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Year 3 > MSK > Flashcards

MSK Flashcards

1
Q

define osteoporosis

A

reduced bone density (T score < -2.5) increases fracture risk

  • cancellous bone affected => crush fractures
  • cortical bone affected => long bone fractures
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2
Q

causes of osteoporosis (ME DR G/ SHATTERED)

A

Primary

  • idiopathic
  • post-menopausal

Secondary

  • Malignancy (myelomas)
  • Endocrine (cushings, thyrotoxicosis, hyperparathyroidism, hypogonadism)
  • Drugs (steroids, heparin)
  • Rheumatological (RA, ankylosing spondylitis)
  • Gastrointestinal (liver/ renal problems, malabsorption- low Ca2+)

or
Steroid
Hyperparathyroidism
Alcohol
Thin
Testosterone (low)
Early menopause
Renal/ liver disease
Erosive bone disease (RA)
Dietary calcium (low)

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3
Q

presenting symptoms of osteoporosis

A
  • usually asymptomatic till fracture
    => NOF- after minimal trauma
    => vertebral- stooped posture, pain on lifting
    => colles -radius fracture after falling on outstretched hand
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4
Q

examination findings of osteoporosis

A

none usually till fracture

  • pain on external hip rotation + flexion (NOF fracture)
  • tenderness over vetebrae
  • thoracic kyphosis (over multiple vertebrae)
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5
Q

investigations + findings for osteoporosis

A
  • Bloods (calcium, phosphate, ALP => usually normal in primary osteoporosis)
  • X-ray (diagnose fracture- biconcave vertebrae/ crush fractures)
  • DEXA scan (T
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6
Q

Management for osteoporosis

A
  • bisphosphonates (alendronic acid)- reduce osteoclast function
  • Selective oestrogen receptor modulators (raloxifene)
  • PTH - stimulates osteoblasts
  • Ca2+/ Vit D supplements
  • HRT (for menopausal women)
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7
Q

The heart in ankylosing spondylitis

A

Conduction defects
AV block
Aortic regurgitation

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8
Q

Ankylosing spondylitis

A

Chronic inflammatory disease of spine + sacroiliac joint

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9
Q

Aetiology of ankylosing spondylitis

A

Unknown

Strong genetic/environmental interplay

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10
Q

Typical presentation of ankylosing spondylitis

A

Gradual onset of lower back pain
Worse during the night
Spinal morning stiffness
Relieved by exercise
Radiates from sacroiliac joints to hips/buttocks
Improves towards end of day

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11
Q

Progression of ankylosing spondylitis

A

Variable disease course

Progressive loss of spinal movement in all directions (therefore, decreased thoracic expansion)

Kyphosis

Neck hyperextension

Spinocranial ankylosis

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12
Q

Features of ankylosing spondylitis

A

Enthesitis (Achilles tendinitis, plantar fasciitis, tibial/ischial tuberosities, iliac crests)

Costochondritis

Acute iritis

Osteoporosis

Aortic valve incompetence

Pulmonary apical fibrosis

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13
Q

Testing for and diagnosing ankylosing spondylitis

A

Clinical supporting by imaging

MRI - detection of active inflammation and destructive changes

XR

  • SI joint space narrowing/widening, sclerosis, erosions, ankylosis/fusion
  • bony proliferation from enthesitis between ligaments and vertebrae

FBC normocytic anaemia
Increased ESR, CRP

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14
Q

Management of ankylosing spondylitis

A

Exercise not rest ideally with specialist physio

NSAIDs relieve symptoms and may slow radiographic progress
Local steroid injections

TNF-α blockers in severe cases

Surgery - hip replacement, spinal Ostrogoth (rare)

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15
Q

Ankylosing spondylitis prognosis

A

Worse if:
ESR > 30
onset < 16
Early hip e0cement
Poor response to NSAIDs

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16
Q

define Osteomalacia

A

Low mineral content of bone

Rickets - mineralisation problem during bone growth
Osteomalacia - after fusion of epiphyses

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17
Q

Signs and symptoms of rickets

A

Infants:
Growth retardation
Hypotonia
Apathy

Once walking:
Knock kneed
Bow legged
Deformities of metaphysical epiphyseal junction

Features of decreased Ca2+ (mild)

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18
Q

Signs and symptoms of osteomalacia

A

Bone pain and tenderness
Fractures (especially femoral neck)
Proximal myopathy (waddling gait)

Decreased phosphate
Vit D deficiency

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19
Q

Causes of osteomalacia

A

Vitamin D deficiency
Vitamin D resistance
Liver disease
Renal osteodystrophy
Tumour induced
Drug induced

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20
Q

How does vitamin D deficiency contribute to osteomalacia

A

Malabsorption, poor diet, or lack of sunlight

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21
Q

How does vitamin D resistance contribute to osteomalacia

A

Mainly inherited conditions

Responsive to high doses of vitamin D

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22
Q

How does liver disease contribute to osteomalacia

A

Reduced hydroxylation of vit D to 25-hydroxy-cholecalciferol
Malabsorption of vitamin D

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23
Q

How does renal osteodystrophy cause osteomalacia

A

Renal failure causes 1,25-dihydroxy-cholecalciferol deficiency

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24
Q

Tumour induced osteomalacia

A

raised tumour production of phosphate in FGF-23 which causes hyperphosphaturia
Low serum phosphate often causes myalgia and weakness

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25
Q

Investigations for osteomalacia

A

Plasma serum levels
Biopsy
X ray

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26
Q

Plasma investigation findings in osteomalacia

A

Reduced:

  • calcium (mild but may be severe)
  • phosphate
  • 25OH-vit D (except in vit D resistance)
  • 1,25(OH)2-vit D in renal failure

Increased:

  • ALP
  • PTH
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27
Q

biopsy findings in osteomalacia

A

incomplete mineralisation
muscle biopsy normal

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28
Q

x ray findings in osteomalacia

A

loss of cortical bone

partial fractures without displacement, esp. on:

  • lateral border of scapula
  • inferior femoral neck
  • medial femoral shaft

cupped, ragged, metaphysical surfaces seen in rickets

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29
Q

treatment of osteomalacia due to dietary insufficiency

A

vitamin D
calcium D3 tablet

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30
Q

treatment of osteomalacia due to malabsorption or hepatic disease

A 
vitamin D2 (ergocalciferol) 
parenteral calcitriol
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31
Q

treatment of osteomalacia due to renal disease/vit D resistance

A

alfacalcidol
calcitriol

can cause dangerous hypercalcaemia

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32
Q

what needs to be done alongside medication for osteomalacia

A

monitor plasma calcium
initially weekly
and if nausea/vomiting

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33
Q

risk factors for septic arthritis

A

pre-existing joint disease
DM
immunosuppression
chronic renal failure
recent joint surgery
prosthetic joints
IV drug abuse
age > 80 yrs

34
Q

investigations for septic arthritis

A

joint aspiration for synovial fluid microscopy & culture
blood cultures

plain radiograph and CRP may be normal

35
Q

ddx for septic arthritis

A

crystal arthropathies

36
Q

treatment of septic arthritis

A

empirical IV antibiotics after aspiration until sensitivities are known

IV antibiotics for approx. 2 weeks

consider orthopaedic review for arthrocentesis, washout, and debridement

urgent referral if there is prosthetic joint involvement

37
Q

common causative organisms of septic arthritis

A

staph aureus
streptococci
neisseria gonococcus
gram -ive bacteria

38
Q

Define Osteoarthritis

A

Degeneration of cartilage and underlying bone

Usually primary (generalised)

Can be secondary to joint disease or other conditions

39
Q

Signs and symptoms of localised disease in osteoarthritis

A
  • pain and crepitus on movement
  • background ache at rest
  • worse with prolonged activity
  • brief stiffness after rest
  • joints may feel unstable
40
Q

Signs and symptoms of generalised disease in osteoarthritis

A
  • nodal OA (DIP, PIP, CMC joints, and knees in post menopausal females)
  • joint tenderness, derangement, and bony swelling
  • reduced range of movement and mild synovitis
41
Q

Testing for osteoarthritis

A

Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts

Elevated CRP

42
Q

Management of osteoarthritis

A

Core treatments:

  • exercise
  • weight loss if overweight

Analgesia:

  • paracetamol +/+ NSAIDs
  • codeine/short term oral NSAID
  • topical capsaicin
  • intra-articular steroid

Non-pharmacological:

  • physios, OTs
  • heat/ice packs
  • walking aids
  • stretching/manipulation

Surgery:
- joint replacement

43
Q

define rheumatoid arthritis

A

chronic inflammatory condition affecting small joints of hands/feet

  • x3 more common in females
  • Autoimmune disease (HLA-DR1/DR4)
  • associated with other autoimmune diseases (Sjorens)
44
Q

presenting symptoms of rheumatoid arthritis

A
  • gradual onset
  • symmertrical joint pain + swelling (polyarthritis -multiple small joints affected)
  • morning stiffness
  • common systemic symptoms (fever, fatigue, weight loss, pericarditis, pleurisity) FFWPP
  • RARE extrarticular features (LEAF) - lung fibrosis, episcleritis, amyloidosis, fetty syndrome (splenomegaly, RA, leucopenia)
45
Q

examination findings of rheumatoid arthritis

A

early

  • swelling of MCP/PIP joints (usually symmetrically)
  • warm/tender joints
  • reduced joint movement

late

  • ulnar deviation due to subluxation (partial dislocation) of MCP
  • radial deviation of wrist
  • swan neck deformity
  • boutteniere deformity
  • z line deformity of thumb
  • muscle wasting
  • palmar erythema
  • rheumatoid nodules (elbows/hands)
46
Q

investigations for rheumatoid arthritis

A

bloods:

  • FBC- low Hb, high platelets (inflammation)
  • high CRP/ESR- inflammation
  • +ve Rhematoid factor
  • Anti-cyclic citrulinated peptide antibodies (specific)

Joint aspiration- exclude septic arthritis

Joint X-ray (BONDS)

  • Bone erosions
  • Osteopenia (low bone density)
  • Narrow joint space
  • Deformity
  • Swelling

US/MRI of joint => check for synovitis

47
Q

management of rheumatoid arthritis

A

mild disease

  • DMARDs - Methotrexate
  • NSAIDs -
  • Corticosteroid/ immunosuppresant - Prednisilone (avoid long term use)

Use biologics for severe disease (anti-TNF = infliximab, anti-CD20 antibody = Rituximab)

if pregnant

  1. corticosteroids (SAFER)
  2. hydroxychloroquinolone/ sulfasalzine - DMARDs

*DMARDs= disease modifying anti-rheumatic drugs

48
Q

define reactive arthritis

A

inflammation of larger joints after an extra-articular infection (GI/urogenital)

  • affects men more comonly (20-40)
  • Reiter’s syndrome (reactive arthritis, uveitis, conjuctivitis)
  • affects more large joints + lower extremeties
  • HLA-B27 involvement
49
Q

causes of reactive arthritis (pathogens)

A

GI infection

  • salmonella
  • shigella
  • campylobacter
  • yersinia

Urogenital infection

  • chlamydia
50
Q

presenting symptoms of reactive arthritis

A

symptoms can occur up to 30 days after infection

  • burning during urination (urethritis)
  • asymetrical joint swelling - lower extremities (arthritis)
  • lower back pain (sacroillitis)
  • (enthesitis- tendon/ligament attaches to bone PAINFUL)
  • conjuctivitis -red painful eye
51
Q

examination signs of reactive arthritis

A
  • Arthritis- asymmetrical oligoarthritis, sausage digits
  • circinate Balnatis- red painless patches on glans of penis
  • Conjuctivitis- painful red eye
  • Keratoderma Belenhorragia- browinsh red maccules on SOLES/PALMS
52
Q

investigations for reactive arthritis

A

Bedside

  • Stool culture/ Urine culture- check for STIs -chlamydia

Bloods

  • FBC
  • high ESR/CRP
  • HLA B27 testing
  • anti-nuclear antibody/ rheuamtoid factor - rule out other arthritis

Joint aspiration - rule out septic/crystal arthritis

Joint X-ray - see sarcoillitis

53
Q

Management for reactive arthritis

A

symptomatic relief

  1. NSAIDs- naproxen/ibuprofen
  2. corticosteroid- prednisilone

chronic arthritis

  • DMARDs - sulfasalazine
54
Q

define crystal arthropathy

A

joint inflammation due to crystal deposition

  1. gout
  2. pseudogout
55
Q

Epidemeiology for crystal arthropathy

A

gout

  • more common in older males

pseudogout

  • more common in elderly
56
Q

pathophysiology of gout

A
  1. deposition of monosodium urate (uric acid) crystals in joints/tissue
  2. engulfed by phagocytes
  3. pro-inflammatory cytokines (TNF-a) are released causing joint inflammation
57
Q

causes of gout (hyperuricemia)

A
  1. increased uric acid synthesis/production
  • increased purine intake -red meat, seafood
  • increased nucelic cell turnover -lymphoma/leukaemia
  1. reduced uric acid excretion
  • alcohol
  • dehydration => AKI
  • drugs (loop diuretics, cyclosporine)
  • renal dysfunction
58
Q

risk factors for gout

A
  • XS alcohol
  • family Hx of gout, hyperuricemia, renal disease
  • diabetes
  • hypertension
  • obesity
  • CVD
  • chemotherapy/radiation
  • high purine rich diet (seafood, red meat)
59
Q

presenting symptoms of gout

A

Acute:

  • SUDDEN joint pain (SEVERE)
  • usually affects metatarsalphalangeal (MTP) joints usually BIG TOE
  • joint swelling
  • joint stiffness
  • resolves 7-10 days
  • RECURRENT ATTACKs

Chronic

  • low-grade fever
  • painful tophi (urate crystal deposits on ear, elbows)
  • symptoms of renal calculi (dysuria)
60
Q

examination findings of gout

A
  • examine other joints
  • check for arthritis signs (red, warm, swollen joints, painful on movement)
  • check for tophi (urate deposits on elbows, pinna of ear)
61
Q

investigations for gout

A
  • Generally clinical diagnosis unless doubt

Bloods: FBC, U&Es, LFTs, HbA1c, lipid profile

Joint aspiration

  • crystals - needle shaped monosodium urate crystals (uric acid)
  • light microscopy- negative befringence
  • MC&S- exclude septic arthritis

X-ray

  • later stage: rat-bite erosions
  • non-specific soft tissue swelling

Check for complications

  • CVD
  • renal disease (AXR/CT KUB- renal stones)
62
Q

management for gout

A

Acute

  • NSAIDs (+ gastro protection e.g. omeprazole)
  • oral colchicine

Prevent recurrent attacks:

  • allopurinol - not for acute attacks as it can worsen acute gout
63
Q

pathophyisology of pseudogout

A
  • deposition of calcium pyrophosphate dihydrate (CPPD) crystals in joint cartilage causing inflammation
64
Q

causes/ triggers for pseudogout

A

Precipitating factors:

  • surgery
  • illness
  • trauma

RARE CAUSES:

  • Haemochromatosis
  • Hyperparathyroidism
  • Hypomagnesaemia
  • Hypophosphatasia
  • acromegaly (XS GH), Wilson’s disease (XS copper)
65
Q

presenting symptoms of pseudogout

A
  • ACUTE joint PAIN and swelling
  • affects larger joints (knees, elbows)
  • symptoms of arthtitis (stiffness, swelling, reduced movement)
  • systemic: fever, chills
  • RESOLVES weeks-months
  • can have tendon inflammation (tendinitis)
66
Q

examination findings of pseudogout

A

acute

  • RED, swollen, hot, tender joints
  • restricted movement
  • mild fever

chronic

  • crepitus
  • deformity
  • bony swelling
  • restricted movement
67
Q

investigations for pseudogout

A

Bloods

  • high WCC
  • high ESR
  • blood culture - exclude septic arthritis

Joint aspiration

  • crystals- CPPD crystals, brick shaped
  • light microscopy- positive befringence
  • MC&S- exclude septic arthritis

X-ray (signs of osteoarthritis)

  • Loss of joint space
  • Osteophytes
  • Subcondral cysts
  • Sclerosis
68
Q

management of pseudogout

A
  • treat symptoms
  • ice pack, rest
  • NSAIDs/ colchicine
69
Q

define osteomyelitis

A

infection of bone leading to inflammation, necrosis and new bone formation

  • acute- SUSPECT IN UNWELL LIMPING CHILD/ immunocompromised patient
  • chronic- adults with open fractures, previous orthopaedic surgery
70
Q

common organisms that cause osteomyelitis

A
  • Staph. Aureus
  • Group B streptococcus?
71
Q

risk factors for osteomyelitis

A

Acute:

  • YOUNG CHILDREN

Chronic:

  • DIABETES
  • traumatic injury
  • IV drug user
  • immunocompromised
  • previous surgery
  • previous osteomyelitis
  • sickle cell
  • rheumatoid arthritis
72
Q

presenting symptoms of osteomyelitis

A
  • fever
  • malaise/rigors
  • pain in area affected
  • restricted movement/ limping
  • PMHx: open fracture, orthopaedic surgery
  • Risk factors
73
Q

examination findings of osteomyelitis

A
  • red, warm, tender, swollen joints
  • signs of previous surgery- scars, flaps, fixed fractures
  • acute/healed sinus tracts (signs of wound drainage)
  • reduced range of movement
  • reduced sensation (diabetic foot)
  • pus/discharge from ulcers
74
Q

investigations for osteomyelitis

A

Bloods:

  • FBC- high WCC (infection)
  • ESR/CRP
  • Blood culture - identify organism

X-ray (diagnostic)

  • osteopenia (reduced bone density- due to bone destruction) 6-7days after infection
  • bone sequestrum (dead bone separated from normal bone during necrosis)
  • soft tissue swelling

Bone scan - show areas of bone density

75
Q

Management of osteomyelitis

A
  • antibiotics (adults- flucloxacillin, children - ceftriaxone)
  • more severe/ pressing on spinal chord/ pus leakage => surgery (debridment, revascularise, amputate)
76
Q

complications of osteomyelitis

A
  • septic arthritis
  • squamous cell carcinoma
  • destruction of surrounding soft tissue
  • pathological fracture
  • secondary amyloidoses
77
Q

define polymylagia rheumatica

A

chronic, systemic inflammatory disease charachterised by aching and morning stiffness in neck/shoulder/pelvic girdle

78
Q

risk factors for polymylagia rheumatica

A
  • older age (>50)
  • giant cell arteritis
  • female (more common in)
  • north european
  • infection (high rates in winter season)
79
Q

presenting symptoms of polymylagia rheumatica

A
  • shoulder/pelvic girdle pain and stiffness >2 weeks
  • morning stiffness (lasting >45 mins)
  • rapid repsonse to corticosteroids
  • Risk factors:
  • systemic: low-grade fever, weight loss, fatigue, anorexia, depression
80
Q

investigations for polymylagia rheumatica

A

Bloods: (exclude other causes)

  • ESR/CRP - inflammation
  • FBC
  • TSH (exclude hypothyroidism)
  • RF (exclude rheumatoid arthritis)
  • anti-CCP (exclude RA)
  • U&Es, LFTs
  • Ca2+, ALP
  • creatine kinase

Other:

  • protein electrophoresis (exclude myeloproliferative disorders)

Imaging:

  • US (check for bursitis, tne
  • MRI
81
Q

Management for polymylagia rheumatica

A
  • corticosteroids (gradually reduce dose when symptoms fully controlled)
  • treat complications: osteoporosis
  • refer to rheumatologist if corticosteroids needed for >2yrs/ can’t reduce steroid dose without relapse.

Year 3 (27 decks)

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