Introduction to diseases of the musculoskeletal system Flashcards
Tendonitis
Tendon problem
Bursitis
Inflammation of bursa
Bursae are synovial membrane lined pockets that serve to allow free movement of adjacent structures where otherwise, there could be friction
Enthesitis
Inflammation of an enthesis
Entheses are the points where tendons, ligaments or joint capsules insert into bone
The largest site is the achilles insertion
Osteoporosis
Reduced bone density
Osteomalacia
Poor bone mineralisation
Osteomyelitis
Bone infection
Osteosarcoma
An example of malignant bone tumour
Myalgia
Pain in muscles
Very common
Commonly associated with viral infections
Can be drug induced
Myositis
Inflammation of the muscles
Far less common than myalgia and can be autoimmune
Ways of classifying rheumatic disease
Articular vs non-articular/ periarticular
Inflammatory vs non-inflammatory/ degenerative/ mechanical
Number of joints affected
Duration of onset
Joint pain
Periarticular
- point tenderness over the involved structure
- pain reproduced by movement involving that structure
Articular
- joint line tenderness
- pain at the end range of movement in any direction
Joint inflammation nomenclature
Monoarthritis- affecting 1 joint
Oligoarthritis- affecting 2-4 joints
Polyarthritis- affecting 5 of more joints
Importance of rheumatic disease
Common and getting more common
Expensive
Important
Leading cause of disability
UK impact
Third greatest impact on the health of the UK population, considering both death and disability
- MSK disorders account 15.6%
- low back pain accounts for over half of this
- ranking of major causes of death and disability
MSK disorders and work
Poor musculoskeletal health is a major barrier to workplace participation
People with MSK conditions are less likely to be employed than people in good health and more likely to retire early
Septic arthritis
Always think about it in a patient with a (usually) single, hot and swollen joint
Mortality rates are of 11%, increases to 50% in polyarticular disease with sepsis
Commonest organisms are staph and strep
Do not have to be systemically unwell and they may be able to weight bear
Gout
Crystal deposition is often clinically silent
About 10% of people with hyperuricaemia develop clinical gout
UK GP studies show the prevalence of gout per 1000 has been steadily increasing from 2.6 in 1975 to 3.4 in 1987, and 9.5 in 1993
Clinical cure is achievable with treatment which is cheap, widely available, and under prescribed
Who gets gout?
Men aged 40 years and over
Women over 65 years
It increases with age, affecting 15% of men aged over 75 in the united kingdom
Epidemiology studies show that the metabolic syndrome and its components are strongly associated with gout
Risk factors for gout
Male sex Older age Genetic factors Chronic kidney disease Metabolic syndrome Osteoarthritis Dietary factors
Crystals
Gout is caused by negatively birefringment rods- monosodium urate
Pseudogout by positively birefringent rhomboids- calcium pyrophosphate
Management of gout
Acute attacks
- NSAIDs
- colchine
- steroids
Long term
Urate lowering therapy
Rheumatoid arthritis
Common, chronic, multisystem inflammatory condition affecting up to 0.5-1% of the world
More common in women (3:1)
Peak onset is 45-65 years
Unknown cause with around 30% genetic susceptibility and the rest environmental
Main problem with inflammatory arthritis
Synovium
Main problem with osteoarthritis
Cartilage
Rheumatoid arthritis pathophysiology
Early lymphocyte invasion of the synovium
Acute inflammatory reaction- swelling and increased vascular permeability
Synovial proliferation
Pannus formation
Cartilage destruction and bone erosion
Symptoms and signs of pathophysiology
Onset varies, can be acute or chronic
Symmetrical pain and boggy swelling of the small joints of the hands and feet
Early morning stiffness > 1 hour
Malaise and fatigue
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
Extra-articular manifestations of RA
Nodules
Bursitis/ tenosynovitis
Eyes: dry eyes/ scleritis/ scleromalacia
Splenomegaly
Anaemia of chronic disease
Lung fibrosis/ effusion
Pericarditis
Neurological: atlanto-axial sublaxation/ carpal tunnel syndrome
Renal amyloids
Lef ulcers/ pyoderma gangenosum
Vasculitis
Increased risk of CV disease
Rheumatoid arthritis invesitgations
ESR and CRP
FBC: anaemia of chronic disease
Rheumatoid factor positive- IgM antibody against the FC portion of human IgG antibodies
Anti CCP antibodies
X-rays: normal in early disease… erosion/ peri-articular osteoporosis and reduced joint space/ cysts
RA principles of management 1
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
RA principles of management 2
Disease modifying anti-rheumatic drugs
Synthetic DMARDs
- methotrexate
- hydroxychloroquine
- leflunomide
Biological agents
- anti TNF agents
- anti B cell
- anti interleukin 6 receptor blockers
- anti T cell- selective co-stimulation modulator
- janus kinase inhibitor
RA principles of management 3
Multidisciplinary team input
- nurse specialist (education and disease monitoring)
- physiotherapy (improve strength and stamina)
- occupational therapy (work, home environments)
- podiatry
Osteoarthritis
Common, degenerative disease of which the prevalence increases with age
Affects 70% of over 65 year olds
Most commonly clinically affects the knees, hips and small joints of the hands
Characterised by joint pain and very variable degrees of functional limitation
Pathophysiology of osteoarthritis
Metabolically active, dynamic process, involving all joint tissue (cartilage, bone, synovium, capsule, ligaments/ muscles)
Focal destruction of articular cartilage
Remodelling of adjacent bones- hypertrophic reaction at joint margins
Remodelling and repair process (efficient but slow)
Secondary synovial inflammation and crystal deposition
Clinical features of arthritis
Age > 50 years
Morning stiffness < 30 minutes
Persistent joint pain aggravated on use
Crepitus
No inflammation
Bony enlargement and/ or tenderness
Systemic lupus erythematosus
Chronic, relapsing, remitting disease
Broad spectrum of clinical features involving almost all organs and tissues
Prevalence in the UK 97 per 100000
F:M is 10-20:1
Peak onset between 15-40 years
More common and severe in those of Afro-Caribbean, Indian, Hispanic and Chinese origin living in USA and Europe
SLE investigations
Urinalysis- urinary protein: creatine ratio
Full blood count
Urea and electrolytes
ESR
CRP
Liver function test
Antibodies: ANA; ENA; Anti-dsDNA; lupus anticoagulant; anti C1q; C3, C4
