Corrections - MSK Flashcards
What are the different patterns of psoriatic arthropathy?
1) symmetric polyarthritis (30-40%) - most common type
2) asymmetrical oligoarthritis: typically affects hands and feet (20-30%)
3) sacroiliitis
4) DIP joint disease (10%)
5) arthritis mutilans (severe deformity fingers/hand, ‘telescoping fingers’)
Signs seen in psoriatic arthritis?
1) joint disease
2) psoriatic skin lesions
3) periarticular disease
4) nail changes: pitting, onycholysis
Mechanism of injury of posterior dislocation of hip?
Direct longitudinal impact onto a flexed hip (i.e. sitting in a car)
How will leg appear in posterior dislocation of hip?
- Leg will appear shortened
- Leg will be flexed, internally rotated, and adducted
Features of optic neuritis?
- pain on movement
- reduced visual acuity
- an RAPD due to reduced response to light of the afferent pathway in the affected eye
What is reactive arthritis?
Is typically a consequence of an infection elsewhere in the body such as the genitourinary or GI tract.
Its onset is usually acute with asymmetric lower limb oligoarthritis being common.
What is pseudogout?
A form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium.
Cause of gout vs pseudogout?
Gout: caused by monosodium urate monohydrate crystals
Pseudogout: caused by calcium pyrophosphate (CPP) crystals
What is pseudogout strongly associated with?
Increasing age
Patients who develop pseudogout at a younger age (e.g. < 60 years) usually have some underlying risk factor.
What are some risk factors?
- haemochromatosis
- hyperparathyroidism
- low magnesium, low phosphate
- acromegaly, Wilson’s disease
What joints are most commonly affected in pseudogout?
- wrist
- knee
- shoulders
Characteristic xray finding in pseudogout?
Chondrocalcinosis: in the knee this can be seen as linear calcifications of the meniscus and articular cartilage
What is chondrocalcinosis?
the finding of calcification of the articular cartilage
What 4 conditions are associated with HLA-B27?
1) ankylosing spondylitis
2) IBD
3) psoriatic arthritis
4) reactive arthritis
Management of acute RA flare?
IM steroids e.g. methylprednisolone
What is reactive arthritis?
An arthritis that develops following an infection where the organism cannot be recovered from the joint.
E.g. following an STI
What triad is seen in reactive arthritis?
1) urethritis
2) conjunctivitis
3) arthritis
‘can’t pee, can’t see, can’t climb a tree’
What STI can cause reactive arthritis?
Chlamydia trachomatis
Give some risk factors for osteoporosis
- history of glucocorticoid use
- rheumatoid arthritis
- alcohol excess
- history of parental hip fracture
- low body mass index
- current smoking
These are risk factors that are used by major risk assessment tools such as FRAX.
What medications can worsen osteoporosis?
- glucocorticoids
- SSRIs
- antiepileptics
- proton pump inhibitors
- glitazones
- long term heparin therapy
- aromatase inhibitors e.g. anastrozole
What is typically the 1st sign of systemic sclerosis?
Raynaud’s
What is systemic sclerosis?
Systemic sclerosis is a condition of unknown aetiology characterised by hardened, sclerotic skin and other connective tissues.
What joint disease is squaring of the thumb seen in?
OA
Classic patient with ankylosing spondylitis?
A young male with lower back pain and stiffness of insidious onset, which is worse in the morning and moves with exercise.
Characteristic changes in psoriatic arthritis?
- Dactylitis
- DIP swelling
- spinal stiffness
- reduced cervical spine mobility
Note a patient can have psoriatic arthritis without having psoriatic skin changes.
What scoring system is a measure of disease activity in rheumatoid arthritis?
The DAS28 score
What is spinal stenosis often relieved by?
Spinal stenosis is often relieved by sitting down or leaning forward
Patients will often find walking uphill easier.
How does spinal stenosis present?
Spinal stenosis typically presents with back pain that might radiate to the thigh and/ or calves.
Risk factors for spinal stenosis?
previous back surgery and manual labour.
What are 4 key risk factors for avascular necrosis of the hip?
1) long term steroid use
2) chemo
3) alcohol excess
4) trauma
What is CREST syndrome?
CREST syndrome is a subtype of limited systemic sclerosis and includes:
- calcinosis
- Raynaud’s phenomenon
- oesophageal dysmotility
- sclerodactyly
- telangiectasia
What medications can cause thrombocytopenia?
- quinine
- abciximab
- NSAIDs
- diuretics: furosemide
- antibiotics: penicillins, sulphonamides, rifampicin
- anticonvulsants: carbamazepine, valproate
- heparin
What is polymyositis?
An inflammatory disease commonly caused by Anti-Jo-1.
Who does polymyositis typically present in?
typically presents in male patients >40 years
How does polymyositis typically present?
- symmetrical proximal muscle weakness
- raised creatine kinase as a result of muscle breakdown
- absence of a rash
How is polymyositis typically treated?
corticosteroids and/or immunosuppressants such as methotrexate.
Pain in scleritis vs episcleritis?
Scleritis: can be very painful
Episcleritis: episclera becomes inflamed and red but NO pain (gritty sensation)
What is an early xray feature of RA?
Juxta-articular osteoporosis/osteopenia
What should be co-prescribed with NSAIDs in all patients with osteoarthritis?
PPIs
What are some side effects of thyroxine therapy?
- hyperthyroidism (over treatment)
- reduced bone mineral density: risk of osteoporosis
- worsening of angina
- AF
What investigation is recommended in all patients with suspected RA?
Xrays of hands and feet
what is Buerger’s disease (or thromboangiitis obliterans)?
A small and medium vessel vasculitis strongly associated with smoking.
It causes Raynaud’s phenomenon (discolouration of extremities with cold exposure) and extremity ischemia leading to intermittent claudication (pain in legs which occurs during exercise and is relieved by rest).
What is Buerger’s disease strongly associated with?
Smoking
What 2 features are seen in Buerger’s disease?
1) Raynaud’s
2) Extremity ischaemia (leading to intermittent claudication)
What is the nerve most likely to be injured during knee arthroplasty?
Common peroneal nerve
What are darbepoetin alfa injections used for?
Anaemia caused by renal failure.
Darbepoetin is a long-acting erythropoiesis-stimulating glycoprotein.
What is discitis?
Discitis is an infection in the intervertebral disc space. It can lead to serious complications such as sepsis or an epidural abscess.
Features of discitis?
- Back pain
- Pyrexia, rigors, sepsis
- Neuro: changing lower limb neurology, epidural abscess
What is the most common cause of discitis?
Staph aureus
Pertinent cause of discitis in IV drug users?
Infective endocarditis: (infected) systemic emboli can travel in the bloodstream and induce vertebral involvement, resulting in discitis.
What location of back pain is a red flag?
Thoracic
What is syringomyelia?
Syringomyelia (‘syrinx’ for short) describes a collection of cerebrospinal fluid within the spinal cord.
What condition does syringomyelia have a strong association with?
Chiari malformation
A prolapsed lumbar disc usually produces clear dermatomal leg pain associated with neurological deficits.
Site of compression that causes weakness in plantar flexion of foot?
S1 nerve root compression
Site of compression that causes weakness in foot and big toe dorsiflexion?
L5 nerve root compression
Describe calcium, phosphate, ALP and PTH levels in:
a) osteoporosis
b) osteomalacia
c) Paget’s disease
a) all normal
b) calcium decreased, phosphate decreased, ALP increased, PTH increased
c) calcium normal, phosphate normal, ALP increased, PTH normal
what is osteomalacia?
Osteomalacia, often referred to as “soft bone disease,” is a metabolic bone disorder characterised by the inadequate mineralisation of bone tissue. This condition results from a deficiency in vitamin D, calcium, or phosphate, weakening and softening bones.
Describe calcium, phosphate, ALP and PTH levels in 1ary hyperparathyroidism
Calcium increased
Phosphate decreased
ALP increased
PTH increased
Describe calcium, phosphate, ALP and PTH levels in CKD?
CKD leads to 2ary hyperparathyroidism.
Calcium decreased, phosphate increased, ALP increased, PTH increased
How does CKD lead to 2ary hyperparathyroidism?
Defect in the activation of vitamin D in the kidneys due to CKD leads to hypocalcemia and hyperphosphatemia.
This results in a compensatory increase in PTH production, causing secondary hyperparathyroidism.
Xray changes seen in osteoarthritis?
LOSS:
Loss of joint space
Osteophytes forming at joint margins
Subchondral sclerosis
Subchondral cysts
1st line management for bone protection in patients on long term steroids?
Alendronate + calcium & vit D replete
What level lesions is there weakness in foot and big toe dorsiflexion?
L5 nerve root compression
What level lesion is there sensory loss in the anterior aspect of knee and medial malleolus?
L4 nerve root compression
What is De Quervain’s tenosynovitis?
De Quervain’s tenosynovitis is a common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged 30 - 50 years old.
Features of De Quervain’s tenosynovitis?
- pain on the radial side of the wrist
- tenderness over the radial styloid process
- abduction of the thumb against resistance is painful
- Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus
What is a late sign of cauda equina syndrome that may indicate potentially irreversible damage?
Urinary incontinence
What cancer can cause ‘cannonball mets’ to the lung?
Renal cancer
What are the features of seborrhoeic dermatitis?
1) eczematous lesions on the sebum-rich areas: scalp (may cause dandruff), periorbital, auricular and nasolabial folds
2) otitis externa and blepharitis (itchy red eyelid) may develop
Presentation of ankylosing spondylitis?
1) Inflammatory back pain: often early morning stiffness (gets better with activity), with tenderness of the sacroiliac joints and limited range of spinal motion on examination
2) Enthesitis (Achilles tendonitis, plantar fasciitis)
3) Peripheral arthritis: may occur in up to one-third of patients, with the hips and shoulders most commonly affected
4) Extra articular involvment:
a) Anterior uveitis (20–30%)
b) Aortitis which can lead to aortic regurgitation
c) Upper lobe pulmonary fibrosis
d) IgA nephropathy (5%)
What antibodies support a diagnosis of ankylosing spondylitis?
HLA-B27
What autoantibodies support a diagnosis of Sjogrens?
Anti Ro and Anti La
What is it important to screen for prior to starting biologics?
TB (using a quantiferon test): as biologics can reactivate latent Tuberculosis.
Give some respiratory features that may be seen in RA
1) Pleural disease: pleurisy & pleural effusions (exudative)
2) Rheumatoid nodules on CXR (asymptomatic)
3) Interstitial lung disease
4) Organising pneumonia
5) Methotrexate induced pneumonitis
What is Caplan syndrome?
Involves multiple rheumatoid nodules occurring in the lungs of RA patients with coal-workers pneumoconiosis
What score is used to measure disease activity in rheumatoid arthritis?
DAS-28
DAS-28 scores:
<2.6 – disease remission
2.6–3.2 – low disease activity
3.2–5.1 – moderate disease activity
≥5.1 – high disease activity
Side effects of hydroxychloroquine?
- Retinopathy
- Rash
Main 2 side effects of bisphosphonates?
1) Oesophageal reactions e.g. oesophagitis, oesophageal ulcers, erosions and strictures which can present as odynophagia, dysphagia or new/worsening dyspepsia.
2) Osteonecrosis of the jaw or auditory canal.
3) Hypocalcaemia
What autoantibody is specific to SLE?
Anti-dsDNA
Who are biologics reserved for in RA?
When patients have severe disease (DAS28 score >5.1) despite combination DMARD therapy.
Definitive test for Sjogren’s syndrome?
Salivary labial gland biopsy: should show lymphocytic infiltrates around the duct.
What is the most characteristic feature of ankylosing spondylitis?
Fusion of the sacroiliac joint
What conditions can yield a positive result of HLA B27?
- Psoriatic arthritis
- Reactive arthritis
- Ankylosing spondylitis
1st line management of RA?
DMARD monotherapy (e.g. oral methotrexate).
What antibodies are seen in:
a) RA
b) SLE
c) Drug-induced SLE
d) Sjogren’s syndrome
e) Wegener’s Granulomatosis
a) Rheumatoid factor (50-90%), Anti-CCP (>95%),
b) Anti-dsDNA, Anti-sm, ANA
c) Anti-Histone
d) Anti-Ro, Anti-La
e) cANCA
What is ciclosporin?
an immunosuppressant
e.g. used in organ transplantation to prevent rejection
Main adverse effects of ciclosporin?
INCREASED everything:
1) HTN
2) nephrotoxicity
3) hepatotoxicity
4) fluid retention
5) hyperkalaemia
6) hypertrichosis
7) gingival hyperplasia
8) tremor
9) impaired glucose tolerance
10) hyperlipidaemia
11) increased susceptibility to severe infection
What is discitis?
An infection in the intevertebral disc space.
What 2 serious complications can discitis lead to?
1) sepsis
2) epidural abscess
What the most common organism causing discitis?
Staph. aureus
Features of discitis?
- back pain
- pyrexia, rigors, sepsis
- neuro features
