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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)