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MSKRound-Up Y4PPALs AaliyaAshik MathewPoulose Common Presentations/Conditions DataInterpretation Common Examinations Contents Common Explanations page SBAR Prescribing SummaryCommonMSK • Acutejointpain/red-hotswollen joint Presentations • Chronicjointpain/stiffness &Conditions • Back pain • Commonrheumconditions:SLE, Vasculitides • Others to beawareof Septicarthritis Gout Acute joint pain Pseudogout Reactivearthritis Haemarthrosis • Septic arthritis. An infection in a joint, most commonly caused by haematogenous spread from a distant site of infection (eg. abscess). • Native or prosthetic joints (10x more common) • Risk factors: IVDU, skin ulcers, Immunosuppression, DM, joint prostheses, RA, OA Septic • S.aureus most common. Remember N. gonorrhoea in sexually active adults. Arthritis • Features • Symptoms. Acute painful, swollen joint, restricted movement, fever, lethargy, rigors • Signs. Loss of ROM, warmth, erythema Swabs--> N. gonorrhea(if suspectingSTI) Septic FBC, CRP/ESR:signsof infectionand Arthritis: inflammation Important Bloodculture andsensitivity Investigations Jointaspirationand synovialfluid analysis • MaybeUltrasound-guidedif involvingthe hipjoint • Aspirationintheatreif prostheticjoint • Immediate empirical IV ABx after aspiration & gram- staining • IV Flucloxacilin (usually 1 line) or Clindamycin (Pen. Allergic) Septic • Vancomycin (MRSA positive) • Ceftriaxone (N. gonorrhea) Arthritis: Management • Guided ABx therapy after culture & sensitivity return • Analgesia • Sepsis Six: if showing signs of sepsis/septic shock • Gout. A crystal arthropathy associated with chronicallyhighblood uric acid levels. Urate crystals are deposited in thejoint, causing inflammation. Gout •alcohol, diuretics, CVD, Renal diseaseet, Symptoms: acute Commonly affects: hot, painful, swollen 1 MTP (base of big joint. toe), CMC (baseof the thumb), wrist Gout:Clinical Findings Acute episodes erythema, gouty maximal intensity in tophi (hands, 12 hours and last elbows, back of several day. Often ears) symptom-free between episodes • Diagnosis: Clinical findings + raised serum urate levels (> 360 µmol/L) Gout:Important • Joint aspiration: mono sodium urate Investigations crystals that are needle-shaped and negatively birefringent of polarised light • X-ray affected joint Acutemanagement • 1 line:NSAIDs+ PPI nd • 2 line:Colchicine(NSAIDscontraindicated) • 3 line:Oralsteroidsorintra-articularsteroidinjection Prophylaxis:Allopurinolor Febuxostat Gout: • Startedafew weeks after the first attackhasresolved Management • Continuedthrough subsequentacuteattacks Lifestyle • Weightloss • Hydration • Reducealcohol • Reducepurine-basedfoods(meat,seafood)in diet Pseudogout. A crystal arthropathy caused by calcium pyrophosphate dehydrate crystals in joints. AKA chondrocalcinosis. Pseudogout Associated with: • Increasing age • Hyperparathyroidism • Hemochromatosis • Low Magnesium,Low Phosphate • Acromegaly, Wilson’s disease Acute Pseudogout is usually monoarticular, typically affecting knee or wrist, but can be polyarticular (knee, wrist, ankle or shoulders). A typical acute presentation of Pseudogout: pseudogout is a patient over 65 years old Features with a rapid-onset hot, swollen, stiff and painful knee. Older patients may present with extra- articular manifestations (fever, confusion), so aspiration to rule our septic arthritis is essential.Pseudogout: Investigations • Joint aspiration:fluid shows calcium shaped and positively birefringent ofoid polarise light. • X-ray: chondrocalcinosis Joint aspiration for symptomatic relief NSAIDs+ PPI Pseudogout: Symptomatic Colchicine management Intra-articular steroid injections Oral steroids + PPI • Reactivearthritis ( can’tsee, can’tpee, can’tbend my knee) OtherDDx • 3) conjunctivitisesof 1) Arthritis, 2) urethritisand acutehot • History:triggeredby STI or gastroenteritis • Usually asymmetricaland polyarticular swollen • Diagnosis: clinical signsandHLA-B27antigen tenderjoint • steroidst:may self-resolve,NSAIDs,ABx, oral • Haemarthrosis • Bleedinginto the joint, usually after trauma • Blood in jointaspirate Rheumatoidarthritis Chronicjoint pain/stiffness Osteoarthritis Seronegative spondyloarthropathies • Rheumatoid arthritis. A chronic, systemic inflammatory disease that causes inflammation of synovial joints and extra-articular features. • Risk factors: Smoking, Obesity, HLA-DR4, -DR1, Female, FH Rheumatoid • Antibodies: Anti-CCP and RF • Symptoms arthritis • Symmetrical joint pain, stiffness and swelling • Small joints of hands & feet: PIP, MCP, wrist, MTP • Low-grade fever, fatigue • Tender, stiff and“boggy”joints Rheumatoid • Positivesqueezetest arthritis:MSK • Typically affectsPIP, MCP,wrist, spares the DIP examination • Hand signs • Swan neckdeformity findings • Boutonniere’sdeformity • Z-thumb • Ulnar deviation • RheumatoidnodulesRheumatoidarthritis:ImportantInvestigations CRP/ESR: raised inflammatory markers Anti-CCP (more sensitive) and RF (+ve 60-70%) XR Hands & Feet:erosions Bedside:Urinalysis(hematuria/proteinuria) Others Bloods:FBC(anemia),ANA(check forSLE), Uricacid(excludegout) Imaging:USS,MRIRheumatoid arthritis: X-RaySigns • Soft tissue swelling • Peri-articular osteoporosis & erosions • Absent osteophytes • Deformity • Erosions (late feature) • Subluxation (late feature) Pharmacological • DMARDs • Biologics: poor response to DMARDs • Corticosteroids + PPI: manage flare-ups Rheumatoid • NSAIDs + PPI: analgesia arthritis: Non-pharmacological Management • MDT: rheumatologist, GP, specialist nurse, physiotherapist, OT, dietician, podiatrist, pharmacist, social worker Surgical • Orthopaedic surgical referral in refractory disease • Osteoarthritis. “Wear andtear”of the joint • RF: Age,Obesity, trauma,Female, FH • Commonly affects:Hips, Knees, DIP in hands, CMC (thumbbase), lumbarspine, C- spine • Presentation Osteoarthritis • Joint pain and stiffness, worseafter activity and end of the day • Morning stiffness lastsless than 30 minutes Bony enlargement of affected joints Restricted ROM due to pain Osteoarthritis: Crepitus on movement Examination Joint effusions Findings Hand signs • Heberden’s (DIP)and Bouchard’s (PIP)nodes • Squaring at the base of thumb • Reduced ROM • Weak grip CRP/ESR: exclude inflammatory arthropathies X-Ray • Loss of jointspace,localized to noseside of the joint Osteoarthritis: • Osteophytes(bonespurs) • Subarticularsclerosis(increaseddensityof thebone Investigations alongthe joint line) • Subchondralcysts(fluid-filledholes in thebone) MSK USS (osteophytes, effusions) MRI (early OA changes) Conservative • Education+ advice • Muscle-strengthening exercises • Weight loss if overweight • Occupational therapy: walking aids, home Osteoarthritis: adaptations Pharmacological Management • Topical(1 line) or OralNSAIDs+ PPI (2 line) • Weak opioids+ paracetamol • Intra-articularsteroidinjections Surgical • Joint replacement or jointfusion • A group of inflammatory rheumatic conditions that affect the axial and peripheral joints and cause enthesitis. • Associated with HLA-B27 antigen • RF negative Seronegative • Main conditions Spondyloarthropathies • Psoriaticarthritis • Ankylosing spondylitis • Reactive arthritis • IBD-associated arthritis • Symmetricaldistal polyarthritis(most common pattern, similarto RA) Psoriatic • Other patterns of disease: Asymmetrical oligoarthritis,DIP-joint predominant, Arthritis: Spondylitis/sacroilitis, Arthritismutilans Features • Associatedfeatures • Psoriatic skin lesions • Periarticular disease: enthesitis, tenosynovitis, dactylitis • Nails: pitting,onycholysisPsoriaticArthritis: Investigations& Management • Investigations • X-ray:‘pencil-in-cup’appearance, • Management • NSAIDs • Steroids • DMARDs(eg. Methotrexate) • Biologics: MABs,Anti-TNF • Apremilast • An inflammatory condition that affects the spine and sacroiliac joints • Features • Ageunder 40 • Pain and stiffness in lower back, sacroiliac pain Ankylosing • Stiffness isworsein themorning, takes> 30 mins toresolve Spondylitis • Worse on rest and improves with exercise • Signs: Reduced lateral flexion, forward flexion, chest expansion • Other features include: Chest pain, SoB, enthesitis, dactylitis • Associated: Aortic regurgitation,Anterior uveitis, Achillestendinitis, Apical lung fibrosis, AOCD, AV block, Amyloidosis, And CES CRP/ESR HLA-B27 Ankylosing X-ray Spondylitis: • Squaring of vertebra • Ossificationof ligaments,jointsand discs Investigation • Subchondral sclerosisand erosions • Syndesmophytes • Fusionof facet,SI and costovertebraljoints • Bamboo spine (late): fusionof SI and spinal jkoints MRI spine: bone marrowoedema Refer torheumatologicalMDT Pharmacological • NSAID • Biologics Ankylosing • Intra-articularsteroids Spondylitis: • DMARDs:peripheraljoint involvement Management Lifestyle • Regular exercise • Physiotherapy • Avoid smoking • Bisphosphonates Surgery Mechanical Back pain Sciatica Ankylosing spondylitis (+ other Seronegative Spondyloarthropathies) Backpain MSCC Cauda Equina Syndrome Others: osteomyelitis, epiduralabscess, spinal fracture • Unilateral leg pain, radiating to behind knee and foot/toes (may be bilateral) • Low back and Buttock pain • Neurogenic claudication: worse on walking, eases with sitting and flexion • Weakness and/or reflex changes in a myotomal Sciatica distribution • Parasthesia in the distribution of nerve root • Test: straight-leg raise provokes similar pain Severecompression of the lumbosacral nerve roots Causes • Herniateddisc(most common) • Spondylolisthesis • Cancer, metastasis • Epiduralabscess,discitis Cauda Equina • Trauma Red flag symptoms Syndrome • Severeback pain • Bilateral lower-limb neurological symptoms • Saddle anaesthesia • Bowel &bladder dysfunction • Sexualdysfunction Spine examination + PR: weakness, reduced sensation, reduced anal tone Management: urgent MRI spine and surgical decompression • More common in breast, lung and prostate cancer • Symptoms: back pain, limb weakness, change in sensation • Red flags • Age > 50 • Thoracic pain MSCC:Red • Gradual onset, progressive • Pain worse on coughing or straining Flags • Severe unremitting pain • Night pain that disturbs sleep • Localised spinal tenderness • Weight loss • Past history of cancer • Management: urgent MRI Spine, 16mg dexamethasone + oncology referral for radiotherapy or surgery SLE, APS Vasculitides Common Rheum PMR conditions Polymyositis/dermatomyositis/scleroderma/ Sjogren's-overview • A chronic multi system autoimmune disease with a relapsing-remitting course • Multisystemic symptoms • Constitutional: fatigue, weight loss, mouth ulcers, lymphadenopathy, splenomegaly • Skin: malar rash, discoid rash, hair loss • MSK: symmetrical polyarthritis, myalgia SLE • Cardiorespiratory: dyspnoea, pleuritic chest pain • Renal: haematuria, oedema (due to nephritis) • Neuropsychiatric: anxiety and depression, seizures, psychosis Vitals: fever, hypertension SLE: alopeciaotosensitive malar rash, discoid rash, Examination findings Mouth: Oral ulcers Others: leg oedema, new-onset Raynaud’s phenomenon,lymphadenopathy, splenomegaly Bedside • Urinalysis and UPCR--> haematuria, redcell casts,proteinuria in lupus nephritis SLE: Important Lab Investigations • FBC, U&Es: anaemia, leucopenia, thrombocytopenia, impaired renal function • ESR/CRP may be raised • Antibodies: ANA,anti-dsDNA, anti-Smith) • Low complement levels (C3 &C4) • Medical management depends on severity but includes: • Hydroxychloroquine (1 line for systemic disease) • DMARDs: Methotrexate, Azathioprine • NSAIDs toreduce inflammation SLE: • Steroids: prednisolone or IV Management methylprednisolone (severe) • Lifestyle • Avoiding sun exposure and wearing high SPF sunscreen • Regular exercise • Smoking cessation • An acquired thrombophilia - arterial or venous thrombosis, pregnancy morbidity, presence of at least one of the Antiphospholipid antibody. • APS can be a primary condition or secondary to a rheumatic disease, Around 30-40% of patients with SLE have APS. Antiphospholipid • Features: arterial/venous thromboses, recurrent miscarriages, livedo reticularis, pre-eclampsia, Syndrome pulmonary hypertension • Management: thromboprophylaxis • Primary: low-dose aspirin • Secondary: lifelong warfarin (+/- low-dose aspirin) • Large Vessel • GCA:headache,jawclaudication,scalp tenderness,blurry vision • Takayasu: unequalBP upper limbs, carotidbruit, weak/absentlower limb pulses • MediumVessel • Kawasaki disease: fever,red lips, red eyes, strawberry tongue,red palm & soles • Polyarteritisnodosa: fever,malaise,myalgia,HTN, abdopain,livedoreticularis,mononeuritismultiplex Vasculitides • Small Vessel • GPA: nasal crusting/bleeding,saddle-nose,hearing loss, cANCA • E-GPA:asthma,allergic rhinitis,eosinophilia, mononeuritismultiplex, pANCA • MPA:respiratorysymptoms,renal impairment, palpable purpura, pANCA(70%),cANCA(40%) Sjögren’s syndrome: dry eyes, dry mouth, arthralgia, raynaud’s Dermatomyositis: macular rash over back and 1houlders, heliotrope rash, Gottron’s papules, Anti-Jo- Rheum Polymyositis: proximal muscle weakness, elevated CK Extras DCSS: scleroderma affects trunk and limbs predominantly LCSS: scleroderma face and distal limbs predominantly Shoulder pain: frozenshoulder, subacromial impingement,ACJpathology, rotatorcuff tear,bicepstendinitis Achillestendon Rupture Other presentations tobeawareof Fibromyalgia Falls (ACH,Neuro)Datainterpretation NOFF Gout X-Rays Wristfractures Knee joint Xray ShoulderXray • Shenton’s line:medialedge of femoral neckto the inferior edge ofsuperiorpubicramus • Disruptionof Shenton’sline NOFFXray suggests NOFF in adults or DDH in childrenXray:Gout Joint effusions Maintained joint space (no loss of joint space) Lytic lesions in the bone Punched out erosions causingsclerotic borders with overhanging edges Soft-tissue tophiFractures • Upper Limb fractures – Colle's, Smith’s, Scaphoid, Monteggia, Glezzi, • Lower Limb Fractures – NOFF, Ankle, Tibial Plateau • Paeds – Salter Harris UpperLimbFractures: Colle’s • Classical Colles' fractures: • Transverse fracture of the radius • 1 inch proximal to the radio-carpal joint • Dorsal displacement and angulation • Management • Simple fractures or poor comorbidities status —> manipulation under anaesthetic and below elbow cast for 4-6 weeks • Complex fracture patterns/good co-morbid status —> Closed reduction and K-wiring or ORIF (plates and screws) UpperLimbFractures: Smith’s • Volar angulation ofdistal radius fragment (Garden spade deformity) • Causedby falling backwards onto the palm of an outstretchedhand orfalling with wristsflexed • Management —> ORIF with plate and screws • Volar displacement is always unstable and requires surgical fixation • FOOSH • Risk of avascular compromise and non-union • Symptoms • Deep, dull radial wrist UpperLimb pain & Wrist swelling • Decreased ROM Fractures: • Decreased grip strength • Neurovascular injury: Scaphoid pallor, pain disproportionate to injury (compartment syndrome), paraesthesia • Management UpperLimb • A-E, Analgesia, WristImmobilization • X-ray (AP& Lateral) and MRI/CT Fractures: • Cast 4-6 weeks(distal or occult fractures) Scaphoid or 10-12 weeks (waist/proximal fractures) • Surgicalfixation with K-wiresand screws (for open fracturesor neuro vascular compromise) LowerLimbFractures: NOFF • Symptoms - Pain in hip, groin which may radiate to knee - Unable to weight bear - Decreased or painful mobility of the affected hip • Signs: - Shortened, externally rotated and abducted affected leg - Palpation of the hip produces pain - Unable to perform straight leg raise - Pain on log-roll test (gentle internal-external rotation) - Bruising & swelling around area • Displaced intracapsular fractures —> riskof avascular necrosis LowerLimb • Management • A-Eassessment Fractures: • Analgesia NOFF • Imaging: AP & Lateral Xray • VTE Prophylaxis • Optimize/treat underlying co-morbidities: anemia, infection, diabetes • Surgerywithin 48 hours —> Hemiarthroplasty or THR • Early input from Orthogeriatricians A fracture through the growth plate of a bone Paediatric Damage to vascular supply can Fractures: disrupt bone development in Salter-Harris children Associated with non-accidental injuriesType I Fracture throughthe physis only(x-rayoften normal) Type II (most common) Fracture throughthe physis andmetaphysis Type III Fracture throughthe physis andepiphysis to include the joint Type IV Fracture involvingthe physis, metaphysis andepiphysis Type V Crush injury involvingthe physis (x-raymay resemble type I, and appear normal) Septic joint SynovialFluid Inflammatoryarthritis: Analysis Gout & Pseudogout Osteoarthritis Appearance WCC Proportion of WCC made up of Crystals Staining (cells/µL) Neutrophils(%) Normal Clear,high < 200 < 25 viscosity Osteoarthritis Clear,yellow, <2000 < 25 highviscosity SepticArthritis Opaque, > 50,000 > 75 Positive yellow/green Inflammatory Yellow 2000 – < 50 Negativelybirefringent= Arthritis Cloudy 50,000 Gout Decreased PositivelyBirefringent= viscosity PseudogoutRheumaticAntibodiessimplified • Rheumatoid Arthritis—> RF& Anti-CCP • SLE —> Anti ds-DNA & Anti-Smith • Polymyositis + dermatomyositis —> Anti Jo-1 • Sjögren’s syndrome —> Anti-Rhoand –La • LCSS —> Anti-centromere • DCSS —> Anti-SCL-70 • EGPA —> pANCA • GPA —> cANCA • Antiphospholipid antibodies —> Anticardiolipin, LupusAnticoagulant, Bonedisorders:labvalues(beawareofthis) Disorder Calcium Phosphate ALP PTH Osteoporosis Normal Normal Normal Normal Osteomalacia Decreased Decreased Increased Increased Primary Increased Decreased Increased Increased hyperparathyroidism(→ osteitisfibrosacystica) Chronic kidney Decreased Increased Increased Increased disease(→ secondary hyperparathyroidism) Paget'sdisease Normal Normal Increased Normal Osteoporosis Normal Normal Normal NormalCCA-relatedtopics • NOFF SBAR/MSK • Compartment syndrome Emergencies • Septic arthritis • Cauda Equina syndrome/MSCC • A complication of fractureswhereby elevated pressure within amyofascial compartment impairs perfusion leading to ischemia and necrosis. • Features on examination • Pain Compartment • Pulselessness • Parasthesiae Syndrome • Pallor • Paralysis • Investigations:clinical diagnosis, raised CK (muscleinjury),XR (fracture) • Management —> emergency fasciotomy, irrigation and debridement, may need amputation if significant necrosis • Spineexam: red flags for back pain • Hand + wrist examination: distinguish Common between RA & psoriaticarthritis Examinations • Shoulder exam (+ Xray) signs ofACJ pathology • Knee exam • Hip exam • symptoms, saddle anaesthesia, urinaryological retention/incontinence, fetal incontinence, history of cancer • Cancer: gradual, progressive pain, older age, BackPainRed weight loss, history of cancer, night pain • Spinal fracture/trauma: major trauma, long-term Flags corticosteroid use, point-tenderness • Abscess/infection: fever, IVDUs • Ankylosing spondylitis: morning stiffness, stiffness at rest, age under 40, gradual/progressive onset, night pain RheumatoidArthritis • Typicallyspares DIP • Swan neck and Boutonniere’sdeformity • Z-thumb • Ulnardeviation Psoriaticvs • Rheumatoid nodules RAvsOA Psoriatic Arthritis • InvolvesDIP HandSigns • Nail pitting andonycholysis • Dactylitis Osteoarthritis • Bony enlargements • InvolvesDIP • Heberden’s(DIP) and Bouchard’s(PIP)nodes • Squaring at the base ofthumb Post-fracture,Osteoporosis, DEXA scan, T score Common SLE Explanation stations Medicationcounselling: Methotrexate, HydroxychloroqineBisphosphonate, Prednisolone,Codeine Prescribingfor Septicarthritis & gout Pain relief Prescribing Steroidsfor GCA Bisphosphonates Transient Synoptics Perthe’s disease Other Slippedupper femoral epiphysis conditionsnot Juvenile idiopathic arthritis mentioned Supracondylar fracture Incomplete fracture Fibromyalgia