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Disease Inflammation Osteoarthritis Primary Secondary (<50yrs Trauma, metabolic, Congen, joint inflam, occupation) Idiopathic Rheumatoid Arthritis Morning stiffnes > 1hr Arhtritis/Swelling in 3 joints Symmetrical swelling Radiological changes +ve Rheumatoid factor Connective Tissue Disorders SLE, Scleroderma, Polymyositis, RA Aetiology Pathology Imuuno & nonimmuno, mediators, Eicosanoids (prostaglandins, thromboxanes, leukotrienes), histamine, Platelet activating factor (PAF), cytokines F>M, 80%>75yrs (exponential ↑ after 50yrs), Not a degenerative dis, joint load, ageing of connective tissue, genetic predispose, uncommon in black/asian, obesity, occupation (farmers, footballers, miners) Inflammatory arthritis, F>M, HLA class 2 DR4/DR1, Chippewa/Pina Indians, less in Asian/Black, any age peak 40-60, FHx, Typically a slow progressing, symmetrical, peripheral polyarthritis Vascular – vasodilatation, ↑permeability, exudation Cellular – mediators from mast cells, aggregates of WBC, phagocytosis Rubor, swelling, pain, heat, itching focal cartilage lost, subchondral bone repair ↓articular cart→alter subchondral bone, F>M, Multisystem, immunologicall (autoantibodies) chondrocytes>IL-1, TNFa>matrix degrading enzymes (metalloproteinase) & ↓collagen synth, (also IL6, PGs) Synovitis, RhFa (Abs) from plasma cells, synovial thick, folds, ↑plasia polymorphs, vascular proliferation & permeability→effusion, ↓cartilage→bone exposed, cytokines B cell pathway (RFs, Immune complex, PGs, complement, T Cell Pathway lymphs/phages, cytokines, interleukins Autoantibodies – direct effect, immune complex, prothrombot, Signs Investigations Treatment B Lymphs – inactivate pathogens, ↑complement, ↑phagocytosis T Lymphs – Cytotoxic CD8, Inflammatory CD4 (cytokines etc) COX 1 – produces prostaglandins, vasc homeostasis COX 2 – inflammation Acute – PGE2, PGI2 from local tissues, PGD2 from masr cells Chronic – PGE2 from monocytes & phages NSAIDS, CCS, Anti TNFα (Entanercept), Infliximab, Eburnation (bone smoothing), sclerosis of subchondral plate, hypomineralised bone, 60% ↑ trabecular volume Osteophyte outgrowths, subchondral bone cysts, rice bodies (bone in joint space) Synovium hypertrophy, fibrosed capsule, contracted ligaments, muscle wasting, bone/cartilage loosens, pain (non local, at rest), stiffness (after inactivity, weather), Examin - Crepitus on movement, Swelling (Heberden, Bouchards nodes). Deformity (subluxation, contracture), muscle wasting, Lab test are normal, no systemic features Comps – DVT, PE, inf, fracture, vessel damage, dislocation Radiology MRI XRay (look for cysts, rice bodies, sclerosis, joint space narrowing) No cure, treat symps, NSAIDs, CCS, hyaluronic acid derives, glucosamine/chondroitin (foods), OT, physio, WL, heat, surgery (soft tissue, osteotomy, arthrodesis/fusion, arthroplasty Spondylosis = OA of spine Hallux rigidis – OA of 1st MTP Chronic condition of synovial joints All joint tissues involved (bone, cartilage, synovium etc) Local (single joint) General (many) B pathway → Vasculitis, Inflam, Erosion Tpathway→Erosion Bursa swelling, tendon sheath swelling, morning/inactivity stiffness, FHx, Anaemia (malaise), subcut nodules (fingers, forearm extensors) Spindling (PIPJ swell), Toe clawing, Callous forming on feet, MTP swell, MCP joint sublux, Caplans syndrome (nodules + alveolitis), fever (T cell pathway IL-1) Bloods - ↑ESR, ↑CRP, ↑RhFa, XRays (soft tissue in early stages), Aspiration of joint (cloudy due to WBCs) DDx – OA, viral arthritis, connective tissue dis, NSAIDS (indomethacin, sulindac, aspirin) Comps – keratoconjunctivitis, carpal tunnel, Cysts, tendon rupt, vasculitis, sublux, muscle wasting, pericarditis, anaemia, leg ulcers, amyloidosis, alveolitis Sjogrens/Sicca Syndrome = dry eyes(keratojunctivits sicca) without RA or autoimmune dis, HLA B8/DR3, dry mouth, skin, vagina, salivary/parotid glands enlarged Raynauds, arthralgia, dysphagia, vasculitis, thyroid dis, pulm fibrosis, lymphadenopathy NSAIDS, Disease Modifying Anti Rheumatic Drugs DMARDS (cytokine inhibition, slow acting), Sulfasalazine/5ASA, Methotrexate, leflunamide (all DMARDS), Anti TNFa, etanercept, infliximab (with methotrexate), CCS, surgery, aza, cyclosporin (less common) Schirmer tear test (filter paper in eyelid), Rose Bengal stain (of eyes shows keratitis), ↑Ig, RhFa, Complexes, Auto Abs, (ANA, AMA) Cytokines (interferon, inteleukins) Symptoms Notes Treat with artificial tears and saliva replacement Disease Aetiology Investigations Treatment Systemic Lupus Erythematosus F>M 10:1, Peak 2040yrs, Genetic predispose, HLA DR3/DR2, Premenopausal women, drugs isoniazid, methyldopa, hydralazine F>M 3:1, Peak 3050yrs, genetic, environmental (silica, vinyl cl, rapeseed oil) drugs (bleomycin), Loss of self tolerance, B cell activation→IgG, against nucleus, cytoplasm and membranes, immune complexes form & not removed, ↓ T cell regulation, ↑cytokines IL-1/2 Autoantibodies, vascular damage, fibrosis, cytokines→fibroblasts ↑collagen, Rash (malar & discoid), fibrinoid in blood vessels, haematoxylin bodies (ANAs + Nuclei), Arhtralgia* (symmetrical) but joints appear normal, Widespread vasculitis, fever, malaise, ↑ESR but CRP↔, ANA*, Anti dsDNA Abs (Against RNA), ↑RhFa, ↑IgG/M, CT brain (infarcts), MR white matter ↓cardiovasc RFs, ↓sunlight, NSAIDs, CCS, Prognosis 90% 10yr survival (disease established in this time unlikely, unlikely to become more serious >10yrs) Raynauds (~100%), Sclerodactyly (Tight skin/finger flexion deformity), Small mouth (microstomia), Digital ulcers, Pulm HT (15%) FBC (anaemia), U&Es, Autoantibodies LCS (ACA Abs) DCS(Antitopoisomerase) ↑RhFa, ANA (70%), Proteinuria, CXR, Barium swallow, CT (fibrotic lung) No cure, Organ based treatmetnt, Skin lubricants, PPi, Vasodilators for Raynauds (CCBs, ACEi), Nutrition&Antibs (Malabs), control HT (renal dis) HLA B8 DR3, CoxSB. Rubella, Flu, Malignancy Rash (Purple/Heliotrope over eyelids, red over hands), Malaise, WL Proximal muscle weakness/Wasting (Pelvic/Shoulder) also respiratory and oesophageal if severe, WL, Anorexia, Malaise, Anaemia, Codmans triangle (New bone raises periosteum above bone) ↑CK, ↑ESR, ↑RhFa, EMG, MRI, Biopsy, Myositis Specific Antibodies (Abs to Jo1/tRNA synthetases) Prednisolone, Methotrexate, Aza, Ciclosporin, IV Immunoglobulin Also FBC, ESR, CRP. LFTs (mets), Plasma Protein Electropharesis (Igs Myeloma) XRay (destruct/periosteum), CXR (1O dis mets to chest), MRI*, CT, Isotope bone scan (99Tc), Angiography, Bloods, Biopsy, ↑AlkP, ↑Ca2+, Prostate Specific Antigen PSA, Warmth over swelling + venous congestion = active. Mirels scoring syst for fract. Rarely unite after fract ie prevent (Early chemo/DXT, fixation if lytic+pain or cortical destruction>50%, bone cement) 9000 women with breast ca develop 2Os/year Multisystemic inflammation Systemic Sclerosis Limited Cutaneous Scleroderma/CREST Pathology Diffuse Cutaneous Scleroderma Polymyositis Muscle Inflammation Dermatomyositis (if skin is involved) Bone Tumours Bone (Osteoma, Osteoblastoma, Osteosarcomam) Cartilage (Echondroma, Osteochondroma, Chondrosarcomam) Fibrous (Fibroma, Fibrosarcomam, Malignant Fibrous Histiocytomam MFH) Metastatic Bone Cancer Vertebrae>Femur> Pelvis>Ribs>Sternum >Skull Benign common, malignant rare, common site of metastases bronchial, breast, prostate(>50yrs mets til proven otherwise) Breast1, Lung2, Prostate3, Kidney4, Thyroid5, GI Tract6, Melanoma7, Osteolytic (bone resorption), or Osteosclerotic(↑bone formation/hardening) Invasion of stromal cella→↑press release of lytic enzs→lymphatic/vessel invasion→tumour emboli→mets (Red marrow bones only rare below knee/elbow) Signs Red marrow bones – Sinusoidal vessels + large gaps, ↓endothelial resist, fatty marrow has no sinusoids Symptoms DCS – Oedema, heartburn, dysphagia, anal incontinence, renal dis, myocardial fibrosis, malabs, Arthralgia, Pulm Dis, Dysphagia, Raynauds Pain (deep ache), Loss of function (limp, stiff back), Swelling (end of bone), Fracture, Joint effusion, Deformity (scoliosis, torticolis), Neurovascular effect, Systemic effect Batesons plexus around vertebrae has no valves easy spread DDx – Stress fracture, Osteomyelitis, cellulites, septic arthritis Surgery, Chemo, Radio ↑Ca2+ (N&V, Anorexia, Malaise, Confusion, Coma) Particularly in Breat and Squamous Cell Lung Ca Notes DDx RA Lung 50%, heart 25%, kidneys, eyes, GI tract and nervous system may be involved SLE unlikely if no ANA CREST syndrome Calcinosis Raynauds Esophageal Sclerodactyly Telangiectasia (small dilated surface vessels) Disease Soft Tissue Tumours Vascular (Haemangioma, Angiosarcomam) Adipose (Lipoma, Liposarcomam) Marrow (Ewings Sarcomam, Lymphomam, Myelomam) Osteomalacia Rickets in children Aetiology Pathology Suspicion - Deep to fascia, >5cm, Hard, Rapid growth, non Tender but deep ache Bone destruction – 1 Haem tums (activate osteoclasts via OAF), 2 Bronchial tums + 2Os (direct effect/solid tum, monocytes) 3 Solid tum no 2Os (↑Ca2+ from gut, ↓VitD3 needs PGE2) Abnormal Phosphatonin (PHEX gene mute, X-link, or FGF23 mute/AD) ↓VitD, ↓Sunlight, Poor diet, Rickets without hypercalcuria Fanconis synd (PO3 wasting, renal tubule dysfunc), ↑Al3+ ingestion (eg antacids, prevents PO4 uptake), Pagets Disease M>F 3:2, Peak 60Osteitis Deformans 70yrs, mostly sporadic, Gene AD (sequestersome p62/NFKB or osteoprotegerin OPG), Paramyxoviruses, Seronegative Spondylo arthropathies Ankylosing Spondylitis Spine Inflam, young adults, M>F 3:1, milder in women (men more likely to show symps), lymphocyte/plasma cell infiltrates, bone erosion at site of ligaments which heals with new bone RhFa-ve, HLA B27+ve more susceptible ↓Mineralization (osteoid), ratio of mineralization to matrix is reduced Signs Symptoms Investigations Treatment Notes Asymp, Bone pain (worse of weight bear), Bone tenderness, Prox muscle weak (no atrophy), waddling gate, cant rise from chair, XRay (osteopenia, cortical thin, Loosers zones, Ricketty Rosary), Isotope scan, ↑AlkP (due to osteoblasts), ↓PO4 (due to ↑PTH), ↓serum hydroxy vitD, Biopsy (Iliac crest), Loosers= linear ares of ↓dense with sclerotic borders Bisphosphonates – Etidronate (SE=mineral defects), Pamidronate (SE=Febrile react), Risedronate (SE=GI irritation), Calciton (SE=Flush, N&V), Surgery Reiters Syndrome Clinical triad (reactive arthritis, urethritis and conjunctivitis) nail dystrophy, keratoderma blenorrhagica (red plaques/pustules on feet/hands), oral ulcers, fever, Circinate balanitis (skin inflam of penis) ↓VitDabsorp/metab, 1O (↓sun light, housebound, diet, Asian immigrants) 2O (anticonvulsants (phenytoin & Phenobarbital), coeliac, Crohn’s, Pancreat dis, Chronic renal failure) Comps (cn8 compressed/deaf, increased bone blood flow→cardiac hypertrophy, fractures, nerve root compression, cn palsies Hereditary Multiple Exostoses Gene AD, Cartilage capped bony growths near physes, Sessile or pedunculated, Pain, LoF, Cap similar to growth plate, benign Rickets+Hypercalcuria Dents dis (X-Linked, Clchannel mute) HHRH – Hereditary Hypophosphatemic Ricket +Hypercalcuria (Na+/PO4 IIc cotransporter mute) ↑resorption→↑new bone form (exceeding resorp) Single bone Monostotic or many Polystotic Axial skeleton, long bones and skull commonly affected, ↑bone temp Asymp*, Bone pain at night, joint pain (2O OA), bowed tibia, XRay, 99TC labelled bisphophonate Bone Scintigraphy, ↑AlkP (normal Ca2+ & PO4), (syndesmophyte), sacroiliac inflam, back pain, morning stiff, night pain, relieved by exercise, Schoebers test for spinal stiff, ↑ESR, ↑CRP, XRay, Early diagnosis & exercise to prevent syndesmops, NSAIDS, CCS, Extra articular features, 5As (Anterior Uveitis, IgA nephropathy, Apical Pulmonary Fibrosis, Aortic Valve Regurg, Amyloid) Enthesopathy inflame of entheses (ligament attachment to bone), plantar fasciitis, tennis elbow, Achilles tendonitis, Psoriatic Arthritis M=F, Peak 30-50yrs 5-10% of psorias px CD4+ lymphs cause lesions (release cytokines IL-1, TNFB, Interfer), DIPJ arthritis + dactylitis (sausage finger) + tendinitis or serove polyarthritis (like RA), CCS, NSAIDs Anti TNFa eg Etanercept (severe) Reactive Arthritis Sterile synovitis, follows inf eg STI, M>F, HLA B27+ve more at risk, Salmonella Typh, Camp Jej, Shigella, Yersinia Treat cause, Calcitriol (renal), Ca2+ 1g pd or Ergocalciderol/VitD2 (VitD deficient) Disease Soft Tissue Rheumatism Housemaids Knee Tennis Elbow Tenosynovitis Finger flexors inflam, repetive use, trigger finger, tendons run under sheaths and loops, Ultrasound may alleviate pain Fibromyalgia Fibrositis syndrome Chronic Widespread Pain CWP Psychological Bone Infection Acute Osteomyelitis Chronic Osteomyelitis Aetiology Pathology Signs Symptoms Inflam of ligaments/ Tendons, Back, shoulder, neck, elbow, hip Neck (Spasm, tension headaches, rad→occiput, spondylosis, physio, analgesics, Shoulder (shallow joint, humor head held by cuffs, neck pain rad→shoulder, RA, spodyloarth, surgery pain DeQuervains Tenosynovitis Tender at radial styloid (EPB & APL), worse on thumb flex, +ve Finkelsteins (thumb in closed fist ulnar deviate – pain) Trigger points, tenderness is not all over, middle aged women, associated with other disease (chronic fatigue, irritable bowel, PMS) Trochantyeric Bursitis Trauma, bad exercise, pain going upstairs/abdu Tender to lie on, Inject CCS Frozen Shoulder (DM, 40-60yrs, Freezing/ Frozen/ Thawing phases, 3yr resolution, active/passive moves restricted, F=M, R=L, deltoids waste, associated with DM, trauma, antiepilepts, ↑lipids, Medial Knee Pain More common, ligament, Anserine bursitis, obese women Rotator C/ Calcific Tendonitis (pain on abduct/elevate, worse mid move/ Painful arc synd, worse at night, traps spasm, scap rotates earlier, self limit (calc=chem. Irritate) Anterior Knee Pain Avoid heels, infrapatellar bursitis, swell, inject CCS Treatment Notes Torn Rotator Cuff RA, trauma/fall on outstretched hand, ↓abduction, osteophytes may form, shoulder impingement synd (pain & creps) Investigations Xray, MRI, Rest, Physio, Inject CCS (never into tendon) Elbow compound synovial joint, 4 muscle group, Flexor Pronators, Extensors Supinators. Epicondylitis Tennis (lateral more common), golf (medial), rest, ice, physio, compression strap, inject CCS Plantar Fasciitis Enthesitis, MTP dorsiflex on walk →plantar fascia to tighten→ ↑longitude arch, F>M 2:1, microtears on fascia pain at heel Compartment Syn Ant Tib (severe shin pain, foot drop, surgical decompression to prevent muscle necrosis Chronic Compartment Syn Pain in lower leg, worse on exercise sleep disturbances Widespread, unremitting, aching discomfort 90% Staph, H inf, Salmonella, strep, pseudo, E Coli, Haematogenous (via blood/bacteraemia), children, Boys>girls, boils etc, IVDAs, femur, tibia, humerus, hip, radial head, may proceed to chronic Follows acute, postop, DM, IVDAs, ↓immuno, Staph, E.Coli, Strep, Proteus Starts metaphysis (via Hunter Circle), Vascular stasis end arteries (thromb & congest), inflam, bone necrosis (sequestrum), new bone form (involucrum), granulation Fever, tachycardia, malaise, N&V, old, DM, immunocompromised, Brodies abscess (in cancellous bone) Severe pain (worse on weight bear), toxaemia, backache, Comps – septic, fracture, septic arthritis, Exam (Temp, pulse), ↑WCC, ↑ESR, ↑CRP, Cults, Biopsy, XRay, 99Tc bone scan, Labellew White Cell Scan (In111), MRI Rest, Splinter, Analgesics, Antibs (4-6weeks IV/oral) Fluclox, PenG, Eryth, (Rifampicin & isoniazid for MB) Surgery, debride, DDx – Cellulitis, Necrotising fasciitis, Gas gangrene, Toxic shock, Septic arthritis, tumour, inflam arthritis, Repeated breakdown of healed wounds, discharging sinus fixed to bone with sequestrum with infected gran tissue & involucrum Cavities/Sinuse, Sequestra, Cloacae, Involucrum, chronic inflam, Comps – abscess, growth defect, fracture, epithelioma, amyloidosis, As above Long term antibs, gentamicin cement, collatamp (gentamicin sponge), amputation, surgery, reconstruction, “Time bomb” Analgesics, NSAIDs, Acupuncture, reverse sleep problems (with antidepressants eg amitryptilin) Disease Pathology Signs Symptoms Septic Arthritis Intra articular injury, eruption of bone abscess, haematogenous spread, Staph, E.Coli, Strep, H. Inf, 20% > 1 joint, Synovitis, purulent joint effusion, cartilage attacked by bact toxin, destruction of cartilage, Hot, red, swell, agony, held immobile by muscle spasm DDx – Osteomyleitis, Trauma, Haemophilia, RhF, Gout Aspirate/Cultures, Gram stain, look for O2-, ↑WCC, ↑ESR, ↑CRP, XRay, US Antibs (3-4weeks), surgical drain/lavage, joint replaced, joint destruct in days so start antibs asap (IV fluclox+gent) similar to osteomyelitis but in joint capsule, Medical 999 in young Comps – OA, fusion, Tuberculosis Arthritis 1% TB sufferers, 1O in children, in adults haematogenous from renal or lung, MTB, atypical bact, Synovium, vertebral disk, caseating granulomas, cart/ Bone destruct, Poncet’s dis (Polyarthritis), night sweats, anorexic, fever, WL, deformity, ankylosis (joint stiff), joint swell, Dowagers lump (Kyphosis), muscle wasting 50% spine, 30% hip/knee, other organs involve (early vascular, chronic avascular) Exam (Single joint, synovial thick, muscle waste )Cults, AAFB, ZN, CXR, MRI (spine), +ve Mantoux test, ↑ESR, urine cults, Rifampicin, isoniazid, ethambutol, DDx – synovitis, monoarticular RA, haemorrhagic arthritis, Gout & Hyperuricaemia Inflam arthritis + ↑uric acid, M>F 10:1, peak 4050yrs, rare in women<50, may be precipitated by too much food and drink or dehydration ↓Uric clearance (chronic renal dis, diuretics, HT, ↓thyroid, G6Pase deficient, alco, cyclosporin, Down’s.)↑Uric prod (↑purines, ↓HGPRT, ↑PRPP, CHO store dis) Heavy menstruating girls unaffected, Tophi (accumulation of uric) Asymp, pain/agony, 1st MTP swell,/red, Comps – crystal cellulites Do not treat if asymp! Wait til after acute attack to ↓uric, prophylax NSAIDs & 4weeks after Joint fluid microscopy, Serum urate (>600), Urea & Creatine (renal), No NSAIDs if renal dis (Colchicine, CCS instead), diet control, allopurinol (xanthine ox inhib), uricosurics (losartan, sulphinpyrazone) uric cleared by distal tubule (reabsorption blocked by aspirin) normally big toe polyarticular is unlikely F>M 2:1, Peak >70yrs, Sudden onset shoulder/pelvic stiffness, malaise, WL, fever, anaemia, Arthralgia, pain, ↑ESR (>45 often100) Achilles Tendon Giant cell arteritis (temporal artery) F>M 3:1, Headache, tender, vis disturb, jaw claudication (cramp), anaemia, ↑ESR (>45 often100) PMR, GCA and ↑ESR anaemia all associated Temporal artery biopsy, US, ↑ESR, 50% of GCA Px have PMR 20% of PMR may have GCA PMR 15mg pred, GCA 40mg Pred (80 if vis disturb), gradually decrease, CCS sparers (aza, methotrex) PMR dramatic onset, dramatic response to CCS “Polymyalgia dramitica” Push off with weight bear foor with knee ext (53%) eg jump, sprint start, unexpected dorsiflex (17%), violent dorsiflex (10%) eg fall, M>F 2:1, peak 30-40 & >60, ↑occur, cast, ↑rerupt Musculotendin Tear eg med head of Tract Apophysit OsgoodSchattlers Laceration finger gastrocnemius/ junct with achilles, plantaris synd, partial tear Enthesiopathy Usually at muscle origin not insertion, eg tennis elbow, patellar tendon insertion into ant tib tuberosity, teenage boys Mallet Finger (Avulsion) ext tend insert dorsum of dist phalanx=force flexion (end of finger droops) Tendon Healing Initiated fibroblast & macros, 3 phases (inflam, fibroblastic/ collagen form, remodel), weak at 7-10days, most strength back 34weeks, early movement → ↓adehesons & ↑heal & strength >420umol/L men >360umol/L women Polymyalgia Rheumatica Tendon Injuries Degen, inflam, enthesiopathy, traction apophysitis, intrasubstance tear (rupt),musculotendinous tear, ischaemia, laceration, nodules, avulsion (fract at tendon) Aetiology intrasubstance mucoid degen, swell, pain, tender, asymp, precursor to rupt? Rupture palp /tender gap, +Simmonds (lie face down squeez calf-no plantflex) NB DDx with pseudogout (chondrocalcinosis of knee) Investigations Losartan good for HT Px with diuretics NSAIDs indomethacin, naproxen, diclofenac flexors (FDP, FDS), M>F, young adults, zones 1-5 (begin at DIPJ move prox), 2=bad prognosis, 3=palm, suture/ Kessler techniq, partila tears <60% no repair needed Treatment Notes Crush Ischaemia eg EPL rupt after Colles fract, minimal displacement, 6weeks after injury when cast removed Disease Aetiology Pathology Signs Hiltons Law nerve Neurapraxia trans Axonotmesis compress, trauma (direct/indirect), Seddons classificatio (neurapraxia, axonotmesis, neurotmesis), UMN vs LMN, gives branch to joint it crosses & skin, Compression or entrapment, eg slipped disc, carpal tun, Mortons neuroma (3rd toe) motor paralys (ischaem, demylin) No disrupt to sheath or nerve, ↓conduct, blunt trauma, stretch 8%, Heals in weeksmonths, mildest nerve inj More severe, axon disrupt,sheath intact, stretch 15%, crush, direct blow, Wallerian, recovery sensory better than motor, recov weeksyrs Hand Conditions Dupuytrens Cont surgery, radiotherapy, aponeurotomy, Garrods Nodes Golf players, F>M 3:1, filled with fluid similar to synovium, thickening of nuckle pads Ganglion Carpal Tunnel Syn Cyst Joint cyst, wrist & fingers, 80% scapho-lunate, bodybuilders, waiters, tennis and Numb, tingle, night pain, clumsy, median nerve distribution peak >40yrs, Tinels+ve (tap nervetingle), use splint to dorsiflex wrist→ Most common fract in carpus, 80% at waist, risk of non union or avascular necrosis if in prox 1/3, pain in snuff box Hallux Valgus big toe Hallux Rigidus Lisfranc’s Fracture OA MTPJ, Xray (↓joint space, subchondral sclerosis and cysts, osteophytes), Metatarsalgia pain at head, callous form, treat with cushioned insoles Pes Cavus/ High Arches Diabetic Foot PVD, turn into other toes, painful bunion, metatarsalgia, overriding toes, shoes don’t fit, Xray (metatarsal adducts 18O & phalanx abducts 31O relative) neuropathy, inf osteoporosis, 10-15% develop ulcers, ischaemia→necrosis, Tarsal-metatarsal joint (cuboid+cuneiforms), synovial, limited sliding, falls, twists, 5th MetaTars Commonly fractured, Lisfrancs ligament also affected, slow to heal 80% will suffer in their life time 1% NHS expend, not a result of walking upright, Nerve Root Pain Spinal Claudicat Postional, activity may help, back pain worse than leg pain, leg pain is diffuse ie only in thigh Leg pain worse than back, in nerve distrib, root tensie/ compress signs, cauda equina synd, self limit (90%), 2weeks rest, strong analgesia, refer to hospital after 6weeks DDx vasular claud, bilateral, several mins to ease after stop walk, worse on hill (spinal canal shorter on extend) Serious Path rare, Non mechanic, Hx malig, ↑ESR, limited spinal movement Bone becomes sclerotic, osteophytes around vertebra, L4-S1 common, Schmorls node (protrusion through Vertebral endplate into next vertebra vis on Xray), asymp, Pain, stiff, disc prolapse, spinal stenosis, Spondylolisthesis (ant displace relative to vertebra below) Cauda Equina Sy Nerve Injury Foot Conditions Back Pain pain* 1 Mechanical 2 Nerve root pain 3 Serious Pathology may also be psychogenic Lumb Spondylosis Intervertebral disc, gel breaks down, shrinks, ↓compliance, fissures on fibrous layer, ↓hydrate vis on MRI, circumferential bulge, Nodular hypertrophy Of palm fascia, ring/ little finger common, F>M 10:1, middle aged men, familial, fibroblasts, alco, phenytoin, smoke, liver dis, DM, caucasians, Simple/Mechanical metatarsalgia, Clawed toes, familial, bilateral, Flat Feet/ Pes Planus joint laxity, knock knee, polio, tendon rupt, flex or mobile, LoF of ns below conus, central disc prolapse*, abscess, tumour, paraplegia, urinary retent, leg pain (bilateral), Symptoms Investigations Neurotmesis nerve division, laceration/avulsion, no recovery unless suture, chance of miswiring as sheat disrupt, Wallerian Degen Alleviates pain, can cure & is diagnostic, inject CCS, PRAGMATIC Ulnar Collateral Lig Inj of Thumb MCPJ Scaphoid Fracture Calcaneal Fracture Falls, assoc hip, pelvic, spine injuries, extra/intr articular, Lover’s or Don Juan fracture distal to trauma, begins in 24hrs, ↓axon skele, ↓axon membrane, ↑macros, neurolemma not disrupt, if new nerve sprouts can reach neurolemma nerve may regen (ie no scar tissue) Gamekeepers thumb (overuse attrition rupt) Skiers thumb (trauma to thum), avulsion fract, Claw Hand low ulna nerve lesion, sparing of nerve supply to ulna side of FDP Mechanical (spondylolysis) Inflam (RA, Ank Spond) Inf (TB, bact osteomyelitis, abscess) Malig (myeloma, bone tumour) Bone Dis (Pagets, Osteoporosis, Osteomalacia) Exam (leg/back pain worse, alleviating/ aggrevate fact, age, sex, FHx, look for AAA, DU, hepatomega, scars, erythema, deformity, swell) Measure lumbspine movement (Schober test), Nerve root tense signs (sciatic & femoral ↓ankle reflex, saddle anasthesia, ↓bladder control, surgical decompression within 48hrs, Acute Disc Prolapse Ant/lateral tilt on stand, Severe unilateral Pain→rad to bum, muscle spasm, numb, parasthesia, scoliosis posteriorlateral prolapse, Lifting, twisting, Treatment Notes Sprouts develop after 1month, grow 1mm pd, pain is 1st to recover, more prox inj takes longer to heal, also depends on pure or mixed nerve (sense + motor), PNS much quicker than CNS If severe, lesion at wrist (dorsoulnar sense spared) if mild, lesion at elbow (dorsoulnar sense lost) Osteoarthritis Effects DIPJ and CMC, night pain or on use (active or passive), crepitus, Tinels Sign can Stretch), Exam (muscle tone, power, waste, reflexes), ESR & FBC (if malig suspect), Xray, CT, MRI (soft tissue and if neurological signs), bed rest is bad for backs, analgesia, physio, cauda equina is surgical emergency, ↓Weight Neuro signs in one leg only, straight leg+ve(>30O), perianal sense loss, bed rest 3days (semi erect for Lumbar, flat for lower lesions), analgesia, muscle Less likely if exercise a lot, 3x if weight >40lbs, ↑LBP if smoke, 3x if drive for 50% of day, May have systemic symps (Fever, WL, anorexia), monitor recovery, (tap over site and parasthesia will be felt as distally as regen has progressed Xray (↓joint space, subchondral sclerosis and cysts, osteophytes) Relaxants, physio, epidural, if bladder or anal sphincer symps→ surgical emergency Disease Aetiology Pathology Spinal Canal Stenos worse on walk, better on rest, DDx form periph art claud (no periph pulses), leg pain (bilateral), bending forward helps (opens canal), surgery Spondylolisthesis Teenagers, vertebral slip, with without injury low back pain, Osteoporotic Crush Fracture Dislocation Clavicle Fracture Most commonly dislocated joint (45%), anterior dislocation 98%, manipulation, physio, comps – recurrent, axiallary n injury, brachial plex inj, Middle 1/3 80%, lateral 15%, majority reunite, figure of 8 bandage, broad arm sling, 87% fall onto shoulder, Calcific Tendonitis/ Prog ↓disc height, OA facet joints, osteophytes, ↑size ligamentun flavum, pain & Parasthesia in root distibut, Shoulder Pain/ Injury Knee Pain/ Injury Torn Meniscus Common in sports, inflam arthritis and OA (Never surgery for adolescent) Twists, med/lat pain, dramatic swell within a few hours, pop or crack affected side tender, feel click, large tear →knee locks, ice, MRI, arthroscopic repair, quads exercises, may be recurrent Hip Pain/ Injury OA commonest cause Osteoporosis F>M, hip, wrist & spine commonly affected, postmenopause (↓oest), VitD deficient, hyperparathyroid, genetic predispose, CCS, diet, immobile Bone Mineral Density BMD>2.5 standard deviations below young adult mean of pain >50yrs, pain on stand & walk, stiff Bursitis/Tendonopathy Trauma, poor exercise, pain upstairs & abduct, tender to sleep on, inject CCS, Analgesia, tubigrip, crutches ACL Tear stabilizes in ext, twist with planted foot, pop, haemarthrosis (bleed in joint), lock knee, wobbly knee, physio/ rehab, 1/3 surgery Signs Asymp, pain→rad ribs and abdom, repeated fract→Kyphosis, loss of ant vertebral height/ wedging, bed rest, analgesia, CaPO4 deposits vis on Xray, leads to ischaemia, usually prox to great tuber, ↓movement, hot & swell, DDx gout, pseudgout, arhtritis, Inject CCS, F>M, R>L, ,iddle age, severe pain, ant drawer test, Lachmans test, pivot-shift test, MRI, Med/Collateral Ligaments Valgus force (away), PellegriniSteida lesion (calcification), 3 stages Symptoms Investigations Forrestiers Dis Fibrotic Nodulosis Bony overgrowths, ligamentous ossification, stiff spine, , dramatic Xray changes, patella & feet affected, NSAIDs, exercise Uni/bilateral back pain →rad buttock & post thigh, nodules only relevant if tender, trauma, inject CCS Xray, US, MRI, analgesics, NSAIDs, CCS inject, physio, AC Joint Trauma 1 tender (no opening) 2 Opens on flex 3 Opens on ext 1&2 physio, 3 rheab/ brace, Lateral Ligament Less common, less nice, varus force, bony avulsions, brace & rehab, most require surgery PCL Tear foot fixed 50% of Px are athletes Xray (AP view, Zanca 15O cephalic tilt, stress view with weights), Type I & II broad sling, Type III debatable, Type IV-VI surgery hyperextend, or tibial retropulsion, post tibial sag, post drawer test, Ext Mechanisn Injury Quads or patella tendon rupt, always test SLR, pain, can not walk, swell, paplable defect, MRI, US, always surgery, high recurrence, Femoral Neck Fract Fall, pain in groin & thigh, short ext rotated leg, Xray, review for osteoporosis Avascular Necrosis Severe pain, bone scintography or MRI, causes (CCS, heparin or ↑press ie divers, alco), Inflam Arthritis Pain in groin, stiff, worse in morn, ankylos spond & sero-ves can cause it Crush Syndrome ↓bone dense/ strength→↑fract, microarchitect disrupt, resorption>formation 1g Ca2+ daily, musc relax (pain), SubCut calcitonin (pain), VitD, exercise, ↓smoke, physio, TENS transcut elec nerve stim spine fract, Teriparatide (recomb parathyroid horm ↑osteoblasts), Raloxifene (oest rec modulator in bone), Stront Ranelate (↓resorpt & anabolic), HRT, Calcitriol Lateral Vertebral Assessment, Xray (fracts), Bone scintography, CT (volume), US, Duel Energy Xray Absorptiometry DXA* (density) Rare, life threat, crush inj to large musc (thigh), ischaemia, myoglobin release→ acute tubular necrosis→renal failure, dark urine (Hb+ve), metab acidosis, Treatment Impingement Synd Rotator abrasion, due to narrow of bony tunnel thru which tendon pass 90% ant half supraspin tend, associated changes to ACJ, trauma, mechanical wear & avascularity, peak4050yrs, painrad→chest, Osteochondritis Dissecans pain, swell, adolescents, M>F, trauma, genetic predispose, avulsions, ache, microfracture, Xray, MRI Hypovolaemia, ↑K+, ↓Ca2+, DIC, IV fluids +++, fluid expansion + osmotic diuresis, alkalisation of urine (with NaHCO3 to prevent Hb precipitation at tubule Milk, Alco→↓bone loss, Bisphosphonates (alendronate, risendronate, ↓osteoclasts), Notes Traps, or elbow, cant sleep on affected side Painful arc of abduction, Hawkins test (exagerated on intern rotate at 90O elevate), power norm, Xray, US, MRI, Inject CCS, Physio, Surgery, Aka Rhabdomyolysis ↓Bone density normal >40yrs Genes responsible for bone mass (80%) Also diet & exercsise Fat intake→↑bone loss (ie diet)