MSK Flashcards
What is the typical age of onset of osteoarthritis?
45+
What is the pattern of joint involvement in osteoarthritis?
Asymmetrical
What are the most common joints affected in osteoarthritis?
DIPJs
Hips
Knees
Describe the joint stiffness seen in osteoarthritis.
Transient joint stiffness <30 mins
Describe the effect on movement in osteoarthritis.
Pain worsens with movement
What are the systemic symptoms of osteoarthritis?
None
What age does rheumatoid arthritis typically present?
20-40
Describe the pattern of joint involvement for rheumatoid arthritis.
Symmetrical
What are the most common joints affected in rheumatoid arthritis?
PIPJs
Wrists and feet
DIPJs rarely affected
Describe the joint stiffness seen in rheumatoid arthritis.
Early morning stiffness >30 mins
Describe the effect of movement seen in rheumatoid arthritis.
Pain eases with movement
What are the systemic symptoms of rheumatoid arthritis?
Fever and malaise
What is osteoarthritis?
Non-inflammatory degenerative arthritis
What is the pathology of osteoarthritis?
Progressive destruction and loss of articular cartilage
When can you diagnose osteoarthritis without investigations?
45+, activity related joint pain, no morning stiffness/stiffness lasting <30 mins
How do you investigate osteoarthritis?
Bloods - FBC and ESR normal
X-ray
What is the non-medical management of osteoarthritis?
Physio to improve strength/lose weight
What is the medical management of osteoarthritis?
Paracetamol/NSAIDs/intra-articular corticosteroid (hydrocortisone) injections
What should you consider prescribing with continuous oral NSAIDs?
PPIs
What is the surgical management of osteoarthritis?
Arthroscopy/arthroplasty
What is arthroscopy?
Scope inserted into joint to assess and remove loose bodies e.g. bone and cartilage fragments
What is arthroplasty?
AKA knee/hip replacement if uncontrolled pain and significantly limited function
What does an x-ray show for osteoarthritis?
LOSS
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
What are the signs of osteoarthritis in the hands?
Heberden’s and Bouchard’s nodes
Which joint do Heberden’s nodes present in?
DIPJs
Which joint do Bouchard’s nodes present in?
PIPJs
What is rheumatoid arthritis?
Chronic systemic autoimmune disorder causing a symmmetrical polyarthritis
What type of arthritis is rheumatoid arthritis?
Inflammatory?
What makes rheumatoid arthritis an inflammatory condition?
Synovial inflammation (synovitis)
What are the genetic associations of rheumatoid arthritis?
HLA DR1/DR4
How must a patient present to diagnose rheumatoid arthritis?
5 Ss
Slowly progressive Symmetrical Swollen Stiff Systemic symptoms (+pain)
What are the extra-articular manifestations of rheumatoid arthritis?
Subcutaneous nodules
Caplan’s syndrome - swelling (inflammation) and scarring of the lungs
Felty’s syndrome - RA + splenomegaly + neutropenia
Anaemia of chronic disease
Episcleritis and scleritis
CTS
What is Caplan’s syndrome?
Pulmonary fibrosis with pulmonary nodules
What is Felty’s syndrome?
RA + splenomegaly + neutropenia
How is rheumatoid arthritis investigated?
Bloods: FBC Rheumatoid factor Anti-CCP CRP/ESR
What does FBC show for rheumatoid arthritis?
Normochromic normocytic anaemia
Describe the ESR/CRP levels in rheumatoid arthritis.
Raised (inflammation)
Describe the levels of rheumatoid factor in rheumatoid arthritis.
Raised in 80% - low specificity, high sensitivity
Describe the levels of anti-CCP in rheumatoid arthritis.
Raised in 30% - low sensitivity, high specificity
What characterises a worse prognosis of rheumatoid arthritis?
Raised anti-CCP
What does an x-ray show for rheumatoid arthritis?
LESS
Loss of joint space
Erosion
Soft tissue swelling
Soft bones
How does rheumatoid arthritis present in the hands?
Boutonnière deformity of thumb
Ulnar deviation of MCP joints
Swan-neck deformity of fingers
Z-shaped deformity of thumb
What characterises gout under polarised light microscopy?
Yellow needle shaped monosodium urate crystals, strongly negative birefrigence
What characterises pseudogout under polarised light microscopy?
Blue rod/rhomboid calcium pyrophosphate dihydrate crystals. Weak positive birefringence.
What is gout?
Inflammatory arthritis associated with chronically high blood uric acid levels
Where does the majority of gout present?
60% occurs at 1st MTPJ of big toe
What are the risk factors for gout?
Male Obesity High purine diet e.g. red meat, shellfish, beer Alcohol Diuretics Existing cardio or kidney disease FHx
What is the pathophysiology of gout?
Uric acid usually excreted out via kidneys but if there is excess uric acid and the kidneys can’t cope - converted into monosodium urate
How do the kidneys produce uric acid?
Purines > hypoxanthine > xanthine > uric acid
What enzyme is responsible for the conversion of hypoxanthine to uric acid?
Xanthine oxidase
How does acute gout present?
Sudden onset of severe pain, swelling and redness of metatarsophalangeal (MTP) joint of big toe
How many joints does acute gout usually affect?
Usually monoarticular
What differential is important to rule out in gout?
Septic arthritis - gout will have no bacteria in aspirate
Who does chronic polyarticular gout usually affect?
Patients with renal failure on long term diuretics
How does chronic tophaceous gout present?
Monosodium urate forms large, smooth, white deposits (TOPHI) in skin around the joints (particularly DIPJs/ear)
Until proven otherwise, what is the cause of any hot swollen red joint?
Septic arthritis
What is the 1st line treatment of acute attacks of gout?
High dose NSAIDs
What is the 2nd line treatment of acute attacks of gout?
Colchicine
What is the 3rd line treatment for acute attacks of gout?
Corticosteroids
How is gout prevented?
Avoid purine rich foods
Reduce alcohol consumption
Lose weight