Diseases of the musculoskeletal system Flashcards
What prefix is used to describe a problem with bones?
Osteo
What prefix is used to describe a problem with muscle?
My/Myo
What prefix is used to describe a problem with joints
Arth
What prefix describes a problem with cartilage?
Chondro
Which suffix denotes inflammation?
-itis
Which suffix denotes pain?
-algia
What is tendonitis a problem of?
Tendon
What is bursitis?
Inflammation of bursa
What are bursae?
Bursae are synovial membrane lined pockets
What is the function of bursae?
allow free movement of adjacent structures where otherwise, there could be friction.
What is enthesistis?
Inflammation of an enthesis.
What are entheses?
points where tendons, ligaments or joint capsules insert into bone.
Where is the largest site of an enthesis?
Achilles insertion.
What is osteoporosis?
Reduced bone density
What is osteomalacia?
Poor bone mineralization
What is osteomyelitis?
Bone infection
What is osteosarcoma?
Malignant bone tumour
Which word is used for muscle inflammation?
Myositis
What is myalgia?
Muscle pain
How common is myalgia?
Very common
What is myalgia commonly associated with?
Viral infection
Drugs (satins)
What can myositis be?
Autoimmmune
How common is myositis?
Less common than myalgia
What is a joint?
Where or more bones meet one another
How would you approach a patient with a msk problem?
Full history - often enough to make diagnosis
Physical examination
Serology tests - help support diagnosis
List some ways of classifying Rheumatic disease
Articular Non-articular/periarticular Inflammatory Non-inflammatory/degenerative/Mechanical Number of joints affected Duration of onset
Describe periarticular pain
Point tenderness over the involved structure
Pain reproduced by movement involving that structure
Describe articular pain
Joint line tenderness
Pain at end of movement in any direction
Which structures does periartciular pain affect?
Bursae
Tendon
Tendon sheath
Ligaments
How can articular pain be further differentiated?
Inflammatory/mechanical
What is monoarthritis?
Arthritis affecting 1 joint
What Is oligoarthritis?
Arthritis affecting 4 or fewer joints
What is Polyarthritis?
Arthritis affecting 5 or more joints
You are asked to review a patient presenting with thenar eminence atrophy. Which nerve do you think is affected?
Median nerve
Which epicondyle is affected in tennis elbow?
Lateral
What are soft tissue conditions?
Problems with radiolucent moving tissues
Give some examples of soft tissue conditions
Tennis elbow (lateral epicondylitis) Golfers elbow (medial epicondylitis) Carpal tunnel (median nerve compression at the wrist)
What is the importance of rheumatic disease?
Increasingly common
Important
Expensive
Leading cause of disability
Which is the most common form of arthritis in the UK?
Osteoarthritis
Describe the worldwide impact of MSK disorders
2nd most common cause of disability
Low back pain is leading cause
Disability due to MSK problems is increasing - ageing population and sedentary lifestyle
How much do you estimate the NHS in the UK spends in a year on treating musculoskeletal conditions?
10 billion
How do msk problems affect work?
Barrier to work
People with these conditions are less likely to be employed
What is septic arthritis classed as?
Medical emergency
You are asked to review a 35 year old male, who presents with a 2 days history of a painful, swollen right knee. What are your differential diagnosis?
Posttraumatic hemarthrosis
Gout
Septic arthritis
What must be considered in cases of hot swollen joints?
joint aspiration and gram stain
Describe septic arthritis
Single, hot and swollen joint
Most common organisms are staph and strep
Patient may be systemically well and able to bear weight
What are the mortality rates of septic arthritis?
11% which rises to 50% in polyarticular disease with sepsis
What is gout?
Most common arthropathy worldwide
Serum urate levels are high (>408)
Monosodium urate crystals form and deposit In cartilage, bone, periarticular tissues of peripheral joints
Who gets gout?
2.5% of population
Men over 40
Women over 65
What is associated with the risk of gout?
Increasing age Male sex Metabolic syndrome components - insulin resistance, obesity, hypercholesterolemia and hypertension Drugs - loop and thiazide diuretics Osteoarthritis Genetics Chronic kidney disease Diet
What crystals are you expecting to find in the knee fluid aspirated from a patient if you suspect clinically that he has gout?
Monosodium urate
What is gout caused by?
Negatively birefringent rods – monosodium urate
How do you manage acute attacks of gout?
– NSAIDs e.g. naproxen
– Colchicine
– Steroids
How do you manage gout in the long term?
Urate-lowering therapy e.g. allopurinol or febuxostat
What is pseudo out caused by?
positively birefringent rhomboids – calcium pyrophosphate
Describe rheumatoid arthritis
Common, chronic, multisystem inflammatory condition affecting up to 0.5-1% of the world population
Unknown cause with around 30% genetic susceptibility and the rest environmental
More common in women (3:1)
Peak onset is 45-65 years
In rheumatoid arthritis which is the first joint component affected?
Synovium
In osteoarthritis which is the first joint component affected?
Cartilage
What is the most important environmental risk factor is Rheumatoid arthritis?
Smoking
Describe the pathophysiology of Rheumatoid arthritis?
Early lymphocyte invasion of the synovium
Acute inflammatory reaction - swelling and increased vascular permeability
Synovial proliferation
Pannus formation
Cartilage destruction and bone erosion
What are the symptoms and signs of rheumatoid arthritis
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
List some extra articular manifestations of rheumatoid arthritis
Nodules (20%)
Bursitis / Tenosynovitis
Eyes: dry eyes (secondary Sjogren’s syndrome) / Scleritis / Scleromalacia
Splenomegaly (Felty’s)
Anaemia of chronic disease
Lung fibrosis /effusion /Nodules (Caplan’s)
Pericarditis
Neurological: Atlanto-axial subluxation / Carpal tunnel syndrome / Mononeuritis multiplex
Renal amyloidosis (AA)
Leg ulcers / Pyoderma gangenosum
Vasculitis
Increased risk of cardiovascular disease
List some investigations for rheumatoid arthritis
• ESR and CRP
• FBC: Anaemia of chronic disease (normochromic normocytic)
• Rheumatoid factor positive
– IgM antibody against the FC portion of human IgG antibodies
– can be falsely elevated by illness
– normal raised levels in 1 in 20 of population
• Anti CCP antibodies - cyclic citrullinated peptide antibodies
– Antigen present on inflamed synovium
– 98% specific for diagnosis of RA
• X-Rays : normal in early disease.. erosions / peri-articular osteoporosis and reduced joint space / cysts
Describe the management of rheumatoid arthritis
• 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 a problem. The main routes are IM or PO though in severe disease we may give IV steroid.
DMARDs – Disease Modifying Anti-Rheumatic Drugs
Synthetic DMARDs
• Methotrexate
• Sulfasalazine • Hydroxychloroquine
• Leflunomide
Biologic Agents • 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)
Describe osteoarthritis
- 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
Describe the pathophysiology of osteoarthritis
- 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
List the clinical features of osteoarthritis
- Age > 50 years• Morning stiffness < 30 minutes• Persistent joint pain aggravated on use
- Crepitus• NO INFLAMMATION• Bony enlargement and/or tenderness
Is there a clinical correlation between the radiological changes and the symptoms in osteoarthritis?
No
Are blood tests helpful in diagnosis osteoarthritis?
No
Describe SLE
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
List some SLE investigations
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
