Week 11 - Orthopaedics

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mewinstanley@googlemail.com
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131191
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Week 11 - Orthopaedics
Updated:
2012-01-29 08:29:45
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orthopedics
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Ortho, Rheumatology, Bone stuff
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  1. Draw and label a synovial joint
  2. For Rhuematoid Arthritis give
    -Pathology
    -CF
    • Pathology
    • Autoimmune → inflammatory response
    • proliferation of T cells [CD4+]
    • Synovitis → macrophages, T cells & plasma cells
    • Formation of pannus [thickened inflamed synovium] → loss of hyaline cartilage
    • Rice bodies [Fibrin]
    • HLA DR4

    • CF
    • Pain
    • Early morning stiffness
    • small joints & symmetrical
    • Fingers → swan neck deformity
    • Rheumatoid nodules [subcut necrosis w macrophages]
    • [Assoc features, corneal melt, scleritis etc]
  3. What are the systemic effects of RA?
    Lungs → rheumatoid fibrosis, Pleural Effusion

    Heart → pericarditis

    Liver & spleen → hepatosplenomegaly [Feiltys syndrome → neutropenia]

    Kidneys → amyloidosis, Nephrotic syndrome, CKD

    Skin → Erythema nedosum & Pyoderma gangrenosum
  4. What Ix would you do for RA?
    • Xray findings
    • Subluxation & deformity
    • joint space narrowing
    • Juxta-articular erosions
    • Periarticular ostepenia
    • soft tissue swelling

    • Bloods
    • FBC, ESR, CRP, LFTs [Raised CRP]

    • Immunology
    • RF → Ig against Fc of Ig [IgM]
    • Anti-CCP → specific for RF
    • [Anti-cyclic citrulinated protein]
  5. How is RA managed?
    • Pharmacotherapy
    • NSAIDs → inhibit Pg synth decrease inflammation

    DMARDs → Salazopyrin, methotrexate

    Steroids → Intra-articular, IM, PO

    Biologics → Anti-TNF [Infliximab]

    • Surgical
    • Tendon repair
    • Synovectomy
    • Joint Replacement
    • Joint fusion [Arthordesis]
  6. For Psoriatic Arthritis give
    -Hx
    -CF
    -Radiological findings
    • Pt Hx
    • PMH → psoriasis
    • FH → 1st degree relative

    • CF
    • onset 30-50yo
    • Mainly DIPJ
    • Asymetrical oligoarthritis/ Symmetrical polyarthritis
    • Mutilating
    • Sausage digits
    • Enthisitis [tendon swelling, dont give fluoroquinolones]

    • Radiology
    • Sclerotic bone
  7. For spondyloarthropathies give
    -Hx
    -CF
    -Radiology
    • Pt Hx
    • <40yo
    • insiduous onset
    • improve w exercise, no improve w rest
    • pain at night [2am]
    • FH → psoriasis & colitis

    • CF
    • HLA B27
    • Crooked spine
    • ^^inflammation
    • Loss of lumbar lordosis

    • Radiology
    • Chronic spinal changes → sclerosis, syndesmophytes, bridging syndesmophytes [Bamboo spine]
  8. What is the DDx for Inflammatory arthritis?
    • RA
    • OA
    • Crystal arthritis
    • SLE
    • Lyme disease → erosive arthritis
    • AS
    • Reactive arthritis
  9. For septic Arthitis give
    -Pc
    -Likely organisms
    -Ix
    • Pc
    • Painful swollen joint
    • Febrile
    • Loss of function

    • Likely orgs
    • Staph Aureus
    • N. Gonorrhoeaie
    • H. Influenzae [Children]

    • Ix
    • Joint aspirate → C+S
    • B/C
    • FBC → Leukocytosis
  10. For Reactive Arthritis give
    -Definition
    -CF
    -Trigger orgs
    • Reactive Arthritis
    • Sterile synovitis following infection
    • HLA B27 assoc

    • CF
    • Acute symmetricla lower limb arthritis
    • >M;F
    • days - wks after infection
    • Enthesitis, spondylitis & Anteritor Uveitis

    • Trigger orgs
    • Salmonella
    • Shigella
    • Chlamydia Trachomatis
  11. For Gout Give
    -Pathology
    -Ix
    -Mx
    • Pathology
    • excess uric acid → urate crystals in joints/ soft tiss [Tophi]
    • Acute → precipitation in joint → inflammation = pain
    • Chronic → tophi formation, subcut around joints, elbows, fingers & toes

    • Ix
    • Serum urate & U+Es
    • FFine needle aspiration → needle shaped crystals in polarised light

    • Mx
    • ^NSAIDs for pain
    • Allopurinol → Xanthine oxidase inhibitor, dec production
  12. For Pseudogout give
    -Pathology
    -Ix
    -Mx
    • Pathology
    • Calcium phosphate crystal deposition
    • Acute → synovila deposition
    • Chronic → Cartilage & extra-articular cartilage

    • Ix
    • FNA → rhomboid crystals

    • Mx
    • Aspirate to reduce pain & swelling
    • NSAIDs
    • Colchicine
  13. For OA give the
    -Pathology
    -CF
    • Pathology
    • Loss of hyaline cartilage
    • due to; Cartilage composition, excessive loading, abnormal loading, direct damage [trauma/ infection]

    • CF
    • Pain
    • Stiff joint
    • decreased range of movement
    • crepitus
    • joint locking/ instability
    • deformity
  14. What are the non-operative options for OA?
    • Weight loss
    • PT
    • Analgesia
    • Support
    • Splint
  15. What are the surgical options for OA?
    • Joint Replacement
    • Replace bearing side
    • restore joint mechanics [both sides]
    • ^ function, relieve pain

    • Excision Arthorplasty
    • Fibrous union, floppy joint
    • relieve pain, poor function

    • Fusion [Arthrodesis]
    • remove pain & function
    • bail-out
  16. Draw the stages of fracture healing
  17. What are the stages of Secondary healing?
    Natural healing of fractures

    • Reparation phase
    • Cellular movement & proliferation
    • Fibroblasts → chondroblasts → osteoblasts
    • Cartilage → ossified

    • Remodelling
    • Resorption followed by depostion
    • Osteoclasts
  18. What is Primary healing?
    How does it differ from secondary?
    • Reduction & plating of bone
    • Cell-cell aposition

    No callus formation
  19. What is osteoporosis?
    • Low bone mass
    • architectural eterioration of bone
    • w enhanced bone fragility

    Patho → ^osteoclast activity
  20. What fractures are associated with osteoporosis?
    • Distal radius
    • Proximal femur
    • Spine

    • Hip #
    • extracapsular → inter/pertrochanteric, Tx = internal fixation
    • Intracapsular → reduced & internally fixed Avascular necrosis → hemi-arthoplasty
  21. For bisphosphonates give
    -MoA
    -Indications
    -A/E
    -PK/PD
    -WWJD?
    Bisphosphonates e.g. Alendronate, residronate

    • MoA
    • incorporated into bone [calcium hydroxapaptite matrix]
    • ingestion by osteoclasts [reduce osteoclastogenesis, promote apoptosis & disrupt cytoskeleton]

    • Indications
    • postmenopausal osteoporosis
    • osteoporosis in males
    • FRAX >20%
    • Pagets disease

    • A/E
    • Osteonecrosis of jaw
    • Atypical femoral # → unusual appearance

    PK/PD

    • WWJD?
    • TAking sitting up on empty stomach → dyspepsia
  22. Name another drug used in Tx of osteoporosis
    • Strontium ranelate
    • Calcichew
  23. What is the commonest bone tumour?
    • Commonest = Mets from other tumours
    • [Bronchial, BrCa, Prostate, Kidney]

    Commonest primary tumour = Myeloma
  24. What are the CF of a secondary tumour of bone?
    • Often asymptomatic
    • Bone pain/ Destruction
    • Long bones → patho #
    • Spinal mets → vertebral collapse, spinal cord compression, nerve root compression
    • Hypercalcaemia
  25. What is myeloma?
    CF?
    • Myeloma = monoclonal neoplasm of plasma cells
    • solitary or multiple

    • CF
    • Bone lesions → lytic foci [pepperpot skull], general osteopenia
    • Marrow Replacement → anaemia, infections & bleeding
    • Renal impairment → precipitated paraprotein = nephrotoxic
  26. Name 2 malignant tumours of bone?
    Osteosarcoma → 10-25yo ^^malignant, early mets

    Chondrosarcoma → >45 M:F 2:1

    Ewings sarcoma → 5-15yo, dia/metaphysis of longbones, 11-22 translocation
  27. Name 3 benign tumours of bone?
    Osteoid osteoma → small, benign osteoblastic proliferation

    Endochondroma → benign proliferation of cartlage, hands & feet

    Giant cell tumour
  28. What is pagets disease?
    -Patho?
    -CF
    Disorder of excessive breakdown & formation of bone

    • Patho
    • ^osteoclasts
    • ^^bone formation → structurally weak
    • disorganised architecture

    • CF
    • Bowed tibia
    • Lytic moth eaten cortex
    • bone pain
    • Patho #
    • OA
    • Deafness → CN8 compression
    • Spinal cord compression
    • ^CO → vascular bone → cardiac failre
  29. What are the Ix for Pagets?
    Radiology → lytic lesions & new formed bone

    Bone scan → extent of disease

    • Bloods → Ca, Phos & PTH normal
    • Alk Phos = variable
  30. What are the blood results of osteoporosis?
    • Ca normal
    • Phos normal
    • Alk Phos Variable
    • PTH normal
  31. What are te blood results of osteopetrosis?
    • Ca normal
    • Phos Normal
    • Alk Phos → Elevated
    • PTH normal
  32. What are the blood results of osteomalacia & rickets?
    • Ca → decreased
    • Phos → decreased
    • Alk Phos → Variable
    • PTH → Elevated

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