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Core Conditions > Locomotor > Flashcards

Locomotor Flashcards

1
Q

Pathogenesis of gout ?

A

Deposition if monosodium urate crystals in and near joints

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2
Q

Presentation of gout

A
  • acute monoarthropathy
  • severe joint inflammation
  • typically at the metatarsophalangeal joint of hallux
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3
Q

Conditions presenting similarly to gout

A
  • septic arthritis
  • haemarrthritis
  • pseudogout
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4
Q

Causes of gout

A
  • hereditary
  • increased dietary purines
  • alcohol excess
  • diuretics
  • leukaemia
  • ## cytotoxics
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5
Q

What conditions is gout associated with?

A
  • CV disease
  • hypertension
  • DM
  • chronic renal failure
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6
Q

Investigations and findings in Gout ?.

A
  • polarised light microscopy of synovial fluid shows negatively birefringent urate crystals
  • serum urate usually raised
  • radiographs show only soft tissue swelling in early stage
  • later, well define ‘punched out’ erosions seen in juxta-articular bones
  • joint space preserved til late
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7
Q

Treatment of acute gout ?

A
  • high dose NSAID or coxib
  • colchicine if NSAID contraindicated (e.g. Peptic ulcer) - as effective but slower to work
  • steroids can also be used
  • rest and elevated affected joint
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8
Q

Long term prophylaxis of gout attacks ?.

A
  • allopurinol (may bring on acute attack so wait 3 weeks after acute attack and cover with NSAID)
  • lose weight, avoid prolonged fasting, alcohol excess, purine rich meat and low dose aspirin
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9
Q

What is pseudogout ?

A

Calcium pyrophosphate deposition in and near joints

  • weakly positively birefringent on polarised light microscopy
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10
Q

Who is osteoarthritis most common in ?

A

Women > 50

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11
Q

Classical presentation of osteoarthritis ?

A
  • localised, usually knee or hip
  • pain on movement and crepitus
  • ## worse at end of day
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11
Q

Investigations and findings in osteoarthritis

A
  • plain radiograph: loss of joint space, osteophytes, subarticular sclerosis, subchondral cysts
  • CRP may be elevated
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12
Q

Management of osteoarthritis ?.

A
  1. Exercise- improve local muscle strength and general aerobic fitness
  2. Weight loss of overweight
  3. Regular paracetamol +/- topical NSAID
  4. If ineffective use codeine or short term oral NSAID
  5. Intraarticular steroid injections /hyaluronic acid
  6. Joint replacement surgery
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13
Q

What is primary osteoarthritis ?

A
  • no obvious predisposing factor

- wear and tear arthritis

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14
Q

What is secondary osteoarthritis ?.

A

clear association with predisposing factor e.g.:

  • congenital joint abnormality
  • trauma to joint
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15
Q

Risk factors for septic arthritis

A
  • pre existing joint disease (esp. In rheumatoid arthritis)
  • diabetes
  • immunosupression
  • chronic renal failure
  • recent joint surgery
  • prosthetic joints
  • IV drug use
  • age > 80
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16
Q

Which organism most commonly causes septic arthritis ?

A

Staph aureus

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17
Q

Presentation of septic arthritis ?

A

In previously fit and well people:

  • red, hot, swollen joint
  • severe pain
  • immobile by muscle spasm

In immunocompromised or elderly presentation is less dramatic due to decreased inflammatory response- systemic upset e.g. Fever, chills, night sweats

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18
Q

Investigations in septic arthritis ?

A
  • urgent joint aspiration for synovial fluid microscopy and culture*
  • plain radiograph and CRP may be normal
  • blood cultures to guide antibiotics
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19
Q

Treatment for septic arthritis

A

Start empirical IV antibiotics until sensitivities known:

  • Flucloxacillin (clindamycin if allergic)
  • vancomycin if MRSA
  • cefotaxime if gonococcal or gram -ve
  • joint wash out or debridement may be required
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20
Q

How is rheumatoid arthritis characterised ?

A

Symmetrical, deforming, peripheral polyarthritis

21
Q

What is the prevalence of rheumatoid arthritis in the UK ?

A

~1%

22
Q

Who is rheumatoid arthritis most likely to present in ?

A

Women in their 5th/6th decade

23
Q

What is the typical presentation of rheumatoid arthritis ?

A
  • Symmetrical, swollen, painful and stiff small joints of hands and feet
  • worse in the morning
24
Q

What is palindromic rheumatoid arthritis ?.

A

Recurrent mono/polyarthritis that move between joints then disappear after attack

25
Q

Signs of rheumatoid arthritis

A
  • swollen MCP, PIP, MTP or wrist joints
  • ulnar deviation of fingers
  • dorsal wrist subluxation
  • boutonnière and swan neck deformity of fingers
  • z deformity of thumb
26
Q

What is boutonnière deformity ?

A

Flexed PIP, extended DIP

27
Q

What is swan neck deformity of fingers ?

A

Hyperextension in PIP, flexion In DIP

28
Q

What are the extra articular signs of rheumatoid arthritis ?

A
  • nodules - elbows and lungs
  • lymphadenopathy
  • vasculitis
  • fibrosing alveolitis
  • pleural and pericardial effusion
  • raynauds
  • carpel tunnel
  • episcleritis
29
Q

Investigations and findings in rheumatoid arthritis

A
  • rheumatoid factor
  • ACPA and anti-CCP highly specific for RA
  • X-ray : soft tissue swelling, juxta articular osteopenia and decreased joint space
30
Q

Which diseases may palindromic RA be a presage for ?

A
  • RA
  • SLE
  • whipples disease
  • Behçet’s disease
31
Q

Management of rheumatoid arthritis

A
  • early use of DMARDs (1st line) and biologic agents improve long term outcome
  • steroids rapidly reduce symptoms and inflammation/ useful in acute exacerbations
  • NSAIDs good for symptomatic relief, paracetamol and opiates rarely help
  • physio and occupational health
32
Q

What is most effective DMARDs ?

A

Methotrexate, sulfasalazine, hydroxychloroquine

33
Q

Side effects of DMARDs ?

A
  • immunosupression: pancytopenia, increased susceptibility to infection, neutropenic sepsis - monitor FBC !
  • oral ulcers, Hepatotoxicity (methotrexate)
  • rash, decreased sperm count (sulphasalazine)
  • irreversible retinopathy (hydroxychloroquine) - request annual ophthalmology review
34
Q

What is the first line treatment biologic agent for RA after DMARDs therapy failed ?

A

TNF alpha inhibitors e.g. Infliximab, Etanercept etc (often in combo with methotrexate)

35
Q

What is second line biologic agent treatment for RA after DMARDs and TNF alpha inhibitors have failed ?

A

B cell depletion e.g. Rituximab (in combo with methotrexate)

36
Q

Side effects of biologic agents used to treat RA ?

A
  • serious infections e.g. Reactivation of TB and hepatitis
  • worsening HF
  • reversible SLE type illness
37
Q

Pathogenesis of prolapsed disc

A

Part of the inner softer part of the disc (nucleus pulposus) herniates out through a weakness in outer part of disc.

  • the herniated disc may press of nearby structures such as nerves coming from spinal cord
  • inflammation develops around the prolapsed disc
38
Q

Presentation of lumbrosacral disc herniation

A

If the is nerve entrapment in the lumbrosacral spine leads to symptoms of sciatica which include:

  • unilateral leg pain that radiates below knee to foot/toes
  • the leg pain being more severe than the back pain
  • numbness, parathesia, weakness and loss of tendon reflexes
  • +ve straight leg raise test
  • pain relieved by lying down and exacerbated by long walks
39
Q

What are the symptoms of caudally enquina compression ?

A
  • saddle anaesthesia
  • urinary retention
  • incontinence
40
Q

Signs of thoracic cord compression?

A
  • paraplegia
  • clonus
  • positive babinski sign
  • bladder/bowel dysfunction
41
Q

What are the red flags of back pain that suggests cauda equina syndrome ?

A
  • saddle anaesthesia
  • recent onset bladder dysfunction and faecal incontinence
  • laxity of anal Sphincter
  • severe or progressive neurological deficit in lower extremities
42
Q

Red flags of back pain that suggests spinal fracture ?

A
  • sudden onset of severe central pain in spine, relieved by lying down
  • major trauma e.g. RTA
  • minor trauma or strenuous lifting in people with osteoporosis
  • structural deformity of the spine
43
Q

Red flag symptoms of back pain that suggest cancer or infection

A
  • > 50 yrs or
44
Q

Red flag symptoms of back pain that suggest spondylopathy

A
  • early morning stiffness lasts >45 mins
  • night pain
  • ‘gelling’
  • easier with movement, worse after rest
45
Q

Red flag symptoms of back pain that suggest high risk of permanent damage to the compressed nerve

A
  • significant muscle weakness or wasting
  • loss of tendon reflexes
  • presence of positive babinski sign
46
Q

What is sciatica ?

A
  • When nucleus pulposus herniates irritating and/or compressing the adjacent nerve root in lumbrosacral spine
  • causes pain, tingling, numbness
  • usually at L5/S1
47
Q

Where do you test sensation in a thoracoabdominal sensory exam when determining level of disc herniation ?

A
  • T4= nipple
  • T7= xiphoid
  • T10= umbilicus
  • T12 = inguinal region
48
Q

Investigations in back pain/disc herniation ?

A
  • none if settles in 6 weeks
  • MRI sensitive in showing disc herniation
  • CT myelography may show lesions not found on MRI
  • plain x Ray may be useful as show misalignments, instabilities and congenital abnormalities
49
Q

What analgesia is used in management of disc herniation and sciatica ?

A
  • simple paracetamol or NSAID first line
  • weak opioid e.g. Codeine or tramadol added if pain still present
  • consider benzodiazepine if muscle spasm
  • consider trial tricyclic antidepressant or gabapentin if persistent sciatica
  • if still pain refer to pain clinic
50
Q

Non pharmacological treatment of disc herniation /sciatica ?

A
  • keep active e.g. Swimming
  • heat and massage to relieve spasm
  • avoid lifting and prolonged sitting
  • surgery e.g. Discectomy or intervertebral disc replacement in degeneration
51
Q

Complications of herniated disc ?

A
  • permanent nerve damage with sensory deficits and/or motor weakness
  • psychosocial problems
  • loss of employment

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