Master Orthopaedics & Rheumatology
for PLAB 1

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.
  (Blood uric acid levels are supportive but not diagnostic for acute gout).
• 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.