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I hope that hello guys. Um Can you guys may be under the chat? Whether you can see me and hear me fine? Can you see me and hear me? Just fine? Yeah, Lisa, can you hear me just fine? Oh Yeah, sure. Yeah, you can. Okay. That's good. Um So thank you everyone for coming to another of our MSK A revision series. Um We have Jamie and Lisa who's our content creator, um who's gonna talk you through some high OTMS you revision series. Um Before we start, can you guys see the slide right now? It was a problem last week. So we just want to make sure that everyone can see the slide at the moment if you guys can or cannot see it. Just reply in the chat, please. Can you guys see it? Okay? I can. Yeah. Okay. Well, if there is no comment will just assume that you guys can, but again, guys, to make the most out of it will really appreciate if you guys can maybe um interact with us either like through, just turn on your microphone or answering in the chat. So yeah, I'll hand over to Jamie who's gonna start the revision series. So, hello, thank you very much for joining us the evening. So this is the following event from last week. So we're talking about more about fractures, um more rheumatology conditions. So, gout pseudogout and um some Latino synovitis as well. So can please some 11 person put yes in the chat. So you can see my slides and they are changing. So I know I'm not just speaking. Um And the slaves aren't changing. I'm just gonna assume. So we're just gonna go on to the first question. Thank you, Tara. So we're just gonna go into the first question. So everyone have a read through and I'm put Jonathan answer down. You've made the effort to come on. Uh I choose the evening. So uh drop an answer down, do some critical thinking and we'll move on. So a 26 year old male has fallen onto an outstretched hand on a night out with friends. He presents to the emergency department with pain in his hand radiating up to his rest. Which of the following is not associated with this condition. Tenderness over the anatomical snuffbox, avascular necrosis pain listed by telescoping of the thumb. A positive Finkelstein's test our pain on ulnar deviation. So how do we think I'll give you 20 seconds and we'll move on to the next slide. So I'm not sure there's a pull pull, popping up, but just drop down an answer. So well done. To everyone that identified. This is a scaphoid fracture. So what is the scaphoid fracture? Well, say void as a carpal bone, a boat shaped bone and there's the most commonly fractured carpal bone. It normally happens in young males between ages of 20 and 30 following a high energy fish injury. So, fish meaning fall onto the outstretched hand. It's important to understand the anatomy of escape the scaphoid just to fully understand avascular necrosis, which is a very common top uh exams and especially when you're in theater, um your superior uh really want to be able to, to note you can identify avascular necrosis. So there's three parts to the skate, avoid the proximal pole, the waist or the mid portion and the distal pole and the distal pole receives blood supply from the dorsal branch of the radio artery which travels in a retrograde fashion. So I hope you can see my cursor here. So essentially all that means is the blood supply is being the supply to the distal part of the scaphoid bone and traveling back proximately. So, if you can imagine there's a fracture in the mid portion of the scaphoid and the proximal part of the skateboard is going to be compromised and it's not going to be receiving any blood supply, which goes on to lead to avascular necrosis, which is essentially the bone, uh not getting any blood supply and dying, which that goes on to lead to early officer arthritis and people may have to have a scale avoid replacement very early on if it's not identified. So this question primarily focuses on the clinical signs of a skateboard fracture. So the classic being anatomical snuffbox tenderness, um really worth knowing your boundaries of the anatomical snuffbox because it's another common uh sort of question that's asked and anatomy exams and certainly emphasized in the Aberdeen curriculum. So the medial part, the medial border being the extensive Paul's longest uh the lash of being the extensor, Paul's Brevis and the abductor Paul's longest and the proximal border being the styloid process of the radius. Another clinical sign is pain elicited by telescoping of the thumb, which is a sexual essentially actual compression of the thumb. So if you can all see me, that's just like pressing down uh compressing towards um be worth having just to be youtube. There's a lot of physio videos out there that show it quite nicely. Pain on all more deviation is another common sign and pain when palpating the skateboard typical. So in the two images here, the in the bottom right, you can see that someone palpating the skateboard typical and the bottom left, the anatomical snuffbox so well done to everyone that identified that a positive Finkelstein test is not associated with a skateboarded fracture. So, going on to question too, 24 year old lady has fallen while playing hockey onto an outstretched hand. She has pain in her anatomical snuffbox initial set of radiographs showed no sign of any fractures. Two weeks later, she presents with continued pain in the wrist and a tender anatomical snuffbox repeated X ray showed no fracture. What investigation do you want to order next? So have we think we have a poll on now as well? So if you guys want to answer it, just answering the pole. Thank you. Last name. I think the pole for now. a yeah, so well done everyone. The correct answer was a sorry, I don't know why that the green never came up there. So um with a skateboard fracture, it's not always detected on the initial X rays. So if clinical suspicion remains after 10 to 14 days, you're going to want to get the patient back in to do a repeat set of X rays. And even if that doesn't show a fracture and you're still suspecting this patient as a skateboard fracture, you're going to want to move on to more sensitive imaging that being an MRI or a CT, I think nice statement says MRI is the most sensitive, but I know this differs from trust to trust, which which, which is what is actually carried out. Um The diagnosis again in includes this combination of clinical examination and imaging and the initial X rays are something called PSCK A foil series which involves a P A lateral and an open oblique view X ray. And the management differs depending on the severity of the fracture. So under put undisplaced fracture will be managed with a futural splint, which is on for 6 to 8 weeks. However, displaced and proximal statewide fractures require surgical fixation, which is demonstrated by this sort of bottom left image here, which is a percutaneous variable pitch screw. So it goes through the whole skate avoid uh and the top left image there again just showing a fracture through the mid portion of the skate void. So that patient would be at risk of privacy on the process. Um So great. Going on to the next question, a bit more of an anatomy based question here. So uh 78 year old women is admitted to a and E having had a fall at home, her head is in significant pain in her leg appears shortened and externally rotated. They're diagnosed, they should be, she, she has diagnosed the fracture of the neck of femur, which blood vessel represents the greatest are arterial supply to that. So, have we think close your anatomy? So it looks like most people are going for D B and D slide between B and D and it is the, so the medial per formal circumflex, the one of the branch of the femoral artery. Of course, that's the main blood supply to the hip. So going on to the neck of femur fractures. So if you ever have a job in orthopedics, I just did my fifth year rotation there. Most of the ward is um uh with poor old wife is that have fallen over and fracture the neck of femur. So there's over 65,000 neck femur fractures recorded every year in the UK. And the mortality up to in the first year of an echo femur fracture can be up to 30%. And for this reason, a relatively very restrictions. So they come in, they help manage all these patient's, they've got neck of femur fractures with all these different comb or abilities. So they specialize in the care of the elderly patient that had orthopedic fractures. And the most common type of neck of femur fracture is a low impact injury amongst osteo osteoporotic elderly patient. So their bones are weak and brittle and it doesn't take a lot for the femur to break. So a very basic breakdown of the anatomy. Um neck, the femur fractures can be split into intracapsular and extracapsular. So, intracapsular fracture is being proximal to the point, the hip joint capsule attaches to the femur and extracapsular be occurs distal to the joint capsule. So um just to sort of explain this in this image showing here. So an inter capsule fracture would be involving the femoral head area or the femoral neck area or an an an extracapsular fracture would be in the intertrochanteric area or the subtrochanteric area. So that's just a very basic breakdown. You can divide it into further, but we'll keep it that just now and much like the scaphoid. Um the female has a retrograde blood supply as well, which puts a risk of a vascular in the process. So there's a distal too proximal blood supply, traveling along the femoral neck to the femoral head, predominantly through the medial circumflex artery. Um So this means displaced inter capsule fractures. Put there's a risk of avascular necrosis and with avascular necrosis again, uh greater risk of developing osteoarthritis and and further orthopedic problems. So, uh something really want to fix. So, moving on to the next slide. Um So again, yeah, the presentation, um the classic short and abducted and externally rotated hip, which is uh demonstrated in the top rape immature. Sorry, it's a bit small. So you can see this lady's right leg is sort of um uh shorten abducted and externally rotated due to the extensive pulling on it and they have doctors pulling it, sorry. And there's also pain in the groin and an inability to wait their. Um something that I'm certainly asking my any placement is, and that might help you identify neck femur fracture. If you're ever looking at the Noski station or you've been asked to look at it is something called Centonze line, which is an emergency line. Uh This yellow line here which is going along the inferior border of the neck and fear and the neck of femur to the superior border of the superior pubic ramus. So that's this line here. As you can see in the right. Uh on the right here, there's this light nice curve line, but on the left and there's a, there's a kind of fracture and there's a disruption of this line. So it's just something to identify and that might help guide towards, help, guide you when looking at the X ray. And the classification is important in the fracture because that's what's going to guide your management, your surgical management. And you, you uh the classification is used the garden classification um increasing in severity. So one being an incomplete fracture that is non displaced to being a complete fracture, that is also that is non displaced. Three being a complete fracture that is partially displaced. And for the worst of block, a complete fracture that is fully displaced. And that's just in that top left image, they're showing the different types of fractures. And this is a sort of rough overview of the different surgical management that's used in the fractures. Again, it's the manager that's gonna, that's gonna be used. It is case specific, but this is just from the nice guidelines. So, and intracapsular fractures, undisplaced fractures normally are fixed with internal fixation is I am nail displaced fractures, some form of arthroplasty um goes on to fix them. So normally it's a, it's a hemiarthroplasty and unfit and patient with multiple morbidity because they won't be able to tolerate the longer procedure. They're more likely to have more blood loss and a total replacement. This is Paradise guidelines. A total hip replacement is the preferred and fit patient's relative situation is most patients have hemiarthroplasty is, but that's, that's just the sort of summarize nice guidelines and, and extracapsular fractures. Um and a stable intertrochanteric fracture. A dynamic hip screw is used in Aberdeen. A lot of Aberdeen has a very high rate of I am Neil usage. I was like it too believe so. I didn't see too many dynamic hips cruise a lot, a lot of time to use and I am near as well. But paradise guidelines that th th S crew and and reversal bleak and subtrochanteric fractures. And I am an instrument that all great advice is used. So go on to the next laid question for so a bit of pediatric orthotics. Mhm. Um So an 11 year old, a beast boy presents any with progressively worse limp. He cannot remember how long as he's been experiencing this pain for. He has reduced range of movement, especially an internal rotation of his left leg. He is otherwise systemically. Well, what is the diagnosis? So have we think there? Bye. So well done. Everyone that identified slept upper femoral epiphysis starting pronouncing that wrong. Um So the most, the two most common commonly asked that sort of pediatric adolescent orthopedic conditions or Perth disease or leg calves, Perth disease and to suffer. So going through both of them one at a time. Um So Perth diseases, the disruption of blood flow to the femoral head causing avascular necrosis to the bone. This is entirely idiopathic and it normally occurs in boys aged 4 to 8. So the real key to being able to identify the difference to these, these two conditions is the age and and suffer. It normally happens to sort of beast boys, slightly heavier, heavier lads. Um The the actual presentation is very much the same which is sort of an insidious hip pain. So progressive hip pain over several weeks and reduced range of movement. Uh in Perth, it's bilateral and 10% of cases. And this top left X ray, this is a bilateral case. So you can see that um the two the two hips are affected here. Uh The diagnosis is used with is found with imaging and the potential complications for parents is due to the sort of revascular revascularization and neovascularization. Neovascularization being the formation of new blood vessels. It leads the reforming of the femoral heads and soft into formed femoral head. Uh leads the sort of early officer arthritis and might result in the patient needing a total hip replacement. Um you know, as you can imagine having a total replacement, a very young age and ideal because they only last for 10 to 15 years, meaning they might have to have multiple surgeries with uh myriad of complications happening with, you know, a total hip replacement because it's a major operation and the management for perth's is normally conservative in my all to moderate cases with bed rest tract, bed rest traction splints, physio input and close monitoring used to, to make sure it's not progressing. Um and severe cases as surgery as you. Sorry, I think the bottom is just cut off in the we slide here for um suffer. So this is the most common hit disorder in adolescence and it's due to the week next weakness of the proximal femoral growth plate which causes inferior and posterior inferior displacement of the capital epifix iss so sorry, I think in this in the next slide, it's a bit more clear. So this is in the right image here, the right image and this patient left hip, you can see the displaced femoral heads. And again, this is the age range is really important to differentiate between these two conditions. It happens to boys aged 8 to 15 plain x rays are used to diagnose and this is normally that normally only affects one hip. So a potential complication is leg length disparity and also a vascular in the process of uh the femoral head. And with suffer, it needs surgical fixation using a cannulated screw. So that's some pediatric orthopedic cases. And those are just the two enlarged x rays here. So the left image being Perth. So you can see bilateral cases affecting both femoral heads and the left image, this displaced femoral head. So going on to the next question. A third seven year old woman presents the G P with pain in the base of the hand. It's been bawling her for four months and the pain is getting progressively worse. There is no history of trauma. There's no past medical history, but she works with Taylor and smokes five cigarettes a day on examination. There is pain at the base of the thumb. What's the diagnosis? What people thinking? So, another few responses people are going for. It's 50 50 between osteoarthritis and the of the farm. And Derek Levine's I think, yeah, Derek veins have just topped it. So this was Derek veins, tenosynovitis. But I can see why Oscar operated the thumb is up there as well. Let me explain why. So also arthritis in the thumb because the individual is 37 there are a bit younger osteoarthritis tends to affect older individuals. But I completely understand your rationale behind that. But just because it's a slightly younger individual, um it's more likely to be tenosynovitis. So this is inflammation of the tendons within the first extensor compartment of the rest. And this most commonly affects individuals between 30 and 50. So slightly younger individuals with hobbies including repetitive movements. So this in the previous question, the the occupation being a tailor being a very hands on occupation, more likely to go on to develop their veins. So just briefly going on too. But anatomy in the path of physiology. So the two most commonly affected tendons, the two commonly affected tendon, sorry and the darker veins can affect sign of ITIS or Doctor Paul's longest, which is responsible for from abduction and the extensor Paula's brevis, which is responsible for some extension. So, um tendons are encased in a tendon sheath which is made of a connective tissue called synovial membrane, which is filled with sinus synovial fluid which lubricates the tendons and allows them to move freely within the tendon sheaths. And um this fibrous band called the extensor retinaculum attendants move under this and this repetitive movement and the tendon chiefs under this cause it causes inflammation and irritation of the tendons leading to uh leading to this pain at the base of the farm. So that's a brief explanation of the path of physiology there. And the classic clinical signs are pain near the base of the farm. A positive Finkelstein's test. So I didn't put that in the previous question because I thought it would make it to clear cut. And that's that this is a this image here on the bottom, right, is a Finkelstein's test. So this is longitudinal traction and ulnar deviation. Um and that's what was it pain down down the farm. And another potential clinical siding with darker veins is uh swelling near the base of the thumb. So the management is uh normally conservative with activity alterations in um splints, the restrict movements and also steroid injections can be can be used and rarely uh in the very effective patient's surgical decompression, maybe it might be used but be a very long waiting list. So, moving on to the next question. So a 34 year old male presented to the emergency department after falling onto an outreach hand, they are diagnosed with a college fracture, which of these features with most likely been seen, most likely be seen on X ray. So how do we look? So this is just about sort of knowing difference between your sort of collies, your Smith's, your Barton's, how would they describe? And the X rays, what are the features so well done? Most of the people picked a which is correct. So, extra articular fracture with dorsal angulations and radio shortening. So this is just to summarize slide of distal risk fractures that are commonly asked about. So, first of all, looking at colleges, so what's the mode of action? So falling onto an outstretched hand forwards um and this so just quickly moving to the next slide. So in the top right image there, you can see this the mechanism action here of a college fracture also called uh well, also known as a sort of a dinner fork deformity fracture. So falling onto uh an outstretched hand and the X ray features are a transverse fracture of it still radius with dorsal angulations and radio shortening. Um The management is dependent on whether it's displaced or non displaced. So a non displaced stable fracture, closed reduction and casting can be used 6 to 8 weeks of casting. Can you use to treat that? However, if there is dorsal or roller combination. So multiple fragments, significant ambulation or the closed reduction is unsuccessful and they might need some surgical input. And what are the potential complications of cause fracture? So, it's, it's important to do a thorough neurological exam, neurological examination for someone that's coming in with a wrist fracture injury because they may have sort of a medial nerve injury, reduced sensation, reduce power in certain areas, uh compartment syndrome. So I'm not sure if everyone attended the previous revision, see revision series. So this would be an increase in the inter compartmentalize pressure leading to sort of uh restriction of blood flow to the muscles and the nerves within that compartment. That's another potential complication, complex regional pain syndrome and malunion. So malunion being a fracture to the to to bone fragments, uh healing in an abnormal position. Um and just to just to go back to previous light. But in the bottom left image here, we can see uh we can see a college fracture. So there's dorsal ambulation coming backwards, radio shortening and this dinner for deformity and the top left image. So demonstrating that there. So moving on to Smith's fracture, which is falling backwards onto an ouch, falling onto out straight hand backwards. So just having a look at that um top right image again. So N words backwards, falling onto that outstretched hand. And, and this is a transfer fracture of the distal radius with bowler ambulation. And also there is also radio shortening. Again, the management is quite similar to Polly's with closed reduction and casting used for non displaced stable fractures and surgical management with dorsal or polar combinations of multiple fragments into articular involvement. So going up involving the radio carpal joint or there's instability postreduction and the complications are much the same with potential nerve injury and malunion and complex regional pain syndrome. And finally, a Barton's fracture which is an inter articular fracture of the distal radius. So this is involving the joint and surgical fixation is normally required for these uh is required for these type of fractures and potential complications developing here, carpal tunnel syndrome and malunion. And just to look at the notes here, the top, the top, the top medal image is probably the best air you can see it. Uh the bottom fraction demonstrated there and the bottom, right also as well going up towards uh the radio radio carpal joint. So we're moving on to the next question. A patient recently underwent open reduction, internal fixation for a spiral tibial fracture. Seven days post surgically, the patient begins to feel unwell with significant leg pain. On examination. There's significant erythema over the hip and the leg. It's hot to touch and there's swelling. The pulses are present. The obs are, they're they've got a fever and they've got a respiratory of 19 heart rate of 94 stats are 97%. What was the most common bacteria cause of this presentation? So, have we think? Yeah. So everyone's went for the classic so well done to everyone that selected staph aureus. That is of course correct. And that's well done to everyone that identified. This was osteo my latest. So infection of the bone. So, osteomyelitis is inflammation of the bone in the bone marrow caused by infection, the most common organism is staph aureus. But in psycho, sell patient's at salmonella, which is a question that came up in our finals. It was very odd. Uh something to keep in mind, there's two main modes of transmission. Um So through the blood to pathogens carried through the blood, uh Magennis or direct examination. So, through a fracture site during an orthopedic operation. So the risk factors for this or uh of course, orthopedic operations, open fractures. So if a fracture isn't exposed to the environment, that's obviously going to get introduced a lot of bacteria, greater chance of infection, patient's with diabetic food alters. So, open wounds again, back to you, you can travel through these wounds towards the site towards a bone site and pee dee that's peripheral peripheral arterial disease. So, patient's with peripheral arterial disease are more likely to suffer from osteoarthritis. The classic presentation is low grade pyrexia, a tender, a tender site or a tender injury site where the bone is affected erythema over the site. Um and an inability to weight bear or uh a potential source of infection. So, you know, there might be an abscess uh superficial to, to the affected bone. And I just want to on the bottom left image here. This is a severe case of osteo osteo. My latest that that's probably went untreated for a while. And as you can see there's a significant disruption to sort of the cortical and soft bone there. Um The definitive imaging uh for auto myelitis is MRI it's it can be picked up on X ray, but it's unlikely I know this the bottom left images up as an X ray, but this is very, very, very severe case of osteo. My latest and blood cultures are necessary to identify the tech pathogen and also a gold standard is a bone biopsy during surgical debridement as well to to confirm the diagnosis, diagnosis of Osteomyelitis. So what's the management, so long term antibiotic therapy? So long term intravenous antibiotics are required for all patient's with the osteomyelitis and also in severe cases like this one here, surgical department uh might be necessary. Uh Is there is clear evidence of bone destruction? So I think that is the end of my questions. So I think Lisa is going to take the second half she applied to stop sharing. All right, let me see if my slides come up. Does everyone see something? I can see it. Okay. Good stuff. So um I'm going to try to get you guys to participate. If no one participates, I'll just keep ahead and talk to myself, which is fine but do try and give you something in the chat. So for our first question, we have a 14 year old boy Museum human with clinic. So he has a swollen red left me and the swollen came on two months ago And in this time has been feeling generally and well, uh parents say that it feels like he has a fever, you perform a full physical examination and besides the joint swelling, erythema and reduced range of motion at the knee. Uh There's also another swollen joint, the ankle and you see that his eyes are red. So if anyone can give me a differential, a differential in the chat or alternatively, if someone wants to give me the skin signs in the chat and that's right, I'll go straight forward. So, differentials are juvenile idiopathic arthritis, which is what I was getting at. But uh you sort of uh never can exclude septic arthritis unless you investigate. So that's always going to be a differential for these inflammatory arthritis, especially those with sudden onset. Uh In this case, it doesn't seem as likely because of the long uh two months duration. But which skill uh sense might this person have, they might have a psoriatic rash or a salmon colored rush, which is a typical colored rush for um, idiopathic juvenile arthritis that is systemic. Um I'm not gonna go for everything that's on the slide. If it's helpful, you can later save it. Basically, there's seven types of G I A and um overall in exam questions, what they will focus on it, it will be long duration, uh symptoms. Well, because it's juvenile should be before 16. Uh, the joint will be hot and uh swollen and um um they will have a high grade fever that will spike 1 to 2 times per week. Uh Great question from Regina in the chat. So why not ankylosing spondylitis? Um because technically, um J can present with Ponty logic like symptoms, basically was reduced spine flexibility even and enthesis enthesitis which is inflammation of where joint and ligaments attached to the bone. But as long as this happens in younger population, it's technically more likely to be a variation of G I A. It's likely to be this anticipate this related variation of J A, right? And so pathophysiology of this is as it says idiopathic, but as it's inflammatory, you might see links to increased ESR CRP and in large lymph nodes, there might be a family history of GI or any other autoimmune conditions. Uh This condition is more prevalent in Trisomy, 21 patient. So that might come up in a question as well. And this patient might themselves have a previous history of inflammatory or autumn conditions such as IBD symptoms and science. Well, all of these subgroups have different symptoms in science, but in general, in the question, you might face joint swelling and the Rahimah reduced range of motion, uh reduce spinal flexibility, some in colored rash, uh ductile itis, which is the swelling of the entire digit and nail changes, psoriatic skin changes, uh involvement. So you've ITIS and morning stiffness. Um if you remember back to the previous session, as Jamie said, morning stiffness is usually indicative of an inflammatory arthritic process. So which investigations can you do, you can do FBC blood film for sort of signs of against systemic inflammation such as anemia, leukocytosis from a cytosis. You can also do rheumatoid factor or anti CCP N A HLA B 27 but they don't necessarily rule out J as a diagnosis. They might just point towards one of those subcategories more than towards the other. You might also want to do X ray um to see joint mal alignment, ankylosis infusion, osteopenia or ultrasound to visualize sinus virus, joint infusion, um erosions, enthesitis and MRI and Dexa scans are really good follow up to because um they're great way to follow up bone density and um that can be compromised by erosions caused by G A. So, diagnosis, um it's basically clinical. You have the history, you have this signs of an examination and by this point, you should have ruled out septic arthritis through other investigations just to be completely. Sure and uh this lovely picture here is this salmon colored rash seem commonly in juvenile idiopathic arthritis. So, um just a small for a question. So the parents are curious whether this person will need uh Glucocorticoid injections as part of treatment. And um what do you guys think? Are you leaning towards? Yes or no? Just give me a yes or no. Okay. And then the other question on uh except the reveal it. So uh yeah. Google corticoid injections have a role in G I A treatment, especially if there are few inflamed joints and those are quite big joints. This is purely out of practical concerns. Um And an important complication you should make these patient's and parents aware about is M A S which is macrophage activation syndrome. I'll talk about in a bit first just to cover management. So from conservative side, there's physiotherapy uh to relieve the stiffness symptoms from medical NSAID again, in Children should be limited to under two weeks at the time. Glucocorticoid injections, as we said, big joints and acute inflammation. D Mart's just like in adults. So, methotrexate this first line. Then we have leflunomide and sulfaSALAzine. Then we have oral corticosteroids uh for acute inflammatory periods, um topical corticosteroids for uveitis and biological agents such as Infliximab, riTUXimab, etcetera, uh complications, growth delays, leg length discrepancies, vision problems. If the you're right, it goes on for too long as I mentioned before. Osteoporosis and other future photography's and of course, macrophage activation syndrome, which is a disproportionate immune response. And it's technically life threatening and represent with high fever, pruritic rash, hepatosplenomegaly, lymphadenopathy e and uh in that case, it requires uh prednisoLONE turkey. Right. Next question. So you're doing a diagnostic citation and the radiologist shows you a right hand X ray showing a pencillin cup deformity at the proximal interphalangeal ring finger joint. She tells you that the patient got the scan as part of investigations for their ongoing joint pain and nail bed deformities or changes. Does anyone want to suggest um what skin condition this patient might have going on in the background? Oh, excellent. Think you Nina. Yes, they are very likely to have psoriasis. And does anyone know another severe late sign of this rheumatological condition that can also sometimes be visible on X ray or even with the naked eye poor neck deformity. Um Kind of that. That's also one of them again. Thank you Nina beginning the whole session. Um So another very classic one for psoriatic psoriasis arthritis mutations. Um And oh yeah. So skin conditions they can have psoriasis and as part of that or necrosis, which is I mentioned before, it's nail separation from nail bed. Uh So, um here in this bottom left corner, you see arthritis, Michelin's, which is a complication of psoriatic arthritis. Quick reminder, psoriasis is red, purple or gray plaques on extensive surfaces and there'll be silver skills on top in psoriatic arthritis in general, there will be a recognized episode of uh psoriasis at any point in that person's life psoriatic arthritis common in older patient. So 30 to 50 years, um again, joint swelling, um pain, every female systemic symptoms and skin changes, it's an inflammatory immune mediated condition. It's a seronegative arthritis. So, um you're not expecting to see rheumatoid factor or the CCP antibodies. Um There might be a family history of psoriasis or psoriatic arthritis or uh personal like previous history of psoriasis. And um one thing that people use is the best tool which is uh screens. How likely are people with psoriasis to develop psoriatic arthritis, symptoms and signs morning stiffness once again, any inflammatory arthritis, uh systemic symptoms, fatigue, fever, malaise arthritis, Michelin's usually only seen in very kind of late disease. So it's a result of phalanx osteolysis. Otherwise, it's called a scopic fingers. Um psoriatic plaques. And you're on the body, nail pitting on Nicolosi. This dactylitis enthesitis involvement, conjunctivitis, orienteering TV, ITIS back stiffness, separate colitis, atlanto axial joint issues. Um This is once again, spondylotic pattern, but most likely you're going to see this asymmetrical passy arthritis pattern which is a symmetrical finger and toe involvement as um kind of pointed doing the question investigations. Um X ray will show you para status, ankylosis, osteal isis ductal isis and this Pencillin cup appearance. Here's a diagram for this Pencillin cup appearance. It's caused by periauricular erosions and uh during your uh bone resumption a joint edge. And um if you're taking bloods again to rule out, for example, um skeptical fighters, you will find an elevated E S R N CRP diagnosis clinical, but there's also Casper criteria if you're struggling, although they're technically not diagnostic criteria are research criteria more. So, um the management um so basically medical and say it's to manage symptoms. Glucocorticoid injections are not routinely done because they may worsen the overlying psoriasis, demarte. So methotrexate is first line, but it's more effective for like peripheral symptoms rather than actual. Uh then there's uh flutamide and sulfaSALAzine. Again, biologics, infliximab use the kingdom mob secukinumab tophus in a tip and, and Aricept. I apologize for the pronunciation of this. And um just ago, reminder before you start biologics in adults, um or even kids, it's a good idea to screen for tuberculosis HIV have been kept. See, because biologics are immunosuppressant and they might reactivate one of those infections which you don't want to do um complications. Um Basically, because of the inflammatory process, you might suffer other complications such as cardiac issues and um are Fridays. Mutual ins is a significant cause of disability, right? Another uh lucky patient, 23 male recently treated for chlamydia. Uh So infection sort of resolved uh sudden onset stiffness and then pain and swelling in his left ankle. Those are diffusely swollen, dull ache in his eyes, the eyes are red and he's also having strange urinary symptoms. So, in general, um what is the name of the sign present in the toes? If anyone remembers? I sort of mentioned it around fingers previously in this presentation. The and right uh mentions it. Yeah, Doctor Litis. Thank you, Regina. Once again. And what other classical sign of this condition can you find in the feet in case somebody knows it's absolutely worth a shot, even if you're doubting yourself. So, just feel free to right, right, undermined, which is gonna skip over that. And the classical sign is keratoderma Brenna Rogic. Um And you can see it here in the left lower corner and it's a basic a pustular rash that presents in reactive arthritis, um reactive arthritis, you can remember it very easily by saying, can't see, can't p and can't climb a tree. So it's a sort of try it of arthritis. Um and Carson blennorrhagia. Um so like limp symptoms, urethritis or balanitis. So, uh urinary and genital symptoms and conjunctive itis and anterior uveitis. So I can't see a bit of that. Um It's a certain negative arthritis and it usually falls an infection. So in the history, there'll be like a GI infection or gender urinary or an upper respiratory one even offer physiology is autoimmune associated with HLA B 27. And uh HIV is a risk factor for its symptoms and science. So, yeah, following severe illness, uh there'll be joint pain infusion. Uh usually it's all the arthritis. So only up to four joints. Anything more is poli arthritis. It's asymmetrical usually in the lower limb. And uh once again, mentioning keratoderma blennorrhagia come as a key sign and dactylitis um investigations. So, um you still ask pretty joint just in case it's a septic arthritis. Uh again, because of the onset after infection and diagnosis is made from the classical science and by exclusion uh uh management. Um It is usually self limiting uh treat underlying infection. If you're suspecting that it's still active, you'd give Ansaids and systemic steroids for symptom relief, especially if the joints are interfering with the range of motion of a person. And if there's no resolution within six months, you would consider deem arts and biologics complications, calcaneal spurs, bony outgrowth, spinal abnormalities and disposition to other uh types of arthritis and in general inflammatory stuff, right? Different questions. So 55 female patient look up with a seven out of 10 pain, right to metatarsus, oh uh phalangeal joint and the joint appeal is swollen and arithmetic. This and there's no overlying skin changes, but she has a past medical history of renal stones and diabetes. So, um just to start anyone has any sort of idea what this could be? All right, I think this answers to these questions might kind of real more about it. So, uh a late representation of this would be gout ito fi and uh on joint aspiration, you would expect to find negatively birefringent needle shaped crystals. So yes, by this point, as people are rightfully pointing out, that's definitely gout, thank you for participating in the chat. Your great. Um So gout is a crystal arthropathy. There's crystals of your eight and um a lot of times those will a current background of dehydration and alcohol. And there's an increased incidence with age, but the physiology is high blood uric acid levels and uh discusses urate crystals to be deposited into your joints. Associations. Basically, all of these associations, either introduce more things that break down into uric acid or make a person more dehydrated, uh particularly um left knee in syndrome is one of those where there's uh an impaired pure in breakdown. So they actually have very high uric acid levels in the deposit everywhere, not just the joints, um right symptoms and signs of gout all of time. It will be nocturnal onset, there'll be joint falling, you're a fema and the gentle be hot to touch. Um It can be metatarsophalangeal joint. Um It's quite a common want to be affected. Um There can be Gauci Toaff I which are deposits of crystals under the skin. You can see Toaff I hear on this um right side of the screen, um these patient's are likely to develop renal issues just because of these high uric acid levels they have to go through. Uh so by renal issues and in renal failure or renal calculate, as was mentioned, a question and usually the symptoms developed quite rapidly in an acute episode. So, uh within a few hours and uh the investigations that should be performed our synovial fluid microscopy. So, um that's when you see the needle shapes negatively birefringent crystals. And um you might want to do imaging or blood tests for uric acid. And on the imaging, there'll be two fi and lytic erosions evidence in later disease. So that would be usually X ray, but it's not very useful in diagnosing. For example, a first acute episode, it's only useful um in someone who already has known gout and has a new episode of this joint. And yeah, once again, for diagnosis, exclude septic arthritis. So he has some more uh X ray signs here on the bottom, right? So joint space maintained, but there will be less equations and parched out erosions um management of uh gout for the acute flare. It's colchicine and say it's and um uh glucocorticoids are considered if NSA is incautious in are ineffective. And for future flare prevention, just because um it's not kind of coming out of nowhere. They have this really high uric acid levels, allopurinal or feet books is that the inhibited rate production. So should they should realistically lower those levels and prevent future attacks? And then you would advise this patient on modifying their diet. So for example, uh not like Putin rich foods. Um You tell them to drink more water because dehydration is a big risk factor and then you tell them to, um, kind of increase physical activity and decrease alcohol. Right. The next one is, um, uh, 65 meal, um, episodically painful, right knee. Uh, they come and go but they come on suddenly and last from like three days to 1.5 weeks at a time. And he has a diagnosis of hyperparathyroidism. And what can someone name a differential? There's kind of a hint to it within the next question. Oh yeah, very good. It's pseudo gout original. You're killing me today. Uh and the rest of your concert. So, uh what are key differentials? I don't know how many times I will keep covering this home in this presentation, but it's always good to exclude septic arthritis. And um well, pseudo gout, as you guys say, and um these positively birefringent crystals are calcium pyrophosphate crystals and they're kind of the main picture of pseudo gout. Uh main kind of difference between pseudogout and gout is this um well, different types of crystals. But in gout, you will generally have this elevated level of uric acid in blood. Whereas pseudogout these crystals are usually formed locally. So you won't have them kind of just randomly floating all over the body unless it's quite a severe presentation. So yeah, uh usually presents in ages over 50. They can be idiopathic hereditary or secondary to damage associated with osteoarthritis. Um because there very likely to lead to osteoarthritis and osteoarthritis is also likely to lead to pseudo gout is kind of like a vicious cycle. Um, so these crystals form because um, chondrocytes produced um calcium pyrophosphate and that increased rate. And then this destroyed the cartilage. And once this cartilage is destroyed, this serves as a night is for more crystals to kind of attached to that space and it may be secondary to hyperparathyroidism, hypothyroidism or diabetes. Um, basically any conditions that are likely to mess with calcium phosphorus, um bone um structure or with um kind of joint integrity symptoms. And scientists chondrocalcinosis iss. So you kind of uh that's what sort of pointed out in this X ray in the question. Um That's basically uh ossification of um ligaments and basically anything the position of bone anywhere that's not kind of meant to be bone. Um Sheila got is common in these wrists, elbows, shoulders and ankles. It may affect spinal ligaments and um as always pain, erythema, swelling and reduced range of motions. But this time, it's kind of episodic, it comes and goes. Um almost sort of by it. Self diagnosis is based on imaging and joint aspiration. And um it can actually be a symptomatic as a change in this case, for example, during a hip replacement or sometimes um it will be noticed that the joint has a particularly choky appearance and this chalky thing would be this costume pyrophosphate crystals. Yeah. And um of course, to mention this synovial fluid aspirate uh microscopy and you get this rhomboid weekly positively birefringent crystals which are different from the needle shaped, negatively birefringent crystals of God. And treatment of pseudo gout is nsaids, colchicine and glucocorticoids and the prevention is also colchicine. So, question six this time, it's a 45 female office worker, unpleasant tingling sensation in thumb, middle and index fingers. Uh examination, you see thinner muscle wasting and making a reverse prayer sign brings on the pain. So and here you can see that our muscle wasting on this image. Can someone name uh this um kind of reverse prayer sign test? Yeah, excellent Charlie. Thank you fans. And does anyone know the borders of the relevant anatomical structure? Kind of the one that's underlying this entire issue? Right? That's okay. It's just um the carpal arch and the flexor rednecks. Um I probably visit poorly. See, this is a question about carpal tunnel syndrome. Um uh The key signs are thinner, eminence, muscle wasting and impaired sensation over the median um nerve innovation area which is uh once again uh found middle and index fingers. Uh the rest are owner um buffet physiology, median nerve compression. This can be for inflammation or um convening inflammatory conditions are just like overuse um poor positioning and stuff like this. Um Yeah. And since it's a confined space and inflammation will cause median nerve compression symptoms and science thinner muscle wasting, new lateral numbness or tingling over from indexed middle fingers, central, central palm is usually spared as that's kind of a different branch of the median nerve, which doesn't travel for the cubital tunnel investigations and diagnosis R E M G, which are electro conductive studies, uh C S S A nerve conduction speed. And that was kind of measured by two electrodes. One that sends the current one that measures it and it should have a reduced um speed of current. Uh As Harold mentioned, the fellow maneuver. Uh so it's kind of this reverse person and this should uh was it pain if there is a median nerve compression? And uh Tinel's sign is when um you tap over the median nerve at the wrist. And that also is it's been and it's kind of just a sign that there's inflammation going under uh investigations and diagnosis. Uh It shouldn't say investigations and diagnosis, it should say treatment. Uh The usual ones you consider is nsaids and postural dictation. So all sorts of ergonomic solutions to not further injured at wrist and splinting. Otherwise you can also inject steroids or, and consider surgery uh so quickly just running over a cubital and radial tunnel syndromes, they're not sort of as common. So, in the cubital um tunnel syndrome, there will be hypo thinner wasting. So just um this side uh tingling and numbness over the ring and pinky finger and it's worse when the elbow is bent. And that's because of the, that kind of source um forces the attendants to go tighter mechanically over this um cubital tunnel, radial is uh even a less specific condition. So it's going to be a nonspecific pain close to the lateral epicondyle. And um it's gonna worse on compression of posterior forearm and solution to this again and say it's physio surgery or sterile injections, right? And um kind of a big rheumatology case. You see uh 75 female patient, seven out of 10 painful unilateral left headache, jaw is sore and kind of uh scalp tenderness. And you think there's a reduced uh temporal pulse. So what is the key differential that pops into your mind? Yeah. Amazing. Uh DCA. So Jane sell arthritis and does anyone want to suggest the most appropriate treatment for G C? All right, just gonna move. Uh they should have. Yeah, the most appropriate treatment is high dose steroids. Um How much of a high dose um being off recommends 40 to 60 mg. Um and I'll go a bit into it in a second. So, pathophysiology, it's a particular type of vasculitis. It um causes granulomatous inflammation of arteries. It usually affects external branches of the carotids. So, kind of temporal facial um distribution but can also affect the atomic uh artery, which is a branch of the internal carotids. And that's the one that causes visual symptoms. Um So, risks for these are being aged over 50 and any other systemic inflammatory conditions, especially polymyalgia, rheumatica, uh symptoms are headache, it can be unilateral, bilateral based on the distribution. Um There's gonna be a tender scalp. Um A lot of times old people will kind of discovered upon brushing hair or something, I guess. Uh there'll be a reduced temporal pulse due to this inflammation. You might hear a keratotic brewery consultation and the patient will have a tongue or job in. It's kind of a classification pain. The same way people get like qualification in um heart disease. And yeah, vision changes are assigned that the atomic artery is involved investigations and diagnosis. Um You want to do this basic blood tests. FBC CRPS are LFTs and they will show high CRP, high s are you can do a temporal artery ultrasound and you can even do a temporal artery biopsy. But I think the consensus is um if you have this strong clinical picture, um you should not kind of spend time doing all of these investigations and diagnosis while this patient has a risk of losing their vision. So um I think at the high clinical suspicion, you can go straight for the um urgent rheumatology, referral and oral prednisoLONE. And here's kind of uh different variations of it. So they recommend um uh 60 to 100 if there's visual symptoms. But I think um usually they're very happy with the 40 to 60 mg and um long term. So they'll have to continue on this uh prednisoLONE and uh they are weaned off of it in kind of over multiple kind of weeks and months time and kind of keeping them on prednisoLONE produces the recurrence of the vasculitis. Yeah, and that's the end of my section. Thank you. Hello guys. Thank you very much. Uh Well, sure back form. Um maybe via your email and that's how you guys can get the slides as well if you're feeling the feedback form. 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