Rheumatology and Orthopaedics

Topics In this Section

Rheumatology

Antiphospholipid Antibody Syndrome
Calcium Pyrophosphate Deposition Disease (pseudogout)
Giant Cell Arteritis
Gout
Polymyalgia Rheumatica
Polymyositis + Dermatomyositis
Rheumatoid Arthritis
Sarcoidosis
Scleroderma
Spondyloarthropathies
Systemic Lupus Erythematosus

 

Orthopedics

Ankle Fracture
C Spine Fracture Suspected
Calcific Tendinitis
Cauda Equina Syndrome
Colles Fracture
Compartment Syndrome
Disc Herniation
Morton's Neuroma
Neck of Femur Fracture
Open Fracture Management
Osteomyelitis
Pelvis Fracture
Scaphoid Fracture
Spinal Stenosis


Orthopaedics

Ankle fracture

Classification: no consensus, but Danis-Weber is commonly used:

  • A: Infra-syndesmotic. Avulsion of lateral malleolus below plafond or torn calcanealfibular ligament.
  • B: Trans-syndesmotic. Spiral fracture of lateral malleolus starting at plafond.
  • C: Supra-syndesmotic. Fibular fracture above plafond.

Investigation:

  • Initial: Ottawa ankle rules (determines if XR required).
    • Ankle XR only required if there is any pain in the malleolar zone PLUS ONE OF
      • Bone tenderness along distal 6cm of posterior edge of tibia or tip of medial malleolus
      • Bone tenderness along distal 6cm of posterior edge of fibula or tip of lateral malleolus
      • Inability to bear weight both immediately/in ED for 4 steps
    • Additional Foot XR indicated if pain in midfoot zone PLUS ONE OF:
      • Bone tenderness at base of fifth metatarsal
      • Bone tenderness at the navicular
      • Inability to bear weight both immediately/in ED for 4 steps
  • Diagnostic: Ankle XR (AP, mortise, lateral)

Treatment:

  • For type A fractures, use a below knee cast and non-weight bearing.
  • For most of type B ORIF is necessary, then same management per type A.
  • For all of type C ORIF is necessary, then same management per type A.

 

C spine fracture suspected

NEXUS criteria:

  • Midline cervical tenderness
  • Altered mental status
  • Focal neurological deficit
  • Evidence of drug/alcohol intoxication
  • Presence of other injury significant enough to distract from neck pain

Investigation:

  • Initial: NEXUS criteria for spinal imaging
  • Diagnostic: Guideline dependent. International guidelines suggest CT is first line. If not obtainable, AP, lateral and odontoid XRs are also useful.

Treatment:

  • Initial: C spine stabilization by cervical collar or neutral supine position on rigid surface with head immobilized by sandbags/towels if collar unavailable.

 

Calcific tendinitis

Clinical Features

  • Severe, disabling pain that occurs spontaneously in the morning
  • Stiffness, giving rise to frozen shoulder-like clinical picture
  • Worsens with overuse

Investigation:

  • Initial/Diagnostic: Plain XR demonstrating calcific deposits above the greater tuberosity

Treatment:

  • Best management is conservative - 90% success NSAIDs, physiotherapy, extracorporeal shock wave therapy or injections/needling/lavage or corticosteroid injections.
  • Operative management is controversial; can attempt arthroscopy if no response to conservative management

 

Cauda equina syndrome

Clinical Features:

  • May be acute (disc herniation, trauma) or insidious (spinal stenosis, tumour)
  • Motor: Weakness of multiple root distributions, reduced reflexes
  • Autonomic: Urinary retention/faecal incontinence/loss of anal sphincter tone
  • Sensory: Lower back pain radiating to legs (sciatica), bilateral sensory loss, saddle anaesthesia (S2-S5)

Investigation:

  • Initial/Diagnostic: Spine MRI (CT myelography if patient cannot undergo MRI)

Treatment:

  • Urgent surgical decompression within <48 hours, severe symptoms may prompt more urgent surgery. Discectomy or laminectomy are both appropriate procedures.

 

Colles fracture

Clinical Features:

  • Classical sign is the “dinner fork”
  • Other features will include: swelling, tenderness and ecchymoses
  • The median nerve may be compromised, so assess neurological function

Investigation:

  • Diagnostic: Plain XR (AP and lateral wrist). CT may be useful for intra-articular fractures for operative planning.

Treatment:

  • Best:
    • If the fracture is comminuted (and therefore unstable) or intra-articular extension an ORIF will be required.
    • In other circumstances
      • (1) Sedation or haematoma block and closed reduction
      • (2) Repeat plain XR post reduction
      • If the fracture is not reduced successfully the procedure may be reattempted or an ORIF can be used.
      • If the fracture is reduced successfully a backslab is to be applied for 5-6 weeks.
      • Further XR at 1 week is necessary to ensure a successful reduction

 

Compartment syndrome

Clinical Features:

  • Pain on active contraction of compartment, and a swollen/tense compartment
  • 5Ps: Pain (out of proportion to injury), Pallor (late), Paraesthesia (late), Paralysis (late), Pulselessness (late)

Investigation:

  • This is usually a clinical diagnosis
  • Workup for rhabdomyolysis is recommended especially in the trauma setting (CK, renal function, urinalysis, urine myoglobin)
  • Compartment pressure monitoring with catheter is the standard for diagnosis, and should be done immediately following clinical suspicion

Treatment:

  • Consider management of possible rhabdomyolysis (IV fluids + bicarbonate)
  • Urgent fasciotomy. 48 hours later the wound should be closed and debrided.

 

Disc Herniation

Clinical Features

  • Pain onset while lifting or stooping
    • Back pain suggests central herniation
    • Symptoms worsened by coughing or straining
    • Leg dominant pain suggests lateral herniation
  • Muscle spasms
  • Neurological deficits (motor, reflexes, sensation)
  • Positive leg raise
  • Positive Lasegue test

Investigation:

  • Diagnostic: CT and MRI
  • XR: is helpful only to rule out bony pathology, myelography has side effects and cannot diagnose far lateral disc protrusions

Treatment:

  • Best:
    • NSAIDS, heat and strengthening exercises
    • Acute attacks: bed rest with hips and knees flexed for 2 weeks, reduction by local anaethetic and corticosteroid injection
    • Indications for surgery (laminotomy):
      • cauda equina syndrome (urgent)
      • persistent neurological deficit, esp. if clinically progressing
      • severe pain unresponsive to conservative management

 

Morton’s neuroma

Clinical features:

  • Intermittent pain (sharp/burning) and dysthesia of forefoot and toes adjacent to the neuroma ‘sensation of pebble in shoe’
  • May be relieved clinically by massage
  • Pain reproducible by laterally compressing affected interspace – Mulder’s click as neuroma displaces between metatarsal heads

Investigation:

  • Initial: plain XR (will be normal) to rule out ddx
    • If: palpable. Then: clinical diagnosis
    • If: not palpable. Then, diagnostic: USS

Treatment:

  • Initial/best:
    • 1st Line: Change in footwear (wider shoes), orthoses
    • 2nd Line: Corticosteroid injection
    • Definitive: Surgical release

 

NOF fracture

Clinical Features

  • Pain: Impacted/stress fractures (groin or medial thigh/knee) OR displaced (entire hip)
  • Inability to weight bear and reduced range of movement
  • Shortened and externally rotated leg for displaced fracture
  • Assess for nerve damage

Investigation:

  • Initial/Diagnostic: AP pelvic Xray

Treatment:

  • Due to the injury being traumatic, resuscitation may be necessary
  • Management of fracture
    • Intracapsular fractures will depend on Garden type
      • Type I/II: internal fixation
      • Type III/IV: ORIF in young, hemi/total-arthroplasty in elderly
    • If: extracapsular. Then: ORIF (fixation with plate, dynamic hip screw or IM nail)
    • If: life expectancy is poor. Then management may be conservative.
  • Complications
    • Avascular necrosis in subcapital fractures, also can lead to secondary osteoarthritis
    • In general DVT, non-union, malalignment, wound infection

 

Open fracture

Clinical Features:

  • Clinically apparent
  • Assess neurovascular status

Investigation:

  • Diagnostic: Clinical diagnosis

Treatment:

  • Initial:
    • ABCs (control haemorrhage – tourniquet/pressure and correct coagulopathy)
    • Give early antibiotics
    • Analgesia, sedation and possible tetanus immunoglobulin
    • Wound irrigation with normal saline if there is more than an hour delay for theatre. Cover with sterile dressing.
    • For neurovascular compromise, urgent traction and splint of the limb with elevation
    • Referral for surgery: irrigation and debridement.

 

Osteomyelitis

  • See Medicine → infectious diseases

 

Pelvis fracture

Tile classification:

  • Type A: Stable avulsion fracture
  • Type B: Open book (rotationally unstable)
  • Type C: Unstable vertical fracture (vertically and rotationally unstable)

Clinical Features:

  • Pain and inability to weight bear
  • Assess for lower extremity deformity (skin, perineum, scrotum, etc)
  • Test pelvic instability by gentle rotational force on each iliac crest
  • Neurological examination (often L5/S1 injury)
  • Urogenital exam (may show blood at urethral meatus) and rectal exam (high prostate suggests urethral injury)

Investigation:

  • Initial/Diagnostic: AP, inlet, outlet and Judet views.
  • CT can be useful for detecting acetabular fractures and posterior ring injuries or any serious injury

Treatment:

  • Initial: ABCDEs. Be wary about significant haemorrhage in all pelvic injuries. Assess for genitourinary injury. Pelvic binder is used to stabilise the fracture and prevent further injury to surrounding structures.
  • Fracture management:
    • Severe injuries should be managed early by external fixation
    • If the fracture is stable, conservative management by bed rest and allowed to mobilised with crutches after 4-6 weeks
    • An unstable fracture such as open book that is markedly displaced, is operatively managed (ORIF)

 

Scaphoid Fracture

Clinical Features

  • Often preceding history of fall on outstretched hand
  • Anatomic snuff box tenderness dorsally
  • Scaphoid tubercle tenderness volarly
  • Pain with resisted pronation

Investigation:

  • Diagnostic: X-ray (AP, lateral and oblique views)
  • If there is strong clinical suspicion but no fracture visible, a thumb spica cast can be placed and re-x-ray in 2 weeks. Scaphoid fractures may not be immediately radiologically evident (25%).
  • CT or MRI can be considered if there is still strong clinical suspicion, but not suggestive on XR at 2 weeks.

Treatment:

  • Best:
    • Nonoperative thumb spica cast is used in the setting of a stable, non-displaced fracture. This is done for 3-5 months depending on site of fracture. Examine wrist clinically and radiologically.
    • Operative ORIF/percutaneous screw is used in unstable fractures. May also be used for athletes or people who need fast recovery for work purposes.
  • Complications:
    • The proximal-third scaphoid fractures are most prone to avascular necrosis

 

Spinal Stenosis

Clinical Features:

  • Neurogenic claudication (progressive back and leg pain caused by movement, and relieved by rest)
  • Usually unilateral symptoms
  • Bladder symptoms (autonomic dysfunction)
  • Kemp sign: unilateral radicular pain made worse by extension of back

Investigation:

  • Initial: Plain lateral X-ray (may show spondylolisthesis)
  • Diagnostic: CT myelography/MRI to exclude other causes of similar neurological dysfunction

Treatment:

  • Conservative treatment involves NSAIDs, weight loss, abdominal strengthening
  • Persisting symptoms warrants epidural steroid injection
  • A decompression with spinal laminectomy can be considered (but has high chance of recurrence after surgery)
  • Acute, severe myelopathy warrant emergency decompression


Rheumatology

Antiphospholipid antibody syndrome

Clinical Features & Investigation:

  • Diagnosis (1 clinical and 1 laboratory required) per international consensus criteria 2006
    • Clinical: Vascular thrombosis (stroke/TIA, multi-infarct dementia, MI, DVT, PE, renal vein thrombosis OR Pregnancy morbidity (fetal death <10wk GA, recurrent spontaneous abortions or premature birth).
    • Laboratory: SLE anticoagulant, Anti-cardiolipin Ab, Anti-beta2 glycoprotein-I Ab

Treatment:

  • Optimise risk factors such as OCP, smoking, hypertension and hyperlipidaemia
  • Prophylactic: consider low dose aspirin
  • Treatment: Lifelong anticoagulation for any venous event (warfarin INR 2-3). An INR score >3 is indicated for vascular or recurrent events
  • Pregnancy: prophylactic anticoagulation during pregnancy and 6 weeks postpartum with LMWH. Do not use warfarin during pregnancy

 

Calcium pyrophosphate deposition disease (pseudogout)

Clinical Features:

  • A majority of patient will be asymptomatic, but crystal deposition are seen on X-Ray
  • Will present with acute onset joint tenderness and erythema
  • Consider in recurrent self-limiting monoarticular arthritis
  • Commonly affects knees – 50%
  • Trigger include dehydration, acute illness, trauma

Investigation:

  • Diagnostic: Arthrocentesis (positively birefringent rhomboid crystals). This must be done to also rule out septic arthritis.
  • XR may show chondrocalcinosis (frequently used as synonymous with pseudogout actually just means calcification of cartilage)

Treatment:

  • Preferred treatment are NSAIDs
  • Prednisolone is second line treatment

 

Giant cell arteritis

Clinical Features

  • Abrupt monocular loss of vision
  • Headache, generalised ache
  • Pain over temporal artery, jaw claudication, ccalp tenderness, fever
  • Associated with polymyalgia rheumatica

Investigation:

  • Initial: ESR (be cautious as this may not necessarily be raised)
  • Temporal artery biopsy must be performed in the setting of any clinical suspicion

Treatment:

  • Do not delay treatment for workup of GCA. Start treatment with steroids when clinically suspected (if visual symptoms, then IV steroids + aspirin) immediately

 

Gout

Clinical Features:

  • Acute gout attacks: severe pain, erythema, joint swelling. It usually affects lower extremities (common big toe), and spontaneously resolves over days-weeks
  • Tophi: caused by chronic gout attacks and hyperuricaemia. These are collections of urate crystal masses that may erode bone and joint.
  • Kidneys: uric acid stones

Investigation:

  • Diagnostic: Arthrocentesis (negatively birefringent needle shaped crystals)
  • XR can assess for tophi (soft tissue swelling and punched out lesions)

Treatment:

  • Treat with high dose NSAIDs, which can be tapered as symptoms improve
    • If NSAIDs are contraindicated (renal function <60 or active peptic ulcer) oral/intra-articular steroids should be used instead
    • Colchicine can only be used in the first 12 hours, but limited by narrow therapeutic range
    • Adjunct: rest, ice and elevate joint
  • To prevent gout attacks:
    • Allopurinol (given with colchicine or NSAID as may precipitate gout attack)
    • Do not give allopurinol for acute gout as this can worsen an acute flare

 

Polymyalgia rheumatica

Clinical Features

  • Pain and stiffness of proximal extremities in the morning lasting more than 1 hour
  • Often systemic symptoms present (fever, weight loss, malaise)
  • Physical exam will demonstrate no muscle weakness or wasting

Investigation:

  • Initial: elevated ESR that responds rapidly to steroids
  • Diagnostic: Diagnosis of exclusion. Do RF/anti-CCP/ANA for conditions that may mimic PR.

Treatment:

  • This condition should be treated by symptomatic monitoring
    • Oral prednisolone (low dose) and tapered gradually. In the setting of raised ESR with no symptoms, no treatment is required.
    • Physiotherapy, steroid side effect monitoring (eg osteoporosis)

 

Polymyositis + Dermatomyositis

Clinical Features

  • Many shared clinical features:
  • Progressive symmetrical proximal muscle weakness typically of shoulder and hip girdle over weeks-months
  • Cardiac involvement (pericarditis/cardiomyopathy)
  • Dysphagia or aspiration
  • Dermatological features specific too DMM: Gottron’s papules (pink-violaceous flat topped patches over joints), Gottron’s sign (erythematous patches over joints), heliotrope rash (violaceous rash over eyelids), shawl sign, mechanic’s hands

Investigation:

  • Initial: Increased CK and anti-Jo-1 antibodies
  • Diagnostic: Muscle biopsy
    • Endomysial infiltration of inflammatory cells suggests polymyositis
    • Perifascicular atrophy of muscle cells suggests dermatomyositis

Treatment:

  • High dose steroids and taper
  • Consider azathioprine/methotrexate for steroid sparing immunosuppression
  • Role of treatment such as IVIG is unclear due to lack of RCTs and rarity of the disease
  • Occupational and physical therapy
  • Surveillance for malignancy due to higher risk association

 

Rheumatoid arthritis

Clinical Features

  • Insidious onset of symptoms
  • Morning stiffness >1h that improves with use
  • Symmetric joint polyarthritis with swelling and tenderness
  • Common sites: PIP, MCP, Wrist, Elbow
  • Deformities: swan neck, boutonniere, ulnar deviation
  • Extra-articular: rheumatoid nodules, pulmonary fibrosis, episcleritis

Investigation:

  • Diagnostic: Anti-CCP (specific) and rheumatoid factor (80% sensitive). No pathognomonic test.
  • Disease activity monitored by Hb (anaemia of chronic disease) and ESR
  • X-rays performed to allow for serial comparisons. Radiological signs may demonstrate periarticular osteopenia and erosions.

Treatment:

  • Early intervention with DMARD
    • Methotrexate is first line therapy
    • Sulfasalazine/Lefunomide if MTX contraindicated
  • If the patient remains significantly symptomatic on DMARD. Then biologics are next in line (e.g. infliximab)
  • Short term symptomatic relief: NSAIDs or steroids
  • Surgical intervention by joint replacement, excision or reconstruction may be considered late in disease progression

 

Sarcoidosis

Clinical Features:

  • Cough, dyspnea (50%, most common presentation)
  • Fever, arthralgia, erythema nodosum
  • Extra-pulmonary: cardiac arrhythmias, uveitis, skin papules, lupus pernio, peripheral lymphadenopathy

Investigation:

  • Initial workup includes CXR (bilateral lymphadenopathy)
  • Suggestive investigations findings include elevated serum ACE, elevated calcium
  • Diagnostic: Lymph node or lung biopsy (non-caseating granulomas). Can be diagnosed by high resolution chest CT (in absence of other causes of ILD).

Treatment:

  • Prednisolone for management of symptoms. MTX can be utilised as a steroid sparing agent
  • There is 10% mortality due to progression to lung fibrosis

 

Scleroderma

Clinical Features

  • Localised: morphea (hard oval patches of skin) and linear pattern of thickened skin
  • Limited systemic sclerosis: CREST (calcinosis, raynauds phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia), pulmonary hypertension, musculoskeletal (arthralgia/myalgia), renal injury.
  • Diffuse systemic sclerosis: broader distribution of skin changes, faster progressing renal and pulmonary disease

Investigation:

  • Diagnostic: anti-centromere ANA (specific for CREST). Anti-Scl70 (anti-topoisomerase 1 antibodies) (specific for diffuse scleroderma).
  • After diagnosis, use spirometry and CXR are used to assess for interstitial lung disease. As the complication of pulmonary artery hypertension can lead to right heart failure, an echocardiogram may also be indicated.

Treatment:

  • Management is based on symptoms and controlling complications. There are no medications that are proven disease modifying.
    • Skin: low dose topical steroids
    • Vascular (Raynaud’s): CCB (amlodipine)
    • GORD: PPI
    • MSK pain: NSAIDs

 

Spondyloarthropathies

Clinical Features:

  • Ankylosing spondylitis:
    • Chronic inflammatory arthritis involving sacroiliac joints and vertebrae
    • Mid-lower back stiffness, positive Faber test, decreased spine range of motion, decreased range of Schober test
  • Reactive arthritis:
    • Onset of asymmetric peripheral arthritis 1-4 weeks following gastrointestinal (shigella, campylobacter, salmonella) or genitourinary infection (chlamydia)
    • Classic triad of conjunctivitis, urethritis and arthritis (can’t see, can’t pee, can’t climb a tree)
  • Enteropathic arthritis:
    • Large joint asymmetrical arthritis in context of ulcerative colitis or Chrohn’s disease
  • Psoriatic arthritis:
    • Affects 10% of patients with psoriasis
    • Most common pattern is asymmetric oligoarthritis
    • Dactylitis (35% patients)

Investigations:

  • If you suspect:
    • AS: Primarily clinical diagnosis and HLAB27 (90%)
    • Enteropathic arthritis: colonoscopy
    • Reactive: Primarily clinical diagnosis and HLAB27 (80%)
    • Psoriatic: look for psoriasis
    • Inflammatory markers, ECG (heart block), ophthalmology consult (Anterior uveitis)

Treatment:

  • Treat underlying disease (e.g. crohn’s or psoriasis)
  • All: NSAIDs and physiotherapy
  • If: significant morbidity. Then: DMARDs (MTX, sulfasalazine), biologics

 

Systemic lupus erythematosus

Clinical Features:

  • Joint pain
  • Systemic symptoms – malaise, anorexia, weight loss, fever
  • Butterfly rash of the face
  • Raynaud’s phenomenon
  • Peripheral vasculitis
  • Mixed nephritic-nephrotic picture

Investigation:

  • Diagnostic: Anti-Smith (most specific), anti-dsDNA (almost as specific), ANA (sensitive)
  • Supportive: Anemia, leucopenia and elevated ESR
  • Biopsy of involved tissues shows evidence of characteristic inflammation and immunoglobulin deposition.

Treatment:

  • Management of SLE often involves a multi-disciplinary approach, with input from rheumatologists, dietitians, psychologist and physiotherapist.
  • Acute exacerbations are usually treated with high dose steroids.
  • DMARDs (e.g. Hydroxychloroquine) should be used in most patients.
  • Hydroxychloroquine is indicated for management severe skin rash.
  • Cyclophosphamide may be used for severe nephritis, cerebral vasculitis or interstitial lung disease.