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Orthopedics > Ortho & Rheumato 2022 > Flashcards

Ortho & Rheumato 2022 Flashcards

1
Q

What are signs of flexor sheath infections/ flexor tenosynovitis

A

Kanavel signs-
1. Pain with passive extension of the affected finger.( earliest sign)
2. Flexed resting position of the affected finger.
3. Fusiform swelling of the whole finger.
4. Tenderness along flexor tendon sheath.

  • they have specificity over 90% for infection of flexor tendons.
  • must treat immediately if these signs are positive to prevent complications such as soft tissue necrosis, osteomyelitis, necrotizing fasciitis.
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2
Q

Causes of flexor sheath infections

A

Can be caused by
1. Direct inoculation by trauma( animal bites, puncture wounds , IV drugs , wounds exposed to fresh water)
2. Spread from adjacent tissues
3. Hemato genius spread.

Due to infection exudative fluid builds up and increases pressure leading to ischemia, and results in Septic necrosis later.

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3
Q

Features of osteoarthritis

A

X-ray features of weight bearing joints such as hip , knee, ankle are

  1. Joint space narrowing
  2. Osteophytes at the outer edges of the joint lines.
  3. Subchondral sclerosis
  4. Subchondral cysts
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4
Q

OA vs RA

A

OA is not inflammatory like RA
OA is aggravated by exercise and relieved by resting.

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5
Q

X-ray findings of Septic arthritis

A
  1. X-ray could be normal in early stages,
  2. Joint effusion
  3. Juxta articular osteoporosis due to hyperemia
  4. Joint space narrowing due to cartilage destruction
  5. Destruction of subchondral bone.

CF- acute, fever, joint pain and tenderness, warmth, redness

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6
Q

Osteomyelitis X-ray features

A

Bone is affected. Not the joint. But joint effusion may be seen.

  1. Regional osteopenia of the bone
  2. focal bony lysis or cortical loss
  3. Loss of trabecular architecture
  4. New bone formation
  5. Periosteal reaction( thickening or elevation by periosteitis)
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7
Q

Typical presentation of RA

A

Symmetrical arthritis affecting wrists and MCP and PIP joints of hand or MCP of feet.
Occasionally large joints such as knee or ankle in isolation are affected.

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8
Q

Features of radicular lower back pain

A
  1. Sharp and shooting pain.
  2. Unilateral pain is commony seen
  3. leg pain is worse than back pain
  4. extends below the knee
  5. pain,numbness,paresthesia folows the dermatoal destribution.
  6. Reflexes are absent or reduced
  7. motor weakness isnt always present.
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9
Q

How is radicular pain commonly managed

A

Conservatively with analgesics , physiotherapy and maintained daily physical activity.

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10
Q

What are red flags of back pain which indicated further investigations

A

one red flag could be present in about 80% patients.so more than one red flags is suspicious.

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11
Q

Gout management

A

Acute - either NSAIDS ( indomethacin or naproxen ) or colchicine as first line
[colchicine 1.2mg/stat flowed by 0.6mg in 6 hours and then 0.6mg once or twice daily for 2-3 days of Norma kidney function: should be used continually if reduce renal function]
[ celecoxib is not used commonly for gout; hepatic renal and cvs risks ]

When first line meds are CI or not tolerating - prdnisolone or intra articular steroid injections given.

  1. Allopurinol - Uric acid lowering agent. Indicated for patients with high uric acid levels. As a measure of prophylaxis. No role in acute gout.
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12
Q

Why not aspirin in gout

A

It can impair excretion of urate crystals form kidneys,

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13
Q

Prednisolone in gout

A

In reduced kidney function prednisolone or intra-articular steroid injection ( if only one joint is affected) or low dose of colchicine can be used as second line options.

Prednisone dose - 0.5mg/ kg for 5-10 days with gradual dose tapering.

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14
Q

PCM and codaine in gouty arthritis

A

Although they relieve pain, they don’t have anti inflammatory effects like NSAIDs, which is required for gouty arthritis

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15
Q

What’s NEONATAL LUPUS ERYTHEMATOSUS ( NLE )

A

By transplacental passage of maternal autoantibodies

Manifestations -
Commonest are cardiac, dermatological or hepatic
Cardiac is common- CONGENITAL HEART BLOCK is the commonest ( profound bradycardia resulting in congestive cardiac failure) usually between 10-20th week.

Risk is high - mothers with primary sjogren syndrome or undifferentiated autoimmune syndrome.

Maternal - anti- Ro (in 95%) , anti- LA or anti- U1- RNP antibodies are could be positive( vertically transported to fetus)

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16
Q

What are SLE diagnostic criterias

A

S- Serositis ( pleuritis, pericarditis)
O- Oral or nasal ulcers
A - arthritis/synovitis (>2 joints)
P - photosensitivity
B - Blood ( anemia, leukopenia <4000, thrombocytopenia<100,000
R - renal( lupus nephritis)
A - ANA
I - immunologic ( DsDNA etc)
N- Neurological ( psych, seizures)
M- Malar rash
D - Discoid rash

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17
Q

SLE management

A
  1. Hydroxychloroquine is the main management ( for mild lupus with skin conditions,tenosinovitis, serositis)
    It is well tolerated, has few side effects, decreased flareups , good for survival benefit.
  2. For severe lupus( neuropsychiatric features, renal involvement, hemolytic anemia, thrombocytopenia) - high doses of steroids for acute management and in long term management steroid sparing agents ( like cyclophosphomide, mycophenolate , methotrexate can be used)
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18
Q

When to do MRI In back pain

A

If there’s a significant motor deficit which cannot be justified by single nerve root pathology, any suspicious cord compression, cauda equina syndrome.

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19
Q

Acute severe back pain in metastatic cancer patient , initial step?

A

?pathological fracture

Do Xray

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20
Q

How to manage RADICULAR PAIN with no red flags

A
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21
Q

What’s a lateral epicondylitis

A

Aka tennis elbow.
Causes by degenerative ( rather than inflammatory) changes of wrist extensor muscles at the origin in the lateral epicondyle of the humerus ( attachment point of extensor carpi radialis brevis is commonly affected)

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22
Q

CF of lateral epicondylitis

A

Common in repetitive movements.( by microtears of the origin of ECRB due to eccentric overload by repetitive movements of wrist extension and forearm pronation )

Features -
Pain with gripping
Decreased grip strength
Pain with wrist extension
Tenderness over lateral elbow

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23
Q

Management of tennis elbow

A

Conservative management
1. Counterforce brace to reduce tension force over wrist extensors and provide rest.
2. Immobilization of elbow joint
3. Home bases exercises
4. Movement modification with palm facing up rather than down to limit forearm pronation.
5. Adequate analgesics
6. Intra articular steroid injection - used if conservative management fails.

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24
Q

Olecranon bursitis/ bursitis elbow/ Popeyes elbow

A

Filled sac at the tip of elbow due to trauma, infection , inflammation of conditions like RA and gout.
Bursa provides protection and decreases friction of elbow joint. Contains a little fluid.
When bursa is inflamed fluid is accumulated.

Causes pain , swelling and tenderness of elbow tip.

Treatment - analgesics, NSAIDS, antibiotics , ice therapy, aspiration ( culture and for crystals)

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25
Q

What’s medial epicondylitis

A

Affects pronator teres and flexor carpi radialis at the proximal insertion at medial epicondyle of the humerus.
Causes by excessive use of flexor muscles.
Pain reproduced by resisted flexion of the wrist and passive terminal wrist extension with elbow in full flexion.

Managed with activity modification, rest from causative movement, ice , NSAIDs, physiotherapy

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26
Q

complications of colles fracture

A
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27
Q

Compartment syndrome

A

Increased pressure in a closed space or a compartment which will result in decreased perfusion and ischemia muscles and nerves.
Eventually it may lead to volkmans ischemic contracture.

CS for 4-6 hours - variable ischemia
For 8 hours - irreversible damage( surgical ischemia)
CS for 1 hour- normal nerve function
For 1-4 hours - reversible damage
8hours - irreversible damage

Causes- hemorrhage, muscle injury causing edema, decreased volume due to tight cast or dressing.

Presentation-
Pain out of proportion to injury or the surgery.not relived by analgesics.
5Ps - Pain ( only early finding ) and swelling, paresthesia, pallor, pulselessness, paralysis.

If compartment pressure > 30mmHg , immediate fasciotomy should be done.

Treatment -
Once diagnosed -all four compartment fasciotomy.

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28
Q

What’s volkmann’s ischemic contracture

A

Of all the complications volkmans contracture is the earliest possible complication of colles#. ( malunion, rupture of extensor pollicis longus tendon, nonunion)

Result of untreated ischemic injury that’s causes muscle and nerve necrosis in the involved compartment. Without release it will lead to muscle and nerve damage.

Causes-
Neglected CS.
Crush syndrome.
Fractures with vascular injury.
Bleeding disorders.

Presentation-
Elbow flexion, forearm pronation, wrist flexion, MP extension, thumb adduction, IP flexion, severe ulnar and median nerve damage, PAIN IN PASSIVE STRETCHING IS THE MOST RELIABLE FINDING.

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29
Q

What’s the single moist common muscle affected in volkmans ischemic contracture

A

Flexor digitorum profundus.
( next are flexor policus longus, flexor digitorum superficialis,
Pronator teres)

Presentation- elbow flexion, forearm pronation, wrist flexion, MP extension, thumb adduction, IP flexion, severe palsy of median and ulnar nerve.

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30
Q

What’s red common fractures for CS and VIC

A

Humerus,elbow, forearm, wrist.

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31
Q

Describe the cast for colles fracture

A

Wrist flexed 10 degrees and ulnar deviated 10 degrees.
Cast includes wrist and forearm but NOT elbow and thumb.
However in severe displacement elbow including casts may be considered.
Keep cast for 4-6 weeks.

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32
Q

Whats the commonest carpel bone to fracture

A

scaphoid bone
by falling with outstretched hand

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33
Q

Describe scaphoid fracture

A

presnt with pain in anatomical snffbox and swelling. and eliciting pain by applying axial pressure on the thumb.
Initial xray could be negative.
fracture may have difficulty healing and may cause avascular necrosis (due to interrupted blood supply) of proximal part.

Even if xray is negative you should immobilize the wrist adequately with a thumb spica cast for 10-14 days.

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34
Q

How to manage scaphoid fracture if xray is negative?

A

Depend on the availability of MRI and CT imaging. MRI is preffered over CT bcos we can visualize soft tissue as well.
After confirmed by imaging or if imaging not available , immobilize using thumb spica cast for 7-14 days and xray repeated after 14 days.

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35
Q

Whats the commonest complication of scaphoid fractures

A

Avascular necrosis
second commest - malunion
joint stiffness is not that common

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36
Q

What are preffered methods of pain relief for shoulder relocation

A

IV midzolam and intranasal fentanyl
Ketamine,etomidate and propofol are other options.
Midaolam is a short acting benzodiazepine unlike diazepam which has a long acting and unpredictable effect.

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37
Q

What movements affected in anterior shoulder dislocation

A

Often causes axilary nerve injury (which runs inferiorly to the humeral head and wraps around the surgical neck of humerus)
axillary nerve innovates deltoid and teres minor mucles and skin of lateral shoulder.
damage causes deltoid muscle weakness and loss of sensation over shoulder badge region.

38
Q

xray of anterior shoulder dislocation

A

Humeral head out of the glenoid fossa and displaced inferiorly is typical finding of anterior dislocation of glenohumeral joint.

39
Q

mechanism of anterior shoulder dislocation

A

blow to the abducted ,externally rotated, and extended arm (eg- blocking a basketball shot)

appearance- adbcted slightly and externally rotated.

40
Q

appearance of acromioclavicular joint dislocation

A

causes pai,tenderness and classic step deformity in AC joint. Arm raise is limited due to exquisite pain when attempted.

41
Q

stepwise management of OF

A
42
Q

Joint fluid aspirate differentiation

A
43
Q

Whats the first line for AS

A

NSAIDS is the first line
however for very mild pain or any CI for NSAIDS, only pcm and opioids can be used

44
Q

Whats the use of systemic steroids in AS

A

Used in Extra spinal manifestations of AS such as uveitis, IBD ,etc. Bu not used in spinal manifestations.

45
Q

What are tumor necrosing factor (TNF) inhibitor.

A

A type of biological DMARDS.
In AS first line is NSAIDS.
As second line TNF inhibitors cn be used.
indications- Not responding to 2 types of NSAIDS with exercises, and having xay features ofsevere AS.
eg- infliximab, etanercept, adalimumab, golimumab

46
Q

Whats dupuytren contracture

A

Almost always clinical diagnosis
RF - Diabetes
USS can be used to visuaize thickening Palmar fascia and presence of a nodule.
(xray,ct,mri almost never indicated)

47
Q

How to treat dupuytren contracture

A
48
Q

Whats are seronegative spondylopathies?

A

1.Ankylosing spondylitis
2.Psoriatic arthritis
3.Reactive arthritis
4.Inflammatory bowel disease

almost all the about are associated with HLA-B27 GENE and ANTERIOR UVEITIS.

*HLA-B27 gene doesnt have a relationship with bachet disease.

49
Q

Whats bachet’s disease

A

*Diffuse vasculitis with unknown origin.
*Triple symptom complex-
1.Recurrent oral/aphthous ulcers
2.Recurrent genital warts.
3. uveitis

*No association with HLA-B27

50
Q

Phrmacological management of osteoarthritis

A

1.PCM upto 4g per day
2.NSAIDS ( ibuprofen, diclofenac, naproxen) if no peptic ulcers and dyspepsia.
3.Although COX 2 inhibitors have same effects they are safe to use in peptic ulcers. But cant be used if CVS DISEASES.
4.If HEART DISEASES AND PEPTIC ULCERS presnt, we can use Opiates (codeine)
5.after codeine Tramadol can be used.
6.Intra articular coticosteroid injections (can relieve pain upto 4 weeks duration with a single injection)

51
Q

Most imp step in fracture/ dislocation management

A

Early reduction/ alignment is the most imp step. ( if not reduced in the field immediate attempt to reduce in the ED)
More crucial when neurovascular damage is evident.
If neurovascular damage is evident alignment of reduction should be tried with adequate analgesia with IV opiates(morphine)

*ankle dislocation requires immediate orthopedic consultation and for surgical intervention such as IF or EF of the fracture and repair of any ligamentous or capsular tears.

52
Q

What are the causes of DC

A
53
Q

whats an open fracture/dislocation

A

bone and/or joint exposed to the external environment or when fracture/dislocation is caused by blunt or penetrating forces sufficient to disrupt or penetrate the skin, subcutaneous tissue, muscle fascia, muscle and/or the bone or joint.
Often contaminated by foreign material(clothing grass,dirt,gravel) ,dead tissue and bacteria.

54
Q

Whats wound debridement and where should we do it

A

Surgical removal of all devitalized soft tissues and bone is crucial for OPEN FRACTURES to prevent infection.
It should be done in a STERILE ENV like theatre (not a nonsterile place like emergency departement)

55
Q

Whats the best test to diagnose Sjogren syndrome

A

Minor salivary gland biopsy ( disease caused by lymphocytic infiltration and fibrosis of exocrine glands particularly salivary and lacrimal)
But its not necessary in the clinical stand point.
It can be treated syptomatically and observed for the development of rheumatic disorders or lymphoma.This can be done withour the biopsy.

56
Q

What are two types of osteoarthritis

A
57
Q

How to use a stick as a walking aid?

A

stick should be in the opposite hand of the affected side and first step should start with the affected leg/side.

58
Q

Whats the initil manifestation of hip pathologies

A

In osteoarthritis of hip or other hip pathologies first movement restricted is internal rotation of hip followed by hip flexion.

59
Q

Osteopenia and osteoporosis around the joint is seen in-

A

Rheumatoid arthritis and neuropathic arthropathy

60
Q

What are causes and xray findings of neuropathic arthropathy

A
61
Q

Causes of hip pain in adults

A
  1. Flare up of chronic inflammatory condition like RA
  2. Degenerative changes of hip joint(eg- osteoarthritis)
  3. Fracture of femoral neck
  4. Degenerative spondylosis of lumbar spine causing neurogenic claudication
  5. Polymyalgia rheumatica
  6. Bony Mets of primary tumor
  7. A vascular necrosis of femoral head
62
Q

Risk factors of ANFH

A

1.long term steroid use
2. Chronic alcohol use and liver disease
3. Sickle cell disease
4. Past hip fracture

63
Q

What’s the mobilizing plan for hip fracture patients who undergone surgery

A

Crucial to mobilize within 24 hours.
Effective pain management is a must , because patient may be reluctant to mobilize due to severe pain caused by it.

64
Q

Possible complications in immobilized patients in post op hip surgery.

A

Pressure ulcers
Pneumonia
Venous thromboembolism

65
Q

What’s usually used for prophylaxis VTE post operatively

A

LMWH used throughout hospital stay.
Warfarin is not indicated.

66
Q

Management of AS

A

NSAIDs are first line for symptomatic AS.

When disease progresses and not responding to ATLEAST 2 NSAIDS —-> b-DMARDS ( biological DMARDS)

Among them TNF inhibitors (infliximab, etanercept, adalimumab, golimumab) are given if CXR features of advance AS present.
(Traditional DMARDS have little effect on spinal disease.)

Systemic steroids may be used for extra articular presentations of AS such as uveitis, IBD etc.

67
Q

What two dieseases together produces following features

A

Polymyalgia rheumatica and Giant cell arteritis/Temporal arteritis ( can develop solitary but also develop together in 20% cases)

68
Q

Classic features of PR

A

Pain and stiffness of shoulders and hips in a symmetrical fashion. Cervical spine maybe involved.
Marked stiffness usually in the morning lasting for 30mins, subside by the end of the day.
Constitutional symptoms- malaise,low grade fever, anorexia and weight loss.

69
Q

Features of GCA/TA

A

Headache not or poorly responding to analgesics, scalp tenderness, ipsilateral eye involvement, jaw claudication, weak or absent pulse of temporal artery.

70
Q

How to manage PR and GCA together

A

Initial- measure ESR
IF ESR HIGH- important to START CORTICOSTEROIDS IMMEDIATELY( to prevent permanent visual loss.

If visual signs already present - IV corticosteroids instead of oral for first 3 days of therapy.

71
Q

PR almost never seen before which age ?

A

50 yo age

72
Q

Is weight loss seen in PR

A

Yes.
Except pain and stiffness of shoulder and hip girdle, other systemic features are -
1. Low grade fever
2. Weight loss
3. Malaise and fatigue
4. Depression
5. Anorexia

73
Q

Is muscle weakness seen in PMR

A

Nope

74
Q

Criteria of PR diagnosis

A
75
Q

In open fractures what’s the most initial step

A

Non surgical removal of any gross contamination and analgesia.
( initial irrigation and Debridement is NOT RECOMMENDED IN ER, and should be done in the theatre)

76
Q

What’s the golden time of open fractures and order of priorities

A
77
Q

What’s sjogren disease

A

Chronic inflammatory disease with lymphocytic infiltration and fibrosis of exocrine glands ( socially lacrimal and salivary glands)
Mostly in women 90%

Common extraglandular features-
1. Skin- xeroderma, purpura
2. Swallowing difficulty , GORD,
3. Pulmonary- dryness of trachobronchus- dry cough
4. Pericarditis, pul hypertension
5. Renal nephritis , interstitial cystitis.
6. Nasal and vaginal dryness.
7. PAROTID GLAND ENLARGEMENT.

78
Q

Lab findings of sjogren disease

A

High ESR
High CRP
Positive RF
Positive ANA ( anti Ro and anti La)

79
Q

Osteoarthritis of hip which movements are affected

A

Internal rotation and followed by flexion

80
Q

Commonest causes of hip or groin pain in adults

A
81
Q

When should we mobilize patients with hip fracture

A

After 24 hours of surgery
Therefore most imp step is - pains management. Bcos with pain patient won’t walk after surgery.

82
Q

What hip joint condition seen with chronic use of steroids

A

Avascular necrosis of femoral head

83
Q

What are investigations for ANFH. What’s the X-ray finding of ANFH

A

Variable density of femoral head.

Uss- exclude joint effusion due to acute inflammation such as RA or septic arthritis.

Most accurate tool - MRI

84
Q

Why not aspirin in gout?

A

It impairs renal excretion of urate which worsens gout.

85
Q

Which antibody is most commonly associated with NLE?

A

Anti-Ro antibody

86
Q

What’s the most commonly affected muscle in lateral epicondylitis?

A

Extensor carpi radialis brevis

87
Q

What’s the initial and best tests for GCA/ polymyalgia rheumatica?

A

Initial is always ESR ( if less than 40 , unlikely)
Best is temporal artery biopsy.

But for PMR no need to do biopsy.

88
Q

Initial therapy of PMR?

A

Corticosteroids

89
Q

If a patient has PMR and osteoporosis how to manage ?

A

Long term corticosteroids may worsen the osteoporosis but there is not alternative for corticosteroids in this scenario.
Therefore following measures should be taken with corticosteroid use for more than one month.

90
Q

Most characteristic finding of PMR / GCA?

A

Elevated ESR

Orthopedics (1 decks)

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