A 23-year-old female presents with a painful ankle following an inversion injury whilst playing tennis.
Which one of the following findings is least relevant when deciding whether an x-ray is needed?
Correct Answer A:
Ankle injury: Ottawa rules:
The Ottawa Rules with for ankle x-rays have a sensitivity approaching 100%.
An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:
There are also Ottawa rules available for both foot and knee injuries.
A 28-year-old man is diagnosed with having ankylosing spondylitis. He presented with a six month history of back pain. On examination there is reduced lateral flexion of the spine but no evidence of any other complications.
Which one of the following is he most likely to offered as first-line treatment?
Correct Answer A: The anti-TNF drugs are currently only used for patients with severe ankylosing spondylitis which has failed to respond to NSAIDs.
Ankylosing spondylitis: investigation and management:
Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 5:1) aged 20-30 years old.
Investigation:
Inflammatory markers (ESR, CRP) are typically raised although normal levels do not exclude ankylosing spondylitis. HLA-B27 is of little use in making the diagnosis as it is positive in:
Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis.
Radiographs may be normal early in disease, later changes include:
Spirometry may show a restrictive defect due to a combination of pulmonary fibrosis, kyphosis and ankylosis of the costovertebral joints.
Management:
Early diagnosis is now more important following the advent of anti-TNF therapy:
Which one of the following is most consistently associated with a poor prognosis in rheumatoid arthritis?
Rheumatoid arthritis: prognostic features:
A number of features have been shown to predict a poor prognosis in patients with rheumatoid arthritis, as listed below.
Poor prognostic features:
In terms of gender there seems to be a split in what the established sources state is associated with a poor prognosis. However both the American College of Rheumatology and the recent NICE guidelines (which looked at a huge number of prognosis studies) seem to conclude that female gender is associated with a poor prognosis.
You review a 40-year-old mechanic who presents with joint pains. For the past two months he has noticed intermittent pain, stiffness and swelling of the joints in his hands and feet. The stiffness tends to improve during the day but the pain tends to get worse. He has also noticed stiffness in his back but cannot remember any aggravating injury. You order some blood tests (taken during an acute attack) which are reported as follows:
What is the most likely diagnosis?
Correct Answer E: Anti-cyclic citrullinated peptide antibodies are associated with rheumatoid arthritis.
Anti-cyclic citrullinated peptide antibody is highly specific for rheumatoid arthritis.
Rheumatoid factor:
Rheumatoid factor (RF) is a circulating antibody (usually IgM) which reacts with the Fc portion of the patients own IgG.
RF can be detected by either:
Other conditions associated with a positive RF include:
A 30-year-old female who is known to have antiphospholipid syndrome is diagnosed as having a deep vein thrombosis. This is her first thrombotic event.
How should her anti-coagulation be managed?
Correct Answer B: This is a tough question and some textbooks may contradict this answer, suggesting either lifelong warfarin or a target INR of 3-4. Please see the link to the BCSH guidelines. There is also a recent review in JAMA 2006; 295(9): 1050-7.
Antiphospholipid syndrome:
Antiphospholipid syndrome is an acquired disorder characterized by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder or secondary to other conditions, most commonly systemic lupus erythematosus (SLE) A key point for the exam is to appreciate that antiphospholipid syndrome causes a paradoxical rise in the APTT.
This is due to an ex-vivo reaction of the lupus anticoagulant autoantibodies with phospholipids involved in the coagulation cascade.
Features:
Associations other than SLE:
Management - based on BCSH guidelines:
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