Orthopaedics and Rheum Flashcards

Question

vit d physiology

Answer 1

Cholecalciferol (D3) -> liver = 25 hydroxyvitamin D3 (inactive circulating) -> kidney = 1,25 dihydroxyvitamin D3 (active hormone) To bone: increases Ca mobilisation, increases osteoclast function To intestine: increases Ca absorption, increases PO4 absorption To PTG: decreases PTH

Answer 2

Low Ca -> increased PTH To bone -> increase osteoclast function To kidney -> increases 1,25vD3 (1-alphahydroxylase), + decreases Ca excretion + increases PO4 excretion

Answer 3

def Increased turnover of bone Lytic phase - increased bone resorption by osteoclasts Sclerotic phase - *Rapid bone formation by osteoblasts: disorganised and mechanically weaker and deformity/larger. where axial skeleton: lumbosacral spine, pelvis, skull, femur, tibia gene AD SQSTM1 mutation pres asymp classically - older male with bone pain and isolated raised ALP bone pain + deformity with increased skin temp pain at night comp Bone pain Deformity: sabre tibia, kyphosis, skull bossing, enlarged maxilla/jaw Pathological fracture (heavy bleeding as v.vascular) Deafness/tinnitus compression of CN 8 by ear ossicles Increased vascularity may lead to high output cardiac failure assoc osteosarcoma ``` ix ALP - high ca, phos, PTH normal XR - Osteolysis and osteosclerosis (lytic and scleortic lesions), *Blade of grass lesion between healthy and sclerotic long bone, Cotton wool pattern of multifocal sclerosis in skull isotope bone scan ``` mgmt Control pain and reduce or prevent progression Pain: NSAIDs and paracetamol Antiresorptive: bisphosphonates N.b. IV may give flu-like symptoms Zoledronate popular as good with single IV dose Monitor ALP

Answer 4

causes ARTHRITIS others = reactive arthritis, tendon/muscle damage, hyperuricaemia, referred pain, immune (e.g. SLE), tumour, ischaemia, sponyloarthtitides inflam = Ease on use, worse in morning (>60 mins), hot and red, responds to NSAIDs, swelling *synovial and bony, young/psoriasis/fam Hx deg = Worse with use, morning (<30 mins), mainly evening, prior occ, sport, *no swelling, not inflamed which joints - OA - distal interphalageal RA = MCP, MTP, PIP

Answer 5

Levels fluctuate wrt injury e.g. trauma/MI/burns exampls CRP, ESR, fibrinogen, ferritin, C3/C4, caeruloplasmin etc. ESR Increases with inflammation and infection. More fibrinogen produced, RBCs crosslinked and sediment quicker. Affected by RBC shape and number <22mm/Hr (men), <29mm/Hr (women) also increases with... Age, sex, drugs e.g. steroids, obesity (fat produces IL-6) Slow on, slow off: peak at 7 days CRP Acute phase protein which increases in inflammatory conditions, connective tissue disorders, neoplastic disease and infection (esp bacterial) Quick on, quick off - peak at 1 day, normal at 7 days SLE, OA, UC Binds to damaged cells and activates complement, phagocytosis by M

Answer 6

``` def Clinical syndrome of joint pain + functional limitation + reduced QoL ``` patho Deterioration of *articular cartilage and formation of new bone - osteophytes at joint margins ``` common joints knees hips small joints hands spine ``` rfs Age, female sex, obesity, occupation/hobbies, genetic (50%), joint laxity dx triad Aged > 45 + activity related jt pain + no morning stiffness (<30 minutes) pres Jt pain exacerbated exercise + relieved rest, stiffness after rest (gelling), reduced function Joint swelling/synovitis - warmth + effusion Reduced ROM Crepitus Pain on movement *may lead to disuse atrophy and weakness Bony swelling and deformity - osteophytes: DIP (Heberden’s) + PIP (Bouchard’s) squaring of the thumbs - fixed adduction No systemic features ``` classic XR LOSS Loss of joint space Osteophytes Subchondral/subarticular sclerosis Subchondrial cysts ``` other ix bloods - normal joint aspiration - ?SA/gout RF + ANA negative ``` ddx hip + knee = bursitis referred pain gout all arthritis ``` mgmt Patient education, weight loss, screen depression, *exercise for muscle strength, aids and devices (walking sticks, tap turners) Local analgesia: topical NSAID for knee or hand + para (first line) + oral NSAID +/- PPI, opioids, capsaicin cream , intrarticular steroids - methylpred (2) non-pharmacological treatment options include supports and braces, TENS and shock-absorbing insoles or shoes For persistent pain affecting QoL: Replacement (arthroplasty), fusion (arthrodesis)

Answer 7

Failure to maintain homeostasis of cartilage matrix synthesis and degradation Synovial inflammation - IL1/6/TNF stimulates chondrocyte production Chondrocytes produce increased MMP (matrix metalloproteinases e.g. collagenase) catalyse collagen and proteoglycan degradation Increased catabolic cytokines (IL-1), loss of anabolic CKs (IGF-1) Cartilage loss -> decreased joint space -> increased stress on subchondral bone Microfracture, new bone (sclerosis) and synovial fluid seep (cysts)

Answer 8

hip - cemented hip replacement, uncemented, sometimes hip resurfacing over femoral head recovery physio home exercises walking sticks/crutches - 6w ``` advise avoiding flexing the hip > 90 degrees avoid low chairs do not cross your legs sleep on your back for the first 6 weeks ``` comps wound and joint infection thromboembolism - LMWH for 4w post op dislocation

Answer 9

``` OA LOSS Loss of jt space Osteophytes Subchondral cysts Subchondral sclerosis ``` ``` RA LESS Loss of jt space Erosions Softening of bones (osteopenia) Soft tissue swelling ```

Answer 10

``` def Chronic inflammatory autoimmune disease characterised by inflammation of synovial joints leading to joint and periarticular tissue destruction ``` who 40/50 yr old women main joints HANDS + FEET patho INFLAMMATION OF SYNOVIUM: 1. Increased angiogenesis, influx inflammatory cells + CKs, cellular hyperplasia 2. Cells (MP, TCells, plasma cells) release IL1/IL6/TNF - promote proliferation and MMP expression -> joint destruction PROLIFERATION 1. Angiogenesis and hypertrophic synovium form pannus over articular cartilage LOCALLY INVASIVE SYNOVIAL TISSUE Pres Active Symmetrical Polyarthritis >6w in 50 yr old woman RHEUMATISM RF+ve (80%), radial deviation wrist HLA DR(rheumatism) 1/4 ESR/extra-articular e.g. restrictive lung disease/nodules Ulnar deviation fingers Morning stiffness, MCP, MTP, PIP swelling ANA +ve (30%), assoc AnkSpon/AI T-cell (CD4) and TNF Inflammatory synovial tissue, IL1/IL6 Swan neck, boutonniere, Z-deformity thumb, loss of knuckle valleys when making a fist Muscle wasting hands + cervical spine instability - atlanto-axial joint subluxation extra articular Rheumatoid nodules @ extensor surface of tendons (palisade ring of MP and fibroblasts with necrotic core) and *lungs Vasculitic lesions - commonly skin rashes, leg ulcers (@Feltys) Pleuritic chest pain - pleuritis or pericarditis, effusion Eye problems: secondary Sjogren’s: scleritis and episcleritis, oral dryness Neurological: peripheral nerve entrapment, mononeuritis multiplex, atlanto-axial subluxation (C1,C2) - soft tissue swelling within rigid tunnel Respiratory system: rheumatoid nodules, Caplan’s syndrome, pulmonary fibrosis Anaemia of chronic disease ix RF - 70% +ve Anti-CCP abs - 70%, very specific so more likely erosive XR hands and feet - erosions + soft tissue swelling, loss of jt space, periarticular osteopenia, absent osteophytes, deformity, subluxation FBC - (normochromic normocytic chronic dis) ANA (+ve 30%) ESR/CRP raised ferritin high, Pt high (reactive thrombocytosis) U/E , LFTs mgmt Physiotherapy, OR, psych services (depression), podiatry First line: one DMARD (not working, increase dose) Second Line if not winning >6m: Combination DMARD (with *methotrexate) Choice DMARD = methotrexate or sulfasalazine or leflunomide Adjunct - bridging treatment if really active to get under control: corticosteroid (low dose pred) + NSAID (lowest effective dose) short term If not winning >1 yr: biologicals (expensive) ``` monitoring DAS28 (disease activity score) <3.2 = well controlled, >5.1 = active + CRP at each visit ```

Answer 11

30% symps dyspnoea, cough, wheeze types 1. interstitial lung disease - often middle age men with dry cough and dyspnoea, mgmt corticosteroids 2. rheumatoid nodules - benign but lead to pleural effusion 3. caplans - assoc with coal workers pneumoconiosis (massive fibrosis) - well rounded nodules at lung periphery 4. methotrexate pneumonitis - not common, cough, dyspnoea, fever

Answer 12

TRIAD RA, neutropenia, splenomegaly + leg ulcers, brown pigment of legs, lymphadenopathy

Answer 13

``` palmar erythema wasting of thenar eminence - carpal tunnel sydnrome fixed flexion contracture swan neck button hole z thumb ``` due to rheumatoid tenosynovitis

Answer 14

boutonneires rupture of central slip but lateral slips intact finger pushes up swan neck rupture of lateral slip of extensor expansion, so proximal pharyngeal joint is extended

Answer 15

elbows and ears ears for gouty tophus and elbows can have rheumatoid nodules

Answer 16

IgM against your own IgG lots of normal people have it high titres assoc with progressive disease

Answer 17

identical to sero posi but unlikely to have nodules or extra articular features no IgM just IgG 40% hve antibodies to CCP - if so more progressive

Answer 18

once per week with folic acid on a non-MTX day adverse effects bone marrow suppression renal and liver tox pneumonitis/pulm fibrosis excretion inhibs by - NSAIDs CI trimethoprim monitoring FBC, eGFR, LFT every 4-6 weeks in first year

Answer 19

tuberculin skin test or interferon gamma release assay chest radiograph hep B,C, HIV serology treat latent TB warn significant risk of serious infection

Answer 20

top of cervical spine is held together by tendons which can be weakened by rheumatoid tenosynovitis if the odontoid peg subluxes backwards over days and weeks -> compress upper cervical cord causing progressive spastic tetraparesis if compression is sudden - a rapid output of inhibitory impulses down vagus can cause cardiac arrest so preoperatively I would arrange a lateral upper cervical radiograph in gental flexion

Answer 21

RA psoriatic arthropathy systemic lupus OA with inflammatory component

Answer 22

myelosuppression - watch out for sore throat, fever

Answer 23

infliximab anti-TNF alpha SE increased infection lupus like symptoms reactivate TB patho T cell -> CK release -> activated MP (IL1/6/TNFa) + activated B cell (AA, RF, IL6) -> osteoclast and chondrocyte -> inflammation and destruction

Answer 24

Purines -> xanthine (by *xanthine oxidase) -> uric acid monosodium urate Uric acid (low urinary excretion) -> allantoin (high urinary excretion) (by *urate oxidase) ``` Uricase promotes (urate oxidase) Allopurinol (xanthine oxidase) ```

Answer 25

Reduced renal excretion (90%) Drugs (diuretics impair urate excretion), high insulin levels/sugars (lower urate excretion) High intake (diet), cell turnover (production), cell damage (surgery), cell death (chemo)

Answer 26

``` def Arthritis due to deposition of monosodium urate (MSU) crystals within joint ``` ``` precip Trauma + surgery (cell damage), starvation (increased insulin), infection (cell damage), diuretics (reduced renal excretion) ``` cause chronic hyperuricaemia who men 30-60 ``` rfs Alcohol (beer highest), purine rich foods (red meat/sea food), fructose (sugary drinks/cakes), diuretics, DM, CKD, CHD, HTN, hyperlipidaemia ``` protective diary coffee vit c pres acute monoarthropathy with severe joint inflam + fever + malaise florid synovitis extreme tenderness and erythema ddx in monoarthritis - SA site - 50% of all attacks are big toe - MTP also knee, midtarsal, wrist, ankles assoc tophi - onion like aggregates of urate crystals: common at pinna, tendons, joints duration of attack - will resolve without treatment in 5-15 days ix serum urate - raised demonstrate MSU in synovial fluid - Joint aspiration and polarised light microscopy of synovial fluid: Negatively birefringent needles of MonoSodium Urate monohydrate XR - soft tissue swelling, late/chronic: punched out lesions, tophi, sclerosis, eccentric erosions, no periarticular osteopenia acute mgmt 1st line - NSAIDs high dose for 48 hours then reduce for 10-14days, if not tolerated = colchicine (SE diarrhoea) if already on allopurinol - continue this if both CI - corticosteroids prophylaxis - lifestyle mods + manage RFs (thiazide + loop diuretics, HTN, ReFu, hyperlipidaemia) drugs - allopurinol or febuxostat (xanthine oxidase inhibitors) - start post attack Start low and increase until SUA < 300 micromol/L Co-prescribe NSAID or colchicine for acute attack for 6 month

Answer 27

what Calcium pyrophosphate dihydrate crystal deposition in synovium who elderly precipitants Dehydration, illness, hyperparathyroidism, haemochromatosis, Wilson’s, low mag/phos, long term steroid use, surgery/trauma where knee or wrist or shoulders pres similar to gout acute joint pain and swelling, hot, monoarticular chronic - similar to OA but may be more severe - pain, stiffness, crepitus, LoF ix Joint fluid aspiration: positively birefringent rhomboids, neutrophils Joint XR: chondrocalcinosis - linear opacification of articular cartilage on joint surface Exclude septic arthritis mgmt No specific therapies therefore symptomatic: Ice packs, elevation, aspiration of joint, NSAIDs, IA steroid injections or oral steroids as for gout

Answer 28

IgG antibody + antigen Forms complex Deposition in tissue Attracts complement Reaction with complement attracts neutrophils Inflammation Enzymes and cytokines cause further inflammation

Answer 29

``` def Inflammatory, multisystem autoimmune disease with antinuclear antibodies ``` involves Skin, joints, kidney, brain Serositis, nephritis, haematological cytopenias, neurological complications who Women in reproductive years afro-caribbeans/asians genetics HLA DR2/DR3/B8 environmental triggers UV light, virus (EBV), smoking -> sun protection and exercise suspect... Multisystem disease with raised ESR but normal CRP pres Criteria + systemic: fatigue, fever, weight loss, lymphadenopathy assoc Raynaud’s (50%), other AI e.g. alopecia, thyroiditis, venous or arterial thrombosis at risk of... HTN, dyslipidaemia, diabetes, NHL, APLS (anti-phospholipid syndrome) main mgmt Hydroxychloroquine - ocular toxicity patho type 3 hypersenstivity Immune complex formation and deposition Complement activation and influx of neutrophils criteria 4/11 of DOPAMINE RASH Discoid rash - over malar eminence Oral ulcers - usually painless Photosensitive rash - skin rash from sunlight Arthritis - non erosive 2 or more peripheral joints Malar rash - fixed erythema, spares nasolabial folds BUTTERFLY Immunological phenomena - anti-dsDNA, anti-Smith, antiphospholipid aBs Neurological symptoms - seizures or psychosis, anxt, dep ESR raised (*not CRP) Renal disorder - proteinuria > 0.5g/day or +++, or casts, glomerulonephritis ANA +ve Serositis - pleuritis (pleural rub on ausc or pleural effusion), pericarditis (on ECG, pericardial rub), myocarditis Haematological disorders - haemolytic anaemia (with reticulocytes) or leukopenia (<4x10^9), lymphopenia, thrombocytopenia ix ESR/CRP - ESR raised, CRP normal FBC - anaemia, leukopenia, thrombocytopenia Autoantibodies: ANA (99%), antidsDNA (60%), antiSmith (30%), RF (20%), anti-ro, anti-la Complement levels: low C4 and C3 - active disease Urinalysis: haematuria, casts, proteinuria U+E (renal disease) CXR: pleural effusions, cardiomegaly ECG: pericarditis Antiphospholipid antibodies: lupus anticoagulant, anti-cardiolipin mgmt dietry advice, smoking cessation, sun protection, exercise joints = NSAID ± hydroxychloroquine ± steroids (GI and bone protection) mucocutaneous = sunscreen, mouthwash, saliva, tears, + oral hydroxychloroquine lupus nephritis = cyclophosphamide/tacrolimus/mycophenolate + prednisolone + hydroxychloroquine neuropsych = cyclophos + pred or IVIG if life threat = cyclophos

Answer 30

``` def AI disorder characterised by arterial/venous thrombosis and adverse pregnancy outcomes ``` AAB Anticardiolipin, antiB2glycoprotein1, lupus anticoagulant ``` assoc SLE RA SS sjorgrens ``` criteria One clinical criteria and one lab criteria Clin: vascular thrombosis, pregnancy morbidity (unexplained death beyond 10 weeks or x3 before 10 weeks) Lab: Lupus antiocoagulant or anti-cardiolipin or anti-B2 glycoprotein 1 present on 2 occasions (12 weeks apart) pres Thrombosis, DVT, pregnancy loss, pre-eclampsia, thrombocytopenia, livedo reticularis: violaceous lace like on trunk, stroke ix paradoxically low platelets - FBC prolonged APTT - LFT This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade mgmt primary - low-dose aspirin secondary: warfarin - 2-3 target avoid clotting, increase to 3-4 if clot when on warfarin lifestyle - smoking, contraception, healthy diet, low alc

Answer 31

``` def AI condition with lymphocytic infiltration of exocrine glands ``` genetics HLA DR3 pres sicca complex diminished lacrimal and salivary glands: dry eyes (xerophthalmia, keratoconjunctivitis sicca), dry mouth (xerostomia) - cant eat dry food, altered taste, oral candidiasis enlarged parotid gland dry vagina Fatigue (80%), myalgia/polyarthralgia, Raynaud’s (20%), vasculitis dry cough ``` assoc SL RA SS CREST ``` who w>m 30-40yrs ix Schirmer tear test (filter paper, +ve if less than 5mm in 5 mins) Autoantibodies anti-Ro (SS-A), anti-La (SS-B) ± RF, ANA, APLS AAb Sialometry/sialography Biopsy salivary gland - mononuclear cell infiltrate (B and T cells) Rose-Bengal staining eyes ``` mgmt artificial tears, saliva drink plenty oral pilocarpine joint pain - NSAID + hydroxychlorquine + steroid ``` comp low C4 - risk of NHL infections - eyes, mouth, parotid gland

Answer 32

``` def multisystem AI disease with increased fibroblast activity -> excessive collagen -> fibrosis -> vascular damage + immune system activation ``` ``` locations vascular - raynauds and renal skin GI tract heart lungs ``` types LIMITED CUTANEOUS 'below elbow scleroderma' - 70% face, forearms + lower legs - synonymous with CREST - calcinosis, raynauds, oesophageal dysmotility, sclerodactyly, telangiectasia + organ fibrosis DIFFUSE CUTANEOUS 30% 'malignant scleroderma' - rest of skin + organ fibrosis much higher risk of lung, gut, heart or renal involvement ``` RF fam hist viral - CMV/EBV chemicals - pesticides, plastics drugs - bleomycin, vit k ``` pres SKIN - Raynaud’s, swelling, thick + hard skin - sclerodactyly, calcinosis FACE = small mouth, beaked nose, wrinkled skin MSK = Joint pain, swelling, myalgia, loss of ROM due to sclerosis GI = Heartburn + reflux oesophagitis, dysphagia, watermelon stomach (gastric antral vascular ectasia - bleeding), delayed gastric emptying, reduced motility (constipation) PULM = *Pulmonary fibrosis (interstitial lung disease) in 80% - dry cough etc… *Pulmonary artery HTN - in 12% = leading cause of death CARDIAC = Microvascular CAD - MI, accelerated atherosclerosis, arrhythmias RENAL = ANCA glomerulonephritis *Scleroderma renal crisis: accelerated HTN, headache, oliguria GU = ED limited = slow onset, so internal comps in pres diffuse = rapid onset, skin thickening fatigue weight loss ix FBC esr/crp u/e Spirometry - restrictive picture, disproportionate drop in DLCO to FVC - pul HTN ECG - arrhythmia CXR - lung disease = infiltrate, heart disease = cardiomegaly + heart failure Barium swallow = oesophageal disorders and delayed emptying serum autoantibodies - ANA, AntiScl70 - diffuse, Anti-centromere - limited, anti-topoisomerase 1 - ILD mgmt Physiotherapy, avoid tobacco, home exercise, prevention of Raynaud’s (gloves, no smoking) PPI for life pulm? cyclophosphamide (fibrosis), sildenafil (PAH) + O2 Synovitis/arthritis - pred skin - topical emollient +/- topical corticosteroid for itch +/- cyclophosphamide (skin thickening) renal crisis - ACEi +/- other antiHTN monitoring BP weekly yearly spiro, lung volumes, DLCO echo for ILD + PAH

Answer 33

peripheral digital ischaemia due to recurrent spasm of digital arteries phenomenon may be secondary to SS, SLE, BB, thrombocytosis pres cold hands go white then blue then red when warmed mgmt nifidipine could try sildenafil

Answer 34

``` def AI connective tissue disorders characterised by inflammation of striated muscles ``` ``` location proximal muscles skin joints oesophagus lungs heart ``` causes HIV coxsackie who women>men x 2 onset 30-60 ``` extramuscular fever arthralgia raynauds ILD ``` rule out neoplasm - lung, breast, ovary POLY pres - Not painful Progressive symmetrical proximal muscle weakness - pelvic girdle Difficulty rising from chair, climbing stairs, combing hair Pharyngeal weakness - dysphagia Interstitial lung disease and AV nodal disease ddx - paraneoplastic syndrome ix - CALL JO CK elevated x 50 AAb - anti Jo-1 (poor prognosis - lung disease) in ⅓ Elevated muscle enzymes: LDH, aldolase *EMG and muscle biopsy - for Dx and confirmation - fibrillation potentials at rest Ca125 (ovary), Ca19-9 (pancreas) to screen for malignancy ``` DERMATO pres RASH (may be UV related) - Heliotrope - violaceous eyelid - Gottron’s papules - purple scaly patches on extensors - Nailfold erythema - Shawl sign - macular rash SYSTEMIC upset: fever, arthralgia, malaise, weight loss AV conduction defects Interstitial lung disease 50% GI ulcers IX - CK elevation, LDH, aldolase AAb: anti-Jo1 (more common in poly), anti-Mi2, ANA EMG and muscle biopsy CXR LuFT HRCT ``` mgmt steroids - if anti-jo long term second line - azathioprine lung disease - cyclophosphamide +/- ciclosporin/tacrolimus ``` comp GI ulceration - malaena or haematemesis high risk malig ILD AV nodal disease ```

Answer 35

patho defect in collagen genes COL5A/3A when suspect joint + skin + hypermobility who women>men pres Skin: increased elasticity + fragility Joints: laxity, hypermobility, pes planus, prone to dislocation CV: dizziness, palpitations, heart valve abnormalities, mitral valve prolapse, aortic root dilatation Ocular: abnormal globe, cornea Hearing: tinnitus due to ossicle laxity mgmt Physiotherapy, regular gentle exercise, genetic counselling Periodic echo for floppy mitral valve or aortic root dilatation

Answer 36

``` def Inherited connective tissue disorder with characteristic skeletal, dermatological, cardiac, aortic, ocular malformations ``` patho Decreased extracellular microfibril formation. Fibrillin 1 - elastin matrix glycoprotein (missense) genetics AD fibrillin gene FBN1 death aortic root dilatation aortic dissection suspect tall skinny white man with long arms and legs/fingers (arachnodactyly) pres skin - striae CV - aortic dilation, dessection, MR Lung - pleural rupture - pneumothorax Eyes: lens dislocation, closed angle glaucoma Skeleton: arachnodactyly, hypermobility, pectus excavatum Facial: retrognathia, high arched palate, enopthalmos arachnodactyly Walker’s sign - encircles wrist with overlapping finger and thumb ix annual ECHO - aortic root width CV MRI - every 5 yrs mgmt MDT - geneticist, ophthalmologist, cardiologist, orthopaedics Avoid maximal exertion: scuba diving, weight lifting Prophylactic beta-blockers - propanolol Reduce MAP and pulse rate

Answer 37

def Group of rheumatic diseases with involvement of: 1) axial skeleton - sacrolitis 2) peripheral joints, 3) enthesitis (tendons and ligaments) and dactylitis - Pain, stiffness and tenderness without much swelling @ achilles, patellar rheumatoid factor negative other features ant uveitis IBD gene HLA B27 Chromosome 6 ``` class Class II (D) antigen from outside of cell to CD4 T cells for Abs, class I (A,B,C) presents peptides from inside cell to CD8 T cells (2x4 = 1x8) ``` diseases 1. Ankylosing spondylitis, 2. Reiter’s syndrome, 3. enteropathic arthritis, 4. psoriatic arthritis, 5. Behcet’s disease, 6. JIA criteria Inflammatory spinal pain or synovitis (in lower extremities) + - Fam Hx: anky spon, psoriasis, reactive arthritis, IBD - Past or present psoriasis - Past or present IBD - Past or present pain alternating between buttocks - Past or present pain spontaneous pain and achilles or plantar fascia - Diarrhoea one month before arthritis

Answer 38

Major histocompatibility complex - contains large number of genes relating to immune system function. Cell surface antigen presenting proteins

Answer 39

``` def Seronegative spondyloarthropathy of axial skeleton sacroiliitis and spondylitis (vertebral inflammation) ``` dx Inflammatory back pain + enthesitis Stiffness and pain waking in early morning Gradual onset Improvement with movement, no improvement with rest Age at onset < 40 Tenderness at sacroiliac region (felt in buttocks) or limited spinal motion who 20-30 m>f genetics 90% HLA B27 (if positive 1-2% develop AS), AD pres Insidious onset, relapse and remit In active disease: fever and wt loss (systemic) Inflammatory back pain Peripheral enthesitis (50%): Achilles and plantar fascia Peripheral arthritis (50%): asymmetrical, hips, shoulder girdle, chest wall (costovertebral, costochondritis) extra-articular EYES - ant uveitis - 40% (painful red eye and photophobia) CV - aortitis, dissection + aortic regurg LUNG - restrictive: costovertebral/sternal involvement limits chest expansion, apical fibrosis overlap with psoriatic arthritis enteropathic arthritis (IBD) reactive arthritis O/E Reduced chest expansion <5cm Schober’s test: reduced forward flexion <5cm + loss of lumbar lordosis Reduced lateral flexion ix Pelvic XR: sacroiliitis (blurring, loss of definition), uni or bilateral, grade 1-4 HLA B27: +ve XR of whole spine: *Bamboo spine (late + uncommon) erosions, squaring, syndesmophytes (bony spud) BESS ?LuFT - spiro - restrictive ``` mgmt no cure symptom control physio, rehab, exercise NSAIDs (+/- para) if pain refractory to NSAID - TNFalpha inhibitor enthesitis - intra-articular corticosteroid injection peripheral arth - DMARD sulfalasine ``` ``` comps THE 6 A's Apical fibrosis Ant uveitis Aortic regurg Achilles tendonitis AV node block Amyloidosis + cauda equina ```

Answer 40

def Seronegative inflammatory arthritis (axial, peripheral and enthesitis) in people with psoriasis correlates poorly with the skin cond patterns 1. Distal interphalangeal joint arthritis (DIP) 2. Asymmetric oligoarthritis (up to 5) - typically hands and feet 3. Symmetric polyarthritis (similar to RA) - women 4. Arthritis mutilans - severe destruction, osteolysis and bone shortening - gives classic pencil in cup in fingers/hand 'telescoping fingers' 5. Psoriatic spondylitis with sacroiliac and spinal involvement (sim AS) - men imp ddx Symmetric polyarthritis from RA: by dactylitis and no anti CCP pres NAILS - Nail pitting, onycholysis (splitting of nail from bed) FINGERS - dactylitis TENDONS - enthesitis ``` ix Plain film XR feet and hands: Erosion in DIP Periarticular new bone formation Osteolysis *Pencil in cup deformity ESR/CRP (normal or elevated) RF (+ve or -ve) *+ve in 2-10% Anti CCP (-ve) ``` mgmt Limited peripheral: NSAID + physio ± joint injection Progressive peripheral high ESR/CRP: DMARD (methotrexate) Dactylitis: NSAID + physio Spondylitis: NSAID + physio + TNF alpha

Answer 41

``` def Occurs 1-4 weeks post exposure to dysentry and STI infections ``` infections Campylobacter/salmonella/shigella or chlamydia reiters cant see pee or climb a tree (typically lower limb) Conjunctivitis, non-gonococcal urethritis + post-infectious arthritis pres acute asymmetrical, lower extremity oligoarthritis lower back pain + heel pain (enthesitis) extra-articular Conjunctivitis Skin: erythema nodosum or circinate balanitis (painless penile lesions) Nails: psoriatic nail changes GI: intermittent abdo pain and diarrhoea CV: aortitis ± aortic regurgitation if prolonged ix ESR/CRP very high, FBC - WCC Joint aspiration - rule out septic or crystal arthropathies Culture: stool, throat UG tract - for causative organism Serology chlamydia: PCR or NAAT and contract tracing mgmt NSAID + rest ± intra-articular steroids ± ABX chlamydia (azithromycin injx single or doxy week) oral pred if multiple joints

Answer 42

``` def Arthritis associated with IBD (CD or UC), coeliac or reactive… ``` symp Axial arthritis + peripheral arthritis (lower limb) + enthesitis + bowel symptoms + anterior uveitis mgmt Similar + treat bowels - consider sulfasalazine (bowel and rheumatic)

Answer 43

pres multisystem - recurrent oral ulcers, genital ulcers, eye lesions (anterior uveitis), skin (erythema nodosum), joints - non-erosive arthritis (lower limb) assoc HLA B51 mgmt topical corticosteroids systemic steroids - 1/2 yrs

Answer 44

Large vessel: Polymyalgia rheumatica, Giant Cell Arteritis, Takyasu’s arteritis Medium vessel: Polyarteritis nodosa, Kawasaki’s Small vessel: ANCA assoc = Wegener’s/granulomatosis with polyangiitis, Churg-Strauss Immune complex mediated = HSP

Answer 45

``` def Inflammatory granulomatous arteritis of aorta and large cerebral arteries (extracranial branches of carotid) ``` main worry anterior ischaemic optic neuritis - inflam of ophthalmic artery - sudden vision loss = MED EMERGENCY who w>m age >50 assoc PMR pres Recent onset temporal headache + scalp tenderness + transient visual symptoms (diplopia) + jaw claudication (on chewing) B symps = + malaise + myalgia + fever + night sweats + anorexia O/E Abnormality on palpation of temporal artery (absent pulse, beaded, tender) other vessels - thoracic aortic aneurysm ix diagnosis = ESR > 50mm/hr + temporal artery tenderness + *temporal artery biopsy biopsy = Granulomatous inflammation, multinucleated giant cells, intimal hypertrophy and inflammation, skip lesions consider aortic arch angiography - stenosis or occlusion mgmt High dose oral prednisolone 1mg/kg/day for 4 weeks then taper + Aspirin (lower visual problems) Osteoporosis prevention - Ca + Vit D + bisphosphonate If refractory - methotrexate if visual problems - urgent ophthalmology review comp stenosis of branches of arch of aorta - subclavian and axillary arteries - 20% aortic aneurysm subclavian steal - Retrograde blood flow in vertebral artery due to proximal stenosis of subclavian artery

Answer 46

pres Severe bilateral pain and morning stiffness: shoulders, neck, pelvic girdle (>2 weeks) with systemic features at onset (malaise, fever, fatigue) assoc 50% with GCA who >50 ix diagnosis: Symp > 2w, Morning stiffness > 45 mins, Evidence of acute phase response ESR/CRP others: ESR/CRP, FBC, UE, LFT, Bone profile, protein electrophoresis, TFT, creatinine kinase, RF, urinalysis mgmt prednisolone - 2 yrs start high 15mg and lower comp steroid induced osteoporosis - DEXA + bisphos + ca + vit d

Answer 47

synonym pulseless disease who rare young women 20-40 def Chronic, progressive, inflammatory, occlusive disease of aorta and branches that leads to: Stenosis, occlusion, dilatation, aneurysm stages Systemic stage + occlusive stage 1. Systemic: fever, fatigue, wt loss, arthralgia, tenderness on arteries 2. Occlusive: Limb claudication Cardiac: angina, dyspnoea (CHF) Neurological: dizziness, headache, TIA, visual disturbance, stroke Vascular: claudication of jaw, back pain (aortic arch), *HTN Pulmonary: haemoptysis GI: abdo pain from ischaemia/infarction Renal: haematuria O/E *Difference in SBP of >10mmHg between arms Impalpable peripheral pulse High BP - renal artery stenosis Arterial bruits on all arteries and aortic regurgitation ix ESR > 50 CRP elevated with active disease Aortic angiography: (CT/MRI) of aorta and main branches and pulmonary arteries: occlusion, stenosis, aneurysm, thickened arterial wall ``` mgmt glucocorticoids aspirin bisphos persistant - TNFalpha antagonist ?PCP pneumonia proph + flu + pneumococcal ```

Answer 48

``` def Necrotising inflammation of medium sized or small arteries without glomerulonephritis ``` assoc HBV features Any organ BUT spares pulmonary and glomerular arteries Nerves and skin most common Nerves: *mononeuritis multiplex Skin: purpura, subcutaneous nodules, necrotic ulcers, *livedo reticularis Systemic symptoms: fever, wt loss, headache, myalgia Renal: *not glom - *HTN or AKI GI: 50% - postprandial abdominal pain from ischaemia ix HBsAg - 30% p-ANCA - negative Acute phase response: leukocytosis/neutrophilia, ESR Complement - reduced C3/C4 *Arteriography: microaneurysms in small and medium sized arteries + focal narrowing = ROSARY SIGN Small artery biopsy: necrotising inflammation (but can do skin or muscle biopsy) - focal and segmental transmural necrotising inflammation Urinalysis: proteinuria mgmt Prednisolone ± DMARD (cyclophosphamide) - if relapse If active Hep B: antivirals and plasma exchange comps *Renal failure - not due to glomerulonephritis - due to microaneurysms and infarcts - accelerated HTN - *requires regular renal monitoring - poor prognosis = half die within 3 months

Answer 49

who 6m-5yrs asian ``` def idiopathic self-limiting systemic vasculitis ``` features CRASH and BURN Conjunctivitis (bilateral + non-purulent) Rash - non vesicular Adenopathy (cervical + unilateral) Strawberry tongue + inflammation of lips and mouth (cracked lips) Hands/feet - palmar erythema/swelling/desquamation (2-5 days after onset) Fever > 5 days assoc coronary art aneurysm + dilation - echo mgmt first line IVIG + high dose aspirin comp reyes from aspirin treatment

Answer 50

Anti-neutrophilic cytoplasmic antibodies C-ANCA - cytoplasmic major antigen proteinase-3 P-ANCA - perinuclear major antigen myeloperoxidase

Answer 51

``` classic triad ELK disease (ENT, lungs, kidneys) Upper respiratory tract involvement Lower respiratory tract involvement Glomerulonephritis ``` others Cutaneous, ocular, MSK pres 1. Upper resp: otorrhoea, sinus pain, nasal discharge, hoarseness, stridor * Saddle nose deformity, nasal septal perforation, subglottic stenosis 2. Lower resp: SOB, cough, haemoptysis, chest pain, dyspnoea, rhonchi, reduced air entry 3. Renal: oedema, HTN, haematuria (later) 4. Ocular: redness, pain, tearing, proptosis, visual blurring marked bilateral periorbital oedema from kidney… 5. Cutaneous: palpable purpura or petechia 6. MSK: myalgia and arthralgia Neurological: numbness, weakness, etc ix Kidney: urinalysis and microscopy + renal biopsy - Haematuria, proteinuria, RBC casts, epithelial crescents in bowman's capsule Lung - CT chest/CXR - lung nodules (cavitating) ANCA by immunofluorescense- c-ANCA (anti-PR3) FBC - anaemia, ESR - raised mgmt Life threatening/organ involvement -> Remission with IV methylpred (3d) + pred oral + cyclophosphamide Non-life threatening: -> Remission with IV methylpred (3d) + oral prednisolone + methotrexate Maintain remission with oral pred + methotrexate + folic acid worry about AKI Resp failure

Answer 52

suspect when adult onset asthma pres triad = tissue eosinophilia, granulomatous inflammation, vasculitis dx criteria = Asthma (wheeze), eosinophilia in peripheral blood, paranasal sinusitis, pulmonary infiltrates, histological confirmation vasculitis, *mononeuritis multiplex ELK ENT - allergic rhinitis, paranasal sinusitis, nasal polyposis Lower RT - pneumonitis, haemoptysis Renal - glomerulonephritis - HTN ix p-ANCA (antimyeloperoxidase Ab) - 40% FBC - eosinophilia + anaemia, elevated ESR/CRP CXR - pulmonary infiltrates Pulmonary CT - peripheral consolidation - ground-glass attenuation Biopsy small necrotising granulomas and necrotising vasculitis score five factor Proteinuria, serum creatinine, GI tract involve, cardiomyopathy, CNS involvement -> higher mortality ``` mgmt corticosteroids remission = IV methylpred 3d then oral pred if score include cyclophosphamide + asthma mgmt ```

Answer 53

p-ANCA suspect Rapidly progressive glomerulonephritis and pulmonary haemorrhage where lungs + kidney mgmt pred cyclophosphamide

Answer 54

pres Arthralgia, purpura, hepatic involvement, Raynaud’s, glomerular disease assoc Hep C ix Cryoglobulins, Hep C serology ANCA -ve

Answer 55

synonym Henoch- Schonlein purpura who Young man with previous URTI - GpA strep (pyogenes) what IgA immune complexes deposited in small vessels pres triad - Arthralgia, abdo pain, rash Low grade fever, *abdominal pain and vomiting, purpuric rash on buttocks and extensor, joint pain 40% -> nephrotic syndrome ix urinalysis - proteinuria, RBC, casts, 24 hour urine protein mgmt joint or abdo pain - ibuprofen or paracetamol kidney - supportive/ steroids 1/3 relapse

Answer 56

patho Lungs and kidneys: pulmonary renal syndrome -> glomerulonephritis and pulmonary haemorrhage -> haemoptysis and renal failure (AKI) AAb Alpha 3 chain of type 4 collagen -> glomerular basement membrane and alveoli, anti-GBM Ab HLA DR2 who male 20-30 or 60-70 pres Reduced urine output, haemoptysis, oedema, SOB, cough ix Renal function: abnormal Renal biopsy: crescentic glomerulonephritis - perform *urgently Anti-GBM - positive mgmt If reversible renal or any pulmonary involvement - oral prednisolone + cyclophosphamide + plasmapheresis If pulmonary haemorrhage: supportive + smoking cessation ``` comp pulm haem things that increase the likelihood of that: - smokig - LRTI - pulm oedema - inhalation of hydrcarbons - young males ```

Answer 57

``` Sole native kidney ESRD Neoplasm Bleeding disease Uncontrolled severe HTN Acute pyelonephritis ```

Answer 58

haem - FBC, ESR, clotting biochem - U/E, cr, LFT, PAN and cryo assoc HBV, HCV, CRP, immunoglobs + protein electrophoresis immunology - ANCA, RF, C3/4, anti-cardiolipin, cryoglobulins micro - HBV/HCV serology, urine micro + culture radio - CXR

Answer 59

when consider Any patient with acutely inflamed joint *less dramatic if immunocompromised why imp destroy joint in under 24 hours where knee organism most common - s.aureus strep eg GBS gonococcal pres Hot, red, swollen, *immobile/restricted if prosthetic - Prolonged, low grade course, gradually increasing pain. No swelling/fever. *Cellulitis RF *Prosthetic joint (x10), RA, OA, IV drug abuse, alcoholism, diabetes, immunosuppression, skin infection ix Urgent joint aspiration - synovial fluid Gram stain and culture, WCC, polarised microscopy (exclude gout) Blood culture x2 ± gonococcal cultures (rectal, urethral, pharyngeal) Acute phase markers: ESR, CRP, WCC raised XR - limited value - Early: Oedema and effusion - fat pad displacement, swelling of capsule and soft tissue, joint space widening Late: joint space narrowing (cartilage destruction), subchondral bone loss, joint destruction CT/MRI - most sensitive for periarticular abscess, osteomyelitis mgmt Surgical drainage and lavage (wash) + high dose IV abx IV abx 2/3 weeks then oral 3/4 weeks - 6 total If suspect G+ use vancomycin, if suspect G- use 3rd gen cephalosporin When cultures back For staph flucloxacillin If suspect MRSA vancomycin or teicoplanin (IV vanc then oral clindamycin) If gonococcal arth or G- cefotaxime or ceftriaxone if had prosthesis - remove joint and fill with abx impregnanted spacer comp Osteomyelitis Joint destruction

Answer 60

``` def infection of bone marrow may spread to cortex and periosteum via haversian canals, leading to inflammatory destruction of bone ``` types 1. haematogenous - bacterial seeding from far source - common assoc with children - children = metaphysis of long bones, adults = vertebral bodies 2. direct/contiguous - more localised, contact of infected tissue with bone ie post surg or trauma organism s.aureus - MRSA if diabetic or IVDU or immuno comp salmonella - sickle cell anaemia staging 1 = medullary cavity only 2 = superficial involving cortical bone only 3 = localised involving medullary and cortical bone 4 = diffuse entire bone thickness RF Trauma, prosthetics, diabetes, PAD, chronic joint disease, alcoholism, IVDU, immunosuppression pres - LONG - Acutely febrile + bacteraemic + painful immobile *limb - swelling and tenderness and erythema - *exacerbated by movement VERTBRAE - post acute septicaemic episode, localised oedema, erythema, tenderness or chronic back pain potts disease - vertebral osteomyelitis from haematogenous spread of TB - damage to two neighbouring vert - collapse and cold abscess formation worry about With diabetic foot ulcers may be absent signs local infection and absent pain due to neuropathy ``` ix FBC (WCC) Blood cultures (+ve) Acute phase markers: ESR + CRP + WCC MRI - modality of choice *Plain radiograph- Areas appear dark, soft tissue swelling, periosteal thickening (at 7 days), patchy osteopenia (lytic changes are late) Cultures from debrided bone ``` ``` mgmt 1) Bone and soft tissue debridement, 2) stabilise bone + immobilisation, 3) local ABX - fluclox or clinda in pen allergic, 4) reconstruction Analgesia and limb splinting if long bone Culture directed ABX + debridement IV for 2 weeks then oral for 4 weeks Chronic treatment is for 12 weeks ``` comp amputation - diabetic spread to joint if breaks through cortex

Answer 61

when dead bone detaches from healthy bone

Answer 62

``` def Chronic widespread pain disorder ``` who Women > men x 10, normally 20-50 years old patho Peripheral and central hyperexcitability, altered pain perception, somatisation assoc fatigue, memory problems, mood difficulties, stress where everywherre mgmt 1st - amitriptylline + CBT 2nd - gabapentin or pregablin

Answer 63

RED FLAGS TUNA FISH Trauma Unexplained weight loss, loss of appetite - cancer/myeloma Neurological symptoms including bowel bladder dysfunction - cauda equina Age > 50 or < 20 Fever and night sweats - osteomyelitis/cancer IVDU/immunosuppression - osteomyelitis Steroid use - immunocompromise + osteoporotic fracture History of cancer (prostate, breast, lung, renal) ``` MAIN WORRIES Cauda equina - bowel or bladder dysfunction, bilateral sciatica, saddle anaesthesia - high possibility of being sued!!! Multiple myeloma Metastatic cancer Psoas abscess ```

Answer 64

usually caused by.. Chronic disc degeneration (CERVICAL OSTEOARTHRITIS) pres simple neck pain + radiculopathy (pain, numbness, tingling, weakness in upper limbs) + myelopathy (spinal cord) worse on movement stiffness referred pain to -> occiput, between shoulder blade, retro-orbital/temporal (C1/2) ix radiculopathy - Spurling test: flex neck laterally, rotate and push -> radicular pain c5-c7 -> diminished reflex - biceps + supinator = c5/6, triceps = c7 pain xr - osteophytes, narrowing of disc space, encroachment of intervertebral foramen neuropathy - require MRI mgmt 3-4 weeks = reassurance + keep normal movement 4-12 weeks = physio + yoga + pilates + alexander method

Answer 65

wear and tear osteoarthritis

Answer 66

why worry More commonly due to serious spinal pathology than cervical or lumbar causes Most common = muscular irritation, trauma, sudden injury red flags As before = TUNA FISH esp. Bladder symptoms = myelopathy or collapse disc collapse pres Pain localised to spine + relevant radiculopathy, sensory disturbance in dermatomal distribution comp May cause significant restrictions and exclusion of domestic, leisure, educational activities mgmt Many resolve without Rx ddx Problems affecting the lung (including Pancoast tumour), oesophagus, stomach, liver and gallbladder

Answer 67

RF Demanding jobs, prolonged standing, awkward lifting, *psychosocial work stress red flags CES: saddle anaesthesia, perianal sensory loss, bladder dysfunction, loss of anal tone Spinal fracture: sudden onset pain relieved by lying down, structural deformity e.g. step Cancer or infection (e.g. discitis) - PAIN REMAINS ON LYING DOWN, night pain>50 or <20, recent infx, IVDU etc…. ddx 15-30 = Trauma, fracture, pregnancy, anky spon, prolapsed disc, *mechanical 30-50 = *Degenerative spinal disease, prolapsed disc, malignancy (breast, bronchus, prostate, kidney) 50 + = Degenerative, osteoporotic collapse, myeloma, spinal stenosis, malignancy, Paget’s (pelvis 70%, lumbar 50%) ix FBC, ESR, CRP, UE, Alk phos, serum/urine electrophoresis, PSA Imaging only if serious pathology indicated e.g. red flags (not simple back pain) Plain XR: not routine, only if fracture likely - Prostate = sclerotic - Lung, renal = lytic - Breast = sclerotic or lytic MRI good for soft tissue, disc lesion and impingement of nerves mgmt keep active + analgesia acupuncture physio psychosocial -Beliefs that activity is harmful, sickness behaviour, withdrawal, dissatisfaction at work, depression, manage expectations lumbar discectomy - only in severe nerve compression refer - 6w of sciatica: disabling and distressing

Answer 68

facet joint issues only consider sciatica if shooting pain to bottom of foot

Answer 69

Benign or malignant Benign: bone osteoid osteoma, cartilage chondroma/osteochondroma, fibrous tissue fibroma, BM eosinophilic granuloma Malignant: bone osteosarcoma, cartilage chondrosarcoma, fibrous fibrosarcoma, BM myeloma, Ewing’s sarcoma Uncertain: Giant cell tumour symps Bone pain: unremitting, worse at night swelling, effusion, deformity, nodes, pathological fracture, wt loss

Answer 70

<1cm, surrounded by dense osteoid Young adults XR Radiolucency surrounded by dense bone mgmt Pain with NSAIDs, local excision = curative

Answer 71

Most common benign Young adults Next to epiphyseal plate Painless lump or joint pain, nerve compression = spur on XR

Answer 72

Single or multiple lesions Hands or feet, tubular bones Excise lesion + graft bone

Answer 73

An osteoclastoma = 20% of all, aggressive, recurrent where Sub-articular cancellous region of long bones after closure of epiphyses 20-40 XR Asymmetrical area at end of long bone ``` mgmt Excise lesion (don’t graft) ```

Answer 74

what most common malignant who children 15-19 assoc pagets where epiphyses of long bones - knee 75% or proximal humerus pres painless destroys bone and spreads locally, rapidly mets to lung XR combine bone desctution and formation soft tissue calcification = sunburst/hair on end + codmans triangle - area of new subperisosteal bone created when tumour raises periosteum from bone

Answer 75

primitive neuroectodermal tumour who 15 boy pres mass or swellling in long bones of arms/legs, pelvis, chest pain, redness, malaise, fever xr bone destruction with onion skin layers of periosteal bone formation + codmans triangle

Answer 76

``` Isotope bone scans (for mets) XR Alk phos/Ca CT/MRI for stage Biopsy fine needle or core ``` mgmt Benign - manage symptoms (analgesia ± excision) Malignant = complex MDT - refer to sarcoma clinic

Answer 77

Potential for dissemination - local recurrence therefore immobilise post biopsy (with external splint, not internal fixation)

Answer 78

high vascular

Answer 79

groin | medial knee

Answer 80

rotator cuff - supraspinatus tendonitis adhesive capsulitis - true frozen shoulder (all movements prohibited) - cant move hands out with shoulders tucked in acromio-clavicular joint arthritis OA shoulder - glenohumeral

Answer 81

OA of acromioclavicular joint = top bit supraspinatus tendonitis = middle bit full thickness tear of supraspinatus = lower portion (cannot initiate abduction)

Answer 82

infraspinatus + teres minor - external rotation supraspinatus = abduction subscapularis = internal rotation coracohumeral ligament -> stengthens ant capsule and implicated in the restricted external rotation of adhesive capsulitis

Answer 83

1. projection - need at least two views - normally AP + lateral - shaft of a long bone fractured then should always xr the joint above and below - comment on maturity of bone - open epiphyseal plates? 2. patient details 3. technical adequacy - entire area in - exposure - rotation 4. obvious abnormalities 5. SR of xray - look around all edges for fractures - look at medulla for lucent or sclerotic lines - assess for soft tissue swelling + joint effusion - look at joint surfaces for evidence of subluxation or dislocation - assess for degenerative (LOSS) or inflammatory (LESS) changes - review bone density and texture looking for any abnormal lucent or sclerotic areas

Answer 84

which bone which part - proximal 1/3, middle or distal, intra-articular fracture pattern - simple, open, comminuted, impacted type of fracture - transverse, oblique, spiral, greenstick, vertical translocation displacment - relationship of distal fracture to proximal (essential to use two xrays to assess this) angulation - movement of the distal fragment in relationship to the proximal one in degrees rotation - internal or external (long bone fractures) shortening joint space - smaller? foreign bodies? joint cartilage bone texture - radiolucency?

Answer 85

positive in achilles tendon rupture suspect achilles tendon rupture if hear a pop in ankle and sudden onset pain in calf or ankle and inability to walk

Answer 86

reduction and realignment backslab for 1-2 weeks to accomodate swelling repeat xray then apply full cast for 6 weeks

Orthopaedics and Rheum Flashcards

(110 cards)