11 MUSCULOSKELETAL & 12 RHEUMATOLOGY 15 CHILD HEALTH / PAEDIATRICS 15.12-13 Neurological disorders
ORTHOPAEDIC CONDITIONS • Epilepsy • Status epilepticus
12.01 • Rheumatoid arthritis 12.04 Vasculitic disorders 15.01 • Paediatric life support • Brain tumours
11.01 Orthopaedic emergencies • Osteoarthritis • Wegener's • Churg-Strauss • Newborn life support [15.13] • Neural tube defects
• Septic arthritis • Psoriatic arthritis • Giant cell arteritis • Takayasu arteritis • Intraosseous infusion • Anaphylaxis • Autism spectrum disorder
• Compartment syndrome • Microscopic polyangitis
• Spinal cord compression 12.02 • Ankylosing spondylitis • Polyarteritis nodosa 15.02-03 Infections 15.14-15 Haemonc disorders
- Cauda equina syndrome • Reactive arthritis • Enteropathic arthritis • Polymyalgia rheumatica • Traffic light assessment of kids • Anaemia • Iron deficiency
• Open fractures • Gout • Pseudogout • Henoch-Scholein • Behcet's • Meningitis • Encephalitis • Sickle cell disease
• Tendon sheath infection (hand) • Fibromyalgia • Chronic fatigue syndrome [15.03] • Measles • Mumps • Rubella • Hereditary spherocytosis
12.05 • Anti-GBM disease • Erythema infectiosum • HFMD • Henoch-Schonlein purpura
11.02 Upper limb orthopaedic issues 12.03 • Systemic lupus erythematosus • Juvenile idiopathic arthritis • Roseola infantum • Chickenpox [15.15] • Immune thrombocytopaenia
• Shoulder • Elbow • Systemic sclerosis (scleroderma) • Adult-onset Still's disease • HIV in children • Acute lymphoblastic leukaemia
• Fractures: Colles', Smith's, Barton's, • Dermatomyositis • Polymyositis • Hypermobility disorders • Primary immunodeficiencies
Monteggia's, Galeazzi • Sjogren syndrome • Autoantibodies (list) 15.04 Respiratory disorders • Severe combined immunodeficiency
• Upper respiratory tract infections
11.03 Hand & foot - Croup - Epiglottitis 15.16-18 Endocrine disorders
• Hand • Ganglions 13 EAR NOSE THROAT 14 PSYCHIATRY - Bacterial tracheitis - Diphtheria • Diabetes mellitus + MODY • DKA
© quackquackmed.com
• Foot, incl club foot • Lower respiratory tract infections • Hypothyroidism
13.01 Ear 14a Substance abuse / overdose - Bronchiolitis - Viral-induced wheeze [15.17] • Hyperthyroidism
11.04 Hip, including neck of femur • Otalgia • Discharging ear • Cannabis • MDMA/Ecstasy - Pneumonia - Whooping cough • Inherited metabolic diseases
fractures • Otitis externa • Otitis media • Cocaine • Nitrous oxide • Asthma • Cystic fibrosis [02.04] • Glycogen storage disorders
• Glue ear • LSD / acid • Opioid misuse • Phenylalanine ketonuria
11.05 Knee & ankle issues • Overdose / poisoning 15.05-06 Cardiovascular disorders • Lysosomal storage diseases
13.02 Ear • Hearing loss • Ventricular septal defect (VSD) [15.18] • Precocious puberty
09.06 Spinal orthopaedics • Tinnitus • Vertigo 14.01 Mood disorders • Atrial septal defect (ASD) • Congenital adrenal hyperplasia
Including rib fractures, autonomic • Depression • Suicide • Patent ductus arteriosus • Genetic disorders summary
dysreflexia 13.03 Ear • Childhood deafness • Bipolar disorder • Coarctation of the aorta
• Deafness in adults • Otosclerosis • Congenital aortic valve stenosis 15.19 Developmental disorders
09.07 Miscellaneous • Vestibular schwannoma 14.02 Anxiety & related disorders • Eisenmenger's syndrome • Developmental milestones
• Dermatomes • Fat embolism • Benign paroxysmal positional vertigo • Generalised anxiety disorder [15.06] • Tetralogy of Fallot (ToF) • Speech delay • Cerebral palsy
• Osteomalacia • Osteomyelitis • Meniere's disease • Panic disorders • OCD • PTSD • Transposition of great arteries (TGA) • Muscular dystrophies (incl Duchenne)
• Osteochondritis dissecans • Vestibular neuronitis • Labyrinthitis • Acute stress disorder • (Others) • Ebstein's anomaly • Kawasaki disease • Global developmental delay
• Charcot joint • Murmurs and heart sounds in children
13.04 Nose 14.03 Psychotic disorders 15.20-21 Genetic disorders
09.08 Miscellaneous • Rhinosinusitis (acute & chronic) • Features that define psychotic 15.07-09 GI disorders • Down + other trisomies
• Joint replacements • Nasal fractures • CSF rhinorrhoea disorders • Abdominal pain • Neuroblastoma • Klinefelter • Triple X • Turner
• Paget's disease of the bone • Epistaxis • Nasal cancers • Schizophrenia • Psychosis • Coeliac disease • Malnutrition [15.21] • Cri du chat • DiGeorge
• Osteoporosis • Antipsychotics • Diarrhoea & vomiting • Williams • Achondroplasia
• Pathological fractures 13.05 Throat [15.08] • Appendicitis • Intussusception • Marfan • Noonan • Fragile X
• Fracture types • Sore throat (includes tonsilitis) 14.04 Personality disorders • Pyloric stenosis • Hirschsprung
• Obstructive sleep apnoea • A: Paranoid, schizoid, schizotypal • Oesophageal atresia 15.22-23 Neonates
09.09 Malignancies & trauma • Stridor – causes • Croup • B: Antisocial, borderline, histrionic, [15.09] • Congenital diaphragmatic hernia • Neonatal sepsis • Seizures
• Osteosarcoma • Chondrosarcoma • Acute epiglottitis • Laryngomalacia narcissistic • Inguinal hernia • Imperforate anus • Respiratory distress • Jaundice
• Ewing's sarcoma • Giant cell tumour • C: Avoidant, dependent, obsessive- • Mid-gut malrotation [15.23] • Necrotising entercolitis
• Bone metastases • Trauma surgery 13.06 Throat convulsive • Gastroschisis & omphalocele • Hypoglycaemia • Hypotonia
• Dysphonia • Dysphagia • Meckel's diverticulum • Minor problems, including skin issues
09.10 Paediatric orthopaedics • Head and neck squamous cell 14.05 Eating disorders & miscellaneous • Infant feeding problems
• Juvenile idiopathic arthritis carcinoma (HNSCC) • Bell's palsy psychiatric disorders 15.24 Miscellaneous
• Transient synovitis of the hip • Anorexia nervosa • Bulimia nervosa 15.10-11 Renal & urological disorders • Non-accidental injury
• Developmental dysplasia 13.07 Throat • Insomnia • Unexplained symptoms • UTIs • Nephrotic syndrome • Screening schedule (perinatal)
• Perthes' • SCFE • Rickets • Neck lumps • Xerostomia • Electroconvulsive therapy • Acute glomerulonephritis • Sudden infant death syndrome
• Paediatric fractures • Salivary gland problems [15.10] • Phimosis • Cryptorchidism - Brief unexplained resolved event
• Teeth problems 14.06 Drugs used in psychiatry & • Hypospadias • Horseshoe kidney • Vaccination schedule
Mental Health Act / Sectioning • Wilms' tumour (nephroblastoma)
• Haemolytic uraemic syndrome
, Rheumatoid arthritis Osteoarthritis Psoriatic arthritis
D: chronic, erosive arthritis. Affects ~1% of (Mx cont) DMARDs D: degenerative joint disorder, the result of Mx: surgical - joint replacement D: chronic inflammatory joint disease
population. • MTX - monitor FBC, LFTs mechanical and biological events that • For pts with significant pain associated with psoriasis. Oligo or mono-
- AE: myelosuppression, liver failure, destabilise the normal process of • Hips: cemented hip replacement, articular initial pattern + DIP
R: F>M, FHx (main), ?smoking pneumonitis degradation and synthesis of articular uncemented HR (in younger, more active
• Sulfasalazine cartilage chondrocytes, extracellular matrix, pts; more expensive), hip resurfacing R: psoriasis, FHx of psoriasis or PA
A/P: Inflamed synovium → infiltration of
- AE: rashes, oligospermia, heinz body and subchondral bone (preserves femoral neck)
Exacerbating factors: trauma, alcohol,
inflammatory cells + cytokines → erosions
anaemia, ILD (lung) • Post-op: physio, home-exercises, walking
• Leflunomide R: >50yo, F>M, obesity, genetic factors, sticks / crutches for ≤6w drugs (βBs, lithium, antimalarials, NSAIDs,
- AE: liver failure, interstitial lung disease, knee alignment, ↑activity, post-trauma • How to avoid dislocation: avoid flexing hip ACEI, infliximab), withdrawal of steroids.
Earlier s/smx: HTN >90', avoid low chairs, do not cross legs, Strep infxn for guttate psoriasis
• Symmetrical arthritis >6w (insidious
development; small → large joints)
• Hydroxychloroquine S/smx: pain, functional difficulties, ↓ROM, sleep on back for first 6w
- AE: Retinopathy, corneal deposits malalignment. Knee > hip > hand Mx: conservative + medical A/P: likely genetic, a/w HLA B27. Sero-
• Swollen, painful joints in hands/feet • Gold – AE: Proteinuria • wt loss, muscle strengthening negative. CD8 T-cells eat away at the
• Stiffness worse in the morning • Penicillamine – AE: proteinuria, ↑MG OA of the hip • non-Rx: supports, braces, TENS, shock- joints.
• ± systemic disturbances • chronic hx of groin ache; ↑by exercise,
© quackquackmed.com
absorbing insoles/shoes
TNFα inhibitors ↓by rest - "C sign" •☝🏻 paracetamol, NSAIDs
Later s/smx:
• Deformities: swan neck, boutonniere,
> indicated if inadequate response to ≥2
DMARDs including MTX
• Oxford Hip Score to Ax severity •✌🏻 Opioids, capsaicin cream, intra-
S/smx:
• Symmetric polyarthritis (similar to RA)
• Etanercept = recombinant protein, acts articular corticosteroids • or asymmetrical oligoarthritis (hands and
Z-thumb, ulnar deviation OA of the hand - PPI must be prescribed with NSAIDs
• ?+ve FHx, F>M, >55yo, ↑risk for hip,
• +ve squeeze test as decoy receptor for TNF-α feet – less common than above)
- SQ admin • Sacroiliitis
knee OA
• R: hypermobility, ↑working with hands
Others: relapsing/remitting monoarthritis of - AE: demyelination, reactivation of TB Complications: • DIP joint disease (10%)
different large joints (palindromic • Infliximab = (mab) binds to TNF-α and • VTE, fracture, nerve injury, surgical site • Athritis mutilans (severe deformity of
• Usually bilateral, basal thumb joint
rheumatism) prevents it from binding TNF receptors infxn; leg-length discrepancy hands, 'telescoping fingers')
(CMC), DIPs
- IV admin • Posterior dislocation - presents acutely • Nail changes (80-90%): pitting,
• Episodic joint pain (intermittent), stiffness
- reactivation of TB with clunk, pain, inability to wt bear. O/E onycholysis, subungual hyperkeratosis,
Dx: clinical + lab confirmation (short)
• Adalimumab: (mab) SQ admin internal rotation, shortening of affected leg loss of nail
• Rheum screen: RF (70%), anti-CCP • painless nodes - Hebedern's (DIP),
• Aseptic loosening (most common reason ± Psoriatic skin lesions
(90-95%) Rituximab Bouchard's (PIP) - 2/2 osteophytes
for revision) + prosthetic joint infxn ± Periarticular disease
• X-rays of hands & feet (NICE rec) • anti-CD20 mab, ↓B cell • Squaring of the thumbs (causes fixed
- Enthesitis
- early: loss of joint space, juxta-articular • two 1g IV infusion, 2 weeks apart adduction of thumb)
- Tenosynovitis (esp hand flexors)
osteoporosis, soft-tissue swelling • AE: infusion reactions 🚩 rest pain, night pain, morning stiffness - Dactylitis - uniquely psoriatic arthritis
>2h → ?alt cause
- periarticular erosions, subluxation
Abatacept (not recommended by NICE)
• Fusion protein that modulates key signal Ix: XR - erosive Δs, new bone formation,
Am College of Rheumatology criteria
• joint involvement required for activation of T-cells; ↓T cell Ix: XR of affected joint - LOSS periostitis, 'pencil in cup' appearance
- more points for more joints prolif, ↓cytokines • Loss of joint space Bloods - ESR, CRP, RF, anti-CCP
- ≥1 small joint must be involved • IV infusion • Osteophyte formation Spondyloarthritides (SpA)
• serology (+ve ↑↑RF, anti-CCP) • Subchondral cysts & sclerosis • Also referred to as seronegative Mx: Tx as for RA
• acute phase reactants (↑CRP, ESR) P: following a/w ↓prognosis r/o RA if needed (FBC, RF, anti-CCP) spondyloarthritis • with mild arthritis, NSAID monotherapy
• duration of smx (>6w) • RF • anti-CCP • HLA-DR4 • Family of diseases including may be sufficient
• poor functional status at presentation - Psoriatic arthritis • Ustekinumab and secukinumab
• X-ray: early erosions (<2y) - Ankylosing spondylosis
Mx:
• Extra-articular features - Reactive arthritis P: better than RA
• Start DMARD asap!!
- monotherapy ± short-course of • Insidious onset • ?F sex - Enteropathic arthritis
- Juvenile-onset SpA (if SpA onset is
bridging prednisolone
Complications / extra-articular manifestations <16yo, except in the case of ankylo-
• Monitoring: CRP + DAS28 score
• Ocular manifestations in 25%: keratoconjunctivitis sicca, sing spondylosis, which does not have
episcleritis, slceritis, corneal ulceration, keratitis a lower age limit of diagnosis)
Flares: • Corticosteroids PO/IM
• Respi: pulmonary fibrosis, pleural effusion, pulmonary - Undifferentiated SpA
nodules, bronchiolitis obliterans, pleurisy • Can be ÷ axial SpA (affecting spine,
• Osteoporosis (2/2 steroids?) pelvis, thorax more) or peripheral
• Ischaemic heart disease (affecting extremities more)
• ↑risk of infections (2/2 DMARDs?) • High correlation to HLA B27 gene
• Depression • Amyloidosis • Test negative to autoantibodies tested
• Felty's syndrome: RA + splenomegaly + neutropenia for (eg RF, ANA, etc)
12.01 Rheumatology – RA, OA, Psoriatic arthritis
ORTHOPAEDIC CONDITIONS • Epilepsy • Status epilepticus
12.01 • Rheumatoid arthritis 12.04 Vasculitic disorders 15.01 • Paediatric life support • Brain tumours
11.01 Orthopaedic emergencies • Osteoarthritis • Wegener's • Churg-Strauss • Newborn life support [15.13] • Neural tube defects
• Septic arthritis • Psoriatic arthritis • Giant cell arteritis • Takayasu arteritis • Intraosseous infusion • Anaphylaxis • Autism spectrum disorder
• Compartment syndrome • Microscopic polyangitis
• Spinal cord compression 12.02 • Ankylosing spondylitis • Polyarteritis nodosa 15.02-03 Infections 15.14-15 Haemonc disorders
- Cauda equina syndrome • Reactive arthritis • Enteropathic arthritis • Polymyalgia rheumatica • Traffic light assessment of kids • Anaemia • Iron deficiency
• Open fractures • Gout • Pseudogout • Henoch-Scholein • Behcet's • Meningitis • Encephalitis • Sickle cell disease
• Tendon sheath infection (hand) • Fibromyalgia • Chronic fatigue syndrome [15.03] • Measles • Mumps • Rubella • Hereditary spherocytosis
12.05 • Anti-GBM disease • Erythema infectiosum • HFMD • Henoch-Schonlein purpura
11.02 Upper limb orthopaedic issues 12.03 • Systemic lupus erythematosus • Juvenile idiopathic arthritis • Roseola infantum • Chickenpox [15.15] • Immune thrombocytopaenia
• Shoulder • Elbow • Systemic sclerosis (scleroderma) • Adult-onset Still's disease • HIV in children • Acute lymphoblastic leukaemia
• Fractures: Colles', Smith's, Barton's, • Dermatomyositis • Polymyositis • Hypermobility disorders • Primary immunodeficiencies
Monteggia's, Galeazzi • Sjogren syndrome • Autoantibodies (list) 15.04 Respiratory disorders • Severe combined immunodeficiency
• Upper respiratory tract infections
11.03 Hand & foot - Croup - Epiglottitis 15.16-18 Endocrine disorders
• Hand • Ganglions 13 EAR NOSE THROAT 14 PSYCHIATRY - Bacterial tracheitis - Diphtheria • Diabetes mellitus + MODY • DKA
© quackquackmed.com
• Foot, incl club foot • Lower respiratory tract infections • Hypothyroidism
13.01 Ear 14a Substance abuse / overdose - Bronchiolitis - Viral-induced wheeze [15.17] • Hyperthyroidism
11.04 Hip, including neck of femur • Otalgia • Discharging ear • Cannabis • MDMA/Ecstasy - Pneumonia - Whooping cough • Inherited metabolic diseases
fractures • Otitis externa • Otitis media • Cocaine • Nitrous oxide • Asthma • Cystic fibrosis [02.04] • Glycogen storage disorders
• Glue ear • LSD / acid • Opioid misuse • Phenylalanine ketonuria
11.05 Knee & ankle issues • Overdose / poisoning 15.05-06 Cardiovascular disorders • Lysosomal storage diseases
13.02 Ear • Hearing loss • Ventricular septal defect (VSD) [15.18] • Precocious puberty
09.06 Spinal orthopaedics • Tinnitus • Vertigo 14.01 Mood disorders • Atrial septal defect (ASD) • Congenital adrenal hyperplasia
Including rib fractures, autonomic • Depression • Suicide • Patent ductus arteriosus • Genetic disorders summary
dysreflexia 13.03 Ear • Childhood deafness • Bipolar disorder • Coarctation of the aorta
• Deafness in adults • Otosclerosis • Congenital aortic valve stenosis 15.19 Developmental disorders
09.07 Miscellaneous • Vestibular schwannoma 14.02 Anxiety & related disorders • Eisenmenger's syndrome • Developmental milestones
• Dermatomes • Fat embolism • Benign paroxysmal positional vertigo • Generalised anxiety disorder [15.06] • Tetralogy of Fallot (ToF) • Speech delay • Cerebral palsy
• Osteomalacia • Osteomyelitis • Meniere's disease • Panic disorders • OCD • PTSD • Transposition of great arteries (TGA) • Muscular dystrophies (incl Duchenne)
• Osteochondritis dissecans • Vestibular neuronitis • Labyrinthitis • Acute stress disorder • (Others) • Ebstein's anomaly • Kawasaki disease • Global developmental delay
• Charcot joint • Murmurs and heart sounds in children
13.04 Nose 14.03 Psychotic disorders 15.20-21 Genetic disorders
09.08 Miscellaneous • Rhinosinusitis (acute & chronic) • Features that define psychotic 15.07-09 GI disorders • Down + other trisomies
• Joint replacements • Nasal fractures • CSF rhinorrhoea disorders • Abdominal pain • Neuroblastoma • Klinefelter • Triple X • Turner
• Paget's disease of the bone • Epistaxis • Nasal cancers • Schizophrenia • Psychosis • Coeliac disease • Malnutrition [15.21] • Cri du chat • DiGeorge
• Osteoporosis • Antipsychotics • Diarrhoea & vomiting • Williams • Achondroplasia
• Pathological fractures 13.05 Throat [15.08] • Appendicitis • Intussusception • Marfan • Noonan • Fragile X
• Fracture types • Sore throat (includes tonsilitis) 14.04 Personality disorders • Pyloric stenosis • Hirschsprung
• Obstructive sleep apnoea • A: Paranoid, schizoid, schizotypal • Oesophageal atresia 15.22-23 Neonates
09.09 Malignancies & trauma • Stridor – causes • Croup • B: Antisocial, borderline, histrionic, [15.09] • Congenital diaphragmatic hernia • Neonatal sepsis • Seizures
• Osteosarcoma • Chondrosarcoma • Acute epiglottitis • Laryngomalacia narcissistic • Inguinal hernia • Imperforate anus • Respiratory distress • Jaundice
• Ewing's sarcoma • Giant cell tumour • C: Avoidant, dependent, obsessive- • Mid-gut malrotation [15.23] • Necrotising entercolitis
• Bone metastases • Trauma surgery 13.06 Throat convulsive • Gastroschisis & omphalocele • Hypoglycaemia • Hypotonia
• Dysphonia • Dysphagia • Meckel's diverticulum • Minor problems, including skin issues
09.10 Paediatric orthopaedics • Head and neck squamous cell 14.05 Eating disorders & miscellaneous • Infant feeding problems
• Juvenile idiopathic arthritis carcinoma (HNSCC) • Bell's palsy psychiatric disorders 15.24 Miscellaneous
• Transient synovitis of the hip • Anorexia nervosa • Bulimia nervosa 15.10-11 Renal & urological disorders • Non-accidental injury
• Developmental dysplasia 13.07 Throat • Insomnia • Unexplained symptoms • UTIs • Nephrotic syndrome • Screening schedule (perinatal)
• Perthes' • SCFE • Rickets • Neck lumps • Xerostomia • Electroconvulsive therapy • Acute glomerulonephritis • Sudden infant death syndrome
• Paediatric fractures • Salivary gland problems [15.10] • Phimosis • Cryptorchidism - Brief unexplained resolved event
• Teeth problems 14.06 Drugs used in psychiatry & • Hypospadias • Horseshoe kidney • Vaccination schedule
Mental Health Act / Sectioning • Wilms' tumour (nephroblastoma)
• Haemolytic uraemic syndrome
, Rheumatoid arthritis Osteoarthritis Psoriatic arthritis
D: chronic, erosive arthritis. Affects ~1% of (Mx cont) DMARDs D: degenerative joint disorder, the result of Mx: surgical - joint replacement D: chronic inflammatory joint disease
population. • MTX - monitor FBC, LFTs mechanical and biological events that • For pts with significant pain associated with psoriasis. Oligo or mono-
- AE: myelosuppression, liver failure, destabilise the normal process of • Hips: cemented hip replacement, articular initial pattern + DIP
R: F>M, FHx (main), ?smoking pneumonitis degradation and synthesis of articular uncemented HR (in younger, more active
• Sulfasalazine cartilage chondrocytes, extracellular matrix, pts; more expensive), hip resurfacing R: psoriasis, FHx of psoriasis or PA
A/P: Inflamed synovium → infiltration of
- AE: rashes, oligospermia, heinz body and subchondral bone (preserves femoral neck)
Exacerbating factors: trauma, alcohol,
inflammatory cells + cytokines → erosions
anaemia, ILD (lung) • Post-op: physio, home-exercises, walking
• Leflunomide R: >50yo, F>M, obesity, genetic factors, sticks / crutches for ≤6w drugs (βBs, lithium, antimalarials, NSAIDs,
- AE: liver failure, interstitial lung disease, knee alignment, ↑activity, post-trauma • How to avoid dislocation: avoid flexing hip ACEI, infliximab), withdrawal of steroids.
Earlier s/smx: HTN >90', avoid low chairs, do not cross legs, Strep infxn for guttate psoriasis
• Symmetrical arthritis >6w (insidious
development; small → large joints)
• Hydroxychloroquine S/smx: pain, functional difficulties, ↓ROM, sleep on back for first 6w
- AE: Retinopathy, corneal deposits malalignment. Knee > hip > hand Mx: conservative + medical A/P: likely genetic, a/w HLA B27. Sero-
• Swollen, painful joints in hands/feet • Gold – AE: Proteinuria • wt loss, muscle strengthening negative. CD8 T-cells eat away at the
• Stiffness worse in the morning • Penicillamine – AE: proteinuria, ↑MG OA of the hip • non-Rx: supports, braces, TENS, shock- joints.
• ± systemic disturbances • chronic hx of groin ache; ↑by exercise,
© quackquackmed.com
absorbing insoles/shoes
TNFα inhibitors ↓by rest - "C sign" •☝🏻 paracetamol, NSAIDs
Later s/smx:
• Deformities: swan neck, boutonniere,
> indicated if inadequate response to ≥2
DMARDs including MTX
• Oxford Hip Score to Ax severity •✌🏻 Opioids, capsaicin cream, intra-
S/smx:
• Symmetric polyarthritis (similar to RA)
• Etanercept = recombinant protein, acts articular corticosteroids • or asymmetrical oligoarthritis (hands and
Z-thumb, ulnar deviation OA of the hand - PPI must be prescribed with NSAIDs
• ?+ve FHx, F>M, >55yo, ↑risk for hip,
• +ve squeeze test as decoy receptor for TNF-α feet – less common than above)
- SQ admin • Sacroiliitis
knee OA
• R: hypermobility, ↑working with hands
Others: relapsing/remitting monoarthritis of - AE: demyelination, reactivation of TB Complications: • DIP joint disease (10%)
different large joints (palindromic • Infliximab = (mab) binds to TNF-α and • VTE, fracture, nerve injury, surgical site • Athritis mutilans (severe deformity of
• Usually bilateral, basal thumb joint
rheumatism) prevents it from binding TNF receptors infxn; leg-length discrepancy hands, 'telescoping fingers')
(CMC), DIPs
- IV admin • Posterior dislocation - presents acutely • Nail changes (80-90%): pitting,
• Episodic joint pain (intermittent), stiffness
- reactivation of TB with clunk, pain, inability to wt bear. O/E onycholysis, subungual hyperkeratosis,
Dx: clinical + lab confirmation (short)
• Adalimumab: (mab) SQ admin internal rotation, shortening of affected leg loss of nail
• Rheum screen: RF (70%), anti-CCP • painless nodes - Hebedern's (DIP),
• Aseptic loosening (most common reason ± Psoriatic skin lesions
(90-95%) Rituximab Bouchard's (PIP) - 2/2 osteophytes
for revision) + prosthetic joint infxn ± Periarticular disease
• X-rays of hands & feet (NICE rec) • anti-CD20 mab, ↓B cell • Squaring of the thumbs (causes fixed
- Enthesitis
- early: loss of joint space, juxta-articular • two 1g IV infusion, 2 weeks apart adduction of thumb)
- Tenosynovitis (esp hand flexors)
osteoporosis, soft-tissue swelling • AE: infusion reactions 🚩 rest pain, night pain, morning stiffness - Dactylitis - uniquely psoriatic arthritis
>2h → ?alt cause
- periarticular erosions, subluxation
Abatacept (not recommended by NICE)
• Fusion protein that modulates key signal Ix: XR - erosive Δs, new bone formation,
Am College of Rheumatology criteria
• joint involvement required for activation of T-cells; ↓T cell Ix: XR of affected joint - LOSS periostitis, 'pencil in cup' appearance
- more points for more joints prolif, ↓cytokines • Loss of joint space Bloods - ESR, CRP, RF, anti-CCP
- ≥1 small joint must be involved • IV infusion • Osteophyte formation Spondyloarthritides (SpA)
• serology (+ve ↑↑RF, anti-CCP) • Subchondral cysts & sclerosis • Also referred to as seronegative Mx: Tx as for RA
• acute phase reactants (↑CRP, ESR) P: following a/w ↓prognosis r/o RA if needed (FBC, RF, anti-CCP) spondyloarthritis • with mild arthritis, NSAID monotherapy
• duration of smx (>6w) • RF • anti-CCP • HLA-DR4 • Family of diseases including may be sufficient
• poor functional status at presentation - Psoriatic arthritis • Ustekinumab and secukinumab
• X-ray: early erosions (<2y) - Ankylosing spondylosis
Mx:
• Extra-articular features - Reactive arthritis P: better than RA
• Start DMARD asap!!
- monotherapy ± short-course of • Insidious onset • ?F sex - Enteropathic arthritis
- Juvenile-onset SpA (if SpA onset is
bridging prednisolone
Complications / extra-articular manifestations <16yo, except in the case of ankylo-
• Monitoring: CRP + DAS28 score
• Ocular manifestations in 25%: keratoconjunctivitis sicca, sing spondylosis, which does not have
episcleritis, slceritis, corneal ulceration, keratitis a lower age limit of diagnosis)
Flares: • Corticosteroids PO/IM
• Respi: pulmonary fibrosis, pleural effusion, pulmonary - Undifferentiated SpA
nodules, bronchiolitis obliterans, pleurisy • Can be ÷ axial SpA (affecting spine,
• Osteoporosis (2/2 steroids?) pelvis, thorax more) or peripheral
• Ischaemic heart disease (affecting extremities more)
• ↑risk of infections (2/2 DMARDs?) • High correlation to HLA B27 gene
• Depression • Amyloidosis • Test negative to autoantibodies tested
• Felty's syndrome: RA + splenomegaly + neutropenia for (eg RF, ANA, etc)
12.01 Rheumatology – RA, OA, Psoriatic arthritis
