EMQs in Clinical Medicine.pdf - Peshawar Medical College

126 Orthopaedics and rheumatology
Septic arthritis is a medical emergency and so, when a patient presents
with a red, hot, swollen knee, treatment for any other possible diagnosis
must not be initiated before septic arthritis is excluded. The joint space
should be aspirated and the fluid sent for urgent Gram staining and culture
as soon as possible.
J
D
A 60-year-old woman presents with a painful swollen knee. Her radiograph
shows chondrocalcinosis and joint aspiration reveals presence
of weakly positive birefringent crystals.
Pseudogout refers to the acute synovitis caused by the deposition of calcium
pyrophosphate crystals into a joint. The knee and the wrist are the
two most commonly affected sites. Diagnosis is made by detection of
crystals that are weakly positively birefringent in plane polarized light.
Risk factors include hypovolaemia, hyperparathyroidism, diabetes,
haemochromatosis, acromegaly and any other pre-existing arthritis.
A 65-year-old woman presents with a 1-month history of pain and
stiffness in her shoulders, worse in the mornings. She says that she
was treated in hospital last year for headache and jaw pain.
Polymyalgia rheumatica is associated with giant cell arteritis and is very
rare before the age of 50 years. Patients also often complain of fatigue
and depression. It is often associated with a high erythrocyte sedimentation
rate (ESR). Oral prednisolone is the treatment of choice.
44 Pain in the hip
Answers: A M C J E
A
M
An obese 12-year-old boy presents with pain in his right hip. On
examination the hip is flexed, abducted and externally rotated. His
mother has suffered from TB in the past.
This is a classic presentation of slipped femoral epiphysis and the previous
history of TB in the mother is not significant. The patient is often
obese and presents with limping and pain in the groin, thigh or knee.
This condition is most common in the 10- to 16-year age group. A lateral
radiograph is required to show the abnormality.
Tuberculous arthritis is very rare in the UK, affecting mostly elderly people
and infants.
A 6-year-old boy presents with a pain in the hip and a limp. All
movements at the hip are limited. His radiograph shows decrease in
size of the nuclear femoral head with patchy density.
Perthes’ disease is osteochondritis of the femoral head and classically
affects children in a younger age group compared with slipped femoral
epiphysis (around 3–11 years). It is around four times more common in