57 - Diseases of musculoskeletal system Flashcards by David Thomas

Acute arthritis presentation

Pain, heat, redness and swelling

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Chronic arthritis presentation

Commonest - osteoarthritis & rheumatoid

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Osteoarthritis -

Commonest type of joint disease aka degenerative

Progressive erosion of articular cartilage resulting in bony spurs and cysts in joint margins

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Osteoarthritis (OA) - pathogenesis (mechanical)

Deterioration or loss of cartilage

As cartilage is worn away it forms spurs and fluid filled cysts appear in the marrow (subchondral cysts)

Results in pain and limited movements

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Osteoarthritis (OA) - pathogenesis (biological)

Chrondrocytes produce IL-1 and initiate matrix breakdown.

Prostaglandin derivatives induce the release of lytic enzymes - preventing matrix synthesis.

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Osteoarthritis (OA) - primary OA

Abnormal stressed in weight bearing joints - fingers, knees, cervical + lumbar spines

Fingers -> Herberden’s or Bouchard’s nodes

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Rheumatoid arthritis - what is it?

Chronic systemic disorder

Producing non suppurative proliferative synovitis - destruction of articular cartilage and ankylosis of joints

Affects skin, muscles, heart lung and blood vessels (woman 3-5 times more than men)

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Rheumatoid arthritis - pathogenesis

Polypoid fibrovascular thickening of synovium with hyperplasia, producing pannus that erodes articular cartilage.

Growth penetrates subchondral bone and cysts form .

Joint fills producing ankylosis of joint space

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Rheumatoid arthritis - clinical feature

Malaise, fatigue + general MSK pain

Involved joints: swollen, warm, painful and stiff in morning or after activity.

Slow or rapid

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Rheumatoid arthritis - pathogenesis

Genetic susceptibility 
Primary exogenous arthritogen
Autoimmune
Cytokine problems
IL-1,6 and TNF alpha and beta

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Rheumatoid arthritis - diagnosis criteria

morning stiffness
arthritis in 3 or more joint areas
arthritis in hand joints
Symmetric arthritis
Rheumatoid nodules
Serum rheumatoid factors

Radiographic presentation

Rheumatoid factor - present in most

Analysis of synovial fluid - confirms presence of neutrophils (hence inflammatory)

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Sero-negative arthritides

Lack rheumatoid factor:

ankylosing spondylitis
reiter’s syndrome
psoriatic arthritis
enteropathic arthritis

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Gout -

hyperuricemia

uric acid is the end produce of purine metabolism

caused by enzyme deficiencies

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Gout - clinical features

Acute arthritis
Chronic arthritis
Tophi in various sites
Gouty nephropathy

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Pyogenic osteomyelitis - clinical presentation

Systemic illness - fever, malaise, chills and marked pain over region

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Pyogenic osteomyelitis - investigations

X ray - lytic focus of bone destruction surrounded by zone of sclerosis

Blood cultures are positive

Biopsy

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Pyogenic osteomyelitis - pathogenesis

Caused by bacteria

Haematogenous

Extension from a contiguous site

Direct implantation

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Infective arthritis -

acutely painful and swollen joints with restricted movements

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Infective arthritis - clinical presentation

fever, leucocytosis and elevated ESR

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Infective arthritis - bacterial

Staph, strep, gonococcus, mycobacteria

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Infective arthritis - predisposing factors

Trauma, IV drug abuse, debilitating illness

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Osteoporosis -

Increased porosity of the skeleton

Reduction in bone mass

Localised or entire skeleton

Primary or secondary

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Osteoporosis - risk factors

Physical activity
Muscle strength
Diet
hormonal status

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Osteoporosis - clinical features

Vertebral fractures
Kyphosis
Scoliosis

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Secondary Osteoporosis - clinical features

Endocrine disorders - hyperparathyroidism, Type 1 diabetes Neoplasia - multiple myeloma Malnutrition

Paget's disease -

Disease of collagen matrix Caused by paramyxovirus

Paget's disease - problems with which thing

Predominant osteoblastic activity with burnt out osteosclerotic phase Net effect is gain in bone mass

Paget's disease - epidemiology

Begins in 50s | M>F

Paget's disease - clinical presentation

pain most common | chalk stick type fractures

Paget's disease - tumours

Benign and malignant Giant cell - benign Malignant - osteosarcoma, chrondrosarcoma, malignant fibrous histiocytoma

Osteomalacia -

Defects in matrix mineralisation Lack of vit D Decreased bone density and too little bone - osteopenia

Hyperparathyroidism - pathogenesis

Excessive secretion of PTH Increases bone resorption and Ca mobilisation from the skeleton Increaces renal tubular reabsorption and retention of calcium === hypercalcaemia Causing osteitis fibrosa cystica - loss of bone mineral with osteoporosis

Renal osteodystrophy -

``` Skeletal changes of chronic renal disease: Increased osteoclastic bone resorption Delayed matrix mineralisation Osteosclerosis Growth retardation Osteoporosis ```

Lipomas are

fat tissue

fibromas are

fibrous tissue

leiomyomas

smooth muscle

heamangiomas

blood vessel

lymphangiomas

lymphatics

neuromas

peripheral nerves

soft tissue tumour syndrome

neurofibromatosis type one - neurofibroma gardner syndrome - fibromatosis carney syndrome - myxoma, melanotic schwannoma turner syndrome - cystic hygroma

Soft tissue tumour diagnosis

US guided core biopsy Wide excision Cytogenetics - culture of fresh tissue and karyotypic analysis Molecular genetics - FISH, PCR and RT-PCR

Bone tumours

from bone and cartilage

benign bone tumours

osteomas, osteoblastomas

benign cartilage

chrondromas

mixed

osteochondromas

malignant bone tumours

osteosarcoma | young age group - around knee

other bone tumours

chondrosarcomas Ewing's sarcoma Giant cell tumours

Where do bones met to?

Thyroid, prostate, kidney, breast, GI tract

Systemic lupus erythematosus -

Complex multi system disease Predominantly cutaneous F>M

Systemic lupus erythematosus - clinical presentation

Cutaneous - butterfly rash - typically affecting bridge of nose and the cheeks Cardiac - cardiomegaly, endocarditis CNS - convulsions, hemiplegia Renal - 45% of patients, nephrotic syndrome and glomerulonephritis

Systemic sclerosis - pathogenesis

complex and poorly understood

Systemic sclerosis - what is it?

vessel damage, inflam response and cytokines

Systemic sclerosis - clinical presentation

Diffuse-widespread cutaneous lesions Renal, cardioresp and GI tract Osteoarticular involvement - artharlgia and arthritis

Systemic sclerosis - prognosis

poor

Systemic sclerosis - localised variant

Limited cutaneous involvement, oesophageal involvement and SI malabsorption CREST syndrome

CREST syndrome stands for

``` Calcinosis Reynaud's Oesopageal dysfunction Sclerodactyly Telangiectasia ```

Polymyalgia rheumatica - clinical presentation

stiffness, weakness, aching and pain in neck, limb girdles and upper limbs associated with giant cell arteritis - occipital and facial arteries. Causing pyrexia, headache and severe scalp pain.

Polymyalgia rheumatica - pathogenesis

immunological mechanism

Myopathy definition

muscle disease unrelated to any disorder of innervation or neuromuscular junction

Myositis definition

muscle fibres and overlying skin are inflamed and damaged resulting in muscle weakness

Muscular dystrophy - what is it?

heterogenous group inherited progressively severe muscle weakness and wasting begins in childhood

Malignant hyperthermia - what is it?

inherited | fast rise in body temperature and severe muscle contraction when the affected person general anaesthesia

rhabdomyolysis - what is it?

destruction of skeletal muscle releasing muscle fibre content into blood e.g. myoglobin

rhabdomyolysis - urine

myoglobin filtered through kidney and enters urine - myoglobinuria - brown urine

rhabdomyolysis - causes

``` trauma, crush injuries drugs - cocaine, amphetamine extreme temp severe exertion (marathon) length surgery severe dehydration ```

rhabdomyolysis - complications

acute renal failure

metabolic myopathies

glycogen synthesis and degradation disorders of mitochondrial metabolism

malignant hyperthermia - signs and symptoms

``` bleeding dark brown urine muscle rigidity quick rise in body temp to 105 deg F discovered during anaesthesia may have FH ```