Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Shoulder Osteoarthritis Wrist RheumatoidArthritis Ankle Legs Reactivearthritis Gout/Pseudogout Hip Ankylosingspondylitis Salter-HarrisFractures Osteomyelitis SLE Osteoporosis CompartmentSyndromeACE IT UKMLA Teaching SeriesA20-year-oldmanpresentstotheemergency A Above elbow backslab and follow-up departmentwithawristinjury.Hewasridinghisbike whenhe felloffatalowspeedontohisoutstretched in 4 weeks righthand.Hedeniesanyotherinjuries. Above elbow backslab and follow-up B On examination, thereisnovisible deformity,buthe in 4 days istenderonpalpation ofthe anatomical snuffbox andonlongitudinalcompressionofthethumb. C Elasticated bandage, no follow-up X-raysareperformedwhichshownovisible abnormality. Wrist splint and follow-up in 7 days What treatment and follow-upplan ismost D appropriate? Wrist splint and follow-up in 7 weeks EA20-year-oldmanpresentstotheemergency A Above elbow backslab and follow-up departmentwithawristinjury.Hewasridinghisbike whenhe felloffatalowspeedontohisoutstretched in 4 weeks righthand.Hedeniesanyotherinjuries. Above elbow backslab and follow-up B On examination, thereisnovisible deformity,buthe in 4 days istenderonpalpation ofthe anatomical snuffbox andonlongitudinalcompressionofthethumb. C Elasticated bandage, no follow-up X-raysareperformedwhichshownovisible abnormality. Wrist splint and follow-up in 7 days What treatment and follow-upplan ismost D appropriate? Wrist splint and follow-up in 7 weeks E Background Management Common causes: fall on outstretched hand Ask for plain-film x-rays in Can have distal, waist or proximal • Posterior-anterior view Clinical signs • Lateral views • Oblique (with wrist pronated at 45º) • Hyperextension, radially deviated • Tenderness over anatomical snuffbox, scaphoid • Elongated ‘Ziter’ view: the wrist in ulnar deviation tubercle (volar aspect wrist) and beam angulated at 20º) Consider CT if symptoms continue • Pain elicited on ⚬ Telescoping thumb MRI definite to confirm but not common practice ⚬ Ulnar deviation of wrist If confirmed in imaging: • (Sometimes) wristjoint effusions (4hrs >x>4days) immobilisation with below-elbow backslab/Futuro splint If inconclusive: offer wrist splint, refer to orthopaedics and review in one week Main concern: avascular necrosis of scaphoid in proximal fracture impact on carpal branch, continued non-union predisposing to early osteoarthritis Proximal or distal fractures: require internal fixation Background Image Articulating aspects: distal end of the radius, fibrocartilaginous ligament preventing ulnar articulation, and proximal row of carpal bones 4 ligaments - • Palmar radiocarpal (ensures hand follows forearm in supination), dorsal radiocarpal (ensures hand follows forearm in pronation) • Ulnar collateral - prevents radial (lateral) deviation of hand • Radial collateral – prevents excessive ulnar (medial) deviation of hand Flexion – flexor carpi ulnaris, flexor carpi radialis, flexor digitorum superficialis. Extension – extensor carpi radialis longus and brevis, extensor carpi ulnaris,extensor digitorum. Adduction – Produced by extensor carpi ulnaris and flexor carpi ulnaris Abduction – Produced by abductor pollicis longus, flexor carpi radialis, extensor carpi radialis longus and brevis. Colles’ fracture Smith’s fracture Dorsal (backwards) displacement of Volar (forward) displacement of fragments fragments from distal end of the radius, from distal end of radius - ‘reverse colles’ occurs from a fall onto OUTSTRETCHED hand, caused by falling backwards - resulting in forced dorsiflexion of wrist. fall onto palm with arm pronating Characteristic appearance - dinner fork Characteristic appearance - deformity - deviation backwards, lateral. 'garden spade deformity'. Distinguish using AP and lateral X-rays Manage with either Manage with • Closed reduction (longitudinal traction) • Manual reduction forward and medial or • Immobilise with back-slab for 6 weeks • Open reduction and internal fixation Complications (stabilise with plate and screws) • Acute median or ulnar nerve damage Cast/splint 4-8 weeks and (carpal tunnel) physiotherapy • Malunion Complications include • Compartment • Compartment syndrome syndrome (nerve damage rare) • Malunion or distal radial shortening • Entrapment/rupture of extensor pollicus longus, reduced thumb extension (7 weeks)A57-year-oldaccountantpresentstotheGPwitha painfulrightelbow.Shepointstothemedial A Fluctuant swelling over olecranon epicondyleofthehumerus.Shedoesnotrecallany process predisposinginjurybutdescribesexacerbationofthe painwhenusingthearm,whichcanextendintothe B Worse pain when wrist is extended forearm.Thishascausedhimtostopplayinggolf.Heis and supinated otherwise wellandtakesnomedications. Fromthehistoryalone,aparticulardiagnosisis Worse pain when wrist is extended C suspected.Examinationsupportsthissupposition. and pronated What examination finding ismostconsistent with thesuspecteddiagnosis? Worse pain when wrist is flexed and D supinated E Worse pain when wrist is flexed and pronatedA57-year-oldaccountantpresentstotheGPwitha painfulrightelbow.Shepointstothemedial A Fluctuant swelling over olecranon epicondyleofthehumerus.Shedoesnotrecallany process predisposinginjurybutdescribesexacerbationofthe painwhenusingthearm,whichcanextendintothe B Worse pain when wrist is extended forearm.Thishascausedhimtostopplayinggolf.Heis and supinated otherwise wellandtakesnomedications. Fromthehistoryalone,aparticulardiagnosisis Worse pain when wrist is extended C suspected.Examinationsupportsthissupposition. and pronated What examination finding ismostconsistent with thesuspecteddiagnosis? Worse pain when wrist is flexed and D supinated E Worse pain when wrist is flexed and pronated Fibrous capsule encloses joint, thickened to form ligaments - radial collateral ligament on lateral side extending from lateral epicondyle, and blending with the annular ligament of the radius 3 bursa decrease friction. Muscles: • Extension – triceps brachii, anconeus • Flexion – brachialis, biceps brachii, brachioradialis Medial epicondyle Lateral epicondyle Attachment point for Attachment point for the pronator teres, ulnar radial collateral ligament and extensor muscles - collateral ligament& common flexor tendon) of extensor carpi radialis some of forearm flexors: brevis, extensor flexor carpi radialis, flexor digitorum, extensor digiti carpi ulnaris, flexor minimi, extensor carpi digitorum superficialis ulnaris, supinator and anconeus. Medial epicondylitis Lateral epicondylitis Golfer’s elbow Tennis elbow Inflammation of flexor tendons at Inflammation of extensor tendons at insertion point due to overload. insertion point due to overload - acute May have ulnar nerve involvement ( 4th/5th finger) pain 6-12 weeks, can last up to 2 years Diagnostic sign: pain on active Diagnostic sign: pain on active wrist flexion against resistance wrist extension against resistance Advise on avoiding muscle load, physiotherapy, steroid Advise on avoiding muscle load, physiotherapy, steroid injection injectionA22-year-old manfalls overand presentsto casualty withseverepain in theshoulder.Ashoulder A Anterior glenohumeral dislocation x-rayis performedbeforeand after reduction,and the radiologistcommentsthat a Hill-Sachs lesionis present. B Posterior glenohumoral dislocation What mightthis suggest? Adhesive capsulitis C Axillary nerve palsy D E Acromioclavicular dislocationA22-year-old manfalls overand presentsto A Anterior glenohumeral dislocation casualty withseverepain in theshoulder.Ashoulder x-rayis performedbeforeand after reduction,and the radiologistcommentsthat a Hill-Sachs lesionis present. Posterior glenohumoral dislocation B What mightthis suggest? AHills-Sachs lesionisacortical depressionin the C Adhesive capsulitis posterolateralaspect ofthe humeralheadfrom impaction ontoanteriorglenoidrim,suggesting anteriorglenohumeraldislocation. Axillary nerve palsy D Acromioclavicular dislocation E Anterior Posterior Humeral head dislocated anteriorly to glenoid fossa Humeral head displaced posterior to glenoid fossa of scapula. Most common mechanism of injury is impact to abducted More commonly encountered in young athletic individuals, also and externally rotated arm, or force applied to posterior commonly follows tetanic muscle contraction (seizures and aspect of humerus and falling onoutstretched arm. electrocution). Risk factors - bony abnormalities such as glenoid retroversion or hypoplasia, ligamentous laxity. The arm is usually held in an abducted and externally rotated position with a prominent acromion. Nerve Present with a flexed, adducted and internally rotated arm. Carry a damage, tears of the glenoid labrum and fractures of the higher risk of associated injuries-surgical neck and lesser tuberosity fractures of the humerus, reverse Hill-Sachs lesions (impaction humeral head and glenoid fossa in 40% of cases. fracture of the anteromedial aspect of the humeral head) and Hills-Sachs lesion-corticaldepressioninthe avulsion of the posterior band of the inferior glenohumeral ligament. posterolateralaspectofthe humeralheadfrom impactionontoanteriorglenoidrim Manage with open reduction Summary Supraspinatus - suprascapular nerve • Attachments: Originates from supraspinous fossa of scapula and attaches to the greater tubercle of the humerus. • Actions: Abduction of the upper limb at the shoulder. It performs the first 0-15o of abduction, and assists deltoid muscle for 15-90o Subscapularis - upper and lower subscapular nerves • Attachments: Originates from subscapular fossa, on the costal surface of scapula. It attaches to the lesser tubercle of humerus. • Actions: Medially rotates the arm. Teres minor - axillary nerve • Attachments: Originates from posterior surface of scapula, adjacent to lateral border, to greater tubercle of humerus. • Actions: Laterally rotates the arm. Infraspinatus - subscapular nerve • Attachments: Originates from the infraspinous fossa of the scapula, attaches to the greater tubercle of the humerus. • Actions: Laterally rotates the arm. SUBACROMIAL IMPINGEMENT SUBSCAPULARIS TENDONITIS/TEAR Supraspinatus tendonitis causes Internal rotation and pain between 60 to 120 degrees abduction of abduction Assess with Gerber’s lift-off Assess with Jobe’s test (abduct, test (patient’s dorsum of internally rotate and push arm hand presses on lower back, down) and painful arc/drop arm move hand against test (abduct arm and have patient resistance) put it down) INFRASPINATUS/TERES MINOR Together - external rotation and lateral rotation of the shoulder Assess with infraspinatus test - abduct arm with elbow flexed at 90o, externally rotate against resistance Arm falling back to internal rotation/losing power - axillary nerve lesion Hornblower’s sign - unable to bring hands to mouth without abduction (teres minor)A69-year-oldman isseenin theemergency A Patient controlled analgesia departmentfollowingafallat home.Hecomplainsof severepain in thelefthemithorax.Avisible bruiseis notedonexamination. Achestx-rayrevealssimple fractures ofribs 4and 5.Nootherabnormalityis Prophylactic chest drain B noted. Thefracturesareinitially managed conservativelywithregularmorphineforanalgesia. However,the patient continues tobein significant C Contact cardiothoracic surgeons pain. Hisrespiratoryrate is25/min andhis breathing isshallow. What is themostappropriatenextstepin Intercostal nerveblock D management? Rib belt EA69-year-oldman isseenin theemergency departmentfollowingafallat home.Hecomplainsof A Patient controlled analgesia severepain in thelefthemithorax.Avisible bruiseis notedonexamination. Achestx-rayrevealssimple fractures ofribs 4and 5.Nootherabnormalityis Prophylactic chest drain noted. Thefracturesareinitially managed B conservativelywithregularmorphineforanalgesia. However,the patient continues tobein significant Contact cardiothoracic surgeons pain. Hisrespiratoryrate is25/min andhis C breathing isshallow. What is themostappropriatenextstepin D Intercostal nerveblock management? Intercostalnerveblocksare recommendedbyNICE Rib belt ifpain fromribfracturesarenotmanaged byroad E analgesia. Itis importanttocontrolthepain affected bybreathing. Considerations Background Management Beware causes: NAI, trauma, falls, primary bone tumours or metastatic disease • Chest splinting/pressure therapy Clinical signs and symptoms: • Analgesia: paracetamol, ibuprofen, nerve block • IV fluids • Chest wall pain limiting ventilation • Shortness of breath • Suplemental oxygen • Paradoxical chest wall movements - chest • Chest physiotherapy/ pulmonary hygiene moves in on inspiration, out on expiration due to • If conservative fails after 12 weeks - surgical negative pressure changes • Only urgently involve cardiothoracics on flail chest segments due to ventilation risk ⚬ FLAIL CHEST (3 or 3+ ipsilateral ribs fractured in 2 different places) Complications: • Pulmonary contusions to parenchyma • Atelectasis, impaired gas exchange/shunting • Refractory hypoxaemia • Respiratory distress syndrome • Pneumonia • Pneumothorax or haemothorax- chest drain when develops but not prophylacticA19-year-oldman presentstothe emergencydepartmentwithseverepain A Historyof lower limb fractures andbonytendernesstwocentimetres abovethelateralmalleolusfollowingan inversioninjurytohisankle sustained Reduced ability to walk duringafootballmatch. Theconsultant B sendshimforan X-ray. Severe ankle swelling On examination, hisankleisswollenand C bruised,withminorabrasions aroundthe ankle,and heisonlyabletowalkseven weight-bearingsteps.Heisotherwisein D Immediate bruising goodhealth,althoughhehashad three previouslowerlimbfractures. Bony tenderness2 cm above lateral What symptomjustifies the consultant’s E malleolus decision?A19-year-oldman presentstothe emergencydepartmentwithseverepain A Historyof lower limb fractures andbonytendernesstwocentimetres abovethelateralmalleolusfollowingan inversioninjurytohisankle sustained Reduced ability to walk duringafootballmatch. Theconsultant B sendshimforan X-ray. Severe ankle swelling On examination, hisankleisswollenand C bruised,withminorabrasions aroundthe ankle,and heisonlyabletowalkseven weight-bearingsteps.Heisotherwisein D Immediate bruising goodhealth,althoughhehashad three previouslowerlimbfractures. Bony tenderness 2 cm above lateral What symptomjustifies the consultant’s E malleolus decision? General Ankle composed of distal aspects of tibia and fibula bound by tibiofibular ligaments to form bracket-shaped mortise, fitting body of talus to enable joint stability during dorsiflexion (less so in plantarflexion) Sprains involve ligaments • Lateral ligaments (anterior & posterior talofibular, calcaneofibular ) - resist over- INversion of the foot • Medial ligaments (4 ligaments from malleolus to talus and navicular bones) - resist over- eversion of foot Ottawa Rules Ankle X-rays are only required if there is pain in the malleolar zone with either 1. bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia) 2.bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibula) OR Inability to walk 4 weight-bearing steps instantly afterwards Weber classification of lateral malleolus fractures • Type A = below the syndesmosis • Type B = at the level of the syndesmosis • Type C = above the level of syndesmosis The more proximal the injury, higher likelihood of instability/surgical fixation. Orthopaedics use Lauge- Hansen classification nowA2-year-old childis broughttothe emergencydepartmentafter falling froma A Type I swing atthe park. Thechildhasbeencrying continuouslysince the falland cannot bear weightontherightleg.Examination shows Type II swellingand bruising aroundthe right B ankle, withpain restricting movementin all directions,but the limbisneurovascularly Type III intact. C AnX-rayofthe anklerevealsan oblique fracturelinecrossingthedistal D Type IV metaphysis,physis,and epiphysisofthe distal tibia. Type Which typeofSalter-Harrisfracture is E present?A2-year-old childis broughttothe emergencydepartmentafter falling froma A Type I swing atthe park. Thechildhasbeencrying continuouslysince the falland cannot bear weightontherightleg.Examination shows Type II swellingand bruising aroundthe right B ankle, withpain restricting movementin all directions,but the limbisneurovascularly Type III intact. C AnX-rayofthe anklerevealsan oblique fracturelinecrossingthedistal D Type IV metaphysis,physis,and epiphysisofthe distal tibia. Type Which typeofSalter-Harrisfracture is E present? Management Background Type 2 most common, Types I, II Fracture through the growth plate of long managed with rest, ice, elevation bone (i.e. humerus in the arm and the tibia in the leg). Present in children, the physeal or Type III and IV may need surgery Type V most likely to arrest epiphyseal (growth) plate, is area of cartilage that actively develops into new bone, increasing the bone’s length until the child stops growing around the ages of 14 to 18. Can lead to permanent growth arrest Clinical features: Pain, followed by swelling around the end of the injured long bone. Area around the fracture may also feel painful to touch. A person with a fracture may not be able to put weight on the affected limbor may have a limited range of motion. In addition, a bone deformity may be visible as a result of the fracture.A29-year-oldfemalewasadmittedtoorthopaedics2 dayspreviouslyaftera skiing accident. X-raysshoweda A Accumulationof myoglobin in the renal tubules closedlefttibial shaft fracture withminimal displacement.Shehasbecomemoredistressedinthe last 3hoursduetoseverepain in theleg,despitehourly B Renal hypo-perfusion and acute oralmorphineinaddition toregularparacetamoland tubular necrosis ibuprofen.Herurineappearsdarkand a dipstick is positive forblood. Depositionof anti-glomerular C basement membrane antibodies What is themostsignificant contributing factortoher acute kidneyinjury (AKI)? Obstructionof right ureter due to D calculus formation E Vasoconstriction of afferent arterioles due to ibuprofenA29-year-oldfemalewasadmittedtoorthopaedics 2days previouslyaftera skiingaccident. X-raysshowedaclosedleft A Accumulationof myoglobin in the tibialshaft fracturewithminimaldisplacement. Shehasbecome renal tubules moredistressedinthelast3hoursduetoseverepainintheleg, despitehourlyoralmorphineinadditiontoregularparacetamol Renal hypo-perfusion and acute andibuprofen.Herurineappearsdarkandadipstick ispositivefor B blood. tubular necrosis Whatisthemostsignificant contributing factor toheracute kidneyinjury(AKI)? Depositionof anti-glomerular C basement membrane antibodies Untreatedacutecompartmentsyndromemayprecipitate rhabdomyolysis, releasing myoglobinsandcreatinekinaseinto bloodstream. Obstructionof right ureter due to D calculus formation Vasoconstriction of afferent E arterioles due to ibuprofen Background Investigations/Management Surgical emergency of increased pressure in Diagnosed clinically: intra-compartmental monitoring closed limb compartment by fractures or interruption to homeostatic gradient required (using transducer) Most common cause: tibial fractures, Urinalysis may show dark concentrated urine supracondylar fractures, ischaemia Difference between diastolic BP and compartment reperfusion in vascular patients pressure = <30 Absolute pressure >40 diagnostic Clinical Features Initial management 6 Ps • Remove circumferential casts • Pain (disproportionate to visible injury) • Maintain blood pressure • Paraesthesia Definitive management: emergency fasciotomy For leg - two incisions, 4 compartments technique • Poikilothermia • Pallor Aim for 6 hour window to decrease amputation risk • Paralysis Sodium bicarbonate for urinary alkalinisation in case • Pulselessness (end-stage) of renal involvement/rhabdomyolsis Bloods and bedside may show high urine Post-procedure wound care - sterile field, myoglobin and serum creatine kinase due to debridement of necrotic tissue muscle lysis and necrosis Anterior - extend lower limb at knee joint Quadriceps femoris • 3 vastus (lateralis, intermedius, medialis) + 1 rectus femoris Sartorius Pectineus Psoas major Iliopsoas (psoas major + iliacus) FEMORAL NERVE (L2-L4) Medial - hip adduction Adductor magnus, longus, brevis Posterior - extend hip, flex Obturator externus Gracilis at the knee Biceps femoris OBTURATOR NERVE Semitendinosus Semimembranosus SCIATIC NERVE (L4-S3) Anterior - dorsiflex and invert the foot Posterior - plantarflex and Tibilialis anterior invert the foot Extensor digitorum longus Extensor hallucis longus Fibularis Tertius Superficial • Gastrocnemius DEEP FIBULAR NERVE • Soleus • Plantaris Deep • Popliteus • Flexor digitorum longus • Flexor hallucis longus Lateral - Eversion of the • Tibialis posterior Foot Fibularis Longus TIBIAL NERVE Fibularis Brevis SUPERFICIAL FIBULAR NERVE A Clindamycin A30-year-old intravenousdruguserisdiagnosed as having osteomyelitisofthe righttibia. Giventhe mostlikely causative organism,whatantibiotic Flucloxacillin wouldbemostsuitable forthem? B Vancomycin C D Rifampmicin Cefotaxime E A Clindamycin A30-year-old intravenousdruguserisdiagnosed as having osteomyelitisofthe righttibia. Giventhe mostlikely causative organism,whatantibiotic Flucloxacillin wouldbemostsuitable forthem? B Vancomycin C D Rifampmicin Cefotaxime E Investigations Background Bloods: FBC, UEs, CRP, ESR, blood cultures! inflammatory condition of bone, most commonly Imaging: plain film AP and PA x-rays caused by Staphylococcus aureus. Usually involves Special tests: when indicated, consider bone specimens from open bone biopsy, image-guided fine needle aspiration (FNA), or needle a single bone, may occur in the peripheral or axial skeleton. puncture. Usually performed during the surgical debridement procedure. May need CT guidance Either haematogenous or contiguous-focus. All forms may evolve to become chronic, sharing a final common pathophysiology, with compromised soft-tissue surrounding dead, infected, and reactive new bone. Clinical features • Suspect acute osteomyelitis in an unwell child with limp, or in an immunocompromised patient Management (may find reduced range of movement). Sepsis protocol - take lactate, urine, cultures, give O2, fluids, Abx) • Suspect chronic osteomyelitis in adults with If low MRSA prevalence- flucloxacillin 1-2 g IV every 6-8 hrs or 15-20 mg/kg history of open fracture, previous orthopaedic IV every 8-12 hrs surgery, or discharging sinus. If high MRSA, vancomycin 15-20 mg/kg IV every 8-12 hours or teicoplanin 6 • Consider native vertebral osteomyelitis in mg/kg IV every 12 hours for 3 doses, followed by 6 mg/kg every 24 hours patient with new back pain + systemic Consider taxobactam for pseudomonas cover symptoms. Consider surgical debridement if MRSA-positive or periosteal abscessYouareadoctorin the orthopaedicwardreviewinga 23- A Sciatic year-oldmanwhoattended viaambulance, followinga fallfromatreebranch.Hedescribesfalling ontohis flexed,abducted lefthip,resultingin a hipdislocation. Thiswassubsequentlyreducedundergeneral Femoral B anaesthetic. On currentassessment, the patient complainsofpain C Obturator mainlyin the posterioraspect ofthe leftthigh,radiating downtothe posteriorand lateralaspects oftheleg. Assessmentofgait revealedaleftfootdrop. Tibial D What nervehasmostlikelybeenaffected as aresultof this injury? Pudendal EYouareadoctorin the orthopaedicwardreviewinga 23- A Sciatic year-oldmanwhoattended viaambulance, followinga fallfromatreebranch.Hedescribesfalling ontohis flexed,abducted lefthip,resultingin a hipdislocation. Thiswassubsequentlyreducedundergeneral Femoral B anaesthetic. On currentassessment, the patient complainsofpain C Obturator mainlyin the posterioraspect ofthe leftthigh,radiating downtothe posteriorand lateralaspects oftheleg. Assessmentofgait revealedaleftfootdrop. Tibial D What nervehasmostlikelybeenaffected as aresultof this injury? Pudendal ESciatic (Roots L4-S3) Investigations/Management Innervates muscles of posterior thigh (biceps femoris, semimembranosus and semitendinosus) and hamstring portion of adductor magnus (remaining portion supplied by obturator nerve). No direct sensory innversation. Femoral nerve - roots L2-L4 Motor : Innervates anterior thigh muscles that flex hip joint (pectineus, iliacus, sartorius) and extend knee (quadriceps femoris: rectus femoris, vastus lateralis, vastus medialis, vastus intermedius), Sensory : Supplies cutaneous branches to anteromedial thigh (anterior cutaneous branches of femoral nerve) and medial side of leg and foot (saphenous nerve). Obturator - roots L2-L4 • Motor : Innervates muscles of medial compartment of thigh (obturator externus, adductor longus, adductor brevis, adductor magnus and gracilis). • Sensory : Cutaneous branches innervate skin of medial thigh. Tibial - roots L4-LS3 • Motor : Innervates muscles of posterior compartment of thigh . • Sensory : skin of posterolateral side of leg, lateral side of foot and soleA64-year-oldwomanisbroughtintothe A Anterior hip dislocation causing tibial emergencydepartmentviaambulance aftera roadtraffic collision. She has beengiven nerve injury morphineand paracetamol tomanage herpain andiscurrentlycomfortable.On examination, Anterior hip dislocation causing B herrightlegisinternally rotatedand appears sciatic nerve injury shorterthan theleft.Sheisnotedtohave significant bruisingovertherightbuttock and C Fractured neck of femur causing thigh. Neurovascularexamination shows tibialnerve injury alteredsensation overthe rightposteriorleg andfootand thereisa weaknessofdorsiflexion ofthefoot. Posterior hip dislocation causing D tibial nerve injury What injury hasthis patient likelysustained? Posterior hip dislocation causing E sciatic nerve injuryA64-year-oldwomanisbroughtintothe A Anterior hip dislocation causing tibial emergencydepartmentviaambulance aftera roadtraffic collision. She has beengiven nerve injury morphineand paracetamol tomanage herpain andiscurrentlycomfortable.On examination, Anterior hip dislocation causing B herrightlegisinternally rotatedand appears sciatic nerve injury shorterthan theleft.Sheisnotedtohave significant bruisingovertherightbuttock and C Fractured neck of femur causing thigh. Neurovascularexamination shows tibialnerve injury alteredsensation overthe rightposteriorleg andfootand thereisa weaknessofdorsiflexion ofthefoot. Posterior hip dislocation causing D tibial nerve injury What injury hasthis patient likelysustained? Posterior hip dislocation causing E sciatic nerve injury Extracapsular Intracapsular Occur PROXIMAL to intertrochanteric line Occur BELOW the intertrochanteric line • Neck/head of femur fractures • Subtrochanteric Tend to risk avascular necrosis • Intertrochanteric Don’t tend to damage capsule, preserving Manage with dynamic hip screw or cannulated screws vasculature, thus better prognosis In older patients, total or hemiarthroplasty is advised- replacing the femoral head with Manage with internal fixation using DHS prosthetic implant. If significant osteoarthritis and/or intermedullary nailing present, the acetabulum may also be reinforced with a prosthetic socket. Anterior PIN AX Posterior More rare, associated with rotation force Affected leg is shortened, ADDUCTED, Affected leg is ABDUCTED and externally flexed, internally rotated (more common) rotated, but not shortened. • Pubic (superior-anterior) - from abduction, extension, and external rotation of the hip • Obturator (inferior-anterior) - result from abduction, flexion, and external rotation of hipMost MSK fractures can be managed conservatively with splints, analgesia and 6-8 weeks follow-up, but one should still be wary of damage to neurovasculature and dysfunction We covered wrist fractures, shoulder dislocations/fractures/pathologies, elbow inflammation, rib fractures, ankle pathology, compartment syndrome, osteomyelitis. We did not cover knee or spine! Useful resources: Moore’s Clinical Anatomy, Lange’s Clinical Cases in Musculoskeletal Medicine, Oxford Handbookd of MSK, Osmosis, Radiopaedia, British Society of RheumatologyACE IT UKMLA Teaching SeriesA62yearoldladyhas attended clinic fora A Dactylitis reviewofherosteoarthritis. She recently had anoperationtomanagepain in herleft knee. Howeversheisnowstating that her B Swan Neck Deformity handwriting isbeing affectedbyher long termmedicalcondition. Which ofthe followingclinical signs areyou C Ulnar Deviation mostlikely toidentify onexaminationof this lady’shands? D Bouchard Nodes E OnycholysisA62yearoldladyhas attended clinic fora A Dactylitis reviewofherosteoarthritis. She recently had anoperationtomanagepain in herleft knee. Howeversheisnowstating that her B Swan Neck Deformity handwriting isbeing affectedbyher long termmedicalcondition. Which ofthe followingclinical signs areyou C Ulnar Deviation mostlikely toidentify onexaminationof this lady’shands? D BouchardNodes E Onycholysis Osteoarthritis is typically known as “wear and tear” of the joints. Osteoarthritis is NOT an inflammatory arthritis. It affects the synovial joints due to multifactorial causes such as genetics, injury, and overuse. Risk Factors: Age, Gender (Female) Obesity, Occupation, Trauma, Family Hx Clinical Presentation Examination • Heberden’s nodes (bony swelling in the DIP joints) • Joint pain and stiffness which typically worsens with activity or towards the END of the day - • Bouchard’s nodes (bony swelling in the PIP joints) • Squaring at the base of the thumb (CMC joint) Improves with rest. • Weak grip • No systemic upset • Reduced range of motion • Deformity, instability and reduced function HIGH DEFINITION - Heberdens DIP BLUE PICTURE - Bouchard’s PIP Clinical signs on examination • Bulky, bony enlargement of the joint • Restricted range of motion • Crepitus on movement • Effusions (fluid) around the joint Imaging Management Clinical Diagnosis based on clinical presentation and symptoms. X-rays of hands and wrists can be done to rule out other causes. Conservative X-ray changes: LOSS mneumonic • Patient education and Lifestyle changes, L - Loss of Joint Space Therapeutic exercise, Occupational Therapy. O - Osteophytes S - Subarticular sclerosis S - Subchondral cysts Medical • First Line - Topical NSAIDs (hand and knee osteoarthritis) • Second Line - Paracetamol + Topical NSAIDs Osteophyte • Oral NSAIDs when required and suitable (co- Formation prescribed with PPIs for gastroprotection) Subchondral • Intra-articular corticosteroids Loss of cysts Joint Space Surgical • Joint replacement Subarticular sclerosisA48year oldwomanhasrheumatoid A Hydroxychloroquine arthritis. Shetakesregular paracetamolandhasnodrugallergies. Sheisduetocommencemethotrexate Folic Acid B weekly. Whichadditional treatmentshouldbe Calcium carbonate and Vitamin D C co-prescribed? D Pyridoxine hydrochloride Thiamine EA48year oldwomanhasrheumatoid A Hydroxychloroquine arthritis. Shetakesregular paracetamolandhasnodrugallergies. Sheisduetocommencemethotrexate Folic Acid B weekly. Whichadditional treatmentshouldbe Calcium carbonate and Vitamin D C co-prescribed? D Pyridoxine hydrochloride Thiamine E Rheumatoid arthritis is chronic condition . It is an inflammatory autoimmune arthritis affecting the synovial lining joints, tendon sheaths, and bursa. Synovial inflammation is called synovitis. Described as a symmetrical polyarthritis - affects multiple joints usually symmetrically. Risk Factors: Genetic association -> HLA DR4/HLA DR1, Female (3x), Younger/middle aged, Family History Clinical Presentation Assessment + Investigations • Typically symmetrical pain, stiffness, and swelling in the small joints - usually affects MCPs and PIPs rather than DIPs in the • MSK Exam • DAS28 Score fingers. • Bloods - Rheumatoid factor, Anti-CCP antibodies, Inflammatory • Morning stiffness markers CRP and ESR • Pain improves with activity • Onset of symptoms can be gradual (months) or rapid • X-rays of the hands and feet for bone changes - SPADES (overnight) Mneumonic • Associated systemic upset (fatigue, weight loss, flu-like) ⚬ S - Swelling ⚬ P - Peri-articular osteoporosis ⚬ A - Absent osteophytes ⚬ D - Deformity ⚬ E - Erosions ⚬ S - Subluxation (late changes) • Ultrasound or MRI - synovitis (useful if unclear) Management DMARD Counselling Methotrexate Management involves MDT approach • Once weekly, Folic acid on separate day • Teratogenic (both pregnancy and breastfeeding) - Avoid conception for 6 • Short term steroids (oral or IM) may be given at months. initial presentation (acute phase) to induce • Liver, Pulmonary and Renal Toxicity - Baseline CXR, FBC, LFT and U&Es - remission and during flares. monitor every 2 weeks until stable. • Interactions - Trimethoprim and Co-trimoxazole • Mainstay treatment - to maintain remission - Hydroxychloroquine DMARDs (Methotrexate, Sulfasalazine, • Bull’s eye retinopathy - advise annual optician review Leflunomide, Hydroxychloroquine) Sulfasalazine • Biological Therapies - (adalimumab, infliximab, • Orange Urine ertanacept, rituximab) Leflunomide • Orthopaedic surgery • Hypertension Extra-articular manifestations Felty Syndrome - RA, Splenomegaly and Persistent Neutropaenia Pulmonary Fibrosis, Sjogren’s syndrome, Anaemia of Chronic disease, Carpal TunnelA65yearoldman presentstoyourGPclinic witha A Serum Urate painful leftfoot.Hewasrecentlydischargedfrom the acutemedicalunitat thelocalhospital wherehe wastreatedforacute alcoholintoxication. Serum ESR/CRP B Healsohas apast medicalhistoryofischaemic heart diseaseand type IIdiabetes. C Foot x-ray On examination younotice extremetendernessand markederythemaoverhisleftgreatertoe,witha firm,irregularchalky colouredmassunderneaththe Blood Cultures D skin. Which ofthe followinginvestigations wouldprovidea definitive diagnosis forthe abovepresentation? Synovial fluid aspiration EA65yearoldman presentstoyourGPclinic witha A Serum Urate painful leftfoot.Hewasrecentlydischargedfrom the acutemedicalunitat thelocalhospital wherehe wastreatedforacute alcoholintoxication. Serum ESR/CRP B Healsohas apast medicalhistoryofischaemic heart diseaseand type IIdiabetes. C Foot x-ray On examination younotice extremetendernessand markederythemaoverhisleftgreatertoe,witha firm,irregularchalky colouredmassunderneaththe Blood Cultures D skin. Which ofthe followinginvestigations wouldprovidea definitive diagnosis forthe abovepresentation? Synovial fluid aspiration E Gout is a crystal arthropathy caused by the accumulation of monosodium urate crystals in and around the joints causing inflammation. It is associated with chronically high blood uric acid levels. Risk Factors: Male, Family history, Obesity, High purine diet (e.g., meat and seafood), Alcohol, Diuretics, Cardiovascular disease, Kidney disease Clinical Presentation Diagnosis + Management MSK Exam A single acute hot, swollen and painful joint. Bloods - Inflammatory markers, Serum urate • MUST RULE OUT SEPTIC ARTHRITIS Imaging - X-ray - punched out erosions, lytic lesions Special Test - Joint Aspiration - Negatively birefringent needle The most commonly affected joints are: shaped crystals under polarised light • The base of the big toe – the metatarsophalangeal joint (1st MTP joint) Management • The base of the thumb – the carpometacarpal joint (1st CMC Conservative - Lifestyle changes - weight loss, minimise alcohol joint) and purine-based foods • Wrist Medical • Acute Gouty Tophi (subcutaneous uric acid deposits) - ⚬ NSAIDs, Colchicine, oral steroids • hands, elbows and ears • Urate Lowering Therapy - Prophylaxis ⚬ Allopurinol/FebuxostatA49-year-oldman presentstotheEmergency A Intravenous Drug Use Departmentwithapainful,swollenrightknee.He is otherwisewelland hisobservationsarestable. Anx- rayofhiskneeisreportedtoshowcalcium deposits Chronic Kidney Disease B in thearticular cartilage. Ajoint aspirate revealsnoorganisms butshows positively birefringent,rhomboid-shapedcrystals. C Haemochromatosis Which ofthe followingisassociated withthemost likelydiagnosis? Thiazide Diuretics D Obesity EA49-year-oldman presentstotheEmergency A Intravenous Drug Use Departmentwithapainful,swollenrightknee.He is otherwisewelland hisobservationsarestable. Anx- rayofhiskneeisreportedtoshowcalcium deposits Chronic Kidney Disease B in thearticular cartilage. Ajoint aspirate revealsnoorganisms butshows positively birefringent,rhomboid-shapedcrystals. C Haemochromatosis Which ofthe followingisassociated withthemost likelydiagnosis? Thiazide Diuretics D Obesity EA26yearoldmalepresentstohisGPwithworsening A Tricuspid Regurgitation lowerback pain associated withmorningstifness. Hispain improveswithphysicalactivity. On examination, thereis tendernessat thesacro-iliac Anterior Uveitis B jointand Schober'stestrevealslimitedlumbar flexion. Which ofthe followingextra-articular featuresis C Primary Sclerosing Cholangitis mostcommonlypresentwiththis condition? Basal Pulmonary Fibrosis D Lens Dislocation EA26yearoldmalepresentstohisGPwithworsening A Tricuspid Regurgitation lowerback pain associated withmorningstifness. Hispain improveswithphysicalactivity. On examination, thereis tendernessat thesacro-iliac B AnteriorUveitis jointand Schober'stestrevealslimitedlumbar flexion. Which ofthe followingextra-articular featuresis C Primary Sclerosing Cholangitis mostcommonlypresentwiththis condition? D Basal Pulmonary Fibrosis E Lens Dislocation Ankylosing spondylitis is a seronegative inflammatory arthritis primarily affecting the axial skeleton (axial spondyloarthropathy), More common in males (aged 20-30). HLA-B27 positivity supports a diagnosis but a negative result should not rule out ankylosing spondylitis Clinical Presentation Assessment + Investigations • Spinal Exam • Lower back and buttock pain ⚬ Restricted ROM in lumbar spine • Stiffness worst in morning and better with activity ⚬ Schober’s test positive • Peripheral Enthesitis • Bloods - FBC, ESR/CRP, HLA-B27 • Imaging ⚬ Pelvic/Lumbar X-rays - sacroiliitis, MRI • Extra-articular involvement: 5 A’s - ⚬ DEXA ⚬ Anterior uveitis • Management ⚬ Aortic regurgitation ⚬ Conservative - Physiotherapy/Exercise, Smoking cessation, ⚬ Apical pulmonary fibrosis management of extra-articular complications ⚬ Medical - NSAIDs first line - co-prescribe PPI, Paracetamol +/- ⚬ Atrioventricular block Codeine, Local steroid injections, Biologics ⚬ Anaemia of Chronic Disease. ⚬ Surgical - spinal deformities, complications e.g. fractures, cauda equinaA25 yearoldmalepresentstohisGPwithleftsided A Chlamydia trachomatis kneepain that began2weeksago. He reportsthe pain as beinga 3/10. Hedoesnotrecallanytrauma to hisknee. Neisseria gonorrhoeae B On examination, thereissomeboggyswellingofthe leftkneejoint witha reducedrangeofmovement.He reportshaving dysuriapriortothisepisode. C Escherichia coli Jointaspiration showedraisedwhitecelland neutrophilcounts. Acultureofthisfluid isnegative. Salmonella enteritidis D Urinedipstick showedleucocytes+++ andurine cultureswerenegative. Campylobacter jejuni E Which isthe mostlikely causative organism?A25 yearoldmalepresentstohisGPwithleftsided A Chlamydia trachomatis kneepain that began2weeksago. He reportsthe pain as beinga 3/10. Hedoesnotrecallanytrauma to hisknee. Neisseria gonorrhoeae B On examination, thereissomeboggyswellingofthe leftkneejoint witha reducedrangeofmovement.He reportshaving dysuriapriortothisepisode. C Escherichia coli Jointaspiration showedraisedwhitecelland neutrophilcounts. Acultureofthisfluid isnegative. Salmonella enteritidis D Urinedipstick showedleucocytes+++ andurine cultureswerenegative. Campylobacter jejuni E Which isthe mostlikely causative organism? Reactive arthritis involves synovitis in one or more joints in response to an infective trigger (typically within 4 weeks). Reactive arthritis is a seronegative spondyloarthropathy Clinical Presentation Assessment + Management • Detailed history inc. sexual history • Bedside - nucleic acid amplification tests (NAAT) on urine or a Typical Presentation = Triad: urethral/vulvovaginal swab 1. Can’t see - conjunctivitis • Stool MC&S, C. diff 2. Can’t pee - urethritis • Aspiration of synovial fluid -rule out Septic Arthritis 3. Can’t climb a tree - arthritis • Bloods - FBC, U&E, CRP, HLA B27, Hep B, syphillis, HIV • Rashes, nail changes and mouth ulcers Management Self-limiting condition in the majority of patients and so management is Common causative infections: symptomatic. Most cases resolve within 6 months • Conservative - Ongoing infection - GUM clinic referral and contact Sexually Transmitted Infections - Chlamydia is most common tracing Gastroenteritis - Campylobacter, salmonella, shigella • Medical - 1st line = NSAIDs ⚬ local or systemic steroids may be used if NSAIDs are contraindicated or ineffective. Conjunctivitis Keratoderma blenorrhagica. Anterior UveitisA34yearoldwomanhassudden onsetofright armweaknessand inability tospeak.Shehasmigraines andgeneralised joint pains. A Anti-dsDNA antibody Fouryearsago,shehadadeep veinthrombosis inherright leg. Herpulserateis68bpmandBP178/94mmHg. Shehasan B Anti-Nuclear antibody expressive dysphasia.Shehasflaccidweaknessofherright arm andfacialdrooponthe right lowerhalfofherface. Investigations: Anti-Ro and Anti-La antibodies C Haemoglobin 118g/L (115–150) White cellcount 4.3 ×109/L (3.8–10.0) Neutrophils 2.1×109/L (2.0–7.5) Lymphocytes 0.6×109/L (1.1–3.3) Anti-cardiolipin antibody D Platelets 132×109/L (150–400) Totalcholesterol 4.6mmol/L (<5.0) CTscanofheadleftfrontoparietal infarct E Serum Immunoglobulins Which additionalinvestigation ismost likely to revealtheunderlying causeofherstroke?A34yearoldwomanhassudden onsetofright armweaknessand inability tospeak.Shehasmigraines andgeneralised joint pains. A Anti-dsDNA antibody Fouryearsago,shehadadeep veinthrombosis inherright leg. Herpulserateis68bpmandBP178/94mmHg. Shehasan B Anti-Nuclear antibody expressive dysphasia.Shehasflaccidweaknessofherright arm andfacialdrooponthe right lowerhalfofherface. Investigations: Anti-Ro and Anti-La antibodies C Haemoglobin 118g/L (115–150) White cellcount 4.3 ×109/L (3.8–10.0) Neutrophils 2.1×109/L (2.0–7.5) Lymphocytes 0.6×109/L (1.1–3.3) Anti-cardiolipin antibody D Platelets 132×109/L (150–400) Totalcholesterol 4.6mmol/L (<5.0) CTscanofheadleftfrontoparietal infarct E Serum Immunoglobulins Which additionalinvestigation ismost likely to revealtheunderlying causeofherstroke? Antiphospholipid syndrome is a blood clotting disorder. It is an autoimmune disorder caused by antiphospholipid antibodies. These antibodies target the proteins that bind to the phospholipids on the cell surface, causing inflammation and increasing the risk of thrombosis (blood clots) Clinical Presentation Assessment + Investigations • Associated with SLE • Bloods - The key complications of antiphospholipid syndrome are: ⚬ Antibodies • Venous thromboembolism (e.g., deep vein thrombosis and • The specific antiphospholipid antibodies are: pulmonary embolism) ⚬ Lupus anticoagulant • Arterial thrombosis (e.g., stroke, myocardial infarction and ⚬ Anticardiolipin antibodies ⚬ Anti-beta-2 glycoprotein I antibodies renal thrombosis) • Pregnancy-related complications (e.g., recurrent miscarriage, Management stillbirth and pre-eclampsia) • Long-term warfarin with a target INR of 2-3 is used to prevent thrombosis. • Low molecular weight heparin (e.g., enoxaparin) and aspirin are used in Livedo Reticularis pregnancy to reduce the risks. Warfarin is contraindicated in pregnancy.A29yearoldwomanhaspainandmorning stiffnessinherfinger andwristjoints. Thisimprovesduring thedayandafteractive A Behcet’s disease movement. Shehashadrecurrent mouth ulcers forthelast2 years.Shehadanepisodeofpleuritic chestpain6monthsago whichresolvedwithout seeking help. B Reactive Arthritis HerBPis128/85mmHg. Shehasnowarmth,swelling or tenderness inherhands. C Rheumatoid arthritis Urinalysis: protein 1+,blood1+ Investigations: Haemoglobin 109g/L(115–150) D Sjögren’s syndrome White cellcount 3.8 ×109/L (4.0–11.0) Lymphocytes 0.9×109/L (1.1–3.3) Platelets 160×109/L (150–400) Creatinine90µmol/L(60–120) E Systemic lupus erythematosus CRP21mg/L (<5) Whatisthemost likely diagnosis?A29yearoldwomanhaspainandmorning stiffnessinherfinger andwristjoints. Thisimprovesduring thedayandafteractive A Behcet’s disease movement. Shehashadrecurrent mouth ulcers forthelast2 years.Shehadanepisodeofpleuritic chestpain6monthsago whichresolvedwithout seeking help. B Reactive Arthritis HerBPis128/85mmHg. Shehasnowarmth,swelling or tenderness inherhands. C Rheumatoid arthritis Urinalysis: protein 1+,blood1+ Investigations: Haemoglobin 109g/L(115–150) D Sjögren’s syndrome White cellcount 3.8 ×109/L (4.0–11.0) Lymphocytes 0.9×109/L (1.1–3.3) Platelets 160×109/L (150–400) Creatinine90µmol/L(60–120) E Systemic lupus erythematosus CRP21mg/L (<5) Whatisthemost likely diagnosis?Systemic lupus erythematosus (SLE) is an inflammatory autoimmune connective tissue disorder. ‘Systemic’ - multiple organs and systems ‘Erythematosus’ - red - typical red malar rash - spares nasolabial folds Clinical Presentation Assessment + Investigations • Obs, Urine Dip, ECG, Urine PCR • Bloods ⚬ FBC - Anaemia, Low platelets and white cells ⚬ Inflammatory Markers ⚬ Antibodies ￭ ANA (Anti-nuclear antibodies) - sensitive ￭ Anti-dsDNA (Anti-double stranded DNA) - specific ￭ Anti-phospholipid antibodies Management • Symptom Control ⚬ Conservative - Suncream Factor 50, avoid triggers ⚬ Medical - First line = hydroxychloroquine, NSAIDs, steroids ⚬ More resistant = Other DMARDs and BiologicsA73 yearoldwomanunderwentaDEXAscanandher A Inhibition of osteoclasts Tscoreis -3.5. Herbloodtests have shownthat herCalciumand B Inhibition of osteoblasts Vitamin Dlevelsarenormal. Afterdiscussion withtheRheumatologyConsultant, itis decidedtostart heronamedication toprotect C Inhibition of osteocytes herbones. What is themechanismofaction ofthis medication? D Stimulation of osteoblasts Stimulation of osteoclasts EA73 yearoldwomanunderwentaDEXAscanandher A Inhibition of osteoclasts Tscoreis -3.5. Herbloodtests have shownthat herCalciumand B Inhibition of osteoblasts Vitamin Dlevelsarenormal. Afterdiscussion withtheRheumatologyConsultant, itis decidedtostart heronamedication toprotect C Inhibition of osteocytes herbones. What is themechanismofaction ofthis medication? D Stimulation of osteoblasts Stimulation of osteoclasts E Osteoporosis = Significantly reduced bone mineral density (BMD) = T-score <-2.5 Osteopenia = Reduced bone mineral density = T-score -1 to -2.5 Increased risk of fragility fractures Risk Factors Assessment + Management Alcohol and • FRAX Score - Major osteoporotic fracture risk and hip fracture risk in smoking next 10 years • Bloods - Vitamin D, Bone Profile • Imaging - X-ray, DEXA Scan Management: Conservative - reversible risk factors - exercise, healthy weight, reduce Patients usually asymptomatic The most common fragility fractures seen smoking and alcohol are: Vertebral body, Neck of femur (hip), Distal radius, Proximal humerus and Pelvis Medical - Address any calcium or vitamin deficiency first. First line - Bisphosphonates - once weekly, first thing 30 minutes on empty • T-score: Compares bone density to a healthy 30-year-old. stomach, sitting upright or standing • Z-score: Compares bone density to people of similar characteristics Others include biologics e.g. Denosumab (Age, Gender and Ethnicity) Surgical - Fractures Aim to differentiate between inflammatory and non-inflammatory conditions. This will help in your management. Those that are inflammatory e.g. RA, SLE, Psoriatic Arthritis usually use DMARDs. Try not to neglect MSK examinations in your revision, many patients with these conditions are stable enough to be used as examples in ISCE/OSCE exams. Hand&Wrist, Knee, Spine, Hip Examinations