L5 - Intro to MSK disease COPY

Question 1

NOMENCLATURE

i) what is tendonitis?
ii) what is bursitis?
iii) what is enthesitis?
iv) define - osteoporosis/osteomalacia/osteomyelitis/osteosarcoma

Answer 1

i) tendon problem/inflammation
ii) inflammation of bursa - synovial membrane lined pockets that allow free movement of adjacent structures
iii) enthesitis - inflammation of enthesis (points where tendons/lig/joint capsule insert into bone)

iv) osteoporosis - reduced bone density
osteomalacia - reduced bone mineralisation
osteomyelitis - bone infection
osteosarcoma - malignant bone tumour

Question 2

MUSCLE CONDITIONS

i) what is myalgia? how common is it?
ii) what is myalgia commonly associated with? which drugs may induce it?
iii) what is myositis? is it more or less common than myalgia?
iv) what may be the underlying cause of myositis?

Answer 2

i) myalgia = muscle pain
- very common

ii) myalgia is commonly associated with viral infection
- can be induced by statins

iii) myositis is inflammation of the muscles
- less common than myalgia

iv) underlying cause of myositis - autoimmune

Question 3

CLASSIFICATION OF RHEUMATIC DISEASE

i) what two things are often enough to make a diagnosis? what further tests may be done?
ii) what is an articular disease? what is non/peri articular?
iii) if a disease is non inflammatory - whay may it be? (2)
iv) what is the name for a disease with a) one joint affected, b) 2-5 joints affected, c) 5+ joints affected?

Answer 3

i) history and physical exam
- can send for serological tests/imaging

ii) articular - to do with the joint
- non articular - not the joint
- peri articular - around the joint

iii) non inflamm may be degenerative or mechanical

iv) one joint = monoarthritis
2-5 joints - oligoarthritis
5+ joints = polyarthritis

Question 4

JOINT PAIN

i) what type of joint pain may have point tenderness over the structure and pain reproduced by movement?
ii) which type of joint pain may have joint line tenderness, pain at end range of movement?
iii) name two things characteristic of inflammation? name two things characteristic of a mechanical problem?

Answer 4

i) point tenderness/pain on movement - periarticular
ii) joint line tenderness/pain end range - articular

iii) inflamm - red and swollen
mech - lock and catching

Question 5

DIFFERENTIAL DIAGNOSES IN RHEUMATOLOGY

i) give three differentials for monoarticular
ii) give three conditions for oligo articular
iii) give three conditions for polyarticular

Answer 5

i) mono = trauma, haemoarthrosis, spodyloarthropathy, septic, crystal induced
ii) oligo = spodylo, crystal induced, infection
iii) polyartic - RA, SLE, crystal induced, infectious

Question 6

SOFT TISSUE CONDITIONS

i) what type of tissues is there a problem with? how common is it?
ii) which structure is affected in a) tennis elbow, b) golfers elbow, c) carpal tunnel syndrome
iii) name two treatments for carpal tunnel

Answer 6

i) problem with radiolucent moving tissues

ii) tennis elbow - lat epicondyle
golfers elbow - medial epicondyle
carpal tunnel - median nerve compression

ii) inject with steroids or surgery for decompression

Question 7

EPIDEMIOLOGY OF RHEUMATIC DISEASE

i) what are MSK the second most common cause of world wide? what is the single leading cause for disability globally?
ii) what number in the list is MSK diseases when looking at greatest impact on health of UK population?
iii) how much do the NHS spend on treating MSK problems every year?
iv) what % of the general pop sees a GP for MSK problem every year? how does prevalence of MSK conditions change with age?

Answer 7

i) second most common cause of disability worldwide
- lower back pain is single cause globally

ii) MSK diseases are 3rd in greatest impact of health on UK population
iii) NHS spend £10 billion per year on MSK probelms

iv) 20% pop see GP for MSK probs every year
- prevalence increases with age

Question 8

INFLAMMATORY VS NON INFLAM JOINT PAIN

i) for inflammatory - how long does morning stiffness last? does activity improve or exacerbate pain? does rest improve or exacerbate?
ii) when is inflammatory joint pain the worst? is there associated fatigue? do steroids help?
iii) for non inflam - how long does morning stiffness last? does activity improve or exacerbate pain? does rest improve or exacerbate?
iv) when is non inflammatory joint pain the worst? is there associated fatigue? do steroids help?

Answer 8

i) inflam - morning stiffness >1hr
- activity improves pain and rest exacerbates

ii) inflam is worse in the morning and profound fatigue
- steroids dramatically help

iii) non inflam lasts <30mins
- acitivty exacerbates pain and rest improves it

iv) non inflam pain is worse in the evening
- minimal assoc fatigue and steroids only have a partial effect

Question 9

SEPTIC ARTHRITIS

i) what are the cardinal features? (3) why must diabetic/immunosupressed patients be examined carefully?
ii) what should always be done? what would be a normal result of this?
iii) what four things should be sent for if SA is suspected?
iv) what are the most common causative organisms?
v) does the patient have to be systemically unwell to have SA?
vi) what is the key method of management?

Answer 9

i) single, hot, swollen joint
- diabetic/immunosup may not present like this

ii) joint aspiration should always be done
- should be clear/straw coloured

iii) send for gram stain, bacterial culture, crystals, white cell differential
iv) staph and strep are most common organisms
v) dont need to be systemically unwell

vi) key management is sepsis 6 - take lactate, cultures, urine output
- give high flow oxygen, IV antibiotics and fluid

Question 10

GOUT

i) what type of condition is it the most common cause of?
ii) why do crystals deposit in joints?
iii) what type of crystals deposit? where do they deposit (3) where is the most common area to get it?
iv) what % of people with hyperuricaemia have clinical gout?
v) how many adults in the UK are affected?

Answer 10

i) most common cause of inflammatory arthropathy
ii) crystals depos in joints because the levels reach physiological saturation

iii) monosodium urate crystals
- depos in cartilage, bone, periarticular tissue of periph joints

iv) 10% of people with hyperuricaemia have gout
v) 1 in 40 adults are affected

Question 11

WHO GETS GOUT/RISK FACTORS

i) which age group/sex are highest risk?
ii) name four things that are associated with increased incidence of gout? what is the name for the collection of these symptoms?
iii) give five risk factors for gout

Answer 11

i) men over 40
ii) increased incidence - insulin resis, obesity, hyperlipidaemia and hypertension = metabolic syndrome
iii) RFs = male/older/genetics/CKD/metabolic syndrome/OA/dietary factors

Question 12

CRYSTALS

i) what type of rods cause gout? which crystal is seen?
ii) which type of rods cause calcium pyrophosphate crystal deposition? which crystal is seen?

Answer 12

i) negatively birefringent rods
- monosodium urate

ii) CPPD - positively bifringement rods
- calcium pyrophosphate

Question 13

GOUT/CPPD MANAGEMENT

i) give two conservative approaches for each
ii) give three things that can be given in an acute attack for each
iii) give two long term therapies for each
iv) what may been seen on radiology in CPPD?

Answer 13

i) conservative gout - reduce alcohol/high purine foods and diabetic control

conservative CPPD - hot/cold pack, immobilisation

ii) acute attack gout and CPPD - NSAIDs eg naprooxen, colchicine, steroids

iii) long term gout - urate lowering therapy eg allopurinol
anakinra (IL-1 antagonist)

long term CPPD - cochicine propylaxis, anakinra (IL-1 antag)

iv) radiol CPPD - calcium deposits in joint

Question 14

OSTEOARTHRITIS

i) what type of disease is it? how does prevalence change with age?
ii) what % of over 65s are affected?
iii) what are the most common clinically affected joints? (3)
iv) how is it characterised? (2)
v) give four things that may be seen radiologically and label the diagram

Answer 14

i) degenerative - prevalence increases with age
ii) 70% of over 65s are affected
iii) most common joints affected are knees, hips and small joints of hand
iv) charac by joint pain and variable degree of func limitation
v) radiol - osteophytes (bony outgrowth), sub chondral sclerosis (thickening of joint line), sub chondral cysts, joint space narrowing

A - osteophyte, B - joint space narrowing, C - sub chondral scleorosis, D - sub chondral cysts

Question 15

RADIOL SIGNS OF OA

i) what type of deformity is commonly seen? which joints are affected by this?
ii) name two clinical signs in the hands - which joint is each seen at? label the picture
iii) how do these nodes feel on palpation?

Answer 15

i) gull wing deformity - aff PIP and DIPs

ii) heberdens nodes - prox joints
bouchards nodes - distal joints

A - heberdens, B - bouchards

iii) feel hard

Question 16

PATHOPHYSIOLOGY OF OA

i) is it metabolically active or inactive? what part of the joint tissue does it involve?
ii) what happens to articular cartilage?
iii) what happens to adjacent bone? what may be seen due to this?
iv) does the bone remodel/repair? does this happen fast or slow?
v) what two things may be seen after remod/repair?

Answer 16

i) metabolically active - involves all joint tissues
ii) articular cartilage has focal destruc
iii) adjacent bone is remodelled > hypertrophic reaction at joint margins = osteophytes
iv) yes bone remod/repair but is very slow
v) may see synovial inflammation and crystal deposition

Question 17

CLINICAL FEATURES OF OA

i) over what age is it normally seen?
ii) how long does morning stiffness normally last?
iii) what aggravates pain?
iv) name another assoc feature? is there inflammation?
v) what may happen to the bone?
vi) are blood tests helpful? whats the best way to diagnose? do X rays correlate well with symptoms?

Answer 17

i) >50yrs
ii) <30mins
iii) joint pain aggravated by use
iv) crepitus (creaking) - no inflamm
v) bone enlarges or tender

vi) blood tests not v helpful as no markers
- use hx/examination/imaging
- x rays dont correlate well with symptoms

Question 18

TREATING OA

i) give two lifestyle changes that can be made
ii) give three drug therapies
iii) give three manual therapies
iv) give a surgical therapy

Answer 18

i) lose weight if obese, strengthening exercise, education
ii) paracetamol, topical NSAIDs, capsaicin, opioids, intra carticular corticosteroid infection
iii) supports/braces, shock absorbing shoes, splints
iv) joint arthroplasty

Question 19

RA VS OA

RA - i) what is it a disease of? ii) which joints does it affect? iii) what type of morning stiffness is seen? iv) what relieves pain? v) are inflam markers raised? vi) what is ratio of women:men affected? vii) are extra articular features present? viii) family history?

OA - i) what is it a disease of? ii) which joints does it affect? iii) what type of morning stiffness is seen? iv) what relieves pain? v) are inflam markers raused? vi) what is ratio of women:men affected? vii) are extra articular features present? viii) family history?

Answer 19

RA - synovial disease, ii) bilat and symmetrical MCPs and PIPs,

iii) stiff in morning >30 mins iv) activity relieves pain, v) raised inflam markers, vi) 3:1, vii) extra artic features may be present
viii) yes family history

OA - i) disease of cartilage, ii) bilat and symmet DIPS and thumb base, iii) less morning stiff than RA, iv) pain is relieved by rest v) inflam markets not raised, vi) 2:1, vii) no extra artic features - just a joint disease viii) yes family history