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BSMS204 Theme 2 Musculoskeletal > 13. Introduction to diseases of the musculoskeletal system > Flashcards

13. Introduction to diseases of the musculoskeletal system Flashcards

1
Q

tendonitis

A

Tendon problem.

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2
Q

bursitis

A

Inflammation of bursa. Bursae are synovial membrane lined pockets that serve to allow free movement of adjacent structures where otherwise, there could be friction.

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3
Q

enthesitis

A

Inflammation of an enthesis. Entheses are the points where tendons, ligaments or joint capsules insert into bone. The largest site is the Achilles insertion.

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4
Q

Osteoperosis

A

reduced bone density

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5
Q

osteomalacia

A

poor bone mineralisation

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6
Q

osteomyelitis

A

bone infection

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7
Q

osteosarcoma

A

an example of malignant bone tumour

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8
Q

myalgia

A
  • Pain in muscles.
  • Very common.
  • Commonly associated with viral infections.
  • Can be drug induced (eg by statins).
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9
Q

myositis

A

Inflammation of the muscles.

Far less common than myalgia and can be autoimmune

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10
Q

what is a joint?

A

A joint is formed where two or more bones meet each other

This is an example of a normal joint

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11
Q

Approach to a patient with a musculoskeletal disorder

A

Full history
& } Often enough to
Physical examination make a diagnosis

Serological tests – help to support the diagnosis

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12
Q

Some ways of classifying rheumatic disease

A

Articular or Non articular/ Periarticular
Inflammatory or non-inflammatory/degenerative/mechanical

number of joints affected - suspect infection in all acute monoarthritis
duration of onset

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13
Q

Periartciular joint pain

A

Point tenderness over the involved structure,
Pain reproduced by movement involving that structure
then think about which structure? bursa, tendon, tendon sheath, ligament, others?

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14
Q

articular joint pain

A

joint line tenderness
pain at the end range of movement in any direction
inflammatory or mechanical? any signs of inflammation? features of mechanical problems? locking, catching etc

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15
Q

joint inflammation nomenclature

A

MonoARHRITIS – arthritis affecting 1 joint

OligoARTHRITIS – arthritis affecting 4 or fewer joints (2-4)

PolyARTHRITIS – arthritis affecting 5 or more joints (>=5)

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16
Q

Soft tissue conditions

A

Problems with radiolucent moving tissues
Very common, part of everyday life

Some examples:

- tennis elbow (lateral epicondylitis) 
- golfers elbow (medial epicondylitis) 
- carpal tunnel (median nerve compression as it passes through the carpal tunnel in the wrist)
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17
Q

importance of rheumatic disease

A

Common and getting more common
Expensive
Important
Leading cause of disability

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18
Q

Worldwide impact of rheumatic disease

A

MSK disorders are the second most common cause of disability worldwide, measured by years lived with disability (YLDs)
Low back pain is the single leading cause for disability globally
Disability due to MSK disorders is estimated to have increased by 45% from 1990 to 2010, in particular OA, and is expected to continue to rise with an increasingly obese, sedentary and ageing population.

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19
Q

UK impact of rheumatoid disease

A

Third greatest impact on the health of the UK population, considering both death and disability (Lancet 9 March 2013)
– Musculoskeletal disorders account 15.6%
– Low back pain accounts for over half of this
– Ranking of major causes of death and disability

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20
Q

MSK disorders and work

A

Poor musculoskeletal health is a major barrier to workplace participation. People with musculoskeletal conditions are less likely to be employed than people in good health, and more likely to retire early.

21
Q

Septic arthritis

A

Differential diagnosis of hot swollen joint is wide – ALWAYS consider joint aspiration and gram stain

The commonest organisms are staph and strep

22
Q

Septic arthritis

A

Always think about it in a patient with a (usually) single, hot and swollen joint.
Mortality rates are of 11%. This increases to 50% in polyarticular disease with sepsis.

They do not have to be systemically unwell and they may be able to weight bear.

Seek senior advice. Do not delay antibiotic therapy.

23
Q

Gout

A

Most common inflammatory arthropathy worldwide

• Serum urate levels > physiological saturation point (around 408 μmol/L)

Monosodium urate crystals form and deposit in cartilage, bone and periarticular tissues of peripheral joints

24
Q

Clinical aspects of gout

A

Crystal deposition is often clinically silent
About 10% of people with hyperuricaemia develop clinical gout
UK GP Studies show the prevalence of gout per 1,000 has been steadily increasing from 2.6 in 1975, to 3.4 in 1987, and 9.5 in 1993
1 in 40 adults in the UK is affected by gout= 2.5% - 15 years analysis (2014)
Clinical cure is achievable with treatment which is cheap, widely available, and under-prescribed

25
Q

Who gets gout?

A

Men aged 40 years and over
Women over 65 years.

It increases with age, affecting 15% of men aged over 75 in the United Kingdom

Epidemiological studies show that the metabolic syndrome and its components (insulin resistance, obesity, hyperlipidaemia, and hypertension) are strongly associated with gout

26
Q

gout risk factors

A

Male sex, older age

Genetic factors (mainly reduced excretion of urate)

Chronic kidney disease (reduced excretion of urate)

Metabolic syndrome, obesity, hypertension, hyperlipidaemia, loop and thiazide diuretics (reduce urate excretion)

osteoarthritis (enhanced crystal formation)

deitary factors (increased production of uric acid)

27
Q

Gout crystals

A

Gout is caused by negatively birefringent rods – monosodium urate

Pseudogout (CPPD) by positively birefringent rhomboids – calcium pyrophosphate

28
Q

Gout management

A

Acute attacks:
NSAIDs e.g. naproxen, colchicine, steroids

Long-term: urate-lowering therapy e.g. allopurinol or febuxostat

29
Q

Rheumatoid arthritis

A

Common, chronic, multisystem inflammatory condition affecting up to 0.5-1% of world population

More common in women (3:1). Peak onset is 45-65 years

Unknown cause with around 30% genetic susceptibility and the rest environmental

30
Q

Main problem in rheumatoid arthritis

A

The main problem in inflammatory arthritis is with the SYNOVIUM whereas in osteoarthritis, the main problem is with the CARTILAGE

31
Q

What is the most important environmental risk factor for rheumatoid arthritis?

A

smoking

32
Q

rheumatoid arhritis pathophysiology

A 
Early lymphocyte invasion of synovium
Acute inflammatory reaction - swelling and increased vascular permeability
synovial proliferation
pannus formation
cartilage destruction and bone erosion
33
Q

Symptoms and signs of rheumatoid arthritis

A

Onset varies, can be acute or chronic

Symmetrical pain and boggy swelling of the small joints of the hands and feet (MCP, PIP, wrist, MTP, subtalar, NOT the DIPs)

early morning stiffness > 1 hour

malaise and fatigue are common

systemically unwell

examination - look for pain, swelling and restriction of movement

also really important to examine other organ systems as RA is a systemic disease

34
Q

Extra-articular manifestations of RA

A 
nodules (20%)
bursitis/tenosynovitis
eyes: dry eyes (secondary Sjogren's)/scleritis/scleromalacia
splenomegaly (Feity's)
Anaemia of chronic disease
Lung fibrosis/effusion/nodules (Caplan's)
pericarditis
neurological: atlanto-axial sublucation/carpal tunnel syndrome/mononeuritis multiplex
renal amyloidosis (RA)
leg ulcers/pyoderma gangenosum
vasculitis
increased risk of CVD
35
Q

RA investigations

A

ESR and CRP
FBC: anaemia of chronic disease (normochromic normocytic)
rheumatoid factor positive - IgM antibody against Fc portion of human IgG antibodies (but this can be falsely elevated by illness and are normally raised in 1/20 of population)
Anti CCP antibodies - cyclic citrullinated peptide antibodies (antigen present on inflamed synovium - 98% specific for RA diagnosis)
X-rays: normal in early disease… erosions/peri-articular osteoperosis and reduced joint space/cysts

36
Q

RA principles of management

A

Early and aggressive treatment to reduce inflammation and joint damage
->
Non-steroidal anti-inflammatory drugs for short periods
->
Corticosteroids: intra-articular joint injections if only 1 or 2 troublesome. Systemic if many joints are problem - main routes are IM or PO though in severe disease maybe IV

37
Q

RA drugs

A

DMARDs (disease modifying anti-rheumatoid drugs)

biologic agents

38
Q

Synthetic DMARDs

A

Methotrexate
Sulfasalazine
Hydroxychloroquine
Leflunomide

39
Q

Biologic agents

A

Anti TNF agents ( Etanercept, Adalimumab, Infliximab)

Anti B-cell (Rituximab)

Anti Interleukin-6 receptor blocker (Tociluzumab)

Anti T-cell – selective co-stimulation modulator- CTLA4-Ig (Abatacept)

Janus kinase inhibitor (JAK 2) (Tofacinitib, Baricitinib)

40
Q

Multidisciplinary aspects of RA management

A

Multidisciplinary team input

– Nurse specialist (education and disease monitoring)
– Physiotherapy (improve strength and stamina)
– Occupational Therapy (work, home environments)
– Podiatry

41
Q

Osteoarthritis

A

Common, degenerative disease of which the prevalence increases with age
Affects 70% of over 65 years olds
Most commonly clinically affects the knees, hips and small joints of the hands (DIP, PIP, 1st CMCJ)
Characterised by joint pain and very variable degrees of functional limitation

42
Q

Osteoarthritis pathophysiology

A

Metabolically active, dynamic process involving all joint tissues (cartilage, bone, synovium, capsule, ligaments/muscles)
->
Focal destruction of articular cartilage
->
Remodelling of adjacent bone = hypertrophic reaction at joint margins (osteophytes)
->
Remodelling and repair process (efficient but SLOW)
->
Secondary synovial inflammation and crystal deposition

43
Q

Clinical features of osteoarthritis

A 
Age > 50 years
Morning stiffness < 30 minutes
Persistent joint pain aggravated on use 
Crepitus
NO INFLAMMATION
Bony enlargement and/or tenderness
44
Q

Osteoarthritis investigations

A

A clinical diagnosis
Blood tests not helpful
X-rays do not correlate well with symptoms

45
Q

OA management

A

physiotherapy, weight loss if overweight/obese, education and advice
NSAIDS, paracetamol
opioids, capsaicin, intra-articular corticosteroid injections, local heat and cold, joint arthoplasty, supports and braces, shock-absorbing shoes, manual therapy (manipulation and stretching)

46
Q

Systemic lupus erythmatosus

A

Chronic, relapsing, remitting disease
Broad spectrum of clinical features involving almost all organs and tissues
Prevalence in the UK: 97 per 100,000
F:M= 10-20:1
Peak onset between 15- 40 years
More common and severe in those of Afro-Caribbean, India, Hispanic and Chinese origin living in USA and Europe> Caucasians

47
Q

PATHOPHYSIOLOGY

A

UV light results in cell death (apoptosis) but cells not cleared quick enough, there is abnormal immune response and autoantibodies are formed, leads to inflammation systematically leading to damage

48
Q

Classification criteria for SLE

A

4 of 17 factors have to apply (at least 1 clinical) or biopsy-proven nephritis compatible with SLE in presence of ANA antibodies or anti-dsDNA antibodies

49
Q

SLE investigations

A 
Urinalysis - urinary protein:creatinine ratio
full blood count
urea and electrolytes
ESR
CRP
liver function test
antibodies: ANA, ENA, Anti-dsDNA, lupus anticoagulant, anti C1q
C3, C4

BSMS204 Theme 2 Musculoskeletal (22 decks)

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