management of OA

Answer 24

Exercise to improve muscle strength and general aerobic fitness
MDT approach, PT and OT
Heat or cold packs, walking aids and TENS

Analgesia- regular paracetamol and topical NSAIDs, can use codeine or oral NSAIDs if ineffective
Intra-articular steroid injections temporarily relieve pain in severe cases

Surgical- Joint replacement

Question 25

Management of septic arthritis

Answer 25

Which organisms and how did they get there? immunosuppression, CKD, recent surgery, STI, IV drug abuse 2 weeks broad spectrum antibiotics IV until sensitivities are known and then more specific by local guidelines 4 weeks oral Orthopaedic review for athrocentesis, washout and debridement

Question 26

Extra-articular manifestations of rheumatoid arthritis

Answer 26

Nodules- elbow, lungs, cardiac, CNS, lymphadenopathy, vasculitis Lungs- pleural disease, interstitial fibrosis, bronchiolitis obliterans Cardiac- IHD, pericarditis, pericardial effusion Carpal tunnel syndrome Peripheral neuropathy Felty's syndrome Eye- episcleritis, scleritis, scleromalacia, keratoconjunctivitis sicca Osteoporosis Amyloidosis

Question 27

Investigating ?RA

Answer 27

Anti-rheumatoid factor- positive in 70% Anti- citric citrullinated peptide- highly specific (90-95%) FBC- anaemia of chronic disease, raised platelets ESR raised Raised CRP Xrays- loss of joint space, erosions, soft tissue swelling, juxta-articular osteoporosis

Question 28

Management of RA

Answer 28

Disease activity monitoring via DAS28 DMARDs and biological agents (after trialling at least 2 DMARDs) Steroids to bridge, reducing symptoms and inflammation NSAIDs PT and OT

Question 29

Crystals in gout

Answer 29

Monosodium urate

Question 30

Limited systemic sclerosis

Answer 30

Anti-centromere antibodies | Involves the hands, face and feet, pulmonary hypertension is often subclinical

Question 31

What should be screened for in any myositis?

Answer 31

Malignancy- lung, pancreatic, ovarian or bowel | Can often present as a paraneoplastic phenomenon, even before the disease takes hold

Question 32

Clinical features of dermatomyositis

Answer 32

Myositis- symmetrical, proximal muscle weakness Macular rash- heliotrope rash on eyelids often with oedema Nailfold erythema Gottron's papules- pathognomic if raised CK and weakness

Question 33

Differentials for myositis

Answer 33

``` Dermatomyositis Polymyositis Inclusion body myositis Carcinomatous myopathy Muscular dystrophy (Becker's if older) PMR Endocrine/metabolic myopathy Rhabdomyolysis Infection Drugs- penicillamine, colchicine, statins, chloroquine ```

Question 34

Tests for myositis

Answer 34

CK and other muscle enzymes- ALT, AST, LDH, aldolase EMG Muscle biopsy Anti-Mi2 or anti-Jo1

Question 35

Clinical features of systemic lupus erythematosus

Answer 35

Malaise, fatigue, myalgia, fever Lymphadenopathy, weight loss, alopeecia, nail-fold infarcts, Raynaud's Malar rash- flat or raised, sparing of the nasolabial folds, can be photosensitive Oral nasal uclers Synovitis Serositis- pleura or pericardium Haemolytic anaemia- positive direct Coombs test

Question 36

Antibodies in drug induced lupus

Answer 36

Anti-histone

Question 37

Laboratory features of SLE

Answer 37

``` +ANA Anti-dsDNA Anti-smith Low complement C3 and C4 +direct Coombs test Antiphospholipid antibodies in 20-30% ```

Question 38

Management of SLE

Answer 38

MDT, specialist team/ nephritis clinic General measures- high factor sunblock, hydroxychloroquine, screen for co-morbidities and medication toxicity Maintenance- NSAIDs and hydroxychloroquine Also can use methotrexate, azathioprine, mycophenolate or biologics Mild flares- hydroxychloroquine or low dose steroids Moderate may require DMARDs Severe flares- urgent high dose steroids, mycophenolate, rituximab, cyclophosphamide MDT for neuropsychiatric SLE

Question 39

Antiphospholipid syndrome manifestations | HINT: CLOT

Answer 39

Coagulation defect with paradoxical raised APTT Livedo reticularis Obstetric complications- recurrent miscarriage Thrombocytopenia

Question 40

Antiphospholipid antibodies

Answer 40

Anti-cardiolipin Anti glycoprotein Lupus anticoagulant