MSK Flashcards
chronic pain at multiple sites - 'pain all over' lethargy cognitive impairment sleep disturbance dizziness headache
fibromyalgia
diagnosis of fibromyalgia
11/18 tender points
management of fibromyalgia
aerobic exercise, CBT
medication = pregabalin, duloxetine and amitriptyline
severe pain
erythema
swelling
usually the 1st MTP joint affected
hx of high purine diet, thiazide use and excessive alcohol/dehydration
gout
investigation for gout
joint aspiration and crystal analysis
negatively birefringent crystals
management for gout
acute = NSAIDs (& appropriate gastroprotection)
colchicine can be given but slower to act
chronic = allopurinol, might start with colchicine
second line = febuxostat
pain mainly in the hip and shoulder pain/aching in the morning stiffness in the proximal limbs polyarthralgia lethargy depression low grade fever
polymyalgia rheumatica
Ix for PMR
ESR/CRP
management of PMR
prednisolone
hot, swollen, episodic attacks of joints
knee, wrist and shoulders mainly affected
pseudogout
investigation of pseudogout
aspiration = positively birefringent crystals
(exclude septic arthritis)
calcium pyrophosphate
management of pseudogout
IA steroid injection
NSAIDs
arthritis uveitis urethritis fever dactylitis
hx of GI/GU infection 1-4 weeks prior
usually male and HLA-B27
reactive arthritis/reiter’s syndrome
management of reactive arthritis/reiter’s syndrome
NSAIDs first line
steroid second line
usually in 20-30s , more common in females
multiple, peripheral joins - MCPs and PIPs
symmterical, joint pain and stiffness
stiffness worse in the morning - improves with as the day goes on
positive squeeze test
rheumatoid arthritis
Diagnosis of rheumatoid arthritis
anti-CCP
X - rays = erosions
management of rheumatoid arthritis
DMARDs - methotrexate/sulfasalazine
- usually taken with folic acid
start with bridging steroids
give steroids IM/PO in acute flares
TNF-a/biologics in inadequate responses
Fever, malaise and arthralgia HTN peripheral motor neuropathy livedo reticularis weight loss
commonly with 40-60yrs old and Hep B infections
polyarteritis nodosa
Ix for polyarteritis nodosa
biopsy = full thickness necrotizing inflammation
raised ESR/CRP
normocytic, normochromic anaemia
management of polyarteritis nodosa
steroids
+/- DMARDs
common in knee and DIPs
usually mono/oligoarthritis - asymmetrical
dactylitis
pitting nails
swelling of associated tendons - enthesis
dry erythematous skin
psoriatic arthritis
Ix of psoriatic arthritis
X-ray hands and feet = pencil in cup deformity
ESR/CRP raised
management for psoriatic arthritis
mild cases = NSAIDs
DMARDs and immunosuppressants - TNFa inhibitors
severe dry eyes and dry mouth fatigue arthralgia Raynauds phenomenon vaginal dryness recurrent parotitis positive schimer's test
Sjogren’s syndrome
Ix for sjogren’s
diagnostic = parotid gland biopsy
+SSRA/Ro, +SSA/La antibodies
treatment for sjogren’s
symptomatic relief from eye drops
sialogogues
punctal plugs
C= calcinosis R = raynauds E = esophageal dysmotility S = sclerodactyly T = telangiectasia
scleroderma (fibrosis of skin)
Ix for scleroderma
Scl-70, anti-topoisomerase I
management of scleroderma
relieve symptoms
steroids, immunosuppressants
fatigue, fever and mouth ulcers lympahdenopathy malar/butterfly discoid rash - spares nose raynaud's phenomenon livedo reticularis arthralgia pericarditis glomerulonephritis
systemic lupus erythematous
Ix for SLE
anti-dsDNA, anti-smith
complement C3/4
management of SLE
hydroxychloroquine (anti-malarial) - retinal toxicity
NSAIDs and steroids
weakness in the proximal muscles
weakness>pain
complains of trouble getting out of chair, trouble brushing hair
usually age >40
polymyositis
Ix for polymyositis
CK massively elevated
EMG
definitive dx = muscle biopsy
management of polymyositis
steroids
aged under 16 with arthritis for over 6 weeks
more common in women
joint pain and swelling, commonly in the knee
intermittebn spiking fevers (1-2 a day)
extra articular - uveitis
juvenile rheumatoid arthritis
Ix for JRA
elevated CRP/ESR
possibly positive for RF/ANA
management of JRA
NSAIDs first line
DMARDs second line
joint pain following use, improves with rest
DIPs and PIPs joints - herberden and bouchard nodes
joint crepitus
affects mainly the weight bearing joints
older age
Osteoarthritis
Ix for OA
X-ray = loss of joint space, subchondral sclerosis and osteophyte formation
Management of OA
pt ed, weight loss, exercise
pain control - analgesia, joint aspirations/steroid injection
replace joint as last resort
Osteoporosis risk factors
menopausal women increased age smoking steroid use (long term) low BMI
Diagnosis for osteoporosis
T-score on DEXA scan = - 2.5 SD or below
presentation of osteoporosis
usually asymptomatic until a fracture appears
management of osteoporosis
bisphosphonates - osteonecrosis of the jaw/atypical femoral fractures
give a ‘drug holiday’ = come off medication every 3-5yrs
older male with bone pain
isolated ALP elevation
bowing of tibia, bossing of skull
Paget’s disease
skull x-ray: thickened vault, osteoporosis circumscripta
paget’s disease
management for paget’s disease
bisphosphonate (either oral risedronate or IV zoledronate)
usually a single area non-specific pain fever malaise/fatigue inflammation swelling
hx of IC drug use, HIV and penetrating injuries
acute osteomyelitis
management of osteomyelitis
high dose antibiotics - flucloxacillin
screening of choice for osteomyelitis
MRI
acute hot swollen and erythematous swelling of joint
tender
restricted ROM
systemically unwell with a fever
septic arthritis
diagnosis of septic arthritis
Aspirate - culture and gram stain
if prosthetic joint - refer to ortho specialist
management of septic arthritis
IV vancomycin
typically elderly frail hx of osteoporosis pain in groin shortened and externally rotated leg unable to bear weight
femoral neck fracture
Ix for femoral neck fracture
X-ray
MRI
looking for shenton’s line
management of femoral neck fracture
intramedullary screws/dynamic hip screws