Deck 10 Flashcards
Infective joint pain
Rubella, parvovirus, mumps, Hep B, staphylococci, TB, borrelia
Post infective joint pain
rheumatic fever, reactive arthritis
Inflammatory causes of joint pain
RA, ankylosing spondylitis, SLE, scleroderma, polymyositis
Tumour joint pain causes
primary (osteosarcoma, chondrosarcoma)
Secondary (lung, breast, prostate)
Joint pain with hypermobility
Ehler’s danlos
OA most common joints
knee (often bilateral), hip and small hand joints (DIPS)
Metatarsophalangeal joint, talonavicular joinr, lumbar and cervical spine
crystal associated OA
chondrocalcinosis (calcium pyrophosphate crystals - knees and wrists).
OA S+S
Pain worse on movement, morning stiffness <30 mins
Heberdens nodes, bouchards nodes, thumb squaring, varus knees (medial tibiofemoral OA),
Osteophytes, reduced range of active/passive movement, crepitus, deformity, effusion, atalgic gate
OA RF
genetic (esp hands), aging, female, obesity, high bone density, Hx of joint injury, occupation, reduced muscle strenth, joint malalignment
Typically W>M, 50_
Secondary OA
crystal arthritis, avascular necrosis, acromegaly, haemochromatosis, chondrocalcinosis, haemophilia, haemoblobinopathies, neuropathies
OA definition
clinical outcome of various factors giving pain, disability, stricutral synovial joint failure and remodelling
OA diagnosis
Xray scoring, but not needed for diagnosis. Loss of joint space Osteophytes Subchondral sclerosis Subchondral cysts Cartilage degradation
Hip has painful and reduced rotation, and positive trendelenburg test (sound side sags)
RA
Symmetrical inflammatory polyarthropathy
RA pathophysiology
Neutrophil /T cells, macrophages infiltration during rheumatoid synovitis, exudative effusion, then vascular granulation (pannus via osteoclast and macrophages causes erosions)
Can be secondary to OA
Morning stiffness can be inflammatory mediators or excess cortisol
RA S+S
fatigue, sleep impacted. flares (can be med change, stress, poor adherence - may trigger med review), pain, swelling, erythema in small joints of hands/feet (bilateral)
MCP, PIPs, wrist, elbow, glenohumeral, cervical spine, hip, knee, ankle.
Thoracic/lumbar spine and dips are spared
Morning stiffness lasts >30 mins.
Often goes from feet to hands to knee to shoulder/hip
Valgus deformity and secondary OA can develop
Advanced RA
Ulnar MCP, radial wrist, boutoniere (dip flex, pip extend) or swan neck (pip and dip extension), Z thumb (IP extension, flexed MCP)
Joints sublux, deformity occurs with ankylosis
Pannus formation
vascularised granulation tissue. Synovial membrane becomes hypertrophied
Skin RA features
nodules (esp in seropositive RA), fragility, vasculitis, pyoderma gangrenosum
Heart RA features
pericarditis, atherosclerosis, vasculitis, valvular disease
Lung RA features
pleural effusion, fibrosis, bronchiolitis obliterans (dry cough, SOB), RA nodules, vasculitis
Eye RA features
keratoconjunctivitis sicca (sjogrens), episcleritis, scleromalacia perforans (necrotising scleritis), peripheral ulcerative kerotopathy
Neurological Ra features
carpal tunnel, peripheral neuropathy
Haematopoeitic Ra featuures
anaemia, thrombocytosis, lymphadenopathy, felty syndrome
Felty syndrome
RA , splenomegaly, neutropoenia
Kidney RA features
amyloidosis, vasculitis
Bone RA features
osteopoenis
Nodules in RA form
Local vascular damage allows IgM rheumatoid factor complex to embed in vessel walls. Stimulates monocytes and leads to pallisading granuloma formation
palisading granuloma
macrophages and giant cells in tier formation
RA diagnosis
anti CCP is most specific
RF also used, but can be FP as not as specific
ANA raised if CT disease
XR shows loss of joint space, erosions
Normocytic anaemia of chronic disease, leukocytosis, raised CRP/ESR
Non joint complications of RA
GI bleed due to aspirin therapy, infections/osteoporosis due to steroids, amyloidosis
DDx in early RA
reactive arthritis, seronegative spondyloarthropathies, polymyalgia rheumatica, acute nodal OA
Gout investigations
FBC, CRP, ESR, serum urate, synovial fluid aspiration, HbA1c, lipid profile
xray (punched out erosions)
Gout diagnostic test for crystals
negatively birefringent needle - > urate
Primary gout
Either excess uric acid production or reduced excretion. Alcohol and obesity predispose
Secondary gout
10% of cases. Associated with increased nucleic acid turnover
- diuretics, aspirin, nicotinic acid, lead, glycogen storage disease
Pathophysiology of gout
Typically monoarticular
Crystals activate Hageman factor (inflammation and chemo attractant -macrophages/neutrophils phagocytose crystals and secrete lysozymes, PGs etc which inflame and cause synovitis)
Renal effects of gout
tophi, intratubular urate deposition, nephrolithiasis, chronic urate nephropathy
Pseudogout associated conditions
Typically elderly patients
Associated with hyperparathyroidism, hypophosphataemia, hypomagnesaemia, Wilson’s disease. But may be sporadic
Typical pseudogout joints
often knee, but can get wrist
Pseudogout investigations
Chondrocalcinosis (calcification of articular cartilage and menisci on xray)
Weakly positive,blunted rhomboid calcium pyrophosphate dihydrate crystals)
Most common septic arthritis in children
H influenzae
Most common septic arthritis in older childrenadults
Staphylococcus aureus
Pott disease
Spinal TB
TB arthritis
insidious, chronic onset. Often haematogenous spread, or from osteomyelitis focus.
Lyme disease arthritis
Post skin signs. Migrates. Involves large joints. Often clears spontaneously but may cause long term damage
Enthesitis
Inflammation of ligament/tendon insertion at bone
Tendonitis
Tendon inflammation by trauma, crystals or infection
Tenosynovitis
Inflammation of tendon sheath. Can co-exist with tendonitis
Sprain
Ligament tearing (stretch/rupture)
Strain
Muscle fibre stretching or rupture
Subacromial buritis location
between acromion and supraspinatus, between deltoid tendon and greater tubercle of humerus
Subacromial bursitis symptoms
Pain on front/side of shoulder, pain on arm movement/sleeping on that side. May have stiffness. Pain on reaching up.
Abduction pain, pain on anterior palpation, mild anterior swelling, reduced function
Lateral epicondylitis
Tennis elbow.
Extensor insertion for extensor carpi ulnaris, extensor carpi raialis brevis, extensor digiti minimi, extensor digitorum comunis.
Pain on extening wrist, making fist (gripping objects, supinating, opening doors). Tenderness over lateral epicondyle. Weak wrist and finger extension.
PRICE and analgesia Tx
Plantar fasciitis
Weakness of plantar aponeurosis. Calcaneal bone spurs can develop. May be due to trainer use runing, standing, obesity
Heel pain (esp after initiating movement from rest, worse in morning/after rest, imrpoves with activity) Pain worse on dorsiflexion. Achilles tendon may feel tight
scleroderma overview
Rare autoimmune
F4x
25-55
up to 20% deelop another CT disorder (arthritis, lupus, myositis)
Scleroderma S+S
Skin: sclerodactyly, Reynauds syndrome, nail bed abnormalities (including splinter haemorrhage), digital calcinosis, tight skin around fingers/mouth
1/2 are cutaneous scleroderma (skin only)
In Systemic:
- MSK issues are arthralgia and myalgia
GI features are dysphagia, reflux, dyspepsia
Lung issues are pulmonary artery HTN, interstitial lung disease (large cause of death)
Cardiac features are chest pain, palpitations, pericardia/myocardial disease)
Systemic features: inflammation, fibrosis, vasculopaty, sicca, fatigue
SLE demographics
10x female
8X Black people
20s-40s
SLE types
Chronic autoimmune disease
Can be cutaneous only, or multisystem. Has ds nucleic acid antibodies, affinity for GBM in kidney but also causes inflammation in brain, heart, spleen, lung, GI tract, peritoneum
SLE S+S
S:
- Skin (initial signs): vasculitis, rash, malash rash, discoid rash, photosensitivity, nasal/oral ulceration
- Joints: arthalgias, synovitis, swelling, pain, morning stiffness. May see reducible swan neck deformities as ligament issue rather than subluxation
- Haematological: anaemia, deranged WC and platelets, acquired antiphospholipid syndrome
- Lung/Cardiac: serositis (SOB, pleuritic chest pain, chest pain)
- Renal: glomerulonephritis
Neurological: seizures, psychosis, confusion, peripheral neuropathy, myelitis
Seronegative spondoarthridities
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
IBD related arthopathy
Ankylosing spondilitis
3:1 M:F, 18-30, episodic sacroiliac inflammation. Worse in morning, relieved by exercise. May have uveitis, pulmonary fibrosis, AV node block, amyloidosis Check ESR, Pelvis XR (fusion of sacroiliac), spinal XR (bamboo spine)
Psoriatic arthritis
equal M:F, often symmetrical with DIPJ involvement, nail changes (ochylolysis), spondylitis, dactylitis, psoriasis
reactive Arthritis
Reiter’s syndrome. Acute, asymmetrical lower limb arthritis 4-40 days post GI/GU infection (which may have been asymptomatic). Can be chlamydia, salmonella, campylobacter. More common in Males and HLAB27. Triad of dysuria, conjunctivitis and lower limb oligoarthritides. Skin lesions are also common.
IBD related arthropathy
Symmetrical arthritis, may have spinal or SIJ involvement. In UC, remission of IBD associated with arthritis remission, but less so in Crohns.
facet joints
synovial, allows flex/extension in lumbar spine - no lateral rotation or flexion.
Rotation and lateral flexion in thoracic spine
Spinal ligament
Posterior longitudinal C2-sacrum for stability
Anterior longitidinal C1-sacrum -stability
Supraspinous C7-sacrum
Ligamentum flavum
Adult spinal cord termination
L1
Disk prolapse tends to go
laterodorsal
Mechanical back pain
- Gets better/worse depending on position
- Worse on movement
- Worse in poor posture, lifting, sitting
- Can be due to minor injury (e.g. ligament sprain)
Improves in a few weeks, regardless of treatment
Lumbar spine sprain/strain
often due to lifting. Intense pain, then spasm
Degenerative disc/facet
Often older
Gradual pain onset, worse after rest.
Can be due to OA
Can affect sacroiliac
Back pain worse on extension
?facet joint
Back pain worse on flexion
? disc
Herneated nucleus pulposis
Aging disc in older, trauma in younger. Typically lumbar with dermotomal leg pain. Worse on straight leg raise
Spondylolysis
Congenital. Anterior displacement of L5 body and transverse process (posterior remains in place over sacrum) - Scottie dog
Spondylolithesis
Acquired anterior displacement of L5 body and transverse process, posterior part remains over sacrum. Scottie dog on ray
Back pain red flags
Bladder/bowel issues, non lumbar issues, leg weakness/parasthaesia, erythema over spine, B symptoms, fever, saddle paraesthesia, Hx of cancer, Hx of IVDU, prolonged steroids, patient age/fragility
Infective causes of back pain
discitis, osteomyelitis, epidural abscess - consider infection nearby, surgeries, IVDU, steroids?
Inflammatory causes of back pain
spondyloarthropathies such as AS, Psoriatic arthritis - RA in neck and sarcoiliac joint
Cortical bone
osteons, outer bone layer. Has central bone marrow
Spongy bone
Found in long bones. No bone marrow. Has cortical bone outside
Osteoporosis bone type affected
trabecular
Secondary osteoporosis
primary hyperparathyroidism, thyrotoxicosis, steroid induced, Cushing’s disease, anorexia nervosa, malabsorptive conditions, chronic inflammation/neoplastic disease (suppresses bone formation)
RF for osteoporosis
low BMI, elite female athletes, caucasian/ Asian women who cover skin, Vitamin D deficiency (and associated such as coeliac disease, kidney disease, liver disease), early menopause, late menarchy, alcohol >4 units/day, smoking, overactive thyroid, COPD (steroid use), FHx, RA
Diagnosis of osteoporosis
DEXA gives T score (Deviation of bone density from young adult. T
FRAX
10 year osteoporosis risk
DEXA T score
less than -2.5 is osteoporosis. Less than -1 is osteopoenisa
Z score DEXA
comparison to age matched control
Osteoporosis prevention
calcium intake, vitamin D supplements, weight bearing exercise, smoking cessation, alcohol reduction, medication risks, referral to falls team,
Osteoporosis management
symptomatic with analgesia. Use antireabsorptives (bisphophonates, denosumab), anabolic steroids, dual action bone agents.
Can also have surgical management (kyphoplasty, vertebroplasty)
Ankle plantarflexion
S1
Finger abduction
T1
Wrist extension
C6
Radial nerve
C7
Elbow extension, wrist flexion
C8
Thumb extension, finger flexion
Hip flexion
L2
Knee extension
L3
Ankle dorsiflexion
L4
Big toe extension
L5
Shoulder shrugs
C4
Shoulder abduction, external rotation, elbow flexion
C5
Median nerve Roots
C6-T1
Median nerve motor in arm
Sites in anterior forarm compartment, involved in flexion and pronation.
Median nerve in hand
Thenar muscles.
Lateral 2 lumbracles
Sensation to palmar thumb, 1st, 2nd and 1/2 3rd
Radial nerve roots
C5-T1
Radial nerve sensation in hand
Dorsum of lateral 3 1/2 digits, plus back of thumb
Motor radial nerve
Innervates triceps
Runs in extensor compartment of forearm. Innervates wrist extension, but note sthat wrist drop does not occur in trauma beyond radial groove as branches assist
ulnar nerve
C8-T1
Runs between medial epicondyl and olecranon
Ulnar nerve motor
Flexor carpi ulnaris (flexes and adducts)
Flexor digitorum profundus (medial 1/2) - flexes at dips
Intrinsic hand muscles except lateral 2 lumbicles and thenar.
Ulnar sensation
medial 1.5 of fingers on palm
Common fibular nerve
L4-S2
Innervates lateral leg compartment (foot eversion via superficial) and anterior compartment (deep branch) - includes dorsiflexion
Damage causing foot drop
Common fibular nerve, or deep fibular nerve
Can be due to fibular fracture or tight plaster cast as deep fibular wraps around neck of fibular bone.
Would also loose sensation over dorsum of foot.
Medial foot sensation
Saphenous
Heel and sole of foot sensation
Tibial (from sciatic)
