Case 1: Acute joint disease
1 The most crucial piece of information is that the patient is well. The diagnosis to rule out in every case is septic arthritis, and this seems unlikely in this scenario. However, his diabetes is a risk factor for infection, and a careful history of the previous injury might reveal a route of entry for bacteria. Although sports injuries can cause recurrent problems, acute flares of swelling and pain are unusual in the absence of a clear precipitating event. His psoriasis may indicate the development of a large-joint psoriatic arthropathy, but psoriasis is also a risk factor for gout, and his alcohol intake would certainly put him at risk of this.
2 The combination of a painful red eye and arthropathy raises the possibility of anterior uveitis or scleritis in association with one of the following:
- Reiter’s syndrome (check for a history of urethritis or gastrointestinal upset, circinate balanitis, keratoderma blennorrhagica).
- Enteropathic arthropathy (history of abdominal pain or bloody diarrhoea, erythema nodosum).
- Ankylosing spondylitis (inflammatory back pain).
3 Joint fluid aspiration to rule out septic arthritis and to diagnose gout.
4 First-line treatment for gout is a non-steroidal anti-inflammatory drug (NSAID). If he continues to experience attacks, a urate-lowering therapy such as allopurinol should be considered. All patients with gout should attempt lifestyle modification. In this instance, a reduction in his alcohol intake is crucial. Additional risk factors in his diet would also need to be addressed.
See Chapter 27 for further details.
Case 2: Initial management of polytrauma
1 ABC:
A Check airway with cervical spine control.
B Breathing: give 100% oxygen at 15 l/min; check for pneumothorax.
C Circulation: introduce two wide-bore cannulae. Take bloods for cross-match, haemoglobin, glucose, urea and electrolytes, and drug screen.
2 Distal neurovascular status.
3 The fracture is open and potentially contaminated. The wound must therefore be opened and cleaned. All contaminating material should be washed out, and dead tissue excised. If it is not possible to be sure that the wound is clean, then it should not be closed. The wound should be packed and then inspected daily until it is clean. The fracture needs to be reduced, and then held. The operation should be covered by prophylactic antibiotics. The patient should be mobilised as soon as practicable.
4 Options include intramedullary nail with locking screws; plate and screws; external fixator (Ilizarov or conventional); balanced traction; plaster or brace. An intramedullary nail allows secure fixation and early mobilisation but infection is a dangerous complication. A plate with screws needs a much longer incision, but will also give secure fixation. An external fixator is very difficult to apply, especially in the thigh where the soft tissues are deep so the pins rub on the muscle. Traction is safe but takes many weeks with the patient languishing in a hospital bed. A plaster or brace would be almost impossible to fit to a thigh so that the fracture could be held.
See Chapters 42 and 48 for further details.
Case 3: Rheumatoid arthritis
1 No, but enough to make the diagnosis! The diagnostic criteria stipulate at least four of the following:
- Morning stiffness: duration >1 hour (for >6 weeks).
- Arthritis of at least three joints: soft tissue swelling (for >6 weeks).
- Arthritis of hand joints: MCPs, PIPs or wrist (for>6 weeks).
- Symmetrical arthritis: at least one area (for >6 weeks).
- Rheumatoid nodules.
- Positive rheumatoid factor.
- Radiographic changes: periarticular erosions.
2 Rhematoid factor positivity is associated with more severe disease and a higher incidence of extra-articular manifestations.
3 Methotrexate is effective and generally well tolerated. Side effects include nausea and oral ulcers. Regular blood tests are used to screen for myelosuppression and hepatitis. An idiosyncratic (and reversible) allergic alveolitis/pneumonitis can occur and pre-treatment lung function testing and chest X-ray is advised. Pregnancy is contraindicated as methotrexate is a folic acid antagonist.
4 Differential diagnoses:
- Respiratory disease:
– Pleural effusion
– Pulmonary fibrosis
– Allergic alveolitis due to methotrexate therapy
– Bronchiolitis obliterans (rare)
– Cryptogenic organising pneumonia (rare).
Investigations include arterial blood gases, chest X-ray and lung function testing.
- Symptomatic anaemia:
– Anaemia of chronic disease
– Gastrointestinal blood loss due to NSAID use
– Myelosuppression due to methotrexate therapy
– Associated B12 deficiency (pernicious anaemia).
Investigations include haematinics and endoscopy.
5 Causes include:
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