ortho high yield Flashcards
(112 cards)
1
Q
osteoarthritis X-ray changes
A
Loss of joint space
Osteophytes (bone spurs)
Subarticular sclerosis (increased density of the bone along the joint line)
Subchondral cysts (fluid-filled holes in the bones)
2
Q
signs of OA in hands
A
heberden’s nodes (DIP)
bouchard’s nodes (PIP)
squaring at base of thumb
joint pain worsens with activity
3
Q
Mx osteoarthritis
A
1) topical NSAIDs
2) oral NSAIDs (+PPI)
3) paracetamol and weak opioids last line meds
4) intra articular steroids if nothing else has worked (short term relief)
5) joint replacement
4
Q
what joints does RA usually affect
A
MCP
PIP
5
Q
what joints does OA usually affect
A
knees, hios
DIP PIP
CMC (base of thumb)
6
Q
X-ray changes RA
A
loss of joint space
juxta-articular osteoporosis
periarticular erosions
subluxation
7
Q
Z-shaped deformity, swan neck deformity, boutonniere deformity
A
RA
8
Q
extra-articular complications of RA
A
- respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy
- osteoporosis
- ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus
- increased risk of infections
- depression
Less common - Felty’s syndrome (RA + splenomegaly + low white cell count)
amyloidosis
9
Q
antibodies for RA
A
rheumatoid factor (first line test)
anti-CCP (much more specific) test for this if RF negative
10
Q
initial treatment RA
A
DMARD monotherapy (methotrexate) +/- short course of bridging prednisolone
- TNF inhibitors if inadequate response to 2 DMARDs (infliximab and etancercept)
- rituximab
11
Q
methotrexate plus trimethroprim?
A
bone marrow suppressrion + pancytopenia
12
Q
methotrexate in pregnancy?
A
NO
- sulfasalazine and hydroxychloroquine are safe
- low dose corticosteroids may be used to control symptoms
13
Q
poor prognostic features of RA
A
- Rheumatoid factor positive
- Anti-CCP antibodies
- Poor functional status at presentation
- X-ray: early erosions (after less than 2 years)
- Extra articular features e.g. nodules
- HLA DR4
- Insidious onset
14
Q
side effects of methotrexate
A
myelosuppression
liver cirrhosis
pneumonitis
15
Q
what extra-articular manifestations is psoriatic arthritis assoc with
A
uveitis
inflammatory bowel disease
16
Q
what joints does psoriatic arthritis mainly affect
A
DIP
axial skeleton
17
Q
signs of psoriatic arthritis
A
- Plaques of psoriasis on the skin
- Nail pitting
- Onycholysis (separation of the nail from the nail bed)
- Dactylitis (inflammation of the entire finger)
- Enthesitis (inflammation of the entheses, which are the points of insertion of the tendons into bone)
18
Q
Mx of psoriatic arthritis
A
mild) just an NSAID
mod-severe) methotrexate
19
Q
Ix reactive arthritis
A
septic arthritis must be excluded
- joint aspiration - shows no organism
20
Q
Mx reactive arthritis
A
treat infection triggering
- nsaids
- steroid injections
most resolve in 6 months, if recurrent then DMARDs or anti-TNF
21
Q
gene for RA
A
HLA DR4
22
Q
gene for ank spond
A
HLA B27
also for reactive arthritis
23
Q
presentation of ank spond
A
young man, lower back stiffness
- worse in morning and improves during the day
- pain at night
- reduced flexion and chest expansion (schober’s test)
24
Q
what else is ank spond associated with
A
- Apical fibrosis
- Anterior uveitis (acute iritis)
- Aortic regurgitation
- Achilles tendonitis
- AV node block
- Amyloidosis
- And cauda equina syndrome
- Peripheral arthritis
25
X-ray signs for ank spond
- Sacroiliitis: subchondral erosions, sclerosis
- Squaring of the lumbar vertebrae
- Bamboo spine - late sign (rarely seen in clinical practice)
- Syndesmophytes
Chest x-ray: apical fibrosis
If the X-ray is negative for sacroiliac joint involvement but still sus then = MRI
Signs of early inflammation involving sacroiliac joints confirms diagnosis
26
Mx for ank spond
exercise and NSAIDs
if peripheral joint involvement: DMARDs
27
antibodies in SLE
ANA 99%
anti-dsDNA
anti-Smith
28
cardiac manifestation of SLE
pericarditis
29
Mx SLE
hydroxychloroquine
also NSAIDs and sunblock
30
what is discoid lupus
autoimmune chronic skin conditions
- lesions on face scalp and ears that are photosensitive
5% chance of developing sle
31
limited systemic sclerosis antibodies
anti-centromere
32
antibodies in diffuse systemic sclerosis
anti scl-70
33
symptoms of limited sclerosis
CREST
Calcinosis (deposition of calcium)
Raynaud's phenomenon
oEsophageal dysmotility
Sclerodactyly (skin tightening particularly on the fingers and toes)
Telangiectasia
34
presentation of diffuse sclerosis
CREST plus
- cardio probelms
- lung problems (ILD, PAH)
- kidney problems (scleroderma renal crisis)
scleroderma affetcs trunk and proximal limbs
35
Mx raynauds
nifedipine
36
PMR presentation
muscle stiffness
- worse in morning, proximal limbs
- shoulders, neck, pelvis
-worse after rest
- takes 45 mins to ease in morning
usually rapid onset (<1 month)
37
Mx of PMR
prednisolone!!!! rapid response
38
key complication fo temporal arteritis
vision loss
- anterior ischaemic optic neuropathy
- swollen pale disc and blurred margins
39
presentation of temporal arteritis
unilateral headache
- worse around temple and forehead
- scalp tenderness
- jaw claudication
- blurred cvision
- temporal artery may be thickened with reduced pulsation !!!!
40
Mx temporal arteritis
urgent high dose glucocorticoids (before temporal artery biopsy)
no visual loss - high dose prednisolone
visual loss - methylprednisolone
41
what's polymyositis associated with
malignancy
42
polymyositosis presentation
WEAKNESS
- symmetrical proximal weakness
- tenderness
43
Ix for polymyositosis
elevated CK!!!!!
other muscle enzymes elevated
anti-jo antibodies
44
Mx of polymyositosis
high dose corticosteroids tapered as symptoms improve
45
characteristic skin features of dermatomyositis
- photosensitive
- macular rash on back
- heliotrope rash in periorbital
- gottron's papules
- mechanic's hands
46
antibodies dermatomyositis
ANA
Anti-Jo
47
Ix for anti-phospholipid
paradoxical rise in APTT
thrombocytopenia
48
antibodies for anti-phospholipid
anticardiolipin
anti-beta 2
lupus anticoagulant
49
secondary thromboprophylaxis in antiphospholipid syndrome
initial thrombotic event) lifelong warfarin (INR 2-3)
if another happens while on warfarin) add aspirin and increase INR target 3-4
arterial thrombosis) lifelong warfarin target 2-3
50
treatment of antiphospholipis in pregnancy
low dose aspirin plus LMWH
51
what type of malignancy at increased risk in Sjogren's
lymphoid
52
antibodies in Sjogren's
rheumatoid factor
ANA
Anti-Ro
Anti-La
53
Mx Sjogrens
artificial saliva and tears
pilocarpine to stimualte saliva production
54
GPA presentation
| small vessel vasculitis
saddle shaped nose
nosebleeds
cough, wheeze, haemoptysis
glomerulonephritis (rapidly progressive)
55
antibody for GPA
cANCA
56
Mx GPA
steroids
cyclophosphamide
median survival - 8-9 years
57
eGPA presentation
asthma
eosinophilia
paranasal sinusitis
mononeuritis multiplex
renal involvement in some
58
what antibody for eGPA
pANCA
59
Mx kawasaki disease
high dose aspirin
IV immunoglobin
ECG to screen for coronary artery aneurysms
60
Ix for takayasu's arteritis
CT or MRI angiography
- required for diagnosis
61
diagnosis of gout
measure uric acid levels
- > 360 then supportive
- <360 during a flare = repeat two weeks later
synovial fluid analysis
- needle shaped negatively birefringent urate crystals
62
X-ray features gout
joint space maintained
lytic lesions
punched out erosions
sclerotic borders
overhanging edges
63
acute management gout
1) NSAIDs or colchicine
2) colchicine if NSAIDs contraindicated (avoid in eGFR < 10)
3) intra-articular steroids
64
urate lowering therapy gout
| after first attack
do not start until inflammation of attack and gone and no more pain
1) allopurinol (NSAIDs or colchicine cover should be considered) - titrate dose up every few weeks
2) febuxostat
65
what's deposited in pseudogout
calcium pyrophosphate
66
67
joint aspirate pseudogout
weakly positive birefringent rhomboid crystals
68
Mx pseudogout
NSAIDs
intrarticular/IM or oral steroids
69
what is FRAX or Qfracture
assesses the 10 year risk of developing a fragility fracture
| women > 65 and men > 75
70
when should DEXA be done without FRAX
* > 50 years of age with a history of fragility fracture
* < 40 years of age who have a major risk factor for fragility fracture
* before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer)
71
T score
* > -1.0 = normal
* -1.0 to -2.5 = osteopenia
< -2.5 = osteoporosis
72
what extra thing do you check for osteoporosis in a man
testosterone levels
- hypogonadism can cause osteoporosis
73
Mx osteoporosis
all patients
- calcium and vit D
- bisphosphonates (risedronate and alendronate)
- IV zoledronate following hip fracture
- denosumab second line
if high risk FRAX - get DEXA scan and start bisphosphonates
74
osteoporosis and taking steroids?
bone protection
- bisphosphonates
- don't wait for DEXA scan
75
side effects of bisphosphonates
- Reflux and oesophageal erosions
- Atypical fractures
- Osteonecrosis of the jaw
- Osteonecrosis of the external auditory canal
76
isolated rise in ALP
pagets
- increased bone turnover
- calcium and phosphate usually normal
77
Ix for Paget's
plain radiograph X-rays
- first line and diagnostic
78
Mx Paget's
Indications for treatment:
- Bone pain
- Skull or long bone deformity
- Fracture
- Periarticular Paget's
Bisphosphonate
- Oral risedronate or IV zoledronate
79
Mx septic arthritis
fluclox
clindamycin if penicillin allergic
80
rised CRP in SLE
underlying infection
81
young adults with septic arthritis, what cause?
neisseria gonorrhoeae
82
inflammatory arthritis involving DIP and dactylitis
psoriatic arthritis
83
hip pain, not shortened leg
anterior dislocation
- abducted
84
shortened internally rotated leg
posterior dislocation
- adducted
85
shortened externally rotated leg
hip fracture
- abducted
86
intracapsular undisplaced hip fracture Mx
internal fixation
hemiarthroplasty if unfit
87
intracapsular displaced fracture
THR or hemiarthroplasty
THR only for fit patients (can walk independently with no more than one stick, cognitively okay, medically fit)
88
extracapsular hip fracture
stable intertochanteric
- DHS
reverse obliwue, transverse or subtrochanteric
- intramedullary device
89
colle's fracture
distal radius fracture with dorsal displacement
- dinner fork deformity
90
what nerve injury for colle's fracture
median nerve injury
91
smiths fracture
volar angulation of distal radius
spade = smith
92
Mx scaphoid fracture
futuro spline or back-elbow slab initially
- refer to ortho
- imaging 7-10 days later if initially inconclusive
- undisplaced = cast
- displaced = surgical fixation
93
monteggia fracture
ulnar fracture
dislocation of **proximal** radial head
A = proximal
94
Galaezzi fracture
radial shaft fracture
distal radioulnar dislocation
z = distal
95
salter harris fracture types
Type 1: Straight across
Type 2: Above
Type 3: BeLow
Type 4: Through
Type 5: CRush
96
who gets supracondylar fracture
5-7 year olds
97
median nerve injury presentation
weakness in thumb flexion
98
radial nerve injury presentation
weakness in wrist and finger extension
99
ulnar nerve injury presentation
weakness in finger abduction and adduction
100
who gets MRI in prolapsed disc
if symptoms persit after 4-6 weeks
101
medial meniscus tear presentation
pain and swelling
locking and giving way
102
ACL rupture
popping sound
knee swelling
instability
103
lateral meniscus tear
no pain or swelling
104
key risk factor frozen shoulder
diabetes
105
what are the rotator cuff muscles and what do they do
S – Supraspinatus – abducts the arm
I – Infraspinatus – externally rotates the arm
T – Teres minor – externally rotates the arm
S – Subscapularis – internally rotates the arm
106
when do you get pain in tennis elbow
“In tennis, you serve” Pain on Supination + Extension
107
golfer's elbow pain
on wrist flexion and forearm pronation
108
impingement syndrome presentation
painful arc at 60-120 degrees
| usually supraspinatus
109
AVN Ix of choice
MRI
110
management of spinal stenosis
laminectomy
111
Mx for osteomyelitis
MRI
112
