Master Orthopaedics & Rheumatology
for PLAB 1
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Core Concepts
Orthopaedics deals with musculoskeletal system disorders (bones, joints, ligaments, tendons, muscles). Key areas include trauma (fractures), degenerative conditions (osteoarthritis), infections (osteomyelitis, septic arthritis), and congenital deformities. Rheumatology focuses on systemic inflammatory and autoimmune diseases affecting joints, muscles, and soft tissues, often with multi-system involvement (e.g., Rheumatoid Arthritis, SLE, vasculitis).
Differentiate between:
- Mechanical pain: Worsens with activity, improves with rest (e.g., osteoarthritis, tendinitis).
- Inflammatory pain: Worsens with rest, improves with activity, prominent morning stiffness (>30 mins) (e.g., rheumatoid arthritis, ankylosing spondylitis).
Clinical Presentation
- Pain: Localised, radiating, joint-specific, or widespread. Characterise as inflammatory or mechanical.
- Stiffness: Morning stiffness duration is key (inflammatory >30min, mechanical <30min).
- Swelling: Joint effusion (warm, tender, boggy) or soft tissue oedema.
- Deformity: Joint malalignment, subluxation, contractures.
- Reduced range of motion: Active and passive, painful or restricted.
- Weakness: Muscle wasting or neurological deficit.
- Systemic symptoms: Fever, fatigue, weight loss (suggests inflammatory/infectious cause).
- Specific signs: Crepitus (OA), erythema migrans (Lyme), tophi (Gout), butterfly rash (SLE).
Diagnosis (Gold Standard)
A thorough history and clinical examination are paramount for initial diagnosis.
- Fractures: X-ray (initial imaging), CT (complex fractures, joint involvement), MRI (soft tissue injury, occult fractures).
- Osteoarthritis: Clinical findings + X-ray (joint space narrowing, osteophytes, subchondral sclerosis/cysts).
- Rheumatoid Arthritis: Clinical criteria (joint involvement, serology, acute phase reactants, symptom duration) + X-ray (erosions, joint space narrowing). Bloods: ESR, CRP, RF, anti-CCP.
- Gout/Pseudogout: Arthrocentesis (joint fluid aspiration) for microscopy:
- Gout: Negatively birefringent needle-shaped urate crystals.
- Pseudogout: Positively birefringent rhomboid-shaped calcium pyrophosphate crystals.
- Septic Arthritis: Arthrocentesis with Gram stain & culture (Gold Standard). Bloods: CRP, ESR, WCC.
- Osteoporosis: DEXA scan (dual-energy X-ray absorptiometry) measuring bone mineral density (T-score).
- Ankylosing Spondylitis: Clinical features (sacroiliitis) + X-ray/MRI of SI joints. HLA-B27 is supportive but not diagnostic.
Management (First Line)
- Fractures:
- RICE (Rest, Ice, Compression, Elevation) for minor soft tissue injuries.
- Immobilisation (casts, splints) for stable fractures.
- Analgesia (Paracetamol, NSAIDs, Opioids).
- Surgical fixation (ORIF - Open Reduction Internal Fixation) for unstable, displaced, or intra-articular fractures.
- Osteoarthritis:
- Lifestyle modification (weight loss, exercise, physiotherapy).
- Analgesia (Paracetamol, topical/oral NSAIDs).
- Intra-articular steroid injections.
- Surgery (arthroplasty/joint replacement) for severe cases.
- Rheumatoid Arthritis:
- Disease-Modifying Anti-Rheumatic Drugs (DMARDs) - e.g., Methotrexate (first-line), Sulfasalazine, Hydroxychloroquine, Leflunomide.
- NSAIDs for symptomatic relief.
- Short-course oral corticosteroids or intra-articular injections for flares.
- Biologics for unresponsive cases.
- Gout:
- Acute attack: NSAIDs (e.g., Naproxen, Indomethacin), Colchicine (if NSAIDs contraindicated/ineffective), oral corticosteroids.
- Prophylaxis (after acute attack resolves): Allopurinol (xanthine oxidase inhibitor) or Febuxostat to lower uric acid.
- Septic Arthritis:
- Urgent joint aspiration & IV antibiotics (empiric broad-spectrum, then guided by culture).
- Surgical washout/drainage if aspiration inadequate.
- Osteoporosis:
- Calcium & Vitamin D supplementation.
- Bisphosphonates (e.g., Alendronate) are first-line pharmacotherapy.
Exam Red Flags
- Cauda Equina Syndrome: Saddle anaesthesia, bilateral sciatica, bowel/bladder dysfunction, reduced anal tone. Emergency MRI and neurosurgical referral.
- Compartment Syndrome: Severe pain disproportionate to injury, pain on passive stretch, paraesthesia, pallor, pulselessness (late sign). Emergency fasciotomy.
- Open Fractures: Bone breaks through skin. High infection risk. Urgent surgical debridement and IV antibiotics.
- Septic Arthritis: Hot, swollen, exquisitely painful joint, fever, malaise, unable to weight bear. Urgent joint aspiration and IV antibiotics.
- Giant Cell Arteritis (GCA): New onset temporal headache, jaw claudication, scalp tenderness, visual disturbance (amaurosis fugax, permanent vision loss). Urgent high-dose corticosteroids to prevent blindness.
- Malignancy (Bone/Spine): Unexplained persistent bone pain, night sweats, weight loss, pathological fracture.
- Spinal Cord Compression: Rapidly progressive neurological deficit, back pain, weakness, sensory loss, bladder/bowel changes. Emergency imaging and specialist review.
Sample Practice Questions
A 55-year-old male presents to his GP with sudden onset, excruciating pain, redness, and swelling in his right big toe (first metatarsophalangeal joint). He describes the pain as the worst he has ever experienced. He has a history of hypertension and admits to heavy alcohol consumption, especially beer, over the weekend. On examination, the affected joint is hot, exquisitely tender, and swollen. What is the most appropriate acute management for this patient?
A 35-year-old male presents to the emergency department after falling from a ladder, landing on his outstretched arm. He complains of severe pain in his left forearm. On examination, there is an obvious deformity, swelling, and a 2 cm laceration over the medial aspect of the forearm, through which bone is visible. His distal radial pulse is palpable, and sensation is intact. What is the MOST immediate and appropriate initial management step for this patient?
A 68-year-old male presents with a 12-month history of gradually worsening left knee pain. The pain is exacerbated by prolonged standing and walking, and improves with rest. He reports morning stiffness lasting approximately 15 minutes. There is no history of trauma, fever, or systemic symptoms. On examination, there is crepitus on knee movement and mild effusions. Which of the following is the most appropriate initial management step for this patient?
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