GS Long Case: bilateral patellofemoral compartment OA knees with bilateral Baker’s cysts
They were ALL very nice, tell us the examiners’ names before the exam. Mine were Prof Satku (very nice, puts you at ease) and A/P Lim TC (very nice guy too), and one more Dr (observer) plus one bustling MO who helps you to put up the XRs and even drops in ard the midst of yr clerking to confirm that you’ve got the right diagnosis.
OA knees with bilateral Baker’s cyst with limitation of function. Screened for depression, function as well. I cannot over-emphasize the importance of functional hx in ortho.
PMH: likely essential thrombocytosis BMA clear, on hydroxyurea, dyspepsia + old ulcer on barium meal on domperidone, omeprazole, previous nephrectomy with renal impairment on losartan (causes v bad cough), hypertension on hydrochlorthiazide, atenolol.
PE: NO genu varum, some bilateral medial joint line tenderness (prof S specifically wants to see WHERE exactly the line is! I went a bit off-course at one point) No FFD/scars/obvious swelling. Bilateral two popliteal cysts (Prof S wanted a ‘nicer’ name, so I said Baker’s cyst :) good.
Questions:
What are the essential points supportive of OA? - mechanical pain, period of stiffness (15min) after inactivity, +/- swelling, age, what’s the underlying cause?
What duration of morning stiffness is significant for inflammatory pain? I said 30min but Prof S said… hmm… So I said, 30min to an hour. Hah. Ok accepted.
If I say that this woman has some fluid in the joint cavity, and there’s the cyst posteriorly, how would you explain it? I said that it’s a Baker’s cyst coz got connection btwn the joint fluid and the cyst posteriorly. Said also that it should disappear on flexion.
Tried to make me do cross-fluctuation on the suprapatellar bursa, I said did already, but couldn’t elicit it, just some fullness and mild tenderness there… Just for ‘fun’, Prof S asked what was the Baker’s cyst originally named for, I didn’t know but mumbled ‘aneurysm’ (siao… brain short circuited), Prof was like huh, but that’s an aneurysm… then he said, oh it’s for TB anyway…
Asked what definitive ix, said AP knee XR, before I could say wt-bearing the very efficient MO had flashed the XR, haha so I nonchalantly just added in, wt-bearing XR by the way… very impt. Lolz… Shown AP knee XR. IT WAS PERFECT except prominent pencilling aka prominent vertical trabeculae (was so gan jiong I said prominent trabecal verticulae…) ! Since no OA changes, not even narrowed jt space was present, Prof asked if I wanted to ‘eat my words’, haha, but no lor… I asked for skyline view. WAAAAA NO joint space left laterally, subluxed patellar, ouch, no wonder so painful!
Mx:
- lifestyle changes: loss wt (but not req in this pt), how to walk (more painful leg descends first and so on…), avoid flexing activities
- PT: strengthen muscles, maybe can help to realign the patellae
- pain relief eg. tramadol, intra-art injection, but avoid NSAIDS (dyspepsia and renal impairment)
- Sx: realignment, replacement of that compartment
A/P Lim got a bit restless, and since Prof S didn’t have anymore qns, he let Lim grill me. Lim just asked given her nephrec hx, what would u be concerned about when u mx her? I crapped a bit about the drug-drug side effects and then he still wasn’t extremely happy, then it CLICKED. I said oh, just now I did mention her bone was osteopaenic, and plus she’s on soooo many anti-hypertensives, probably at high risk of fall and high morbidity too. Was going to go on about mx of osteoporosis but I guess he was just happy when I said the magic word… Hehe then MO shooed me away, said ok la, good enough can go… I was a bit puzzled cuz I ended like 5 min earlier…
We had a short break of an hour and a half before short cases…
Lucky no WHK turned up that day… Heng ah…
