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Hey is Daniella. I'm one of the uh foundation year two doctors. Now I'm on the SFP program for orthopedics. And today I'll be presenting, um, MSK and rheumatology cases. So before I begin, I just wanted to give some tips and tricks about how you can ace final a year. To be honest, it doesn't seem like that long ago for me. I was also at Imperial. Um, my general advice would be just make sure, you know, the basics investigation. So diagnostic diagnosis, investigations and management of the main conditions. Honestly, the level of knowledge expected is slightly higher than third year, but it's very clinical. Um I would say definitely attend all the lectures, particularly those run by the course leads and make sure you revise their, the course lead lectures specifically before the exams. Um and then specifically like for the national exam, like it's just a lot of practice for various questions. And you can use pass med ques meed pass tests. Those are the ones I used. And I'm very happy to answer any questions regarding final year. But the most important tip I guess I have to give is just enjoy yourself. This is your final year of med school and everything will be all right. I promise. So. So this is quite a big lecture. So I'm going to take the pace quite fast. If you have any questions, please just interrupt and let me know. Ok, so I'm going to go through common presentations and differentials for each joint, the principles of joint examination, specifically hand knee and shoulder special test for each joint X ray interpretation for common MSK pathologies. And then at the end of the lecture, I'll touch on some other room conditions. So we get on to our first SB Johnny, a six year old child with sickle cell disease presents to P and E complaining of pain in the knee. When you see him, you see that he's tried to avoid putting weight on the knee and he has a temperature of 38.6 degrees. What is the next best step in the management? A obtain a blood sample including white cells, CRP B, conduct joint aspiration and send sampler for mcs and crystals. C prescribe antibiotics. Decent joining home with simple analgesia, E obtain a joint X ray if you don't mind just either putting it in the chat or, or just unmute and telling me what the answer is. Someone said b mhm I'm waiting for a couple more answers. Guys. Are there any other answers in the chat? Uh No. OK. So who was the person that said be what was their name. So, whoever, so whoever said b can you unmute and tell me why? That's the right answer. Uh, yeah. Uh, it could be because that was septic arthritis. So, and why is it important that you do b before the other ones? Um, well, I mean, I want to give you antibiotics but if I give antibiotics first, uh, it might falsely cure the blood culture results. So I want to do a blood culture first before I give antibiotics. Uh Obviously I'm not gonna send him home. Uh So history, I guess I could do it afterwards. Blood sample. Yeah, I could do afterwards as well. Um I guess the most important thing is just to get the ulcer straight away so that I know what antibody to prescribe it. Great. Yeah. So you have to conduct a joint aspiration. So not blood culture, you would be doing blood cultures as part of your septic stream. But jo blood culture, sorry, joint aspirate is the one you have to send off. And this is this picture reduced range of motion chia with a painful knee is septic arthritis until proven otherwise. And the reason why I mention sickle cell disease is because salmonella species are more, is more common in sickle cell patients as a specific bug causing the septic arthritis. But the most common a staph and strep. And then if you're also thinking like in older populations, like in about like our age, you'd be thinking more like ST s like gonorrhea. And then yeah, in the elderly population, you'd be thinking stuff and there are some other funky organisms as well. Are there any questions I'm gonna move on for the interest of time. So the most common presentation for the knee are joint pain, which are both acute and chronic and reduced range of motion. And as we said, those in combination together are septic arthritis. So sorry for the gory picture. So of course, generally, my advice in cases specifically is just categorize until you die. Like, you know, anything that they ask you be like there's acute and chronic, you know, bedside bloods and imaging, make sure whenever you answer something you have, you classify basically everything. So you can have chronic pain, which includes osteoarthritis. It can whereas you can have acute um presentations which are more like crystal arthropathy, which can be gout pseudo gout. But um but most likely gout in the knee. And then of course, ligamentous injury, meniscal injury fracture. And as we said, septic arthritis and at the bottom here, you can see so to the left, you can see an image of a hot tender joint swollen compared to the other side. And then at the top, you can see an open fracture. This looks like a high energy trauma fracture. So as I said, reduced range of motion with pain, uh cannot weight, bear is definitely septic arthritis until proven otherwise. And as I mentioned fracture in osteoarthritis will give you reduced range of motion as well in every examination, always do this. So wash your hands, introduce yourself, identify the patient, obtain permission, tell them what you're going to do. Ask them if there's any pain position the patient appropriately and expose them. Um Just make a 32nd spiel about this and use it in every exam. This is like gonna make you look slick and also make sure that you don't lose points for silly things. So it's quite hard over teams to basically tell you about the knee examination. But in any M SK exam, what you want to do is look at the joint, you want to feel the joint and palpate and then you want to do test the movement, which is both active and passive movement. And then you've got special tests and then you always add gait, add gait to the end because then if you run out of time, it doesn't really matter if you've missed that. Ideally, you shouldn't be missing it. And my advice generally with examinations is practice them on your friends multiple times, try and aim to be able to do them within 5 to 6 minutes. So you're going to look so anywhere really, you're going in terms of joints, you're going to look for erythema or redness. If there's any swelling or if there are any scars, if there's any obvious deformity, any muscle wasting any fixed flexion and any posterior sag sign, we're going to then feel the joint. So we're going to do a sweep test and patella tap test. D does anyone know why we do the sweep and patella tap test for? What are we looking for? An effusion? Yes, exactly. So, what the sweep test basically does is you, you make sure you bring down all the fluid. So, so let's go with the patella tap first, you, you milk the fluid from the quads down until almost you're above the knee and then you want to press on the patella. If you hear a tap, that means that there is potentially fluid collection there underneath the patella. The sweep test is basically bringing sweeping literally what it says, sweeping from one side of knee to the other and seeing if you can feel fluid moving, then you'll feel for joint crepitus. If there's any patella tenderness or laxity that's usually done at 90 degrees. So the patient with their legs off the bed, you want to feel the patella feel across the joint line and to the back and at the back, you may identify a baker cyst or a popliteal aneurysm. Feeling the popliteal pulse is virtually impossible. But if you suddenly feel like there's a bounding pulse against your hand, have a look at the back, but that's most likely because of popliteal aneurysm, you don't want to test movement. You want to see what the patient can do by themselves in terms of flexion and extension. Um And then you want to see with your help, how much further it goes. And then we've got the anterior and posterior jaw test which are testing your ACL and PC. And they're basically looking at how your tibia is moving in relation to your femur. OK. So you put your hands around the tibia and then you press can you can you see what I'm doing and just someone else I can't see myself, which is not really helping. Can anyone see this? Yeah, we can see you. Perfect. So, so you put your hands around just below the knee, on the tibial tuberosity and you will pull up and then you'll press down and basically what those are testing are the anterior collateral ligament which is present pre preventing anterior movement of the, of the tibia in relation to the femur and the posterior collateral ligament, which is preventing posterior movement. OK? So then you're going to do the Lachman test, which is essentially you put one hand on the cords with your thumb underneath and then the other hand you put on the calf with your finger on the tuber tuberosity and then you move that and how, how I do that is I put my knee under their knee uh to sort of prop it up because I'm not that tall. So I find that that's the easiest way to sort of isolate the knee. And if it's very lax. Then that means that they've got a, a ruptured ACL, then we're gonna test valgus and varus stress. So we're going to stress the MCL and the LCL. OK. Then as I said, we're going to put the patient towards the end of the bed and see how they move their legs and when they move their legs, what is the patella doing? And then if they tell you about like meniscal injury or you're suspecting that there's the mcmurray test, which basically puts a twisting force on the knee, but you won't be expected to do that in the exam. But that basically assesses the medial lateral menisci. Any questions on this? OK. I'm gonna assume there are no questions moving on. Can somebody tell me what the scar on the left is potentially indicating it could be a total replacement? Great. You guys said the same thing well done and how about the right? It's a bit more of a sub sign. Look at how the knee is positioned on the left compared to the right. So if I tell you that the right leg is fully touching the bed and the left isn't, what do you think is going on? So this is a fixed flexion, fixed flexion abnormality, sorry. So basically, the patient cannot extend the left knee despite them trying to do so. OK. And sometimes people may need operations to basically prevent this from happening in terms of the left image again, in terms of the scar, usually that's a sign of a total knee replacement. But there are other operations. Like sometimes for some reason, you may have that scar and a unique compartmental knee replacement, although much less likely. Um And then in sometimes, like you may also have some arthroscopy, arthroscopy scars surrounding that showing that they've had minimally invasive surgery to the knee or diagnostic imaging, moving on to the presentation. So this is a spiel that I that you can use. Basically, I got this from geeky Metics. I think it's really good. But essentially you want to say the, you wanna give a brief summary of your investigation of the patient through your examination. So you wanna say on general inspection, how the patient appeared any paraphernalia, how was their gait? How was the appearance of the joint? Then what was the range of motion? Was there any pain? The how were there any findings from the special tests? And then you always want to say, I want to complete a neurovascular examination of the lower limbs. I want to examine the joints above and below that goes for any joint really. So that would be the ankle and the hip and then further imaging if indicated. So X ray, if you're thinking bony injury or osteoarthritis, and MRI if you're thinking soft tissue injury, more complex injury patterns. So here is something they might show you in the exam. So the signs of osteoarthritis, they're a good acronym I use is loss. So you get lots of joint space, you get osteophytes, which are basically thickened bits of bone, which sort of protrude, which are very clearly labeled an image on the right. You can get subchondral cysts which look like lucencies and they're more round. I don't see any on the X ray we have here and then subchondral sclerosis is when you have increased sort of an increased white, white outline around the joint. And that usually is like a late sign of osteoarthritis. So here you can see that there's narrowing on the lateral side. Ok? And we know it's the lateral side because the tibia is always medial. So you'd say that this patient has a degree of a significant degree of lateral compartment, osteoarthritis if you want to be specific, moving on. So, um you've got unicompartmental and total knee replacement. So essentially you have three compartments, ok? You've got the medial compartment, you've got the lateral compartment and you've got the patellofemoral compartment. So what a total knee replacement does is basically it, it replaces everything, right? And it's a well established procedure, it's less specialized. It's got very good survival rate. However, it's more invasive, you've got more restriction of activity, you've got all this implant in your knee. And then in terms of unicompartmental knee replacements, they are less invasive. However, they are very specialized, not everyone does them, it allows for normal knee kinematics, quicker, rehab and it's easier to revise if necessary and you are able to progress to a total knee replacement. Ok. Any question on these, I'm gonna move on. Missus Smith is an 80 year old lady presents to A&E complaining of pain in her wrist. Her xray indicates a fracture in the distal radius that is dorsally displaced and angulated. What is the diagnosis? A A Smith fracture? B Bartons C Collies D Chauffeur's E scaphoid, Please unmute or write in the chat. What you think the answer is we have two people saying C three people. Now any other answers? Well, c is the correct answer so well done to those who said it. So this is very specific and you will learn this. Essentially a colleagues is one of the most common distal radius fracture fractures and the elderly very commonly present with this because it's a fracture. That is that the mechanism of action is basically fallen out to its hand. So the difference between a colleagues and a Smith's is that both of them are distal radius fractures. However, the Smith's fracture, the se the distal segment has a volar displacement which is downwards, right? You can see it very clearly here in the image and then a collis fracture is it's dorsally. So towards the back of your hand, dorsally displaced. OK. And dorsally angulated, you've then got the Barton fractures which you can see here where you've got a fracture, dislocation of the radiocarpal joint a, so first fracture is a fracture of the radios, a scaphoid fracture would be present differently because you'd have pain in the snuff box. OK? Which is here. OK. So this is just something important to note. And then the other thing that's important to know is to know if it's an extraarticular or intraarticular fracture. OK. So here you can see some examples. So if it's involving the joint, it's an intraarticular fracture. However, if it is an it's an extraarticular fracture, and then you also have dis the the words displaced and non displaced. So that just describes where the distal fragment is going in relation to the rest of the bone. OK. So presenting an X ray, I always start by saying this is APRA p with lateral view of plain radiograph of patient X taken on day X time X, it is adequate because showing the proximal and dal joints or inadequate. And then, II usually thought the most obvious abnormality is and then I say other features are because if you run out of time, at least you said what the main thing is, right? And some you can use this acronym old acid which is quite good. So open versus closed, the location of the fracture, the degree of it's a complete fracture of the segment is completely ripped off or not. If there is any articular involvement, as we mentioned, comminution and patterns or comminution is when sometimes you can see at the bottom here, like all the bones, but basically, a comminuted fracture is one which produces a lot of segments, right? Um You may want to comment on the intrinsic bone quality and then displacement, angulation and rotation are very important to mention. And that's why we often have two views of an X ray, right. So we've got the AP or PA and lateral in order for us to tell in which direction the fracture segment is moving in. And then you've got all these different patterns. So you've got transverse oblique spiral. Um And then as I mentioned, so you if it's a simple fracture, it's usually one fracture line. If it's segmental, it's usually two fracture lines. And as I say, comminuted, the complex is usually in high energy trauma and you'll see a lot of bony segments and usually the soft tissue damage associated. Now, as for the complete, incomplete, the only real incomplete fractures that you're going to get are your pediatric fractures, which are your green stick and buckle fractures? Ok. And that's to do with the plasticity of the and ease of regeneration of the pediatric bone. So who can tell me what is shown on the left? There's even a narrow, just unmute yourself and tell me this is a safe space. It doesn't matter if you make a mistake. This is for your learning. OK. Aptina fracture. Great. And how can we improve that answer? So say you're presenting to me in the exam. Um So, I mean, I'm not sure if it's AP or p but I would say it's that and then I'll be off the, oh, not quite sure but right knee. So, so in order to see the patella, usually it's a lateral. OK. I don't know if you can picture it, but this, this is essentially someone, this is most probably, well, we can't really tell. I think it, it may be the left knee, but it could be the right knee depends on the angulation of the patient, right? But this is a lateral film and because you can see the patella and usually you can't OK. Uh So if I take you back to this right, you can't really see the patella, can you? OK. So usually, no, no, it's fine. I'm I'm I'm just, you know, letting you know it's so if, if you could see the patella clearly, it is usually lateral. And what type of fracture is this? Is it, is it in many pieces? Few pieces, one piece seems like it's just broken into two pieces. Fantastic. So we'd call this a transverse fracture most likely. And what can you tell me? Is it displaced at all? And is it angulated or rotated? I think maybe the broken pieces are angulated, but I'm not quite sure. I think the bottom one might be. Yeah. So the distal segment is displaced because it's away from where it should be. And it's angulated towards the joint. So it's basically it's angulated and potentially rotated because if you, you know, the patella is usually one, just blob, it would just continue the, the lines of the uh of the proximal fragment, right? So it's almost as if it just moved there. Great. Um I had a case like this. I'm working currently. It means like there's so much soft tissue hematoma with these patients, um they're exquisitely tender. You need to analges them and call orthopedics. And we put on a cricket pad splint for that patient that I saw and you know, there are various options but this, I doubt can be managed conservatively. This would need operative management most likely. Um But of course, it depends on the patient and the comorbidities well done to whoever was speaking. Um Let's move on to the, right. So I have a quick question. Yes. Um To me, like it appears that there's a connection between the two parts. Would you still say that it's the tra it's a transverse fracture? If, if there's like essentially like a hinge, like it's not broken into two separate parts. I agree with what you're saying. I've seen that too. So what I would say is that, you know, it does, it, it doesn't have to be perfect, right? I would say it's definitely a simple fracture. It isn't in two segments. It was in one segment. I would say, I would say it's almost a complete fracture, right? I wouldn't say it's incomplete because realistically like that needs to be put back into place. Um So I would say it's, it's an almost complete uh transverse fracture. Um The distal segment, yeah, is almost completely um displaced and angulated from the proximal segment, right? Because it, it's just like the whole picture but saying that it's slightly connected wouldn't get you, you know, that's what it shows, but it's just the general pattern, right? We don't have to be completely specific. A good question. I hope that makes sense. Yeah. Great. Right. I've got a clue here on the right. But can anybody tell me what's going on? OK. Has someone call? Oh, great. Someone answered. So you've said Smith, OK. Why do you think it's a semester? Not a college? Uh Because it's got that Den Fork deformity? OK. And where is um where is the distal fragment going though? So the distal fragment is going volar volarly. It's, it's volar. So usually the d deformity is collies. So if you can see, say that the patient's hands like this, right? You see that the white has become the red area. Do you see that? OK. So this is really confusing initially. So the white area which is the distal fragment has become the red area. And if you see my hand like this, it means that the fragment from here has gone here and this anatomically is the dorsum of the hand. So this is actually dorsal displacement of the distal fragment. OK. So it's a distal radius fracture with dorsally displaced and angulated distal segment. So it's a col so if I take you back here, do you see the difference? Does that make sense? OK. That makes sense. So it's really easy to, to con to confuse them? OK. Um It's just about the angulation. So Smith has volar angulation colleagues has so it has um dorsal angulation. Ok. Well done. So, moving on to the shoulder. So it's very important to know the shoulder anatomy because it's very important in terms of the actual examination. So you've got your sternum, you've got your sternoclavicular joint, you've got your clavicle, you've got your chromar joint, you've got your chrom, you got the humerus, OK? And then at the back, you've got your scapula, which is shown on the right and this is a posterior view and you've got the coracoid process which comes towards at the front, which you, which is underneath the acromioclavicular joint. You've got the acromium, which is the actual shoulder joint and then you've got the scapular spine and you've got the supra spine as well, sir, which the super Spinatus muscle goes to or a shock. And then you've got the infra spine as well where the infraspinatus muscle attaches to. Ok. So what you do initially again, look for move special test, concentrate on what I'm saying. I know this slide is very confusing, but it's for your, it's a lot of words, basically, but it's for your, for your um, revision, we always look at the joint. Is there any redness? Is there any swelling? Is there any obvious deformity compare? Right. And if there's any muscle wasting? Right. So, if they have an auxillary nerve injury, they might have deltoid muscle wasting. Or if they've got a spinal accessory nerve lesion, you know, in the cranial nerve exam where we get the patient to shrug your shoulders, it could be that they've got trapezius wasting. OK. So then you're going to feel all the anatomical parts that I told you. So, starting from the sternum going up, feeling for any pain. OK? And then we've got all the movements and as we said, movement is both active and passive. So passive is when you help them, active is when they do it. And then you've got simple and compound movements, right? OK. So you've got flexion, you've got extension, you've got abduction, abduction and then you've got internal rotation, which is usually done behind the back. OK. And then you've got external rotation. And here I've put the muscles which are involved, essentially, you develop a way of doing it quickly and effectively and seeing if there's, you know, anything um abnormal, right? On the exam, special tests, you might want to get them to put their hands towards the wall and see if there's any winging of the scapula. And as we learn in our OS exams that's due to long thoracic nerve injury and then there are special tests, right? So I've got impingement syndrome actually. So I'm like, I was like the perfect patient for my pa for my friends to test and saw me. But with impingement syndrome, there are a lot of reasons around the etiology of it, right? But it's not really known, but usually the basic definition of impingement syndrome is when there is impingement of the subacromial space. So these patients ak me will cannot do the arc, right? I if I have impingement on my right, I cannot lift my arm more than this without it causing pain. However, I am physically able to if necessary, right? So if somebody pushes my arm up, it will go up and that is a very important thing to know, ok, because that will give you a differential and it will point you to the correct diagnosis between adhesive capsulitis, which the common name for it is frozen shoulder and impingement syndrome. Frozen shoulder is literally frozen despite you moving it right, it does not go up. So that's something important to know. Then you've got the MT A test where someone presses down. And if you have impingement that can be really painful and then you want to do resistant external rotation and internal rotation because you might have injuries or weaknesses to the rotator cuff. And then the scarf test, which is literally that you basically get them to their hand like that, that can s um, signify ac joint pathology. So, chromar joint pathology such as osteoarthritis and sometimes you can get a bit of tenderness when you're pressing on the acromioclavicular joint which you can feel on yourselves. Any questions here, I thoroughly recommend that you guys look at videos and particularly the ones that are done by the Imperial Med School medicine, the ones that they have online are really good. But this is just like, you know, a way to revise and having everything concise. And as I said, adhesive capsulitis. So there's a significant reduction in both active and passive movement. OK? And usually it's an older population whereas impingement syndrome. So normal passive range of motion, OK? And as we said, the axillary nerve palsy, so you might get deltoid wasting can be caused by shoulder dislocation and then you might also get um loss of sensation over the lateral deltoid region. So the regimental patch um and as we know, um you can get loss of shoulder abduction with deltoid muscle weakness, OK? Because the deltoids are involved in part of your abduction movement. And as I said, in terms of the presentation, it's exactly like before, important positives, important negatives summarize within a minute and then always offer neurological examination, examination of the joint below and above. So it's sort of the cervical spine because a lot of people may actually have neck pain. And then they think they have shoulder pain, but it's actually pain in the neck and elbow and then further imaging, if indicated. So, can anybody tell me what we have at the top? Let's go. Top. Right. Is this the femur shoulder dislocation? Sorry? Is this posterior shoulder dislocation? The one on the top? Right. Yeah, I mean, I don't know, I thought it looked like a light bulb so I get what you're saying. I don't think it is because it is still intact in terms of GC 01 sec. Let me see if I can get my um how do I get the, I can't do it here, but basically it's still touching the joint. It could be dislocated. It's hard to comment. It's not classic light bulb sign though. OK. What is the most significant thing though about that? X-ray, what screams out to you like a proximal humerus fracture? Perfect. And in how many bits is it, it looks like two, maybe three. And then there's angulation of the distal bit, probably two. And you think this angulation of the distal fragment? Mm Like I'm not sure how you'd describe it. Yeah. So listen, this is a hard one. It is a comminuted fracture. I would say it's not segmental. I would say it's a comminuted fracture. It's a prox proximal humerus, comminuted fracture with um I would say that it basically the the proximal part has almost completely like moved away from the distal part. And yeah, it looks like there's, there's lateral, there's lateral tilt to the distal segment. I agree with that. Um Of course, like we only have one view, but this is like a really bad fracture, like they've really done, done it in, right? And with proximal humerus fractures, we want to comment on whether they involve the surgical neck and if they do, they're most likely to have surgery, right. So this definitely involves the surgical neck. The greater tuberosity is still there as you can see and probably the lesser tuberosity is there. But this is involving the surgical neck, maybe slightly below, but this would definitely be surgery. Ok. Um And then at the bottom, what can we see fracture of the humeral head and the greater cubicles kind of come off? Where do you? So, so yeah, so there's a small fracture and you've got the a displaced greater tubercle? Ok. I agree. What about the positioning of the humeral head in relation to the joint? Just the anterior? Exactly. So the most common dislocation if in doubt, right, if in doubt the, if they ask you what kind of dislocation this is say anterior, if you don't know, say anterior because 99% I don't know if it's 97%. The majority basically like it could be over 90% of dislocations are an interior. So this, I would describe as an anteriorly dislocated humoral head with a fracture leading to complete dis uh complete displacement of the greater tubercle laterally. Ok. And also we can see the lung fields, right. So if you want to seem extra smart, you can comment on the fact that you can see normal lung markings, no pneumothorax and no suspicious lesions. But for completion, you'd like to see another view of the, of the humerus. And you'd also like see a full chest X ray questions for this. Are there any pathological shoulder fractures? So do, do you mean in the context of like malignancy, malignancy or osteoporosis or? Yeah. So you're less likely to get the pathological fractures with the humerus because it's not that much of a weight bearing bone and the ac joint isn't that much weight bearing. So you're more likely to get, so you're more likely to get generalized, you know, weakness of the, you can look at the cortices, the bone cortices common on them. You can also like they are more like if they are to get pathological fractures, usually they are in the spine and in weight bearing joints in severe cases. So more like femur hip, those kind of things. But you know, you can never say never in medicine, right? But those are the more common areas hope that's ok. Yeah, thank you. No problem. Right. Samantha 72 year old retired seamstress presents to you in GP clinic, complaining of pain in her hands. Her hands are as follows. What is the diagnosis? A rheumatoid B, osteo C osteo and ra gout D gout E fracture. Don't think too much into this rheumatoid arthritis, right? Do people agree osteoarthritis? Oh, sorry, I was thinking maybe rheumatoid. OK. So I put this image in a previous lecture and some people said this is why I was like, don't really think to it because realistically like an old lady is like, who also have osteo in her hands. But the main thing here is the ulnar deviation of the hand, which is characteristic of rheumatoid. OK. So you, so this is really late stage. So nowadays, you don't really see it because of the medications that we have. So you get ulnar deviation of the MCP joint, you can get swan necking of the fingers and then you've got the button defin deformity of the thumb. OK? Or um the Z thumb deformity. Whereas in osteo, you usually get boards and Heberden's nodes which are swollen hard around the fingers, usually rheumatoid is poly articular symmetrical. Whereas osteo is more like disjointed and no pun intended, but it's more likely to be like in only a couple of places in the body, right? And this is to do with wear and tear. It's not inflammatory, there is an inflammatory component, but it's not like rheumatoid that it has a huge inflammatory component, right? And the way I remember it is that the letter B comes before H. So B is proximal interphalangeal joint and habit is distal interphalangeal joint So, as I said, osteo degenerative disease, morning stiffness lasting less than 30 minutes. You've got cartilage loss and it's asymmetrical, right? And you can see like with the dots, you can see where the most common distribution is and you can see at the top right corner as well in your hands where the most common distribution is, right? Whereas in rheumatoid, it's an autoimmune disease, it's an inflammatory condition and you have morning stiffness which lasts more than 30 minutes. You can have extra articular manifestations and you've got a lot of inflammation right in the Synovium and it's usually symmetrical. And as you can see with osteo, you get less involvement of the MCP joints. Whereas with rheumatoid, you get less involvement with the distal end joints. And that's just to do with like if you think about it, like we move our fingers so much, right? We we don't move our hands like that, that much, right? We're more likely to get wear and tear on our small joints. So what I do for the hand exam again, look for move special tests. You cannot forget to do this in the exam. I put a pillow under the hands if I would have to do it right? And I want them to be exposed from like literally wearing a tshirt like me and their hair up. So you need to see ears, face and elbows down. OK? So you're looking in the hands for all those things that we were mentioning. So you can get things like um psoriatic changes both in the nails. You can get sausage like fingers and that's dactylitis, which is common in psoriatic arthritis. You can get these patches as you see there Gotts papules in dermatomyositis. So if someone has muscle pains and then also has a rash, think dermatomyositis, right? So you wanna look at the hands, you wanna look at the nails and you wanna look behind the elbows for your psoriatic plaques, rheumatoid nodules and then behind the ears for gouty toe, right? You want to feel the temperature, see if there's any deformity, feel for any nodules test, gross sensation, sometimes feel the pulse, OK? And then you want to test all the movements of the hand and the wrist, right? So wrist, flexion extension, fingers, flex extension, you know, and these can be done with u usually they're done with resistance, ok? Um And then you want to test the pincer grip. So picking up a coin and the power grip, squeezing your hands and you've got the special test which are fans test, OK, which basically is testing the median nerve which and there are a couple for a median nerve. Ok. So carpal tunnel, there's the one that you do this and you press on the carpal tunnel and that can sometimes elicit like weird sensation down the fingers or you can do this basically and not and sorry that and it basically causes irritation in the median nerve. You've also got the Finkel sign test, which is doing, putting your thumbs like that in your hand, closing the palm and then pushing downwards. And that is really painful for me because that's the, the sinus sinusitis, which we basically all will have if we use our laptops and we have this position which is not that good. OK. Are there any questions on this? And just to say for failing test, in order to evoke the symptoms, you have to have them with their hands like this for like 30 seconds minimum. So this is just a matter of practice, right? The hands are come up, sometimes they didn't come up from my exam, but this is like one of the hot topics, right? So make sure you know how to do it and it's usually a more rheumatoid focus. So the Viber questions that will come after usually to do with, you know, rheumatology rather than Ortho. So you thank them, you help them getting dressed as you'd always do. And then you might want to examine the other joints if there's any pathology offered to do a resp exam, if you're concerned, like this is this is like actual next level stuff. But if you want to get those like distinction points like your resp exam, because sometimes you can get pulmonary fibrosis and pleural effusions and rheumatoid an abdominal exam because you can get splenomegaly and fti syndrome, which is rheumatoid arthritis, neutropenia, um splenomegaly, that's a triad and then blood, right. So sometimes you get an anemia of chronic disease. So you would want an FBC to look at the hemoglobin and the MCV use these to see if there's any renal impairment, particularly with more autoimmune diseases or vasculitis, but also for drug dosing LFTs as baseline as well. ESR CRP will correlate with disease activity. So you want to see how much inflammation is there, TFTs if they've got other autoimmune disease, because you want to check if their thyroid is OK. And if you are considering gout, right? So if you see gouty to five behind the ears, so in terms of the immunology, so rheumatoid fracture sometimes is present in rheumatoid arthritis, but it's not that specific, but anti CCP is more specific than rheumatoid factor and it is a predictor of poor prognosis. So, anti CCP is the one that you should remember. So, and you should remember, remember what these acronyms are or like the shortened version is. Um So cyclic citrullinated peptide that may come up. So I'm just telling you remember what the antibody is in full. HLA B 27 is, is sometimes associated with some diseases as we know, particularly psoriatic arthritis. And if you're considering ankylosing spondylitis, usually we do hand x rays to look for bony erosions. But if you want to see some more soft tissue stuff, um and characterize them a bit better, you do ultrasound and if there was any diag like um diagnostic doubt regarding if this is a septic process or if this is like gout or pseudogout less likely in the hand. So you do a joint aspirate. So any questions on the hand examination, I appreciate like this is something like it's really early in the year and it's just a matter of you guys practicing. But like are there any specific questions on anything I said? Or do you want any advice? I'll move on for the interest of time. So carpal tunnel syndrome. So on the left, you can see that this is a severe case of median compression AK carpal tunnel syndrome and you've got wasting of the thenar eminence. You see there is almost like a dip in the muscle. This is very late stage in terms of the management, as I said, class V until you die in paces, conservative measures including wrist splinting, having more frequent breaks, avoidance of tasks which worsen the symptoms, medical. You may consider anti inflammatory medications such as nsaids, but also corticosteroids if necessary. And the like gold standard surgical option is carpal tunnel release, right? Um And here on the right, you can see a nice image where basically you have numbness of the thumb, index and middle finger and a bit of the ring finger and you have compression of the median nerve in the carpal tunnel. And this can happen in pregnancy. It can happen in obesity, it can happen in acromegaly. It can happen just because of a person's lifestyle. Right. So there are many causes. Anything though that increases soft tissue deposition around the carpal tunnel will lead to potential compression of the median nerve. Now, moving on a complete different realm, back pain, I hate back pain. If I see someone that someone was coming on back pain, you know, initially I'm thinking, oh my goodness, I'm going to have to rule out equine in this patient. But that's for me in the easy, I would just say in general, back pain is something, you know, there's so many different causes, right? So you can see on the right, a very nice table which summarizes all the different things that can be going on. But I would just say room conditions, ankylosing spondylitis, psoriatic arthritis because they have that HLA b 27 predisposition. You've got neurological causes including called equina where you'd get bladder and bowel dysfunction and you'd get weakness and numbness of the legs. You can get radiculopathy, which is compression of a nerve root and then you can get spinal stenosis. Of course, you can have masses such as the sarcoma, multiple myeloma metastases causing back pain and the most common which is musculoskeletal back pain. Um But that can be the mu usually mus muscular pain, but it can be fracture, sacroiliac joint dysfunction. In some cases, it can be a disc bulge, you know, so many different things. And of course, you can get referred pain, particularly not to miss an aortic dissection, pancreatitis. And of course, it could be pyelonephritis as well. So, because you've got all those retroperitoneal organs which can cause pain in the back. So, moving on to seronegative spondyloarthropathies, which is basically ankylosing spondylitis. So as we said, it's an autoimmune process with predisposition. In those that have the HLA B 27 gene, you get your collagen gets destroyed, there's fibrin deposit deposition, you get ossification. And in late stages, you can see the bamboo spine which is shown on the right. It's also very important to know that there are extra articular manifestations. So you can get issues with the eyes or uveitis, you can get um issues with the aorta or aortitis, aortic insufficiency, heart block, you can get citi, which is where the tendons is to the bone. So particularly achilles tendon like the achilles tendon, you can get plantar fasciitis, you can get pulmonary fibrosis, everything under the sun, basically. Um And now there are like different criteria as to how to sort of categorize the ankylosing spondylitis. But basically, the characteristic change is sacroiliac joint dysfunction, right? Um So you get sacro sacroilitis, OK. And the important thing to know about the er negative arthritides which include ankylosing spondylitis, psoriatic arthritis, reactive arthritis can't see, can't pee can't climb a tree. That's I still remember that. And enteropathic arthritis is that they are negative for rheumatoid factor and they are usually positive for HLA B 27 right? And they affect the bones in the spine and nearby joints. So the way you treat the seronegative spondyloarthropathies, I'm thinking particularly ankylosing spondylitis is, do they have axial manifestation or not? So, axial means, do they have back pain? Do they have evi evidence of sacro rais? Because if they do that leads to different treatment, if they only have peripheral manifestations such as arthritis, enteritis, dactylitis, and the sausage fingers that we were saying you can go down a slightly different route. So first line, you'll give them some medication like nsaids and you'll give them some conservative advice. So again, conservative medical and then you'd go specialist or um biological treatment. So in peripheral manifestations, you can give local steroids and some disease modifying medications such as sulfaSALAzine, right? But if there, if it's an axial manifestation, you wouldn't go down that road, you'd go probably to a biologic like a TNF alpha inhibitor such as Adalimumab or an il 17 inhibitor like secukinumab. Ok. And of course, we always give analgesics as well to our patients and sometimes in severe cases with a lot of spinal changes, you'd consider surgery as well. Any questions on this, we're almost done, you've done really well. Moving on to a le you get very characteristic findings. Everyone knows the butterfly rash but is truly a condition that can affect the whole body. And I do not envy anybody that has, it can be really difficult, really challenging. And it's really a condition that brings together the DT. So it can affect your heart, it can affect your lungs, it can affect your kidneys. Lupus nephritis is very common, right? But you can also get arthritis and you often get Raynaud's as well to have sla theoretically, you need to have four out of the 11 criteria from the American College of Rheumatology. And the way you remember it is so brain MD. So serositis, um oral nasal ulcers, arthritis, photosensitivity, particular blood picture pancytopenia. Usually the penia is so low counts, renal disease, you may get ana it's an immunological disorder. The antibody that's found in most cases of 60% is antidouble stranded DNA, ok. But sometimes you can anti Smith antibody and antiphospholipid antibody. An antiphospholipid antibody, of course, comes up in the cases of recurrent miscarriage with venous and arterial disease in these patients. Ok. Um And then you can get neuro disease, you can get the malar rash and you can also get a discoid rash which is like a coin shaped rash. And the etiology is unknown, but this is a multisystem autoimmune inflammatory disorder. Those are the most effective for young females. AFCA or Chinese descent. Some people say viruses may be involved and drugs. So again, the management, conservative medical specialist. So conservative lifestyle diet, flu jabs, etc medical would be analgesia and then specialists would be steroids. But we don't want to use those for a long time because you can develop, you know, Cushing's from that Cushing's syndrome. So yet now they're moving more towards hydroxychloroquine cyclophosphamide, my mycophenolate azaTHIOprine and, and biologics, right? So hydroxychloroquine is the one that's used the most, the important thing to know is that you need to do regular eye tests because it can affect your eyes. So, moving on to SB number four, Vanessa, a 59 year old woman presents with a history of headache and jaw pain. She has a longstanding history of shoulder and neck pain. What is the next best step? A temporal artery biopsy, B, ultrasound, temporal artery C assessed for visual impairment. D check the ESR E prescribe steroids. Anyone that can tell me. Do you check for visual impairment? Fantastic. And why is that the correct answer? Because you're worried about temporal arthritis and if there's visual impairment, then the treatment will be different because you'll give IV methoprene rather than oral pred. Exactly well done. So if somebody has visual impairment, you will be admitting them to hospital, right? So yes, we are thinking giant cell arteritis or temporal arteritis where you get inflammation of the walls of larger size arteries and usually your temporal artery right here may be tender and firm to touch. It can cause blindness, which is why it's so important to test for visual impairment, right? Um because it's an arteritis, it can affect other arteries in the body. So it increases your risk of stroke and heart attack. And also you can get jaw claudication and tongue necrosis. Um because of loss of blood flow basically, and you can get other systemic symptoms like fatigue, fever, weight loss, muscle aches, etc. And it's very much linked to PMR right. So 40 to 50% of temporo arteritis patient or giant cell arteritis patient will have polymyalgia, rheumatica, but only 15% of those that have polymyalgia, rheumatica will have temporal arteritis. And this is basically an inflammatory condition of unknown cause where you get basically pain in the shoulder girdle and the pelvic girdle. Ok. But no actual muscle weakness and it's more common in older than people that are older than 50 years old. You get a raised inflammatory picture in terms of the blood. So you have a raised ESR CRP and it's very important to also because they are in this age group. Of course, it's important to screen them for risks of diabetes because usually you will be starting them on steroids, right. So it's 15 mg of prep, which is quite a low dose, right? Um But then when you are giving someone steroids, if they have a lot of steroids or if they are cushingoid, we remember that it can affect the bones. So we give prophylactic bisphosphonates and we may and Vitamin D as well for the bone and sometimes it can cause, you know, gastric reflux symptoms, etcetera So you'll be starting a protein pump inhibitor like omeprazole. So, are there any final questions? I would like to thank you all for coming in. The meantime, I'd greatly appreciate if you could fill in the form. Let me know if you have any questions. I'm happy to answer anything. Even if it's not related to this. If you have any questions later on in the course, I'm also happy to answer. Um I wish you the best of luck and I hope this was useful. Please don't feel daunted this lecture was for like people that are aiming for, you know, quite high scores, but I'm sure that you all go great. Ok. Um Any questions and please fill in the feedback.