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MSK & Rheum Flashcards

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1
Q

Give general fracture and open fracture tx

A

General:
1. Immobilise fracture including proximal and distal joints
2. Document neurovascular status before and after reduction and immobilisation
Ensure tetanus prophylaxis

Open:

1. IV broad spectrum abx
2. Tetanus prophylaxis 3. Thorough debridement and lavage
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2
Q

Tx for displaced and undisplaced NOF fracture. Extracapsular?

A

Pt v unwell intracapsular - hemiarthroplasty
Undisplaced - internal fixation
Displaced - below 70 internal fixation. Above 70 total hip
Extracapsular - dynamic hip screw

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3
Q

S&S of femur fracture?

A
  • Pain

* Shortened and externally rotated leg

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4
Q

Early S&S of compartment syndrome?

A 
• EXTREME Pain or tenderness
		○ Worse on passive movement
		○ Worsening despite analgesia
	• Swelling
Parasthesia
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5
Q

Investigation for compartment syndrome. results?

A

• Measure intracompartmental pressure. >20mmHg is abnormal. >40mmHg is diagnostic.

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6
Q

RFs of compartment syndrome?

A

• Occurs following fractures. Typically suprachondylar and tibial shaft injuries.
Be wary also of tight casts or splints or DVTs

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7
Q

Tx for displaced and non displaced humeral fracture?

A

• Significantly displaced - ORIF
• Non displaced - Collar and cuff for 3 wks followed by physio
Assess neurovascular status

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8
Q

RFs for slipped upper femoral epiphysis?

A

• Obesity
• Age 11-15 most common
M 2:1 F

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9
Q

tx for slipped upper femoral epiphysis

A

• External fixation or Open reduction and pinning AS IS. Attempts to move it back could cause further damage.
Emergency as could lead to avascular necrosis of head of femur

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10
Q

Name the types of salter harris fractures

A 
S - Slip 
A - Above physis
L - Lower. Below physis in the epiphysis
TE - Through everything.
R - Rammed (crushed)
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11
Q

Perthes xray?

A

Flattened femoral head

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12
Q

S&S of perthes?

A

• Hip, knee or groin pain exacerbated by internal rotation
• Limp
Leg length disparity

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13
Q

Tx of perthes

A
  • Minimising damage while disease runs course

* Traction of leg using brace, physiotherapy.

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14
Q

Investigation of congenital hip dysplasia?

A

• Barlow maneuver (adduct hip and push knee) and Ortolani maneuver (abduct hip and push knee) - barlow dislocates and Ortolani relocates. Will hear clunking
Limb length inequality in 1 sided hip dysplasia.

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15
Q

Tx of Congenital hip dysplasia

A

pavlik harness

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16
Q

Osteomyelitis investigation

A

Bloods - WCC
CT - cortical destruction with lytic centre
MRI - edema
Bone biopsy

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17
Q

ADR of methotrexate

A

• Myelosuppression
• Hepatotoxic
PULMONARY FIBROSIS

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18
Q

ADR of sulfasalazine

A

• Rashes
• Oligospermia
ILD

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19
Q

ADR of leflunomide

A

• ILD
• HTN
Hepatotoxic

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20
Q

ADR of infliximab

A

Reactivation of TB

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21
Q

Bisphosphonate ADRs

A

• Oeseophageal ulcers

Osteonecrosis of jaw

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22
Q

OA S&S on hands

A

Bouchons nodes - proximal IPJ

Heberdens nodes - distal IPJ

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23
Q

OA investigations

A 
Xray - LOSS
	• L - Loss of joint space
	• O - Osteophytes forming at joint margins
	• S - Subchondral sclerosis
S - Subchondral cysts
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24
Q

OA tx analgesics

A

1st line Paracetemol + topical NSAIDs NSAIDs for Hand and knee OA only
2nd line Oral NSAIDs, opioids, capsaicin cream, intra-articular corticosteroids PPI co-prescribed with NSAIDs
3rd line Supports and braces, shock absorbing insoles
4th line Joint replacement

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25
OA tx post operative
* LMWH for 4 weeks after hip * Pts need physio and home exercises * Crutches and walking sticks used for up to 6 wks
26
OA general advice
• Weight loss | Muscle strengthening + aerobic fitness
27
How to avoid dislocation in hip replacement?
• Avoid flexing hip >90 degrees • Avoid low chairs • Don’t cross legs Sleep on back for first 6 wks
28
Indications for hip replacement in OA?
Conservative tried, pt still in pain.
29
RA S&S
• Swollen painful joints in hands and feet • Morning stiffness improves with use • Bilateral symptoms over a few months • Systemic upset Positive squeeze test - discomfort on squeezing across joint
30
RA blood tests
• Rheumatoid Factor (RF) detected by Rose-Waaler test. RF not specific to RA. Anti-CCP antibody
31
RA xray findings
• L - Loss of joint space • E - Erosions periarticular • S - Soft tissue swelling S - Soft bones, osteopenia
32
Tx of RA
1st line Methotrexate + 1 other DMARD + Prednisolone 2nd line - If 2 DMARDs don’t work + TNF inhibitor eg infliximab DMARDs - sulfasalazine, leflunomide
33
RA and pregnancy Tx
Use sulfasalazine. Other drugs not safe
34
Give lung, ocular, heart problems of RA
Occular: • Keratoconjunctivitis sicca (conjunctiva dryness) • Episcleritis (erythema) Scleritis (erythema and pain) ``` Lung problems: • PULMONARY FIBROSIS • Pleural effusion • Pleurisy INFECTION DUE TO IMMUNOSUPPRESSION ``` Heart problems: IHD
35
Give 3 spondylarthropathies
• Psoriatic arthritis • Reactive arthritis Ankylosing spondylitis
36
Patho of ankylosing spondylitis?
• HLA-B27 • Rheumatic arthritis affecting joints of spine • Occasionally affects shoulder or hips Affects males aged 20-30 typically.
37
investigation of ankylosing spondylitis
• Xray of sacroiliac joints: ○ Syndesmophytes - ossification of outer fibers of annulus fibrosis ○ Squaring of lumbar vertebrae Sacroiliitis - Sclerosis, subchondral erosions
38
Tx of ankylosing sponylitis?
• Regular exercise • Physio • NSAIDs Last line - TNF inhibitor eg infliximab
39
S&S of ankylosing spondylitis?
• Lower back pain and stiffness with insidious onset • Worse in morning and improves with exercise • Pain at night improves on getting up • Reduced lateral and forward flexion (Schobers test) Reduced chest expansion
40
Patho of reactive arthritis
• HLA-B27 • Arthritis that develops in response to an infection in another part of the body • Part of Reiter's syndrome - triad of urethritis, conjunctivitis, and arthritis: ○ "Reiter cant see, pee, or climb a tree" • Can be post-dysenteric (gastroenteritis resulting in diarrhoea with blood) or post STI
41
What is Reiters syndrome
Part of Reiter's syndrome - triad of urethritis, conjunctivitis, and arthritis: ○ "Reiter cant see, pee, or climb a tree"
42
Organisms of reactive arthritis
• Post-dysentry - Shigella flexneri, Salmonella enteritidis | Post-STI - Chlamydia trachomatis
43
Tx of reactive arthritis
* Symptomatic - Analgesia, NSAIDs, Intra articular steroids | * Persistent - sulfasalazine and methotrexate
44
Patho of soriatic arthropathy
• HLA-B27 associated | Arthritis developing in people with psoriasis
45
Tx of psoriatic arthropathy
• Treat as RA | Better prognosis
46
S&S of psoriatic artrhopathy
• Pain, swelling, stiff joint(s) • Typically symmetrical polyarthritis OR asymmetrical oligoarthritis • Can affect fingers, nails (pitting or separation), and skin Psoriasis over extensor regions
47
Poly vs oligoarthritis?
• Oligo arthritis - 2-4 joints | Polyarthritis - 5+ joints
48
S&S septic arthritis
• Acutely inflamed joint | Extremely Painful to move
49
RFs of septic arthritis
• Pre-existing joint disease esp RA • DM • Immunosuppression IVDU
50
Important thing to remember with septic arthritis?
ASK YOURSELF HOW DID THE ORGANISM GET IN??
51
Investigations for septic arthritis?
• Urgent joint fluid aspirate + culture and microscopy
52
S&S of SLE
• Fatigue • Fevers • Mouth ulcers Lymphadenopathy
53
Skin signs of SLE?
• Malar rash sparing nasolabial folds • Photosensitivity Raynauds
54
Blood tests for SLE?
• ANA, • anti-dsDNA, anti-Smith
55
Renal complications and tx of SLE?
• Diffuse proliferative glomerulonephritis | Tx - treat HTN, prednisolone, immunosuppressants (azathiopine)
56
Patho of Systemic sclerosis?
• Hardened, sclerotic skin and other connective tissues • 3 types: ○ Limited cutaneous - affects face and distal limbs predominantly. AKA CREST syndrome ○ Diffuse cutaneous - Affects trunk, limbs. Involves HTN, lung fibrosis, kidneys Scleroderma - Tightening and fibrosis of skin. No organ involvement
57
Blood for systemic sclerosis?
• ANA positive • RF positive Anti-centromere antibody
58
What is CREST syndrome?
Limited cutaneous systemic sclerosis Calcinosis - thickening + tightening of skin with calcific nodules • Raynauds • Esophageal dysmotility - Food stuck in mid or lower esophagous • Sclerodactyly - Tightening of finger joints Telangiectasias
59
Tx of raynauds?
• 1st line - CCB eg nifedipine | IV prostacyclin infusions - effects last several weeks
60
Patho of raynauds?
• May be primary or secondary • Typically young women with symmetrical attacks Fingers have reduced blood flow due to spasm of arteries
61
Fibromyalgia patho and epidemiology?
• Widespread pain throughout body • Women 10x more likely 30-50 yo
62
S&S of fibromyalgia?
• Lethargy • Chronic pain Sleep disturbance, headaches, dizziness
63
Tx of fibromyalgia?
• Explanation • Aerobic exercise • CBT Medication - pregabalin, duloxetine, amitryptiline
64
Gout patho?
* Comes as episodes * Form of inflammatory arthritis * Results from elevated serum uric acid which crystallises
65
Xray features of gout?
• Joint effusion | Punched out erosion
66
RFs of gout?
• Decreased uric acid excretion - diuretics, CKD • Increase uric acid production - chemo, severe psoriasis Alcohol
67
S&S of gout?
• Pain at max within 12 hrs • Swelling • Erythema Usually affects 1st MTPJ. Also commonly affects ankle, Wrist, knee
68
Tx of acute gout?
• NSAIDs • Intra articular steroid Colchicine
69
Indications of allopurinol prophylaxis for gout
dications: ○ Recurrent attacks - 2+ in 1 year ○ Tophi ○ Renal disease ○ Uric acid kidney stones • Start 2 weeks after acute attack settles or may precipitate another attack Use NSAID or colchicine cover when starting
70
Lifestyle modifications for gout?
• Reduce alcohol and purin intake | Lose weight
71
Gout v pseudogout?
Pseudo affects knee mostly. CCP crystals in pseudogout. Chrondocalcinosis on xray in pseudo.
72
Investigations of pseudogout?
• Joint aspiration - Crystals of CCP | Xray - Chondrocalcinosis (calcification of cartilage). Pathognomonic.
73
Tx of pseudogout?
• Aspiration of joint fluid to exclude septic arthritis | NSAIDs or intraarticular steroids.
74
Red flags for lower back pain?
``` • <20yo or >50yo new case • History of previous malignancy • Night pain • History of trauma Systemically unwell ```
75
Symptoms of lower back pain for facet joint, spinal stenosis, ankylosing spondylitis, peripheral arterieal disease?
Facet Joint • Acute or chronic • Worse in morning and on standing • Pain over facts and on extension Spinal Stenosis • Gradual onset • Leg pain and/or back pain, numbness, weakness worse on walking • Aching pain resolved when sitting, leaning forwards • Investigate with MRI Ankylosing Spondylitis • Young man with lower back pain + stiffness • Worse in morning and improves with activity Peripheral Arterial Disease • Pain on walking, relieved by rest • Absent foot pulses • RFs - smoking, vascular diseases
76
S&S of disc prolapse?
• Leg pain worse than back | Pain worse when sitting (more pressure on spine)
77
Tx of disc prolapsE?
• Analgesia, physio, exercises | Consider MRI and referral if symptoms persist
78
L3 disc prolapse S&S?
• Anterior knee sensory loss • Weak quads +ve femoral stretch test
79
L4 disc prolapse S&S?
• Medial leg sensory loss • Weak quads +ve femoral stretch test
80
L5 disc prolapse S&S?
Sensory loss of lateral leg • Weak foot and hallucis dorsiflexion +ve sciatic nerve stretch test
81
S1 disc prolapse S&S?
• Sensory loss lateral foot • Weak planterflexion of foot +ve sciatic nerve stretch test
82
Dermatomes of lower limb?
Look up
83
Cauda equina syndrome S&S?
• Severe back pain • Saddle anasthesia • Fecal and urinary incontinence Sexual dysfunction
84
Tx of cauda equina syndrome?
• URGENT referral for surgical decompression
85
Investigationf for cauda equina syndrome?
MRI
86
Marfans Patho
• Auto dominant | Fibrillin-1 defect
87
S&S of marfans
``` • Tall stature with arm span to height ratio >1.05 • Pectus excavatum • Scoliosis • Heart problems Repeated pneumothoraces ```
88
Causes of AVN
• LT steroid use • Chemo • Alcohol excess Trauma
89
Polymyalgia rheumatica patho
• Muscle bed arteries affected Histology shows vasculitis with giant cells, skips certain sections of affected artery whilst damaging others (skip lesions)
90
Investigations for polymyalgia rheumatica
• ESR >40mm/hr ○ Statin myopathies have normal ESR Reduced CD8+ T cells
91
Tx for polymyalgia rheumatica
Prednisolone
92
S&S of polymyalgia rheumatica
• Pt >60yo • Rapid onset - <1mth • Aching, morning stiffness in proximal limb muscles Mild polyarthralgia, lethargy, depression, low grade fever, anorexia, night sweats
93
Epidemiology of MS
• 3x F to M | 20-40 yrs old
94
Types of MS
• Relapsing-remitting - Most common. Acute attacks lasting 1-2 months and then remission • Secondary progressive: ○ Relapsing remitting pts who have deteriorated and developed neuro signs and symptoms between relapses ○ Gait and bladder disorders seen • Primary progressive: ○ Progressive deterioration from onset Common in older people
95
Acute tx of MS
• Acute relapse - high dose steroids for 5 days to shorten relapse. Does not alter degree of recovery
96
Osteomalacia patho
• Normal bone but decreased mineral content • Normal density bone but bones soft and weak Osteomalacia if occurs after epiphysis fuse
97
S&S of osteomalacia
• Bone pain • Fractures Muscle tenderness
98
Causes of osteomalacia
• Renal failure • Vit D deficiency • Liver disease Drug induced
99
Investigations for osteomalacia
• Bloods - Low Serum calcium, phosphate, vit D | Xray - translucent bands
100
Tx of osteomalacia
Calcium with Vit D tablets - Adcal
101
Investigations for rickets
• Bloods - Low Serum calcium, phosphate, vit D | Xray - cupped, ragged metaphyseal surfaces
102
Osteoporosis RFs and scoring tool RFs
``` • Female • Age • FRAX scoring tool: ○ Steroid use history ○ RA ○ Alcohol excess ○ History of parental hip fracture ○ Low BMI Smoker ```
103
Investigations for osteoporosis causes?
``` • FBCs • U&Es • LFTs • Bone profile - calcium, phosphate, vit d • CRP TFTs ```
104
When to offer protection for bone protection in steroid users?
• If a pt has or will have to be on steroids for 3+ months then consider treatment as below: ○ If pt over 65 or has had previous osteoporotic fracture - Offer bone protection If pt under 65 give bone density scan - T score of less than -1.5 offer bone protection
105
DEXA scan results interpret
• T score >-1.0 - normal • T score -1.0 to -2.5 - osteopaenia T score
106
Tx of osteoporosis
• 1st line - Alendronate (bisphosphanate), adcal, exercise • If aldendronate not tolerated due to GI upset, use risedronate (another bisphos) If bisphos not tolerated use raloxifene (selective estrogen receptor modulator SERM)
107
Pagets patho
• Increased but uncontrolled bone turnover | Abnormally shaped bones
108
RFs of pagets
• Age • Male FHx
109
Complications of pagets
• Bone sarcoma • Fractures • Deafness Cardiac failure
110
S&S of pagets
• Bone pain | Untreated features - bowing of tibia, bossing of skull
111
Investigations of pagets
• Bloods - Raised ALP | Skull xray - Thickened, osteoporosis circumscripta
112
Tx of pagets
Bisphosphonate - risedronate
113
Give primary benign bone cancer
``` ○ Osteoid osteoma ○ Osteoblastoma ○ Osteochondroma ○ Endochondroma Giant cell tumour ```
114
Give metastatic primary bone cancers
○ Osteosarcoma | Rhabdomyosarcoma
115
Investigations for bone cancers?
• Inflammatory markers - CRP, ESR • Bone profile - calcium, ALP Prostate specific antigen Xray • Mets lesions Pathological fractures Radioisotope scan: Increased uptake in active bone areas
116
Tx of bone cancers?
Bone pain: • Analgesics - Pain ladder Radiotherapy Primary - surgery Secondary - radiochemo
117
Features and tx of osteochondroma?
• Can become malignant | Tx - Excision
118
Features and tx of endochondromata
• Bones of hands and feet • Can become malignant Tx - Curettage and graft deficit
119
Features and tx of giant cell tumour
• Lesion in epiphysis of long bones around knee and wrist • Can become malignant Tx - curettage
120
Osteosarcoma featuers andf tx
• Knee and proximal humerus is commonest • Mets to lung Tx - chemo and surgery with joint replacements
121
Pathogen in dog bites
pasteurella multocida
122
MOs in osteomyelitis
Staph aureus
123
S&S of acute osteomyelitis
• Sudden high fever • Severe bone pain • Swelling, redness, warmth, tender at site ROM restricted
124
S&S of chronic osteomyelitis
``` • Flaring up of symptoms • Bone pain • Lethargy • Local swelling Skin changes ```
125
Rfs for osteomyelitis
``` • DM • Sickle cell • IVDU • Immunosuppressed • Alcohol excess BROKEN BONES ```
126
Investigations for osteomyelitits
MRI
127
Tx of osteomyelitits
• Fluclox | Clindamycin - penicillin allergic
128
Juvenile knee problems
Chrondomalacia patellae • Softening of patella cartilage • Common in teenage girls • Anterior knee pain on climbing stairs Osgood-Schlatter disease • Sporty teens • Pain and swelling over tibial tubercle Osteochrondritis dissecans • Pain after exercise • Swelling and locking Patellar subluxation • Medial knee pain due to lateral subluxation of patella • Knee may give way Patellar tendonitis • Athletic boys • Anterior knee pain worse after running • Tender below patella on exam
129
Patho and epi of de querains
• Extensor pollicis brevis and abductor pollicis longus sheath inflamed Females 30-50 yrs
130
S&S of de quervains
• Pain on radial side of wrist • Abduction of thumb against resistance is painful Finkelsteins test - Thumb flexed, pain reproduced by wrist flexing
131
Tx of de quervains
• Analgesia | Steroid injection
132
Elbow pain
Lateral epicondylitis • Pain and tenderness over lateral epicondyle • Worse on resisted wrist extension or supination Medial epicondylitis • Pain and tenderness over medial epicondyle • Worse on wrist flexion or pronation Radial tunnel syndrome • Compression of posterior interosseous branch of radial nerve • Symptoms similar to lateral epicondylitis but pain is 5cm distal to lateral epicondyle Cubital tunnel syndrome • Compression of ulnar nerve • Intermittent tingling in 4th and 5th finger • Worse when elbow resting on firm surface or flexed for extended periods Olecranon bursitis • Swelling on posterior aspect of elbow • Middle aged males

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