MSK

Question 1

how many vertebral bones are there in the spine?

Answer 1

7 cervical, 12 thoracic, 5 lumbar and 5 sacral - the sacral are fused together to form a single bone - sacrum. 4 further vertebrae are fused to form the coccyx.

Question 2

risk factors for osteoarthritis

Answer 2

increasing age
female sex
obesity
family history
trauma
certain occupations

Question 3

key x-ray changes in osteoarthritis

Answer 3

L – Loss of joint space
O – Osteophytes
S – Subchondral sclerosis (increased density of the bone along the joint line)
S – Subchondral cysts (fluid-filled holes in the bone, aka geodes)

**Xray changes do not necessarily correlate with symptoms

Question 4

signs and symptoms of osteoarthritis

Answer 4

Osteoarthritis presents with joint pain and stiffness. This pain and stiffness tends to be worsened by activity. t also leads to deformity, instability and reduced function in the joint.
crepitus on movement, joint tenderness, bony swellings, reduced range of motion

Question 5

what are the commonly affected joints in OA?

Answer 5

Knees (most common)
Hips (2nd most common)
Sacro-iliac joints
Distal-interphalangeal joints in the hands (DIPs)
The MCP joint at the base of the thumb
Wrist
Cervical spine

Question 6

signs in the hands of OA

Answer 6

Heberden’s nodes (in the DIP joints)
    Bouchard’s nodes (in the PIP joints)
    Squaring at the base of the thumb at the carpo-metacarpal joint
    Weak grip
    Reduced range of motion

Question 7

how is OA diagnosed?

Answer 7

NICE (2014) suggest that a diagnosis can be made without any investigations if the patient is over 45, has typical activity related pain and has no morning stiffness or stiffness lasting less than 30 minutes.

Question 8

management of OA?

Answer 8

1. non pharmacological - patient education, wt loss advice if applicable, physiotherapy and exercise, occupational therapy and orthotics.
2. stepwise analgesia -
   Oral paracetamol +/- topical NSAIDs or topical capsaicin (chilli pepper extract).
   Add oral NSAIDs and consider also prescribing a proton pump inhibitor (PPI) to protect their stomach such as omeprazole. They are better used intermittently rather than continuously.
   Consider opiates such as codeine. These should be used cautiously as they can have significant side effects and patients can develop dependence and withdrawal. They also don’t work for chronic pain and result in patients becoming depending without benefitting from pain relief.
3. Intra-articular steroid injections provide a temporary reduction in inflammation and improve symptoms.
4. Joint replacement can be used in severe cases. The hip and knee are the most commonly replaced joints.

Question 9

side effects of NSAIDs?

Answer 9

Gastrointestinal side-effects, such as gastritis and peptic ulcers (leading to upper GI bleeding)
Renal side-effects, such as acute kidney injury (e.g., acute tubular necrosis) or progressive kidney disease
Cardiovascular side-effects, such as hypertension, heart failure, myocardial infarction and stroke
Exacerbating asthma

Question 10

fibromyalgia

Answer 10

Fibromyalgia is a chronic pain disorder. more common in people who have a rheumatic disease.

Symptoms of fibromyalgia are chronic widespread pain associated with unrefreshing sleep and tiredness.
hx -
Pain at multiple sites. Low back pain with/without radiation to the buttocks and legs and pain in the neck and across the shoulders are common complaints[2]. Patients may complain of “pain all over”.
Fatigue.
Sleep disturbance (sleep may exacerbate symptoms and contribute to depression)[8].
Morning stiffness.
Paraesthesiae.
Feeling of swollen joints (with no objective swelling).
Problems with cognition (eg, memory disturbance, difficulty with word finding).
Headaches (may be migrainous).
Light-headedness or dizziness.
Fluctuations in weight.
Anxiety and depression.

Symptoms are generally reported as worse in cold, humid weather and under times of stress

diagnosis: Routine blood testing can help to exclude other differential diagnoses: eg, ESR, TFTs, antinuclear antibodies, etc.

The Fibromyalgia Impact Questionnaire can be used to assess function. A full social, personal, family and psychological history should be taken.

ddx - myalgic encephalomyelitis/chronic fatigue syndrome, hypothyroidism, polymyalgia rheumatica

Mx - aim of treatment is not to cure fibromyalgia but to reduce symptoms and improve quality of life.
MDT approach
Exercise programmes, physiotherapy and psychological support
Consider an antidepressant, either amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline for chronic primary pain.
Do not initiate any of the following medicines to manage chronic primary pain: gabapentinoids, BDZs, NSAIDs, opioids, paracetamol, corticosteroids