Locomotor Flashcards
Pathogenesis of gout ?
Deposition if monosodium urate crystals in and near joints
Presentation of gout
- acute monoarthropathy
- severe joint inflammation
- typically at the metatarsophalangeal joint of hallux
Conditions presenting similarly to gout
- septic arthritis
- haemarrthritis
- pseudogout
Causes of gout
- hereditary
- increased dietary purines
- alcohol excess
- diuretics
- leukaemia
- ## cytotoxics
What conditions is gout associated with?
- CV disease
- hypertension
- DM
- chronic renal failure
Investigations and findings in Gout ?.
- 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
Treatment of acute gout ?
- 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
Long term prophylaxis of gout attacks ?.
- 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
What is pseudogout ?
Calcium pyrophosphate deposition in and near joints
- weakly positively birefringent on polarised light microscopy
Who is osteoarthritis most common in ?
Women > 50
Classical presentation of osteoarthritis ?
- localised, usually knee or hip
- pain on movement and crepitus
- ## worse at end of day
Investigations and findings in osteoarthritis
- plain radiograph: loss of joint space, osteophytes, subarticular sclerosis, subchondral cysts
- CRP may be elevated
Management of osteoarthritis ?.
- Exercise- improve local muscle strength and general aerobic fitness
- Weight loss of overweight
- Regular paracetamol +/- topical NSAID
- If ineffective use codeine or short term oral NSAID
- Intraarticular steroid injections /hyaluronic acid
- Joint replacement surgery
What is primary osteoarthritis ?
- no obvious predisposing factor
- wear and tear arthritis
What is secondary osteoarthritis ?.
clear association with predisposing factor e.g.:
- congenital joint abnormality
- trauma to joint
Risk factors for septic arthritis
- pre existing joint disease (esp. In rheumatoid arthritis)
- diabetes
- immunosupression
- chronic renal failure
- recent joint surgery
- prosthetic joints
- IV drug use
- age > 80
Which organism most commonly causes septic arthritis ?
Staph aureus
Presentation of septic arthritis ?
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
Investigations in septic arthritis ?
- urgent joint aspiration for synovial fluid microscopy and culture*
- plain radiograph and CRP may be normal
- blood cultures to guide antibiotics
Treatment for septic arthritis
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
How is rheumatoid arthritis characterised ?
Symmetrical, deforming, peripheral polyarthritis
What is the prevalence of rheumatoid arthritis in the UK ?
~1%
Who is rheumatoid arthritis most likely to present in ?
Women in their 5th/6th decade
What is the typical presentation of rheumatoid arthritis ?
- Symmetrical, swollen, painful and stiff small joints of hands and feet
- worse in the morning
What is palindromic rheumatoid arthritis ?.
Recurrent mono/polyarthritis that move between joints then disappear after attack
Signs of rheumatoid arthritis
- 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
What is boutonnière deformity ?
Flexed PIP, extended DIP
What is swan neck deformity of fingers ?
Hyperextension in PIP, flexion In DIP
What are the extra articular signs of rheumatoid arthritis ?
- nodules - elbows and lungs
- lymphadenopathy
- vasculitis
- fibrosing alveolitis
- pleural and pericardial effusion
- raynauds
- carpel tunnel
- episcleritis
Investigations and findings in rheumatoid arthritis
- rheumatoid factor
- ACPA and anti-CCP highly specific for RA
- X-ray : soft tissue swelling, juxta articular osteopenia and decreased joint space
Which diseases may palindromic RA be a presage for ?
- RA
- SLE
- whipples disease
- Behçet’s disease
Management of rheumatoid arthritis
- 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
What is most effective DMARDs ?
Methotrexate, sulfasalazine, hydroxychloroquine
Side effects of DMARDs ?
- 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
What is the first line treatment biologic agent for RA after DMARDs therapy failed ?
TNF alpha inhibitors e.g. Infliximab, Etanercept etc (often in combo with methotrexate)
What is second line biologic agent treatment for RA after DMARDs and TNF alpha inhibitors have failed ?
B cell depletion e.g. Rituximab (in combo with methotrexate)
Side effects of biologic agents used to treat RA ?
- serious infections e.g. Reactivation of TB and hepatitis
- worsening HF
- reversible SLE type illness
Pathogenesis of prolapsed disc
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
Presentation of lumbrosacral disc herniation
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
What are the symptoms of caudally enquina compression ?
- saddle anaesthesia
- urinary retention
- incontinence
Signs of thoracic cord compression?
- paraplegia
- clonus
- positive babinski sign
- bladder/bowel dysfunction
What are the red flags of back pain that suggests cauda equina syndrome ?
- saddle anaesthesia
- recent onset bladder dysfunction and faecal incontinence
- laxity of anal Sphincter
- severe or progressive neurological deficit in lower extremities
Red flags of back pain that suggests spinal fracture ?
- 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
Red flag symptoms of back pain that suggest cancer or infection
- > 50 yrs or
Red flag symptoms of back pain that suggest spondylopathy
- early morning stiffness lasts >45 mins
- night pain
- ‘gelling’
- easier with movement, worse after rest
Red flag symptoms of back pain that suggest high risk of permanent damage to the compressed nerve
- significant muscle weakness or wasting
- loss of tendon reflexes
- presence of positive babinski sign
What is sciatica ?
- When nucleus pulposus herniates irritating and/or compressing the adjacent nerve root in lumbrosacral spine
- causes pain, tingling, numbness
- usually at L5/S1
Where do you test sensation in a thoracoabdominal sensory exam when determining level of disc herniation ?
- T4= nipple
- T7= xiphoid
- T10= umbilicus
- T12 = inguinal region
Investigations in back pain/disc herniation ?
- 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
What analgesia is used in management of disc herniation and sciatica ?
- 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
Non pharmacological treatment of disc herniation /sciatica ?
- 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
Complications of herniated disc ?
- permanent nerve damage with sensory deficits and/or motor weakness
- psychosocial problems
- loss of employment
