MSK Flashcards
Osteoarthritis
Described as Wear & Tear in the joints.
It occurs in the synovial joints & results from genetic factors, overuse & injury.
Osteoarthritis Pathology
Thought to result from an imbalance between the cartilage wearing down & the Chondrocytes repairing it → leading to Structural issues in the joint.
Osteoarthritis Risks
- Obesity
- Age
- Occupation
- Trauma
- Female
- Family Hx
Osteoarthritis affected joints
- Hips
- knees
- Sacroiliac joints
- Distal - interphalangeal joints in the hands
- Carpometacarpal joint at the base of the thumb
- Wrist
- Cervical spine (cervical Spondylosis)
Osteoarthritis Diagnosis
- Diagnose without Ix if patient over 45, has typical pain, no morning stiffness.
Osteoarthritis X-ray changes
L = Loss of joint space O = Osteophytes (bone spurs) S = Subarticular sclerosis S = Subchondral cysts (fluid- filled holes in bone)
Ostoearthritis symptoms
- Joint enlargement & bone swelling in fingers (Heberden & Bouchard)
- Restricted range of motion - Stiffness on rest
- Crepitus on movement
- Effusions (fluid) around joint
Osteoarthritis Signs
In Hands:
→ Heberden’s nodes (in DIP joints)
→ Bouchard’s nodes (in PIP joints)
→ Weak grip
→ Squaring at base of the thumb (at carpometacarpal joint)
1Osteoarthritis Management
- Oral paracetamol & topical NSAIDs
- Analgesics
- Intra-articular Steroid injection - methylprednisolone
- Joint replacement
Rheumatoid arthritis.
Autoimmune condition that causes Chronic inflammation of the synovial lining (synovitis) of the joints, tendon sheaths & bursa.
RA is symmetrical & affects multiple joints (symmetrical polyarthritis).
Rheumatoid Arthritis Risks
Gene:
→ HLA DR4
→HLA DR1
- Female
- Develops in middle age
- Family risk
Rheumatoid Arthritis Pathology
Anti - CCP antibodies - indicate that R.A. will form.
Rheumatoid Factor → autoantibody.
Targets the Fc portion of the lgG antibody → causes activation of the immune system against the Patients own lgG causing systemic inflammation,
Rheumatoid Arthritis Symptoms
Symmetrical Distal Polyarthropathy
- Pain
- Swelling
- Morning Stiffness
Deformities of the hand:
→ Ulnar deviation
→ Swan neck
→ Boutenniere deformities
Osteoarthritis VS Rheumatoid Arthritis Diff.
R.A = Pain is worse after rest but improves with activity.
Osteoarthritis = Pain worse after activity but improves with rest.
Extra- articular manifestations of Rheumatoid Arthritis
→ Pulmonary fibrosis with nodules → Bronchiolitis obliterans → Felty's syndrome (RA, neutropenia, & splenomegaly) → Secondary Sjogren's Syndrome → Anaemia of chronic disease
Rheumatoid Arthritis Investigations
Bloods:
- Check Rheumatoid Factor
- anti-CCP Antibodies
- Check inflammatory markers - CRP & ESR
- X-Ray of hands & feet
Rheumatoid Arthritis X-Ray changes
L = Loss of joint space 0 = Osteopenia E = Erosion of bone S = Swelling of soft tissue
Rheumatoid Arthritis Management
- Methotrexate + Folate (DMARDs) - Hydroxychloroquine - TNF blocker (Infliximab) - B-cell inhibitors (Rituximab) - NSAIDs for pain
Main TNF inhibitors for R. A.
- Adalimumab
- Infliximab
- Etanercept
- Rituximab
Side Effects:
→ Methotrexate
→ Leflunomide
→ Sulfasalazine
→ Hydroxychloroquine
→ Anti-TNF medications
→ Rituximab
→ Methotrexate = Bone marrow suppression & Leukopenia & highly teratogenic.
→ Leflunomide = Hypertension & Peripheral neuropathy
→ Sulfasalazine = Male infertility (low sperm count)
→ Hydroxychloroquine = Nightmares & reduced visual acuity
Osteoporosis
Reduction in the density & mass of the bones & micro- architectural deterioration.
→ more fragility prone to fractures.
Risk factors for Osteoporosis
- Old age
- Female - especially post- menopausal
- Reduced mobility
- low BMI
- Rheum. Arthritis
- Alcohol & Smoking
Osteoporosis Investigations
- FRAX Tool - gives risk of a fragility fracture over next 10 yrs.
- Bone mineral density measured using a DEXA scan (Dual- Energy X-Ray absorptiometry) → check T score at the hip.
Osteoporosis Management
- 1st Line = Bisphosphonates (e.g. Alendronate, Zoledronic, Risedronate)
→ Reduce osteoclast activity preventing reabsorption of bone. - Denosumab (monoclonal antibody) used if Bisphosphonates is contraindicated.
- Hormone Replacement Therapy
- Calcium supplementation with Vitamin D
(Calcichew - D3 + ColecalciferoI)
Giant Cell Arteritis (Temporal)
Systemic vasculitis of the medium & large arteries.
Giant Cell Arteritis Symptoms
Main is severe unilateral headache around temple & forehead
- Scalp tenderness
- Jaw claudication
- Blurred or Double vision
- Irreversible painless complete sight loss
→ Fever
→ Muscle aches & weight loss
→ Fatigue
→ Peripheral oedema
Giant Cell Arteritis Diagnosis
- Temporal artery biopsy (find multinucleated giant cells)
- Bloods (Raised ESR & CRP levels)
- LFT (raised alkaline phosphatase)
Giant Cell Arteritis Management
→ Steroids 40-60mg Prednisolone
→ Aspirin
→ PPIs (Omeprazole)
DON'T = Don't stop taking steroids abruptly → Risk of adrenal crisis S = Sick day rules T = Treatment Card O = Osteoporosis - Bisphosphonates with Calcium & VitD p = PPI for gastric protection
Giant Cell Arteritis Complications
→ vision loss
→ Cerebrovascular accident (stroke)
→ Relapse of condition
→ Aortitis leads to aortic aneurysm & aortic dissection
Osteoporosis Causes
- Endocrine (Cushing’s & Parathyroid)
- Haematology (Myeloma)
- GI (Malabsorption)
→ Iatrogenic (Steroid use)
Systemic Lupus Erythematosus (SLE)
Inflammatory multisystem autoimmune disorder with arthralgia (joint pain) & rashes.
Type III hypersensitivity.
- Female
- 20-40 yrs
SLE Presentation
- Joint pain
- Skin - Malar butterfly rash, discoid rash, Photosensitive rash
- Serositis - Scleritis, Pericarditis, Pleuritis, Oral ulcers
- kidneys - Glomerulonephritis with proteinuria
- GNS - Depressions, Psychosis
SLE Diagnosis
- Bloods - ESR/ CRP
- ANA, Anti-dsDNA, Serum C3 & C4
SLE Treatment
- NSAIDs
- Hydroxychloroquine
- Steroids
Antiphospholipid
Antibody - mediated acquired thrombophilia characterised by thrombosis &/ recurrent miscarriages.
Antiphospholipid Signs & Symptoms
- Coagulation defects
- Livedo reticularis
- Obstetric issues
- Thrombocytopenia
Antiphospholipid Diagnosis
Clinical criteria : Vascular thrombosis, Pregnancy morbidity
Lab Criteria : Anticardiolipin antibody, Lupus anticoagulant, Anti-Beta 2 Glycoprotein 1 antibody
Antiphospholipid Treatment
- Blood clots (anticoagulate with heparin)
- Chronix (Warfarin)
- Pregnancy (Heparin with aspirin)
Prevent CVS issues → Quit smoking, More exercise
Sjogren’s Syndrome
Chronic inflammatory autoimmune disorder.
- Immunologically mediated destruction of epithelial exocrine glands especially the lacrimal & salivary glands.
Sjogren’s Signs & Symptoms
- Dry eyes, mouth, Parotid gland enlargement
- Joint pain
- Raynauds
- Systemic features
Associated with RA, SLE, PBC & Scleroderma
Sjogren’s Diagnosis
Schirmer Tear Test
- Rose Bengal staining & sit lamp exam
Rheumatoid Factors, Anti Nuclear Antibody, Anti - Ro, Anti-La
Sjogren’s Treatment
NSAID
Hydroxychloroquine
M3 agonist - Pilocarpine
Lifestyle: Humidifier, Eye-drops, Mouth wash
Poly / Dermato myositis
Polymyositis = Rare muscle disorder where there’s inflammation & necrosis of skeletal muscle fibres.
Dermatomyositis = Poly + skin involvement
Poly | Dermato myositis
Polymyositis:
Symmetrical progressive muscle weakness & wasting affecting the proximal muscles of the shoulder & pelvic girdle.
Dermatomyositis:
Heliotrope (purple) discolouration of eyelids.
Scaly erythematous plaques over the knuckles.
- Arthralgia, Dysphagia
Poly/ Dermato myositis Diagnosis
- Muscle biopsy
- Bloods: Raised Serum creatine kinase, Aminotransferases, Lactate dehydrogenase & Aldolase
- Immunology - ANA, Anti jo1, Anti mi2
Poly | Dermato myositis Management
- IV prednisolone
- Stronger Immunosuppressants
- Symptomatic treatment of skin disease
Septic Arthritis Causes
- IV Drug Use
- Immunocompromised
- Intra-articular injections
Septic Arthritis Risks
Common Bugs: → Staphylococcus Aureus → Neisseria Gonorrhoea → Gram -ve Bacteria (E. Coli) → Haemophilus Influenza
Septic Arthritis Treatment
→ Flucloxacillin
→ Penicillin or Clindamycin
→ If MRSA give Vancomycin Or Telcoplanin
→ If Gram -ve, Cefotaxime Or Ceftriaxone
Uric Acid Formation & Pathology
Cell breakdown → Hypoxanthine → Xanthine → Uric Acid
+ Diet (Xanthine Oxidase)
Build-up of uric acid → Uric acid crystals → Deposits in joint spaces causing inflammation
Hyperuricaemia Types
Pseudogout = + ve Birefringent Ca Pyrophosphate.
Gout = - ve Birefringent Monosodium Urate
Stages of Gout progression
High Uric acid levels
Acute Gout
Intercritical Gout
Chronic Gout
Hyperuricaemia
> 420umol / L (Male)
> 360umol / L (Female)
Asymptomatic
Hyperuricaemia Causes
Diuretics - Thiazides
High insulin levels
High fructose intake
Dysfunction of URAT-1 transporter
Hyperuricaemia Symptoms
- Red, Hot joint
- Painful
- Swollen
- Acute onset
→ Mainly affects Big toe, Midfoot, Ankle, Knee, Wrist
Hyperuricaemia Investigations
1St Line = Bloods
Gold = Joint aspiration
U+E + eGFR - Renal family history
Uric acid levels
Hyperuricaemia Management
ACUTE:
1st Line = NSAIDs or Colchicine
2nd line = Intra - articular Steroid injection
CHRONIC:
1st Line = Allopurinol - inhibit Xanthine Oxidase
2nd Line = Febuxostat
Osteomyelitis
Infection of bone marrow. Ways of entry: → Haematogenously → Open wound → Contiguously = Skin into blood
Osteomyelitis formation
Acute inflammation → Subperiosteal abscess → Sequestrum → Involcrum → Cloacae
Osteomyelitis Diagnosis
Labs: High CRP, ESR, WBC
Imaging: X- Ray, CT, MRI, Bone scan
Bone biopsy
Bone culture
Osteomyelitis Management
Antibiotic - Penicillin or Clindamycin
Amoxicillin
Cefotaxime
Ankylosing Spondylitis
Inflammation of sacroiliac joints.
Loss of spinal movements
Ankylosing Spondylitis Investigations
- Bloods = HLA B27
- X Ray = Bamboo spine
Ankylosing Spondylitis X- Ray changes
- Bamboo spine due to fusion
- Sacroiliac joints - eroded & Sclerotic
- Unclear margin between rims
- Bone spurs aka syndesmophytes
Reactive Arthritis
Mainly due to infection
Reactive Arthritis Symptoms
- Can’t see - Uveitis
- Can’t pee - Urethritis
- Entheritis
→ Keratoma Blennorhagica
→ Circinate Balanitis
Reactive Arthritis Investigations
Bloods: Inflammatory markers
High ESR, CRP, ANA, Rheumatoid factor
Imaging
Psoriatic Arthritis Signs & Symptoms
Painful Swollen Stiff joints Psoriatic plaques Dactylitis
Ankylosing Spondylitis Treatment
- Supportive
- Pain management : NSAIDs or Corticosteroids
- Biological therapy - Infliximab
Lower Back pain Management
Analgesia ladder Paracetamol NSAIDs Weak opiates Neuropathic Pain Tx - Gabapentin / Tricyclic
Fibromyalgia
Chronic widespread Pain
Fibromyalgia Investigations
Exclude all other differentials with bloods & imaging
Fibromyalgia Treatment
Neuropathic pain relief
→ Tricyclic Acid (TCA)
→ Gabapentin
→ Pregabalin
Opiates
Scleroderma
Disease characterised by fibrosis across multiple organ systems.
- Most common in women aged 30-50
- Due to increased production of collagen in tissues.
Scleroderma Investigations
Usually in fingers: → skin becomes tight → fingers become stiff & inflexible → Symptoms of Raynauds → Joint & Muscle pain
Scleroderma Management
→ Immunosuppressants (e.g. Cyclophosphamide)
→ Physiotherapy / Occupational Therapy
Symptomatic Treatment:
- Analgesia
- Calcium Channel blocker
- Topic skin emollients
- PPI & antacids (Oesophageal reflux)
- Treating Pulmonary Artery Hypertension ( Bosentan, Sildenafil, Iloprost )
Bone Tumours Types
→ Osteosarcoma = Primary bone malignancy, metaphysis of long bones
→ Ewing Sarcoma = From mesenchymal cells originating from long bones
→ Osteochondroma = (Benign) Overproduction of bone which deposits on metaphysis
Secondary Bone Tumours Metastasis
P = Prostate B = Breast k = Kidneys T = Thyroid L = Lungs
Bone Tumour Investigations
Bloods: FBC, U&E, ALP, PSA
Imaging
X-Ray - Lytic lesions
CT Scan - metastases
Bone Tumours Management
- Pain Management
- Bisphosphonates
- Radiotherapy
- Chemotherapy
Paget’s Disease
Disorder of excessive bone turnover due to excessive activity of both Osteoblasts & clasts
Leads to patchy areas of sclerosis & lysis.
Mainly affects axial skeleton
Paget’s Disease Sx
- Bone pain
- Bone deformity
- Fractures
- Bone enlargement
Paget’s Disease Ix
- Osteoporosis circumscripta (less dense)
- Cotton wool appearance of Skull
- V-shaped defects in Long bones
- Raised alkaline phosphatase
Paget’s Disease Tx
Bisphosphonates
NSAIDs
Calcium & Vit. D
Septic Arthritis
Sx
Common Bac.
Infection occurs in joint.
Sx: Hot, red, swollen painful joint
Stiffness
Fever
Staphylococcus Aureus
Neisseria Gonorrhoea
Strep. pyogenes
E. coli
Septic Arthritis Tx
Joint aspiration
Flucloxacillin + Rifampicin
Vancomycin + Rifampicin (penicillin allergy)
Clindamysin
Gout
Risks
Joint’s
High blood uric acid levels.
Risk: High purine diet, Diuretics, Obesity
Joints: Metatarsophalangeal joint, Wrists, Carpometacarpal joints, knee, Ankle
Gout Ix
Tx
Aspiration of fluid:
No bac. growth
Needle shaped urate crystals
-ve Birefringent of Polarised light
Joint X-ray: Lytic lesions, Punched out erosions
Tx NSAIDS Colchicine Steroids Allopurinol - Xanthine Oxidase inhibitor
Pseudogout
Sx
Ix
Tx
Caused by calcium pyrophosphate crystals.
Sx: hot, swollen, Stiff, Painful knee
Ix: Aspirated fluid = Rhomboid crystals, +ve Birefringent of Polarised light
Tx: NSAIDS, Colchicine, joint aspiration, steroids
