CDM possible exam Qs Flashcards
List five things in a joint that can cause pain
- synovium
- periosteum
- joint capsule
- ligaments
- subchondral bone
List four pathological disease process of a joint
- Synovitis
- Infection
- Crystal deposition
- Enthesitis
- Structural and mechanical derangement
List four event occurring in synovitis
- Neovascularisation
- Infiltration of synovium with lymphocytes, plasma cells and macrophages
- Masses of proliferating syncopates and invading inflame cells leads to panes formation
- -> pannus can destroy articular structures
- Synovial cell hyperplasia
List four types of crystals
- Monosodium urate (gout)
- Calcium pyrophosphate dihydrate (pseudogout)
- Calcium phosphate (hydroxyapatite)
- Calcium oxalate
List the four key events in enthesitis
Inflammation of enthesis results in metaplasia of radially orientated collagen fibres giving rise to fibrous bone formation
- > metaplasia: new set of cells developed to replace current set that was unable to handle situation
- > new bone formation (2nd to periostitis)
- > gradual ossification of syndesmosis
- > syndesmophytes formation along outer fibres of vertebral discs
List four examples of entheseal sites
- Tendons and bone
- Ligaments and bone
- Cortical bone and periosteum
- Vertebral bodies and annulus fibrosis
Compare RA and OA joint stiffness
RA
- stiff upon waking, persists for more than 30-60 mins
OA
- occurs upon waking or following periods of inactivity, but is usually brief <30 mins
Compare RA and OA joint pain
RA
- occurs with both rest and with motion
- worse at beginning of movements and improves
OA
- occurs mainly or only during movement
- improves with rest
Compare RA and OA joint swelling
RA
- synovial hypertrophy and synovial effusion
- inflammation of periarticular structures
- degree of swelling varies over time
OA
- osteophyte formation and bone swelling
- ST swelling can contribute - cysts, thickening and effusion
List six descriptors to help diagnose a painful joint
Onset: - abrupt - insidious Distribution - Asymmetrical - Symmetrical Duration of ssx - Acute - Chronic Joint involvement - migratory - additive - intermittent Number of joints affected - mono - oligo - poly Extra-articular manifestations - systemic ssx - skin lesions - ocular lesions
List six descriptors for joint pain
- sharp
- achy
- stabbing
- burning
- throbbing
- pulsating
List six signs of inflammatory joint disease
- Synovial hypertrophy
- Joint effusion (synovial inflammation; trauma; haemarthrosis)
- Pain with motion
- Limited ROM (capsular pattern)
- Erythema (vasodilation - acute inflammatory arthritis)
- Warmth
- Joint tenderness
Define:
monoarthritis:
oligoarthritis:
polyarthritis:
monoarthritis:
when only one joint is affected
oligoarthritis:
between 2-4 joints are affected
polyarthritis: more than 5 joints affected
List three categories of joint pain
In true joint pain, three broad categories of joint disease must be differentiated, they may occur concurrently in the same joint;
- Inflammatory arthritides
- Non-inflammatory arthritides
- Arthralgia
List three ssx of joint disease
- pain
- swelling
- stiffness
- Loss of ROM
- fatigue
- weakness
Joint involvement may be classified as
- migratory
- additive
- intermittent
Manifestations of rheumatoid conditions can be arbitrarily divided into
Constitutional
Extra-articular
Articular
List four conditions in which typically present with a skin lesion/rash
SLE = malar rash
Dermatomyositis = Gottron’s papules
Systemic Sclerosis = dermal induration due to fibrosis
Psoriatic arthritis = psoriasis preceding inflammation
List three conditions presenting with ocular lesions
RA = scleritis AS = anterior uveitis ReA = conjunctivitis
List three conditions that present with systemic manifestations
RA
PsA
PMDM
List the signs of degenerative joint disease
- Bony overgrowth (bouchards nodes)
- Limited ROM
- Crepitus (grating sensation)
- Joint deformity
Define CRP
C-reactive protein is an inflammatory marker produced by the liver in the presence of inflammatory cytokines (interleukin 1 & 6) when there is tissue damage, autoimmune disease or infection
What does CRP tell you that ESR doesn’t
- more sensitive than ESR
- rises and falls faster than ESR
- better mirrors extent pf tissue damage than ESR
- Is independent of factors that raise ESR
- correlates better with disease activity
Define ANA testing
ANA testing is used to detect pathological antibodies which target specific nuclear antigens. Generally presents in those with autoimmune disorders
When would ANA titres be elevated?
- normal people
- in people with autoimmune conditions
- in those with rheumatic conditions
Name three diseases in which ANA titres would be elevated
- SLE
- Sjogren’s
- Polymyositis
- Mixed connective tissue disorder
- Systemic Sclerosis
When would you order ANA tests?
ANA testing is particularly useful in the diagnosis of SLE
nearly all patients with SLE have positive ANA test (93% sensitivity, 57% specificity)
Define Alkaline Phosphatase testing
ALP is a group of isoenzymes produced by the liver cells and bone tissue. When these cells are destroyed serum ALP increases
When would ALP be elevated
ALP is elevated in pathological conditions that increase bone turnover or destruction i.e. paget’s
Also elevated in non-musculoskeletal cases i.e. obstructive biliary cirrhosis
Name three diseases in which ALP is elevated
When would you order ALP tests =?
- Paget’s
- Hyperparathyroid
- Rickets
- Osteomalacia
To aid Dx of liver and bone diseases
Define Rheumatoid factor testing
Test to detect a group of autoantibodies (usually IgM) that for immune complexes that deposit in the tissues, resulting in complement activation and inflammation
When would RF titres be elevated?
In normal people
People with autoimmune diseases
In rheumatic conditions
Name three specific disease for RF
- RA
- SLE
- SSC
- PMDM
when would you order RF testing
Support clinical diagnosis of RA
- is not pathognomonic
Define ESR
Highly sensitive non-specific and inexpensive test for tissue damage and inflammation by a measure of heigh that erythrocytes fall through plasma in a westergren tube over an hour. Falling rate is slowed by acute phase proteins and immunoglobulins in the serum
When would ESR be elevated?
- Inflammatory conditions
- If extensive tissue necrosis has occurred
Name three specific conditions ESR is associated with
- infection
- cancers
- autoimmune diseases i.e. PMDM
When would you order ESR?
to aid diagnosis of a particular disease
Name a test that would be used to diagnose the following: (give justification) OA RA Gout Pseudogout SLE Infective Arthritis PMR
OA
- synovial fluid examination (exclude the presence of inflammatory arthritis or cystalopathy)
RA
- RF titres (80% pt have it but not diagnostic)
Gout
- synovial fluid analysis (negatively bifringent needle shaped crystals)
Pseudogout
- synovial fluid analysis (positively bifingent cuboid shaped crystals)
SLE
- ANA testing (high titres of antinuclear antibodies)
Infective Arthritis
- synovial fluid analysis (positive for presence of immune cells and initiating bacteria)
PMR
- ESR (significantly increased in this condition)
List five indications for synovial fluid joint aspiration
- Inflammatory conditions
- Cancer
- Autoimmune disease
- PMR
List five conditions which might cause increased CRP
- RA
- SLE
- SSC
- Polymyositis
- Dermatomyositis
Define arthography
A test performed using X-rau, CT or MRI to produce a series of images of a joint after administration of a contrast medium
Indications of arthography
- Mainly used to diagnose cause of persisitent, unexplained knee or shoulder pain
- To visualise meniscus, cartilage and ligaments on bone
- To visual joint derangement and synovial cysts
Define HLA-B27
A test to determine the presence of human leukocyte antigen, which is a surface antigen encoded by the B locus on the major histocompatibility complex on chromosome 6. it presents antigen peptides to T cells to differentaite self from non-self
When would HLA-B27 be elevated
- AS
- PsA
- Juvenile AS
- IBD
- Spondylitis
- ReA
define creatine kinase
test used to determine the level of creatine kinase in the blood stream, it is most sensitive to mm injury
When would CK be elevated?
- crush injury
- Rhabdomyolysis
- muscular dystrophy
- myositis
List four ominous radiological findings indicating malignancy
- diffuse hazy invasion of bone
- extensive bone deformity
- diffuse periosteal new bone formation
- extension of tumour into neighbouring ST
List four radiolgrahic findings of a giant cell tumour
- radiolucent areas situated in the end on long bones
- lesion is bounded by subchondral bone
- central lesion may have soap bubble appearance
- thinning and ballooning of cortex occurs
List four radiographic findings of a simple bone cyst
- well demarcated
- radiolucent
- occurring in metaphysis
- may extend to physeal plate
- cortical thinning and expansion
List four lab results that would indicate malignant disease
FBC - anaemia
ESR - elevated in maligancy
Serum protein electrophoresis - elevated IgG
Serum acid phosphatase - elevated
Incidence, distribution, pathology, clinical picture, radiological features, diagnostic investigations and treatment of
OSTEOSARCOMA
Incidence:
- rare but highly malignant
- primarily a malignancy of childhood/adolescence
- possible complication of Paget’s disease
Distribution
- may affect any bone - usually the metaphysis of long bones esp. the knee or pro humerus
Pathology
- destroys and replaces bone
- results in:
> bone loss
> abnormal new bone esp. periosteal margins
- spreads towards periosteym and surrounding ST
- May cross the epiphyseal plate
- histologically arises from primitive bone forming cells
- METs occur early via blood often to the lung
Clinical picture - pain is the first symptom > constant > worse at night > gradually increasing in severity - lump or swelling - tenderness - overlying tissues may be inflamed
Radiological features - hazy, osteolytic areas - dense osteoblastic areas - poor definition of endosteal margin - breaching of cortex > spread to adjacent tissue > new bone extending from cortex > sunburst effect - reactive new bone formation (periosteal elevation) - pulmonary METs
Dx investigations
- increased ESR
- +/- increased serum ALP
- blood tests show elevated WBC
- xray
- bone scan = increased uptake by neoplasm
Tx
- surgery
- chemo
Incidence, distribution, pathology, clinical picture, radiological features, diagnostic investigations and treatment of
CHONDROSARCOMA
A collective term for a group of malignant mesenchymal tumours that are mainly made up of cartilage cells that produce cartilage matrix
Incidence
- second most common bone malignancy
- M:F = 1.5:1
- age?
Distribution
- most common in the femur, humerus, ribs and pelvis
Pathology
- slow growing tumour
- can become very large
- derived from cartilage
- produces cartilage
- late metastasis
Clinical picture
- local pain (deep dull ache)
- pain at night
- local swelling
- decreased ROM when tumour is near joint
- path F#
pelvic tumour will cause additional ssx incl. -
- urinary frequency or obstruction, high groin mm pain and nerve dysfunction
Radiological findings
Primary
- usually large lesion >5cm
- radiolucent area (due to bone destruction)
- variable amounts of stippled calcification
- globular mass on surface of bone
- periosteal new bone formation
Secondary
- patches of calcification in the cartilage cap of osteochondroma
Tx:
- surgery
Lab investigations:
? Would be same as any malignancy?
Fibrosarcoma
A tumour of mesenchymal origin, which is composed of malignant fibroblasts in a collagen matrix
Epidemiology/incidence
- rare in bone (<5% of all primary bone tumours)
- M:F = 1:1
- most common in adults 30-60 yoa
Distribution:
- occurs in the metaphysics or diametaphyseal region of long bone. usually occur in LL, esp. femur and tibia followed by the pelvis
Pathology
Primary
- may originate in bone or invade bone from nearby connective tissue
Secondary
- can be secondary to; Paget’s, FD, GCT, bone infarct or chronic osteomyelitis
clinical picture:
- localised painful mass
- Path F#
Radiological features:
- osteolytic
- well-defined or ragged margin
- periosteal reaction is seen with cortical destruction
- extension into ST is common
CT & MRI are primarily used to define extent of tumour
Tx:
- surgery
- pre and post operative radiation
Labs:
?
Incidence, distribution, pathology, clinical picture, radiological features, diagnostic investigations and treatment of
Ewing’s Sarcoma
A primary malignant bone tumour whose small round tumour cells resemble those of lymphoma or neuroblastoma
epidemiology/incidence
- 10-15% of all bone sarcomas
- bone tumour with youngest predilection
- median age 15 years
- > 50% of patients are adolescents
- peak incidence in 2nd decade
Pathology:
?
Clinical Picture:
- localised pain
- palpable mass
- path F#
- asymmetric neuro ssx
Radiological features:
general -
- large
- poorly marginated
- >80% extend into ST
Plain xray:
- variable but usually have aggressive appearance
- common findings incl. permeative, laminated periosteum, sclerosis
MRI & CT are used to examine bone lesions MRI is best for ST
Tx:
- chemo
- surgery
Labs:
blood test -
- increased ALP
- hypercalcemia
Define Antiphosphlipid Antibody testing
ALPA are a group of antibodies directed against phospholipid associated proteins such as
- prothrombin
- cardiolipin
- beta 2 glycoprotein 1
Who has ALPAs?
- normal people have elevated levels following acute medical illness and infections
- people suffering SLE
- Antiphospholipid antibody syndrome
Indications for ALPA testing
- Unexplained thrombotic episodes
- Recurrent miscarriages
- Thrombocytopenia
- Prolonged PTT test
- Symptoms indicative of autoimmune disease
Define Cryoglobulin testing
Cryoglobulins are a group of abnormal serum immunoglobulins that precipitate (separate) at low temperatures
Cryoglobulin particles float in the serum & precipitate at the bottom of the test tube at 4 degrees C
Particles dissolve on re-warming of serum to body temperature
Precipitated cryoglobulins can lead to;
Thrombosis → increased blood viscosity slows blood flow
Ischemic necrosis → due to small blood vessel blockage
Vasculitis → cryos activate immune system
Who would have elevated cryoglobulins?
Not specific for any conditions, produced in a number of conditions including; • Autoimmune diseases • Infections • Lymphoproliferative diseases • Vasculitic conditions • Glomerulonephritis
Indications for cryoglobulin testing
Ordered in people with ssx suggestive of cryoglobulinaemia; • Bruising • Rashes • Joint pain • Weakness • Raynaud’s phenomenon NOTE: All these ssx can be due to SLE
