Chronic systemic inflammatory disease

Symmetrical, deforming peripheral polyarthritis

Higher prevalance in females; typically from 30s
Does not affect DIP joints
Rheumatoid Arthritis
Acute flares superimposed over moderate progression

Extra articular signs Nodules on elbows

Commonest joint condition, more common in women Worse in the morning

Slow progression, may plateau over time
Chronic inflammation of spine and
Usually knee or hip sacroiliac joints
Pain / crepitus on movement Presentation: <30 years old, gradual
Localised disease onset low back pain, worse at night,
Worse at night Ankylosing Spondylitis
spinal morning stiffness relieved by
Heberden's nodes exercise

Commonly affect DIP, thumb Progressive loss of spinal movement

Generalised disease
carpo-metacarpal joints and the knee
Associated with Crohn's / UC
Osteoarthritis Enteropathic
Loss of joint space Also assoicated with coeliac
Spondyloarthritides / Seronegative
Subchondral sclerosis Occurs with psoriasis, although can
and cysts Classic X-ray features present before skin changes
Rheumatology Inflammatory
Marginal osteophytes Psoriatic Arthritis Can present as oligoarthritis (<5 joints) or
Pain relief polyarthritis (>5 joints)

Quadriceps exercise Sterile arthritis typically affecting lower limb

Reduce weight Reactive Arthritis Often follows urethritis and can present
Management with systemic features
Intra-articular steroid injections
Joint replacement Systemic condition where autoantibodies
are produced against a variety of
autoantigens
Severe joint pain, redness and swelling Typically women of child bearing age
Autoimmune Systemic Lupus Erythematosus
Typically monoarthritis, often the big toe Relasping and remitting
Associated with trauma, surgery, Polyarthritis
starvation, infection, diuretics and
alcoholism Deposition of urate crystals
Gout Typically monoarthritis

Acute: NSAIDs and colchicine

Crystal Arthropathies Analgesia, blood cultures, synovial fluid,
Treatment empirical antibiotics until sensitivities
Chronic prevention: allopurinol known
Septic Arthritis
A number of acute episodes affecting one joint Need to treat ASAP or risk of permanent
joint damage or septicaemia
Similar presentation to gout
One or two joints, single acute episode
Typically monoarthritis Pseudo Gout

Rheumatology.mmap - 12/10/2009 -
 Age of onset usually > 50yrs
Epidemiology F:M 3:1
Polyarticular

Usually hip / knee

Synovial joints

Fibrillates (tiny cracks) > Progressive loss of cartilage > Subarticular sclerosis
Regular paracetamol +/- codeine Pathology in IA Bony overgrowths (osteophytes) > Cysts (which can burst and bleed into joints)
NSAIDs if not contraindicated Pain relief
Predisposing factors
Education / weight loss
Pathology Heberden's nodes Bony lumps at DIP
Exercises for quads - increases muscle
strength and joint stability Management
Physiotherapy / aids Bouchard's nodes Bony lumps at PIP

Intraarticular steroid injections help severe Nodal OA Generalised disease

symptoms in short term
Post menopausal
Joint replacement when severe Commonly affects DIP, thumb carpo metocarpal joints and knee
unmanageable pain or loss of function

Pain / night pain, stiffness, deformity, joint instability

CT / MRI
Pain may exist without x-ray features
Arthroscopy
Clinical Features Pain on movement +/- crepitus, background pain / stiffness at rest
Loss of joint space Osteoarthritis
Investigations RA does not affect DIP joints
Subchondral sclerosis
and cysts Classic X-ray features Distinguishing features from inflammatory arthritis Imaging in Gout: periarticular erosion,
normal joint space, soft tissue swelling
Marginal osteophytes
CRP may be slightly elevated
Incidence reduces as living standards rise
Infection may spread from boils, abscesses, pneumonia or GU tract - although primary site may not be found
Commonly DIP joints, thumb carpo metacarpal joints and the knee Infection of bone
Common organisms: staph A, pseudomonas, e-coli, strept
Joint tenderness
Examination Findings Cortex erosion with holes > pus lifts up periosteum causing death of original bone
Bony swelling (Heberden's nodes @ DIP, Bouchard's nodes @ PIP) Pathology Continued bone formation forms an involucrum > Pus may discharge into joint
Decreased range of movement spaces or to the skin (via sinuses)

Adults - cancellous bone

Clinical features Patterns of infection
Severe joint pain, redness and swelling Children - vascular bone (long bones - femur, tibia)
Typically monoarthritis, often the big toe
Pain, tenderness, warmth, erythema
Associated with trauma, surgery, starvation, infection, diuretics and alcoholism Signs & Symptoms
Deposition of urate crystals Slight effusion in neighbouring joints, signs of systemic infection

Acute: NSAIDs and colchicine Tests Raised ESR, CRP and WCC
Treatment
Chronic prevention: allopurinol Gout
Osteomyelitis Changes not initially apparent
A number of acute episodes affecting one joint
Investigations Radiography Haziness +/- loss of density of affected bone
Periarticular erosion
Later shows involucrum (bone formation from elevated periosteum)
Normal joint space Imaging
MRI sensitive and specific
Soft tissue swelling Acute Pathology
Drain abscesses and remove sequestra infected dead bone) by open surgery
Typically monoarthritis
Vancomycin and cefotaime until sensitivities known
Analgesia, blood cultures, synovial fluid, empirical antibiotics until sensitivities known Management Antibiotics
Continue for 6 weeks
Need to treat ASAP or risk of permanent joint damage or septicaemia
One or two joints, single acute episode Septic arthritis Septic arthritis, fractures, deformity, chronic osteomyelitis
Complications
Young people = gonorrhoea
Infective organism Poor treatment results in pain, fever and
Older people = staph / strep
sinus suppuration with long remissions
Similar presentation to gout X-ray: thick irregular bone
Chronic Osteomyelitis
Typically monoarthritis Pseudo gout Treatment: surgery, antibiotics for > 12 weeks

Osteoarthritis.mmap - 08/11/2009 -
 Symmetrical, deforming peripheral polyarthritis
Chronic systemic inflammatory disease

Painful, swollen and stiff small joints of hand / feet

Higher prevalance in females; typically from 30s
Does not affect DIP joints
Presentation
Worse in the morning
Peak onset in 40s
Acute flares superimposed over moderate progression

Early Joint swelling (symmetrical MCP, PIP wrist), inflammation, synovitis

Joint damage, deformity, ulnar deviation of fingers, dorsal wrist subluxation

Later
Swan neck and Boutonniere deformities of fingers, Z-shaped deformities of thumb
Multi System autoimmune disease, with autoantibodies against a
variety of autoantigens Signs Nodules on elbows, fibrosing alveolitis, pleural effusion, Raynaud's, carpal
Extra articular tunnel, periperhal neuropathy
Polycloncal B-cell secretion of pathogenic autoantibodies and Pathology
formation of immune complexes
Complication of RA
Typically women of child bearing age Felty's Syndrome
Triad of seropostive RA, neutropenia, and splenomegaly
Common in Afro Caribbeans and Asians Epidemiology
Rh Factor Positive in 75% cases
Butterfly rash
Erythematous raised patches Anaemia of chronic disease
with keratotic scales Bloods
Discoid rash Rheumatoid Arthritis Investigations Inflammation causes raised platelets, CRP and ESR
Photosensitivity Soft tissue swelling, juxta articular osteopenia, bony erosions
X-Ray
Oral ulcers
Non erosive arthritis Rapidly reduce inflammation / controls symptoms in short term
Steroids
Pleuritis or pericarditis Useful for acute flares
Serositis
Diagnosing SLE (4 or more) Help control symptoms, try different NSAIDs as response varies
Persistant proteinuria or cellular casts Renal disorder Paracetamol + weak opiates use is limited
NSAIDs
Reduce inflammation
Seizures of psychosis CNS Disorder
COX-2 inhibitors where indicated
Haematological disorder
Early use of disease modifying agents improve symptoms / long term outcomes
Immunological disorder
Weekly dose; avoid in liver disease, pregnancy
Over 95% cases are ANA +ive
Anti-nuclear antibody Connective Tissue Management Methotrexate SE: oral ulcers, nausea, lethargy, myelosuppression, hepatotoxicity
Sensitive test SLE
Disease 1 Anti-inflammatory effects are due to effects on TNF pathways
Relapsing remitting condition
SE: myelosuppression, nausea, rash, low sperm count
Other features: fatigue, pyrexia during flares, weight loss, myalgia, alopecia, Raynaud's Clinical Features DMA Sulfasalazine
Reduces synthesis of inflammatory mediators and cytokines (no immunosupressant action)
A specific test Double stranded DNA Usually via IM injection, high toxicity
Gold
Decreased complement SE: myelosuppression, renal toxicity, rash, photosensitivity
Monitoring activity
CRP typically normal, ESR raised Least toxic, although possibly least effective
Hydroxychloroquine
Over 50 drugs including isoniazid SE: rash, retinopathy
Disease remits if the drug is stopped
Drug induced lupus
OCP may worsen idiopathic SLE Scleroderma - skin fibrosis
Features Vascular disease
Can occur secodary to SLE (25% of cases) or as primary disease
Antiphospholipid antibodies are present CREST syndrome
Coagulation defect, Livedo reticularis, Obstetric Calcinosis (sub cut tissues), Raynaud's, oEsophageal and
Antiphospholipid syndrome gut dysmotility, Sclerdactyly and Telangiectasia (non
(recurrent miscarriage - give LMWH to prevent
miscarriage), Thromobocytopenia blanching haemorrhages)
CLOT features Limited systemic sclerosis
Skin involvement is limited to face, hands and feet
High factor sunblock Associated with anticentromere
If joint / skin symptoms are uncontrolled by NSAIDs antibodies and pulmonary HT
Hydroxychloroquine
Systemic Sclerosis
SE: irreversible retinopathy Diffuse skin involvement, whole body when severe
Treatment
Low dose may be of value in chronic disease More profound organ fibrosis: lung,
Steroids Diffuse systemic sclerosis cardiac and renal disease
High dose prednisolone with severe flares
Prognosis is often poor

Currently no cure
Immunosuppressive regimens are used for organ involvement or
Therapy progressive skin disease
Regular ACE-I reduces risk of renal crisis

Connective Tissue Disease.mmap - 08/09/2010 -

 Tiredness / malaise, weight loss
Inflammatory multisystem disease
Presenting Features Joint inflammation, rash, anaemia
Splinter haemorrhages
Acute phase response
Necrotising vasculitis causing
aneurysms and thrombosis
Lead to infarction in affected organs
Polyarteritis Nodosa (PAN)
with severe systemic symptoms
Medium Vessel
Can be associated with Hep B

More common in Japan

Kawasaki disease Occurs in upto 40% cases of psoriasis; can present before skin changes
Childhood PAN variant
Vasculitis Polyarthritis (RA like)
Associated with glomerulonephritis
ANCA +ive DIP Joints
Wegener's Patterns
Small Vessel Asymmetrical oligoarthritis
Goodpasture's disease Psoriatic Arthritis
ANCA -ive Features Spinal (AS like)

May be secondary to other diseases e.g. SLE, RA, hepatitis X-Ray: erosive changes

Consider vasculitis as a diagnosis in any unidentified multi system disorder Assoicated with nail changes in 80% cases
Vasculitidies Treatment: NSAIDs, sulfasalazine, methotrexate, anti TNF agents
AKA Cranial / Temporal Arteritis
ESR raised
Giant Cell Arteritis
First and worst headache in elderly (Large vessel vasculitis) Primary: more common in females, 40s
Visual consequences Chronic inflammatory Secondary: RA, SLE, systemic sclerosis
autoimmune disorder Associated with other autoimmune conditions
Systemic: fever, malaise, weight loss, arthralgia
Skin: purpura, ulcers, nail bed infarcts Lymphocytic infiltration and fibrosis of exocrine glands (esp. salivary glands)

Eyes: episcleritis, visual loss Connective Tissue Decreased tear production

Pulmonary: haemoptysis, dyspnoea Disease 2 Decreased saliva production
Features
Cardiac: heart failure, angina / MI Other glands are affected: vaginal dryness, dyspareunia, dry cough, dysphagia
Common features
GI: pain, malabsorption (due to chronic ischaemia) Schirmer's test
Sjogren's Syndrome
Renal: raised BP, proteinuria, chronic renal failure Conjunctival dryness Filter paper under lower lid and measure distance
Neurological: sensorimotor neuropathy, stroke, <5mm in 5 minutes is +ive
fits, chorea, psychoses, confusion Tests
Rh factor usually positive
Gland biopsy shows focal lymphocytic aggregation
Progressive symmetrical proximal muscle weakness from striated muscle inflammation
Treat symptoms: artificial tears, frequent
Muscle weakness mat cause dysphagia, dysphonia, or respiratory weakness drinks, sugar free pastilles / gum
Increased risk of malignancy Treatment NSAIDs and hydroxychloroquine for arthralgia
Also features skin signs Increased risk of non Hodgkin's lymphoma
Macular rash, nail fold erythema, roughed red papules over Dermatomyositis
the knuckles, subcutaneous calcifications, Mechanic's hands
Common > 70 years (rare < 69 years)
Fever, arthralgia, Raynaud's, interstitial fibrosis, myocarditis, arrhythmias
Extra muscular signs Polymyositis & Gradual onset symmetrical aching,
Dermatomyositis tenderness and morning stiffness in
Increased muscle enzymes in plasma shoulders and proximal limb muscles
Muscle biopsy confirms the diagnosis Systemic features: fatigue, fever, weight
Diagnosis loss, anorexia and depression
Autoantibody associations
Overlap with GCA
Screen for malignancy Polymyalgia Rheumatica
Resent onset RA, polymyositis, hypothyroidism
Prednisolone
Management Primary muscle disease, occult malignancy or infection
Immunosuppresants in resistant cases Differentials
Osteoarthritis, neck lesions
More aggressive treatment is need in children
Prednisolone 15mg / 24hr PO
Gives dramatic response
Treatment
Decrease dose slowly 1mg / month (according to symptoms and ESR)

Connective Tissue Disease 2.mmap - 08/09/2010 -

 Osteoporosis
Metabolic bone disease - osteomalacia, hyperparathyroidism
Generalised Bone Disease Paget's disease
Myelomatosis

Chronic infection
Site: bone fractures, part of bone (proximal, shaft, distal)
Solitary bone cyst
Line: transverse, oblique, spiral, multi fragmentary Localised Benign
Description Fibrous cortical defect
Displacement: angulation, translation, rotation Types of Fracture Chondroma
Pathological Fractures
Tendon shears of a fragment of bone
Osteosarcoma
Typically in athletes Avulsion fracture
Chondrosarcoma
Primary Malignant
Ewing's tumour

Reduction Lung
Immobilisation Breast
Principles
Rehab Metastases Prostate
GI
Usually need to correct rotational or
valgus or varus deformity
Reduction can be performed as either an
open or closed procedure General
Airway + Oxygen + Check C-Spine
Immobilisation is required until fracture union
Breathing + Ventilation
Intraarticular fractures - to stabilise anatomical reduction
Circulation + Haemorrhage Control
Repair of blood vessels and nerves - to protect vascular and nerve repair Primary Survey
Disability (check GCS and pupillary reflexes)
Multiple injuries
Exposure (check and maintain body temperature)
Elderly patients - to allow early mobilisation
Long bone fractures Indications
ATLS Protocol Radiography: CXR, lateral C-Spine, and pelvis
Urinary catheter (unless urethral injury)
Failure of conservative management
Adjuncts (to add life saving information) NGT (unless facial fracture)
Pathological fractures Internal # Management
Fractures that require open reduction
Limb Trauma Oxygen sats and ABG

Unstable fractures Once pt is stabilised complete check from scalp to toe

Secondary Survey More focused imaging and examination
Infection
Non-union Fixation
Complications
Implant failure
Refracture

Acute trauma - open and unstable fractures

Non union of fractures
Correction of joint contracture Indications Clavicle: common in young from fall; complications include
neurovascular injury and pneumothorax
Filling of segmental limb defects - trauma, tumour and osteomyelitis External
Scapula / Acramion: represent high energy transfer injuries
Limb lengthening
Humerus: for example a child falling from an out stretched hand
Overdistraction
Complications Colles: dorsal angulation and displacement; common in
Pin-tract infection osteoporotic post menopausal women
# Upper Limb Distal radius
Smiths: forward / palmar displacement
Immediate: bleeding, organ injury, nerve Scaphoid: common and easily missed on XR; resulting from falls on the
or skin injury, vessel injury hand; signs are swelling, pain and localised tenderness
Later Local: skin necrosis, pressure Typically 6 week healing - half as much in children
sores, infection, delayed union
Fractures
Just below femoral head
Later General: venous / fat embolism, PE, Circumflex artery supplies the head via
pneumonia, renal stones Intracapsular the neck so with fracture there is risk of
Bleeding into fascial compartment ischaemic necrosis
Hip / Femur: external rotation,
Fluid loss, DIC and myoglobin release cause adduction and shortening Total hip replacement
renal tubular necrosis - dialysis may be needed
# Complications # Lower Limb Between greater and lesser trochanters
Causes vascular occulsion impairing blood supply, Limb and life threatening Compartment Syndrome
with potential for nerve damage and muscle death Extracapsular Blood supply is not compromised

Prompt fasciotomy is limb and life saving Dynamic hip screw fixation
Typically 12 week healing - half as much in children
Results from skeletal muscle breakdown
Release of contents into blood stream - myoglobin, potassium, phosphate, urate and CK
Complications include hyperkalaemia and acute renal failure (myoglobi obstructs renal tubules) Rhabdomylosis
Causes: trauma, prolonged immobilisation, excessive exercise, drugs and toxins
(statins, alcohol), infections (EBV, influenza), inherited muscle disorders

Limb Trauma.mmap - 08/09/2010 -