Unlike named nerve pathology, radiculopathy follows a dermatomal distribution. This means that the pattern of sensory loss cannot be explained by a single named nerve. For example, while the ulnar nerve supplies the ulnar border of the hand and the medial antebrachial cutaneous nerve supplies the medial forearm, these areas are actually covered by the C8 dermatome.

It’s important to note that thumb flexion would not be affected in ulnar nerve lesions, and carpal tunnel syndrome would only affect flexion of the thumb without producing this specific pattern of sensory loss. On the other hand, a cerebrovascular accident would likely result in complete upper limb weakness or numbness.

Understanding Cervical Spondylosis

Cervical spondylosis is a prevalent condition that arises from osteoarthritis. It is characterized by neck pain, which can be mistaken for headaches or other conditions. This condition is caused by the degeneration of the cervical spine, which is the part of the spine that is located in the neck. As the spine degenerates, it can cause the vertebrae to rub against each other, leading to pain and discomfort.

Cervical spondylosis can also cause complications such as radiculopathy and myelopathy. Radiculopathy occurs when the nerves that run from the spinal cord to the arms and legs become compressed or damaged. This can cause pain, numbness, and weakness in the affected area. Myelopathy, on the other hand, occurs when the spinal cord itself becomes compressed or damaged. This can cause a range of symptoms, including difficulty walking, loss of bladder or bowel control, and even paralysis.

A rupture of the biceps tendon can result in a deformity known as the ‘Popeye’ sign in the middle of the upper arm. This is likely the case for the patient, given their reported symptoms and medical history, including smoking and steroid use. A humeral fracture is unlikely, as there is no indication of trauma. Impingement syndrome and radial head fracture are also unlikely, as the patient’s symptoms do not match the typical findings for these conditions.

Understanding Biceps Rupture: Causes, Symptoms, and Diagnosis

The biceps muscle is composed of two tendons that attach to the glenoid and coracoid process, respectively. These tendons then insert onto the radial tuberosity. A biceps tendon rupture occurs when one of these tendons separates from its attachment site or is torn across its full width. This type of injury is more common in men than women, with proximal biceps tendon ruptures occurring in older patients over the age of 60 and accounting for 90% of cases. On the other hand, distal biceps tendon ruptures are less common and usually occur in men around the age of 40.

Risk factors for biceps rupture include heavy overhead activities, shoulder overuse or underlying shoulder injuries, smoking, and corticosteroid use. The mechanism of injury differs between proximal and distal ruptures. Proximal ruptures typically occur during the descent phase of a pull-up, while distal ruptures occur when a flexed elbow is suddenly and forcefully extended while the biceps muscle is contracted.

Symptoms of biceps rupture include a sudden pop or tear followed by pain, bruising, and swelling. Proximal ruptures can cause a Popeye deformity, while distal ruptures can cause a reverse Popeye deformity. Weakness in the shoulder and elbow typically follows, including difficulty with supination. Diagnosis starts with a basic examination, palpation of the affected area, and assessment of neurovascular function in the upper extremities. The biceps squeeze test can also be performed to check for intactness. Musculoskeletal ultrasound is the first investigation for suspected biceps tendon rupture, while MRI can be considered if there is a limited examination or likely concomitant pathology. Urgent MRI is necessary for suspected distal biceps tendon rupture, as diagnosis on clinical signs alone is challenging and usually requires surgical intervention.

After a fragility fracture in women aged 75 or older, a DEXA scan is not required to diagnose osteoporosis and start bisphosphonate treatment, with alendronate being the first-line option. The patient in the scenario has already experienced a fragility fracture and is over 75, so a DEXA scan is unnecessary as it will not alter her management. A skeletal survey is also not needed as there are no indications of bone pathology. Raloxifene is a second-line treatment for osteoporosis and not appropriate for the patient who has had a neck of femur fracture, making alendronate the initial choice.

The NICE guidelines for managing osteoporosis in postmenopausal women include offering vitamin D and calcium supplementation, with alendronate being the first-line treatment. If a patient cannot tolerate alendronate, risedronate or etidronate may be given as second-line drugs, with strontium ranelate or raloxifene as options if those cannot be taken. Treatment criteria for patients not taking alendronate are based on age, T-score, and risk factors. Bisphosphonates have been shown to reduce the risk of fractures, with alendronate and risedronate being superior to etidronate in preventing hip fractures. Other treatments include selective estrogen receptor modulators, strontium ranelate, denosumab, teriparatide, and hormone replacement therapy. Hip protectors and falls risk assessment may also be considered in management.

Patients who are using methotrexate must use effective contraception during treatment and for at least 6 months after treatment, whether they are male or female. In this case, the patient’s husband is taking methotrexate, which inhibits dihydrofolate reductase and folic acid metabolism. Therefore, both partners should stop taking methotrexate for 6 months and use effective contraception before attempting to conceive. Methotrexate can damage sperm in men and eggs in women, which can lead to severe complications such as neural tube defects in the fetus. Additional folic acid supplements will not significantly reduce the risk of complications associated with methotrexate. Therefore, both partners should use effective contraception during the time the husband is taking methotrexate. The advice to take 400 micrograms or 5 milligrams of folic acid until the end of the first trimester is incorrect in this case, as the couple should delay trying for a pregnancy for 6 months due to the husband’s methotrexate use.

Methotrexate: An Antimetabolite with Potentially Life-Threatening Side Effects

Methotrexate is an antimetabolite drug that inhibits the enzyme dihydrofolate reductase, which is essential for the synthesis of purines and pyrimidines. It is commonly used to treat inflammatory arthritis, psoriasis, and some types of leukemia. However, it is considered an important drug due to its potential for life-threatening side effects. Careful prescribing and close monitoring are essential to ensure patient safety.

The adverse effects of methotrexate include mucositis, myelosuppression, pneumonitis, pulmonary fibrosis, and liver fibrosis. The most common pulmonary manifestation is pneumonitis, which typically develops within a year of starting treatment and presents with non-productive cough, dyspnea, malaise, and fever. Women should avoid pregnancy for at least 6 months after treatment has stopped, and men using methotrexate need to use effective contraception for at least 6 months after treatment.

When prescribing methotrexate, it is important to follow guidelines and monitor patients regularly. Methotrexate is taken weekly, and FBC, U&E, and LFTs need to be regularly monitored. The starting dose is 7.5 mg weekly, and folic acid 5mg once weekly should be co-prescribed, taken more than 24 hours after the methotrexate dose. Only one strength of methotrexate tablet should be prescribed, usually 2.5 mg. It is also important to avoid prescribing trimethoprim or co-trimoxazole concurrently, as it increases the risk of marrow aplasia, and high-dose aspirin increases the risk of methotrexate toxicity.

In case of methotrexate toxicity, the treatment of choice is folinic acid. Methotrexate is a drug with a high potential for patient harm, and it is crucial to be familiar with guidelines relating to its use to ensure patient safety.

Medial epicondylitis, also known as golfers’ elbow, is a condition where the tendons of the wrist flexors become damaged due to repetitive use of these muscles. A patient presenting with pain at the medial epicondyle, such as a golf player, is likely to have this condition. Examination of the patient would reveal worsening symptoms when the wrist is flexed and pronated, as this aggravates the wrist flexor muscles at their common attachment point on the medial epicondyle of the humerus.

If a patient has a fluctuant swelling over the olecranon process, it suggests olecranon bursitis, which is caused by inflammation of the fluid-filled bursa overlying the olecranon process. This condition would present with swelling, pain, and tenderness over the olecranon process, rather than the medial epicondyle.

It is incorrect to assume that worsening symptoms would occur with the wrist extended and pronated or extended and supinated in a patient with medial epicondylitis. Lateral epicondylitis, also known as tennis elbow, would cause worsening symptoms when the wrist is extended and supinated, as this aggravates the wrist extensors at their insertion point on the lateral epicondyle of the humerus.

Understanding Medial Epicondylitis

Medial epicondylitis, commonly referred to as golfer’s elbow, is a condition characterized by pain and tenderness in the medial epicondyle. This area is located on the inner side of the elbow and is responsible for attaching the forearm muscles to the elbow. The pain is often aggravated by wrist flexion and pronation, which are movements commonly used in golf swings and other activities that involve repetitive gripping and twisting motions.

In addition to pain and tenderness, individuals with medial epicondylitis may also experience numbness or tingling in the fourth and fifth fingers due to ulnar nerve involvement. This nerve runs along the inner side of the elbow and can become compressed or irritated in cases of medial epicondylitis.

Overall, understanding the symptoms and causes of medial epicondylitis can help individuals take steps to prevent and manage this condition. This may include modifying activities that place strain on the elbow, using proper equipment and technique, and seeking medical treatment if symptoms persist.

If a person experiences a crush injury, swelling in their limb, and an inability to move their digits, it is important to consider the possibility of compartment syndrome. This condition may necessitate a fasciotomy.

Compartment syndrome is a complication that can occur after fractures or vascular injuries. It is characterized by increased pressure within a closed anatomical space, which can lead to tissue death. Supracondylar fractures and tibial shaft injuries are the most common fractures associated with compartment syndrome. Symptoms include pain, numbness, paleness, and possible paralysis of the affected muscle group. Diagnosis is made by measuring intracompartmental pressure, with pressures over 20 mmHg being abnormal and over 40mmHg being diagnostic. X-rays typically do not show any pathology. Treatment involves prompt and extensive fasciotomies, with careful attention to decompressing deep muscles in the lower limb. Patients may develop myoglobinuria and require aggressive IV fluids. In severe cases, debridement and amputation may be necessary, as muscle death can occur within 4-6 hours.

To assess for an Achilles tendon rupture, Simmonds’ triad can be used. This involves three components: palpating the Achilles tendon to check for a gap, observing the angle of declination at rest to see if the affected foot is more dorsiflexed than the other, and performing the calf squeeze test to see if squeezing the calf causes the foot to plantarflex as expected. It’s important to note that struggling to stand on tiptoes or having an abnormal gait are not part of Simmonds’ triad.

Achilles tendon disorders are a common cause of pain in the back of the heel. These disorders can include tendinopathy, partial tears, and complete ruptures of the Achilles tendon. Certain factors, such as the use of quinolone antibiotics and high cholesterol levels, can increase the risk of developing these disorders. Symptoms of Achilles tendinopathy typically include gradual onset of pain that worsens with activity, as well as morning stiffness. Treatment for this condition usually involves pain relief, reducing activities that exacerbate the pain, and performing calf muscle eccentric exercises.

In contrast, an Achilles tendon rupture is a more serious condition that requires immediate medical attention. This type of injury is often caused by sudden, forceful movements during sports or running. Symptoms of an Achilles tendon rupture include an audible popping sound, sudden and severe pain in the calf or ankle, and an inability to walk or continue the activity. To help diagnose an Achilles tendon rupture, doctors may use Simmond’s triad, which involves examining the foot for abnormal angles and feeling for a gap in the tendon. Ultrasound is typically the first imaging test used to confirm a diagnosis of Achilles tendon rupture. If a rupture is suspected, it is important to seek medical attention from an orthopaedic specialist as soon as possible.

For patients with antiphospholipid syndrome who have not experienced a thrombosis before, the recommended thromboprophylaxis is low-dose aspirin. The use of direct oral anticoagulants (DOACs) is not advised as studies have shown a higher incidence of clots in antiphospholipid patients on DOACs compared to warfarin. Low-molecular-weight heparin is not recommended for long-term use as it is administered subcutaneously. Warfarin with a target INR of 2-3 is appropriate only for patients who have previously suffered from venous or arterial clots.

Antiphospholipid syndrome is a condition that can be acquired and is characterized by a higher risk of both venous and arterial thrombosis, recurrent fetal loss, and thrombocytopenia. It can occur as a primary disorder or as a secondary condition to other diseases, with systemic lupus erythematosus being the most common. One important point to remember for exams is that antiphospholipid syndrome can cause a paradoxical increase in the APTT. This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade. Other features of this condition include livedo reticularis, pre-eclampsia, and pulmonary hypertension.

Antiphospholipid syndrome can also be associated with other autoimmune disorders, lymphoproliferative disorders, and, rarely, phenothiazines. Management of this condition is based on EULAR guidelines. Primary thromboprophylaxis involves low-dose aspirin, while secondary thromboprophylaxis depends on the type of thromboembolic event. Initial venous thromboembolic events require lifelong warfarin with a target INR of 2-3, while recurrent venous thromboembolic events require lifelong warfarin and low-dose aspirin. Arterial thrombosis should be treated with lifelong warfarin with a target INR of 2-3.

The primary immunoglobulin present in breast milk, tears, saliva, and GI secretions is IgA. The function of IgD is uncertain, but it may be present on B-cell membranes and in small quantities in serum. IgE is responsible for triggering allergic and anaphylactic reactions and is present on cell membranes. IgG is the most prevalent immunoglobulin in serum, lymph, and the GI tract, and it is the only one that can pass through the placenta.

Characteristics of Immunoglobulins

Immunoglobulins, also known as antibodies, are proteins produced by the immune system to help defend the body against foreign substances. There are five types of immunoglobulins found in the body, each with their own unique characteristics.

The most abundant type of immunoglobulin is IgG, which enhances phagocytosis of bacteria and viruses, fixes complement, and can pass to the fetal circulation. IgA, on the other hand, is the most commonly produced immunoglobulin in the body and provides localized protection on mucous membranes. It is also found in breast milk and the secretions of digestive, respiratory, and urogenital tracts and systems. IgM is the first immunoglobulin to be secreted in response to an infection and fixes complement, but does not pass to the fetal circulation. It is also responsible for producing anti-A and B blood antibodies.

IgD’s role in the immune system is largely unknown, but it is involved in the activation of B cells. Lastly, IgE is the least abundant isotype in blood serum and mediates type 1 hypersensitivity reactions. It is synthesized by plasma cells and provides immunity to parasites such as helminths by binding to Fc receptors found on the surface of mast cells and basophils.

In summary, each type of immunoglobulin has its own unique function and plays a crucial role in defending the body against foreign substances.

Lachman’s test is the superior method for diagnosing anterior cruciate ligament (ACL) injuries compared to the anterior draw test. ACL injuries are often caused by sudden twisting or awkward landings, resulting in a popping sensation, immediate swelling, and difficulty bearing weight. Lachman’s test is more sensitive than the anterior draw test and is therefore the most reliable method for diagnosing ACL injuries. The empty can test is not relevant to knee examinations as it is used to assess the supraspinatus muscle in the shoulder. McMurray’s’s test is used to identify meniscal tears, which can present similarly to ACL injuries, but can be differentiated by the timing of swelling. The posterior draw test is used to diagnose posterior cruciate ligament (PCL) injuries, which are typically caused by a sudden force to the front of the knee.

The anterior cruciate ligament (ACL) is a knee ligament that is frequently injured, with non-contact injuries being the most common cause. However, a lateral blow to the knee or skiing can also cause ACL injuries. Symptoms of an ACL injury include a sudden popping sound, knee swelling, and a feeling of instability or that the knee may give way. To diagnose an ACL injury, doctors may perform an anterior draw test or a Lachman’s test. During the anterior draw test, the patient lies on their back with their knee at a 90-degree angle, and the examiner pulls the tibia forward to assess the amount of anterior motion in comparison to the femur. An intact ACL should prevent forward translational movement. Lachman’s test is a variant of the anterior draw test, but the knee is at a 20-30 degree angle, and it is considered more reliable than the anterior draw test.

Chemotherapy is a significant risk factor for avascular necrosis, which is the process of ischaemic-driven bone cell death. Prolonged oral corticosteroid use is also a major risk factor. Age, alcohol consumption, and sex are less likely to be significant risk factors. Inhaled corticosteroids have a lower dose and are therefore less likely to be a significant risk factor.

Understanding Avascular Necrosis of the Hip

Avascular necrosis of the hip is a condition where bone tissue dies due to a loss of blood supply, leading to bone destruction and loss of joint function. This condition typically affects the epiphysis of long bones, such as the femur. There are several causes of avascular necrosis, including long-term steroid use, chemotherapy, alcohol excess, and trauma.

Initially, avascular necrosis may not present with any symptoms, but as the condition progresses, pain in the affected joint may occur. Plain x-ray findings may be normal in the early stages, but osteopenia and microfractures may be seen. As the condition worsens, collapse of the articular surface may result in the crescent sign.

MRI is the preferred investigation for avascular necrosis as it is more sensitive than radionuclide bone scanning. In severe cases, joint replacement may be necessary to manage the condition. Understanding the causes, features, and management of avascular necrosis of the hip is crucial for early detection and effective treatment.

Fractures of the 5th metatarsal are commonly caused by the foot and ankle being forcefully inverted. These types of fractures are often seen in athletes, including dancers, football players, and rugby players, but can also occur from minor incidents such as stepping off a curb. Avulsion fractures are a specific type of 5th metatarsal fracture that result from the peroneus brevis muscle pulling on the proximal part of the bone during foot inversion. It is important to note that 5th metatarsal fractures are not associated with any other movements of the ankle or hip.

Metatarsal fractures are a common occurrence, with the potential to affect one or multiple metatarsals. These fractures can result from direct trauma or repeated mechanical stress, known as stress fractures. The metatarsals are particularly susceptible to stress fractures, with the second metatarsal shaft being the most common site. The proximal 5th metatarsal is the most commonly fractured metatarsal, while the 1st metatarsal is the least commonly fractured.

Fractures of the proximal 5th metatarsal can be classified as either proximal avulsion fractures or Jones fractures. Proximal avulsion fractures occur at the proximal tuberosity and are often associated with lateral ankle sprains. Jones fractures, on the other hand, are transverse fractures at the metaphyseal-diaphyseal junction and are much less common.

Symptoms of metatarsal fractures include pain, bony tenderness, swelling, and an antalgic gait. X-rays are typically used to distinguish between displaced and non-displaced fractures, which guides subsequent management options. However, stress fractures may not appear on X-rays and may require an isotope bone scan or MRI to establish their presence. Overall, metatarsal fractures are a common injury that can result from a variety of causes and require prompt diagnosis and management.

Psoriatic arthritis is characterized by specific x-ray features known as ‘plantar spur’ and ‘pencil and cup’ deformity. In contrast, osteoarthritis displays ‘LOSS’ changes, including loss of joint space, osteophytes, subchondral sclerosis, and subchondral cysts. Rheumatoid arthritis presents with ‘LESS’ changes, such as loss of joint space, erosions, soft bones, and soft tissue swelling. Ankylosing spondylitis is identified by sacroiliitis on x-ray.

Psoriatic arthropathy is a type of inflammatory arthritis that is associated with psoriasis. It is classified as one of the seronegative spondyloarthropathies and is known to have a poor correlation with cutaneous psoriasis. In fact, it often precedes the development of skin lesions. This condition affects both males and females equally, with around 10-20% of patients with skin lesions developing an arthropathy.

The presentation of psoriatic arthropathy can vary, with different patterns of joint involvement. The most common type is symmetric polyarthritis, which is very similar to rheumatoid arthritis and affects around 30-40% of cases. Asymmetrical oligoarthritis is another type, which typically affects the hands and feet and accounts for 20-30% of cases. Sacroiliitis, DIP joint disease, and arthritis mutilans (severe deformity of fingers/hand) are other patterns of joint involvement. Other signs of psoriatic arthropathy include psoriatic skin lesions, periarticular disease, enthesitis, tenosynovitis, dactylitis, and nail changes.

To diagnose psoriatic arthropathy, X-rays are often used. These can reveal erosive changes and new bone formation, as well as periostitis and a pencil-in-cup appearance. Management of this condition should be done by a rheumatologist, and treatment is similar to that of rheumatoid arthritis. However, there are some differences, such as the use of monoclonal antibodies like ustekinumab and secukinumab. Mild peripheral arthritis or mild axial disease may be treated with NSAIDs alone, rather than all patients being on disease-modifying therapy as with RA. Overall, psoriatic arthropathy has a better prognosis than RA.

Gout is not the correct diagnosis in this case. While it is a possible cause of monoarthritis, the radiological findings and the affected joint suggest pseudogout as a more likely cause. Psoriatic arthritis is also an unlikely diagnosis, as this type of inflammatory arthritis typically presents in multiple joints and may be associated with a family history or psoriatic rash. Similarly, while rheumatoid arthritis can present as monoarthritis, it is more commonly seen as small joint polyarthritis with erosions and osteopenia visible on x-ray. It is important not to miss the correct diagnosis in cases of monoarthritis.

Pseudogout, also known as acute calcium pyrophosphate crystal deposition disease, is a type of microcrystal synovitis that occurs when calcium pyrophosphate dihydrate crystals are deposited in the synovium. This condition is more common in older individuals, but those under 60 years of age may develop it if they have underlying risk factors such as haemochromatosis, hyperparathyroidism, low magnesium or phosphate levels, acromegaly, or Wilson’s disease. The knee, wrist, and shoulders are the most commonly affected joints, and joint aspiration may reveal weakly-positively birefringent rhomboid-shaped crystals. X-rays may show chondrocalcinosis, which appears as linear calcifications of the meniscus and articular cartilage in the knee. Treatment involves joint fluid aspiration to rule out septic arthritis, as well as the use of NSAIDs or steroids, as with gout.

Reactive arthritis does not usually develop acutely, but can appear up to 4 weeks after the initial infection and may have a relapsing-remitting course lasting several months. The correct treatment for this patient’s severe polyarthritis would be oral prednisolone, with dosing based on the severity of the arthritis and tapering to the lowest effective dose. TNF inhibitor therapy would not be appropriate in this case, but may be considered for patients with refractory reactive arthritis. Celecoxib is not the correct choice as the patient did not respond to regular ibuprofen, and intra-articular injections would not be effective for multiple joints and systemic symptoms.

Understanding Reactive Arthritis: Symptoms and Features

Reactive arthritis is a type of seronegative spondyloarthropathy that is associated with HLA-B27. It was previously known as Reiter’s syndrome, which was characterized by a triad of urethritis, conjunctivitis, and arthritis following a dysenteric illness during World War II. However, later studies revealed that patients could also develop symptoms after a sexually transmitted infection, now referred to as sexually acquired reactive arthritis (SARA).

Reactive arthritis is defined as an arthritis that develops after an infection, but the organism cannot be recovered from the joint. The symptoms typically develop within four weeks of the initial infection and last for around 4-6 months. Approximately 25% of patients experience recurrent episodes, while 10% develop chronic disease. The arthritis is usually an asymmetrical oligoarthritis of the lower limbs, and patients may also experience dactylitis.

Other symptoms of reactive arthritis include urethritis, conjunctivitis (seen in 10-30% of patients), and anterior uveitis. Skin symptoms may also occur, such as circinate balanitis (painless vesicles on the coronal margin of the prepuce) and keratoderma blennorrhagica (waxy yellow/brown papules on palms and soles). A helpful mnemonic to remember the symptoms of reactive arthritis is Can’t see, pee, or climb a tree.

In conclusion, understanding the symptoms and features of reactive arthritis is crucial for early diagnosis and treatment. While the condition can be recurrent or chronic, prompt management can help alleviate symptoms and improve quality of life for affected individuals.

The patient’s symptoms are indicative of a hip dislocation, which is consistent with their reported injury. It is common for the sciatic nerve to be damaged or stretched during a posterior hip dislocation, as it runs behind the femur. The pain experienced by the patient follows the path of the sciatic nerve, and the foot drop is a result of damage to the common peroneal nerve, which is supplied by the sciatic nerve. While femoral nerve injury is also possible with a posterior hip dislocation, it would result in different symptoms such as loss of sensation in the front and inside of the thigh and weakness in hip flexion and knee extension. The obturator nerve and pudendal nerve are unlikely to be affected in this case, as they would cause different symptoms such as weakness in thigh abduction or sensory impairment to the external genitalia and bladder/bowel dysfunction, respectively.

Understanding Hip Dislocation: Types, Management, and Complications

Hip dislocation is a painful condition that occurs when the ball and socket joint of the hip are separated. This is usually caused by direct trauma, such as road traffic accidents or falls from a significant height. The force required to cause hip dislocation can also result in other fractures and life-threatening injuries. Therefore, prompt diagnosis and appropriate management are crucial to reduce morbidity.

There are three types of hip dislocation: posterior, anterior, and central. Posterior dislocation is the most common, accounting for 90% of cases. It causes the affected leg to be shortened, adducted, and internally rotated. On the other hand, anterior dislocation results in abduction and external rotation of the affected leg, without leg shortening. Central dislocation is rare and occurs when the femoral head is displaced in all directions.

The management of hip dislocation follows the ABCDE approach, which includes ensuring airway, breathing, circulation, disability, and exposure. Analgesia is also given to manage the pain. A reduction under general anaesthetic is performed within four hours to reduce the risk of avascular necrosis. Long-term management involves physiotherapy to strengthen the surrounding muscles.

Complications of hip dislocation include nerve injury, avascular necrosis, osteoarthritis, and recurrent dislocation due to damage to supporting ligaments. The prognosis is best when the hip is reduced less than 12 hours post-injury and when there is less damage to the joint. It takes about two to three months for the hip to heal after a traumatic dislocation.

DEXA scans are utilized to measure bone mineral density in individuals who are at risk of osteoporosis or have experienced fragility fractures. To assess the risk of osteoporosis, online tools such as FRAX or QFracture can be used. The DEXA scan results comprise a T score and a Z score. The T score compares your bone density to that of a healthy 30-year-old, while the Z score compares your bone density to someone of your age and body size. The Z score is adjusted for age, gender, and ethnic factors.

Osteoporosis is a condition that affects bone density and can lead to fractures. To diagnose osteoporosis, doctors use a DEXA scan, which measures bone mass. The results are compared to a young reference population, and a T score is calculated. A T score of -1.0 or higher is considered normal, while a score between -1.0 and -2.5 indicates osteopaenia, and a score below -2.5 indicates osteoporosis. The Z score is also calculated, taking into account age, gender, and ethnicity.

When a psoas abscess is suspected, CT abdomen is the recommended diagnostic test. Tom has presented with right-sided abdominal pain that is relieved by hip flexion, along with a positive psoas sign and a low-grade fever, which are indicative of psoas abscess. Although MRI has a similar sensitivity to contrast CT, it is less accessible. Retrocaecal appendicitis is less likely based on Tom’s history and examination. While abdominal ultrasound is preferred for investigating appendicitis in children and pregnant women, abdominopelvic CT is preferred for other adults. Hip x-ray is not the most useful test in this case, as osteomyelitis or avascular necrosis are less likely based on Tom’s clinical presentation. Colonoscopy is not the most appropriate test to order next, as his symptoms are unlikely to be caused by a flare-up of his Crohn’s disease.

An iliopsoas abscess is a condition where pus accumulates in the iliopsoas compartment, which includes the iliacus and psoas muscles. There are two types of iliopsoas abscesses: primary and secondary. Primary abscesses occur due to the spread of bacteria through the bloodstream, with Staphylococcus aureus being the most common cause. Secondary abscesses are caused by underlying conditions such as Crohn’s disease, diverticulitis, colorectal cancer, UTIs, GU cancers, vertebral osteomyelitis, femoral catheterization, lithotripsy, endocarditis, and intravenous drug use. Secondary abscesses have a higher mortality rate compared to primary abscesses.

The clinical features of an iliopsoas abscess include fever, back/flank pain, limp, and weight loss. During a clinical examination, the patient is positioned supine with the knee flexed and the hip mildly externally rotated. Specific tests are performed to diagnose iliopsoas inflammation, such as placing a hand proximal to the patient’s ipsilateral knee and asking the patient to lift their thigh against the hand, which causes pain due to contraction of the psoas muscle. Another test involves lying the patient on the normal side and hyperextending the affected hip, which should elicit pain as the psoas muscle is stretched.

The investigation of choice for an iliopsoas abscess is a CT scan of the abdomen. Management involves antibiotics and percutaneous drainage, which is successful in around 90% of cases. Surgery is only indicated if percutaneous drainage fails or if there is another intra-abdominal pathology that requires surgery.

Pregnant patients with rheumatoid arthritis (RA) can safely continue using hydroxychloroquine as a treatment without any changes. While the medication does cross the placenta, it has not been shown to cause harm to the fetus at the doses used for RA treatment. Etanercept may be considered if there is a significant flare of disease during pregnancy, but it is not necessary at this time. Leflunomide is strictly contraindicated due to its high teratogenicity. Methotrexate must be discontinued at least 3 months before pregnancy as it is highly teratogenic and abortifacient. Steroids are not necessary for this patient who is not experiencing a flare.

Hydroxychloroquine: Uses and Adverse Effects

Hydroxychloroquine is a medication commonly used in the treatment of rheumatoid arthritis and systemic/discoid lupus erythematosus. It is similar to chloroquine, which is used to treat certain types of malaria. However, hydroxychloroquine has been found to cause bull’s eye retinopathy, which can result in severe and permanent visual loss. Recent data suggests that this adverse effect is more common than previously thought, and the most recent guidelines recommend baseline ophthalmological examination and annual screening, including colour retinal photography and spectral domain optical coherence tomography scanning of the macula. Despite this risk, hydroxychloroquine may still be used in pregnant women if needed. Patients taking this medication should be asked about visual symptoms and have their visual acuity monitored annually using a standard reading chart.

A knee injury caused by twisting can lead to a tear in the meniscus, potentially accompanied by a sprain in the medial collateral ligament. The affected knee would be swollen and tender to the touch, and a positive McMurray’s’s test (painful clicking) would also be present. Patella dislocation, which can result from direct trauma to the knee, is indicated by a positive patellar apprehension test rather than a positive McMurray’s’s test. Falling onto a bent knee can cause injury to the posterior cruciate ligament, which is indicated by a positive posterior drawer test. Hyperextension knee injury, on the other hand, most commonly results in a rupture of the anterior cruciate ligament, which is indicated by a positive anterior drawer test. Repeated jumping and landing on hard surfaces can lead to patella tendinopathy or ‘jumper’s knee’, which causes anterior knee pain that worsens with exercise and jumping over a period of 2-4 weeks.

Understanding Meniscal Tear and its Symptoms

Meniscal tear is a common knee injury that usually occurs due to twisting injuries. Its symptoms include pain that worsens when the knee is straightened, a feeling that the knee may give way, tenderness along the joint line, and knee locking in cases where the tear is displaced. To diagnose a meniscal tear, doctors may perform Thessaly’s test, which involves weight-bearing at 20 degrees of knee flexion while the patient is supported by the doctor. If the patient experiences pain on twisting the knee, the test is considered positive.

The presence of DIP joint swelling and dactylitis in inflammatory arthritis suggests a diagnosis of psoriatic arthritis. Although there is not always a clear correlation between psoriatic arthritis and cutaneous psoriasis, arthritic symptoms often appear before skin lesions. While there may be some overlap with rheumatoid arthritis, the presence of DIP joint disease and dactylitis are more indicative of psoriatic arthritis. Gout is an unlikely diagnosis as it typically presents as acute and monoarticular or oligoarticular, without the other symptoms seen here. Osteoarthritis is also an unlikely diagnosis as it typically presents asymmetrically in larger joints and does not typically present with dactylitis or the findings seen on X-ray. Rheumatoid arthritis is a possibility, but a blood test for anti-cyclic citrullinated peptide antibodies (anti-CCP) should be performed to confirm the diagnosis, as these antibodies are highly specific to rheumatoid arthritis and are usually absent in psoriatic arthritis.

Psoriatic arthropathy is a type of inflammatory arthritis that is associated with psoriasis. It is classified as one of the seronegative spondyloarthropathies and is known to have a poor correlation with cutaneous psoriasis. In fact, it often precedes the development of skin lesions. This condition affects both males and females equally, with around 10-20% of patients with skin lesions developing an arthropathy.

The presentation of psoriatic arthropathy can vary, with different patterns of joint involvement. The most common type is symmetric polyarthritis, which is very similar to rheumatoid arthritis and affects around 30-40% of cases. Asymmetrical oligoarthritis is another type, which typically affects the hands and feet and accounts for 20-30% of cases. Sacroiliitis, DIP joint disease, and arthritis mutilans (severe deformity of fingers/hand) are other patterns of joint involvement. Other signs of psoriatic arthropathy include psoriatic skin lesions, periarticular disease, enthesitis, tenosynovitis, dactylitis, and nail changes.

To diagnose psoriatic arthropathy, X-rays are often used. These can reveal erosive changes and new bone formation, as well as periostitis and a pencil-in-cup appearance. Management of this condition should be done by a rheumatologist, and treatment is similar to that of rheumatoid arthritis. However, there are some differences, such as the use of monoclonal antibodies like ustekinumab and secukinumab. Mild peripheral arthritis or mild axial disease may be treated with NSAIDs alone, rather than all patients being on disease-modifying therapy as with RA. Overall, psoriatic arthropathy has a better prognosis than RA.

The patient is likely suffering from systemic sclerosis, which is characterized by the tightening and fibrosis of the skin, commonly known as scleroderma. The presence of a dry cough and involvement of the proximal limbs suggest diffuse systemic sclerosis, which has a poorer prognosis than limited systemic sclerosis (also known as CREST syndrome). Eosinophilic fasciitis, a rare form of systemic sclerosis, is unlikely as it spares the hands and does not present with Raynaud’s phenomenon. Primary Raynaud’s phenomenon, which is relatively common, does not typically present with sclerotic features and is likely part of the patient’s wider autoimmune disease.

Understanding Systemic Sclerosis

Systemic sclerosis is a condition that affects the skin and other connective tissues, but its cause is unknown. It is more common in females, with three patterns of the disease. Limited cutaneous systemic sclerosis is characterised by Raynaud’s as the first sign, affecting the face and distal limbs, and associated with anti-centromere antibodies. CREST syndrome is a subtype of limited systemic sclerosis that includes Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, and Telangiectasia. Diffuse cutaneous systemic sclerosis affects the trunk and proximal limbs, associated with scl-70 antibodies, and has a poor prognosis. Respiratory involvement is the most common cause of death, with interstitial lung disease and pulmonary arterial hypertension being the primary complications. Renal disease and hypertension are also possible complications, and patients with renal disease should be started on an ACE inhibitor. Scleroderma without internal organ involvement is characterised by tightening and fibrosis of the skin, manifesting as plaques or linear. Antibodies such as ANA, RF, anti-scl-70, and anti-centromere are associated with different types of systemic sclerosis.

Common Knee Injuries and Their Characteristics

Knee injuries can occur due to various reasons, including sports injuries and accidents. Some of the most common knee injuries include ruptured anterior cruciate ligament, ruptured posterior cruciate ligament, rupture of medial collateral ligament, meniscal tear, chondromalacia patellae, dislocation of the patella, fractured patella, and tibial plateau fracture.

Ruptured anterior cruciate ligament usually occurs due to a high twisting force applied to a bent knee, resulting in a loud crack, pain, and rapid joint swelling. The management of this injury involves intense physiotherapy or surgery. On the other hand, ruptured posterior cruciate ligament occurs due to hyperextension injuries, where the tibia lies back on the femur, and the knee becomes unstable when put into a valgus position.

Rupture of medial collateral ligament occurs when the leg is forced into valgus via force outside the leg, and the knee becomes unstable when put into a valgus position. Meniscal tear usually occurs due to rotational sporting injuries, and the patient may develop skills to ‘unlock’ the knee. Recurrent episodes of pain and effusions are common, often following minor trauma.

Chondromalacia patellae is common in teenage girls, following an injury to the knee, and presents with a typical history of pain on going downstairs or at rest, tenderness, and quadriceps wasting. Dislocation of the patella most commonly occurs as a traumatic primary event, either through direct trauma or through severe contraction of quadriceps with knee stretched in valgus and external rotation.

Fractured patella can occur due to a direct blow to the patella causing undisplaced fragments or an avulsion fracture. Tibial plateau fracture occurs in the elderly or following significant trauma in young, where the knee is forced into valgus or varus, but the knee fractures before the ligaments rupture. The Schatzker classification system is used to classify tibial plateau fractures based on their anatomical description and features.

When performing joint aspiration for gout, the presence of needle-shaped monosodium urate crystals that exhibit negative birefringence under polarised light is observed. Other types of crystals that may be present in joint aspiration include rhombic/brick-shaped calcium pyrophosphate crystals that exhibit positive birefringence under polarised light in pseudogout, coffin-lid shaped calcium phosphate crystals associated with cartilage degeneration in osteoarthritis, and rhombic/brick-shaped cholesterol crystals with negative birefringence in rheumatoid arthritis. The causes of gout can be remembered using the acronym DART, which stands for diuretics, alcohol, renal disease, and trauma. On the other hand, pseudogout can be identified by the presence of polygon-shaped crystals with positive birefringence, which can be remembered using the letter P.

Understanding Gout: Symptoms and Diagnosis

Gout is a type of arthritis that causes inflammation and pain in the joints. Patients experience episodes of intense pain that can last for several days, followed by periods of no symptoms. The acute episodes usually reach their peak within 12 hours and are characterized by significant pain, swelling, and redness. The most commonly affected joint is the first metatarsophalangeal joint, but other joints such as the ankle, wrist, and knee can also be affected. If left untreated, repeated acute episodes of gout can lead to chronic joint problems.

To diagnose gout, doctors may perform a synovial fluid analysis to look for needle-shaped, negatively birefringent monosodium urate crystals under polarized light. Uric acid levels may also be checked once the acute episode has subsided, as they can be high, normal, or low during the attack. Radiological features of gout include joint effusion, well-defined punched-out erosions with sclerotic margins in a juxta-articular distribution, and eccentric erosions. Unlike rheumatoid arthritis, there is no periarticular osteopenia, and soft tissue tophi may be visible.

According to the updated NICE guidelines in 2016, NSAIDs are now the first choice for managing lower back pain. The recommended NSAIDs are ibuprofen or naproxen, and it is advisable to consider co-administration of PPI. Paracetamol alone is not recommended for lower back pain, and for patients who cannot tolerate NSAIDs, co-codamol should be considered. If patients report spasms as a feature of their pain, a short course of benzodiazepines may be considered. NICE recommends referring patients to physiotherapy only if they are at higher risk of back pain disability or if their symptoms have not improved at follow-up. Additionally, there may be some delay in attending physiotherapy, and NSAIDs can be started immediately.

Management of Non-Specific Lower Back Pain

Lower back pain is a common condition that affects many people. In 2016, NICE updated their guidelines on the management of non-specific lower back pain. The guidelines recommend NSAIDs as the first-line treatment for back pain. Lumbar spine x-rays are not recommended, and MRI should only be offered to patients where malignancy, infection, fracture, cauda equina or ankylosing spondylitis is suspected.

Patients with non-specific back pain are advised to stay physically active and exercise. NSAIDs are recommended as the first-line analgesia, and proton pump inhibitors should be co-prescribed for patients over the age of 45 years who are given NSAIDs. For patients with sciatica, NICE guidelines on neuropathic pain should be followed.

Other possible treatments include exercise programmes and manual therapy, but only as part of a treatment package including exercise, with or without psychological therapy. Radiofrequency denervation and epidural injections of local anaesthetic and steroid may also be considered for acute and severe sciatica.

In summary, the management of non-specific lower back pain involves encouraging self-management, staying physically active, and using NSAIDs as the first-line analgesia. Other treatments may be considered as part of a treatment package, depending on the severity of the condition.

Hydroxychloroquine is known to have a severe and permanent side effect on the retina, known as ‘bull’s eye retinopathy’, which can result in significant visual loss. Recent studies suggest that this side effect is more common than previously thought, and the Royal College of Ophthalmologists recommends regular monitoring. While hydroxychloroquine may also cause keratopathy, this is considered less harmful. The other ocular effects listed as options are not associated with hydroxychloroquine.
Long-term steroid use is known to cause cataracts and open-angle glaucoma.
While case reports have linked bisphosphonates to scleritis and uveitis, there is limited data on this association. However, these conditions are commonly associated with rheumatological and inflammatory disorders.

Hydroxychloroquine: Uses and Adverse Effects

Hydroxychloroquine is a medication commonly used in the treatment of rheumatoid arthritis and systemic/discoid lupus erythematosus. It is similar to chloroquine, which is used to treat certain types of malaria. However, hydroxychloroquine has been found to cause bull’s eye retinopathy, which can result in severe and permanent visual loss. Recent data suggests that this adverse effect is more common than previously thought, and the most recent guidelines recommend baseline ophthalmological examination and annual screening, including colour retinal photography and spectral domain optical coherence tomography scanning of the macula. Despite this risk, hydroxychloroquine may still be used in pregnant women if needed. Patients taking this medication should be asked about visual symptoms and have their visual acuity monitored annually using a standard reading chart.

Colchicine is known to induce diarrhoea as a side effect.

One of the common side effects of colchicine, a medication utilized for treating acute gout attacks, is diarrhoea. Due to this, some physicians opt for naproxen or prednisolone instead of prescribing colchicine. The remaining drugs on the list are not typically associated with diarrhoea.

Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with an initial dose of 100 mg od and titrated to aim for a serum uric acid of < 300 µmol/l. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Consideration should be given to stopping precipitating drugs and losartan may be suitable for patients with coexistent hypertension.

Polymyalgia rheumatica is not associated with an increase in creatine kinase levels. Instead, blood tests typically reveal signs of inflammation, such as elevated white blood cell count, C-reactive protein, and erythrocyte sedimentation rate. These findings, combined with the patient’s medical history and demographic information, strongly suggest polymyalgia rheumatica as the diagnosis. In contrast, conditions such as polymyositis and dermatomyositis typically involve a significant rise in creatine kinase levels, and dermatomyositis also presents with a distinctive rash. Fibromyalgia does not typically show any signs of inflammation on blood tests. While statin-induced myopathy is a possibility based on the patient’s history, the absence of elevated creatine kinase levels makes this diagnosis less likely.

Polymyalgia Rheumatica: A Condition of Muscle Stiffness in Older People

Polymyalgia rheumatica (PMR) is a common condition that affects older people. It is characterized by muscle stiffness and elevated inflammatory markers. Although it is closely related to temporal arthritis, the underlying cause is not fully understood, and it does not appear to be a vasculitic process. PMR typically affects patients over the age of 60 and has a rapid onset, usually within a month. Patients experience aching and morning stiffness in proximal limb muscles, along with mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, and night sweats.

To diagnose PMR, doctors look for raised inflammatory markers, such as an ESR of over 40 mm/hr. Creatine kinase and EMG are normal. Treatment for PMR involves prednisolone, usually at a dose of 15 mg/od. Patients typically respond dramatically to steroids, and failure to do so should prompt consideration of an alternative diagnosis.

When starting allopurinol for prophylactic treatment of gout, it is important to use NSAID or colchicine ‘cover’ to prevent an acute flare up of gout. This is because starting allopurinol can trigger an acute flare up of gout. In this case, diclofenac, an NSAID, should be given alongside allopurinol initially. Azathioprine use is contraindicated alongside allopurinol due to the risk of toxicity. Febuxostat is an alternative to allopurinol but should not be used alongside it. Hydroxychloroquine and methotrexate are not used in the treatment of gout but have a role in maintenance treatment for other rheumatological diseases.

Gout is caused by chronic hyperuricaemia and is managed acutely with NSAIDs or colchicine. Urate-lowering therapy (ULT) is recommended for patients with >= 2 attacks in 12 months, tophi, renal disease, uric acid renal stones, or prophylaxis if on cytotoxics or diuretics. Allopurinol is first-line ULT, with an initial dose of 100 mg od and titrated to aim for a serum uric acid of < 300 µmol/l. Lifestyle modifications include reducing alcohol intake, losing weight if obese, and avoiding high-purine foods. Consideration should be given to stopping precipitating drugs and losartan may be suitable for patients with coexistent hypertension.

Isoniazid is the tuberculosis antibiotic that can lead to drug-induced lupus. Drug-induced lupus is a condition that shares some symptoms with systemic lupus erythematosus (SLE), but not all. It usually goes away once the patient stops taking the medication. Anti-histone antibodies are typically positive in drug-induced lupus, but less common in SLE. On the other hand, anti-dsDNA antibodies are present in more than half of SLE cases, but very rarely in drug-induced lupus. Procainamide and hydralazine are the most common drugs that cause drug-induced lupus, but isoniazid is the most likely cause from the list of tuberculosis antibiotics (and pyridoxine). Isoniazid is also known to cause peripheral neuropathy and hepatitis. Ethambutol is another tuberculosis antibiotic that does not cause drug-induced lupus, but can cause optic neuritis. Pyrazinamide is another tuberculosis antibiotic that does not cause drug-induced lupus, but can cause gout and hepatitis. Pyridoxine is vitamin B6 and is given to all patients taking isoniazid to prevent peripheral neuropathy. It does not cause drug-induced lupus.

Understanding Drug-Induced Lupus

Drug-induced lupus is a condition that shares some similarities with systemic lupus erythematosus, but not all of its typical features are present. Unlike SLE, renal and nervous system involvement is rare in drug-induced lupus. The good news is that this condition usually resolves once the drug causing it is discontinued.

The most common symptoms of drug-induced lupus include joint pain, muscle pain, skin rashes (such as the malar rash), and pulmonary issues like pleurisy. In terms of laboratory findings, patients with drug-induced lupus typically test positive for ANA (antinuclear antibodies) but negative for dsDNA (double-stranded DNA) antibodies. Anti-histone antibodies are found in 80-90% of cases, while anti-Ro and anti-Smith antibodies are only present in around 5% of cases.

The most common drugs that can cause drug-induced lupus are procainamide and hydralazine. Other less common culprits include isoniazid, minocycline, and phenytoin.