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Phase 2a > MSK > Flashcards

MSK Flashcards

1
Q

What is the typical age of onset of osteoarthritis?

A

45+

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2
Q

What is the pattern of joint involvement in osteoarthritis?

A

Asymmetrical

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3
Q

What are the most common joints affected in osteoarthritis?

A

DIPJs
Hips
Knees

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4
Q

Describe the joint stiffness seen in osteoarthritis.

A

Transient joint stiffness <30 mins

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5
Q

Describe the effect on movement in osteoarthritis.

A

Pain worsens with movement

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6
Q

What are the systemic symptoms of osteoarthritis?

A

None

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7
Q

What age does rheumatoid arthritis typically present?

A

20-40

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8
Q

Describe the pattern of joint involvement for rheumatoid arthritis.

A

Symmetrical

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9
Q

What are the most common joints affected in rheumatoid arthritis?

A

PIPJs
Wrists and feet
DIPJs rarely affected

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10
Q

Describe the joint stiffness seen in rheumatoid arthritis.

A

Early morning stiffness >30 mins

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11
Q

Describe the effect of movement seen in rheumatoid arthritis.

A

Pain eases with movement

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12
Q

What are the systemic symptoms of rheumatoid arthritis?

A

Fever and malaise

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13
Q

What is osteoarthritis?

A

Non-inflammatory degenerative arthritis

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14
Q

What is the pathology of osteoarthritis?

A

Progressive destruction and loss of articular cartilage

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15
Q

When can you diagnose osteoarthritis without investigations?

A

45+, activity related joint pain, no morning stiffness/stiffness lasting <30 mins

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16
Q

How do you investigate osteoarthritis?

A

Bloods - FBC and ESR normal

X-ray

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17
Q

What is the non-medical management of osteoarthritis?

A

Physio to improve strength/lose weight

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18
Q

What is the medical management of osteoarthritis?

A

Paracetamol/NSAIDs/intra-articular corticosteroid (hydrocortisone) injections

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19
Q

What should you consider prescribing with continuous oral NSAIDs?

A

PPIs

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20
Q

What is the surgical management of osteoarthritis?

A

Arthroscopy/arthroplasty

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21
Q

What is arthroscopy?

A

Scope inserted into joint to assess and remove loose bodies e.g. bone and cartilage fragments

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22
Q

What is arthroplasty?

A

AKA knee/hip replacement if uncontrolled pain and significantly limited function

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23
Q

What does an x-ray show for osteoarthritis?

A

LOSS

Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts

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24
Q

What are the signs of osteoarthritis in the hands?

A

Heberden’s and Bouchard’s nodes

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25
Which joint do Heberden's nodes present in?
DIPJs
26
Which joint do Bouchard's nodes present in?
PIPJs
27
What is rheumatoid arthritis?
Chronic systemic autoimmune disorder causing a symmmetrical polyarthritis
28
What type of arthritis is rheumatoid arthritis?
Inflammatory?
29
What makes rheumatoid arthritis an inflammatory condition?
Synovial inflammation (synovitis)
30
What are the genetic associations of rheumatoid arthritis?
HLA DR1/DR4
31
How must a patient present to diagnose rheumatoid arthritis?
5 Ss ``` Slowly progressive Symmetrical Swollen Stiff Systemic symptoms (+pain) ```
32
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
33
What is Caplan's syndrome?
Pulmonary fibrosis with pulmonary nodules
34
What is Felty's syndrome?
RA + splenomegaly + neutropenia
35
How is rheumatoid arthritis investigated?
``` Bloods: FBC Rheumatoid factor Anti-CCP CRP/ESR ```
36
What does FBC show for rheumatoid arthritis?
Normochromic normocytic anaemia
37
Describe the ESR/CRP levels in rheumatoid arthritis.
Raised (inflammation)
38
Describe the levels of rheumatoid factor in rheumatoid arthritis.
Raised in 80% - low specificity, high sensitivity
39
Describe the levels of anti-CCP in rheumatoid arthritis.
Raised in 30% - low sensitivity, high specificity
40
What characterises a worse prognosis of rheumatoid arthritis?
Raised anti-CCP
41
What does an x-ray show for rheumatoid arthritis?
LESS Loss of joint space Erosion Soft tissue swelling Soft bones
42
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
43
What characterises gout under polarised light microscopy?
Yellow needle shaped monosodium urate crystals, strongly negative birefrigence
44
What characterises pseudogout under polarised light microscopy?
Blue rod/rhomboid calcium pyrophosphate dihydrate crystals. Weak positive birefringence.
45
What is gout?
Inflammatory arthritis associated with chronically high blood uric acid levels
46
Where does the majority of gout present?
60% occurs at 1st MTPJ of big toe
47
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 ```
48
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
49
How do the kidneys produce uric acid?
Purines > hypoxanthine > xanthine > uric acid
50
What enzyme is responsible for the conversion of hypoxanthine to uric acid?
Xanthine oxidase
51
How does acute gout present?
Sudden onset of severe pain, swelling and redness of metatarsophalangeal (MTP) joint of big toe
52
How many joints does acute gout usually affect?
Usually monoarticular
53
What differential is important to rule out in gout?
Septic arthritis - gout will have no bacteria in aspirate
54
Who does chronic polyarticular gout usually affect?
Patients with renal failure on long term diuretics
55
How does chronic tophaceous gout present?
Monosodium urate forms large, smooth, white deposits (TOPHI) in skin around the joints (particularly DIPJs/ear)
56
Until proven otherwise, what is the cause of any hot swollen red joint?
Septic arthritis
57
What is the 1st line treatment of acute attacks of gout?
High dose NSAIDs
58
What is the 2nd line treatment of acute attacks of gout?
Colchicine
59
What is the 3rd line treatment for acute attacks of gout?
Corticosteroids
60
How is gout prevented?
Avoid purine rich foods Reduce alcohol consumption Lose weight
61
What is allopurinol?
Xanthine oxidase inhibitor
62
What medication is used to TREAT gout (rather than manage)?
Allopurinol
63
How does allopurinol work?
Less uric acid production = less monosodium crystals
64
When can you start a patient on allopurinol?
Must not start until 1 month after acute attack. Once started can be taken through any following attacks
65
What is pseudogout?
Deposition of calcium pyrophosophate crystals on joint surface
66
Why does pseudogout resemble acute gout?
Shedding of crystals into joint produces acute synovitis resembling acute gout
67
What does an x-ray for pseudogout show?
Chondrocalcinosis = diagnostic for pseudogout | Linear calcification parallel to articular surfaces
68
How is pseudogout managed?
Symptoms usually resolve on their own over a few weeks | Symptomatic management includes NSAIDs/colchicine/joint aspiration/corticosteroids
69
What is osteoporosis?
Low bone mass = increased bone fragility and fracture risk
70
What are the risk factors for osteoporosis?
MY SHATTERED FAMILY MY - personal history of fracture ``` Steroid use Hyperthyroidism/hyperparathyroidism Alcohol Thin (low BMI) - reduced skeletal loading Testosterone low Early menopause Renal or liver disease Erosive/inflammatory bone disease e.g. RA Dietary calcium low/malabsorption ``` FAMILY - parental history of fracture
71
What is a protective factor for osteoporosis?
Oestrogen - post-menopausal women at greater risk (less oestrogen)
72
What does an x-ray of osteoporosis show?
Fragility fractures
73
How is osteoporosis investigated?
``` X-ray DEXA scan (gold standard) - calculate FRAX score ```
74
What is the FRAX score?
Predicts risk of fragility fracture over next 10 years
75
What do the FRAX scores mean?
> -1 = normal -1 > -2.5 = osteopenia < -2.5 = osteoporosis
76
What lifestyle changes can be made to treat osteoporosis?
Quit smoking Reduce alcohol consumption Regular weight bearing exercise Calcium and vitamin D supplements
77
What is the medical treatment for osteoporosis?
Bisphosphonates e.g. alendronic acid, IV zoledronate/zoledronic acid Denosumab HRT for early menopause
78
How should alendronic acid be taken?
Empty stomach, sitting upright for 30 minutes before moving or eating
79
What are the side effects of bisphosphonates?
Reflux and oesophageal erosions
80
What do bisphosophonates do?
Decrease osteoclast activity - slows down bone resorption and bone turnover
81
What is denosumab?
Monoclonal antibody to RANK ligand - inhibits osteoclasts
82
What are the seronegative spondylarthropathies?
Ankylosing spondylitis, psoriatic arthritis, reactive arthritis
83
What are the common fearures of seronegative spondylarthropathies?
SPINEACHE ``` Sausage digits (dactylitis) Psoriasis Inflammatory back pain NSAIDs - good response Enthesitis (heel) Arthritis Crohn's/UC/high CRP HLA B27 Eye - anterior uveitis/iritis ```
84
What are seronegative spondylarthropathies?
Group of inflammatory diseases of the spine and sacroiliac joints
85
What does 'seronegative' mean?
No rheumatoid factor
86
What is ankylosing spondylitis?
Chronic inflammatory disorder of spine and sacroiliac joints
87
What does inflammation in ankylosing spondylitis cause?
Pain and stiffness
88
What happens after healing of inflammation in ankylosing spondylitis?
Inflammation heals with new bone formation - syndesmophytes
89
How does ankylosing spondylitis present?
``` Lower back (sacroiliac) pain and stiffness Pain improves with exercise Pain worse at night - can wake patient Gradual onset of symptoms over >3 months Morning stiffness >1 hour ```
90
What are the effects on other organ systems in ankylosing spondylitis?
Chest pain - inflamed costosternal joints Anterior uveitis Enthesitis Systemic symptoms (fatigue, fever, weight loss) Dactylitis Achilles tendonitis
91
What is the clinical examination of ankylosing spondylitis?
Schober's test
92
What do bloods show for ankylosing spondylitis?
ESR/CRP raised | HLA B27 genetic test
93
What does an x-ray show for ankylosing spondylitis?
Bamboo spine - late stages of disease
94
What is the 1st line treatment of ankylosing spondylitis?
Exercise and physio
95
What is the 2nd line treatment of ankylosing spondylitis?
NSAIDs
96
What is the 3rd line treatment of ankylosing spondylitis?
Anti-TNF e.g. infliximab/etanercept
97
What is the 4th line treatment of ankylosing spondylitis?
Secukinumab - monoclonal antibody against IL-17
98
Where should you look for hidden psoriasis?
``` Behind ear Inside ear Scalp Nails Umbilicus Genitals ```
99
What is psoriatic arthritis?
Inflammatory arthritis associated with psoriasis (occurs in 10-20% of patients with psoriasis)
100
What are the different patterns of disease for psoriatic arthritis?
``` Symmetrical polyarthritis Asymmetrical oligoarthritis DIPJ arthritis Spondylitic arthritis Arthritis mutilans ```
101
How does symmetrical polyarthritis present?
Similar to RA
102
How does DIPJ arthritis present?
Dactylitis = characteristic
103
How does spondylitic arthritis present?
Similar to ankylosing spondylitis
104
What is arthritis mutilans?
Severe deformity where small bones in hands and feet are destroyed
105
How is psoriatic arthritis investigated?
PEST scoring tool | X-ray
106
What shows on x-ray for psoriatic arthritis?
'Pencil-in-cup' deformity
107
How is psoriatic arthritis managed?
NSAIDs for pain DMARDS e.g. methotrexate/sulfasalazine Anti-TNF drugs e.g. infliximab
108
What is reactive arthritis?
Sterile inflammation of synovial membranes, tendons and fascia
109
What triggers reactive arthritis?
Infection at a distant site
110
What infections can trigger reactive arthritis?
Gastroenteritis e.g. salmonella, shigella | STIs e.g. chlamydia (mainly), gonorrhoea
111
What does reactive arthritis typically cause?
Acute monoarthritis (knee = most common)
112
What differential must be excluded in cases of reactive arthritis?
Septic arthritis
113
What are the classic symptoms of reactive arthritis?
Can't see - conjunctivitis Can't pee - urethritis Can't climb a tree - arthritis
114
What are the other symptoms of reactive arthritis?
Circinate balantis - painless ulceration of penis | Keratoderma blennorrhagia - feet
115
How do you investigate reactive arthritis?
Bloods - ESR/CRP raised Culture stools if diarrhoea/STI swabs Must aspirate joint + culture to exclude septic arthritis (if it is reactive arthritis it will be sterile)
116
How do you manage reactive arthritis?
Treat cause of infection with antibiotics NSAIDs Corticosteroid injections into affected joints Consider systemic steroids if multiple joints affected
117
How long does it take for most cases of reactive arthritis to resolve?
Most cases resolve within 6 months. If they don't, consider DMARDs/anti-TNF drugs
118
What joints does septic arthritis commonly affect?
90% monoarthritis | Knee > hip > shoulder
119
How do you test for septic arthritis?
Urgent joint aspiration - ideally aspirate before giving antibiotics Gram stain and culture to help choose antibiotics Polarised light microscopy to exclude gout/pseudogout Fluid will be opaque/thick/pussy due to high WCC
120
What are the causes of septic arthritis?
Staph aureus - most common (in native joints) Neisseria gonorrhoea if young/sexually active/MSM Staph epidermidis if had a joint replacement E. Coli/pseudomonas at extremes of age/IV drug users/immunocompromised
121
How is septic arthritis managed?
Urgent joint aspiration Gram staining Crystal microscopy Culture Antibiotic sensitivities Don't wait for culture results - treat empirically with IV antibiotics (IV flucloxacillin and rifampicin is often first line) Antibiotics usually continued for 3-6 weeks
122
What is SLE?
Multisystemic inflammatory autoimmune connective tissue disease
123
Who is SLE most common in?
Pre-menopausal women
124
What is the pathophysiology of SLE?
Autoantibodies attack normal healthy proteins causing a chronic inflammatory response
125
What antibodies are associated with SLE?
Anti-nuclear antibodies (ANA) - low specificity, high sensitivity - can be +ve in healthy people/patients with other autoimmune conditions Anti-double stranded DNA (anti-dsDNA) - highly specific for SLE but only positive in 60% of patients (low sensitivity)
126
How does SLE present?
SOAP BRAIN MD ``` Serositis (pleuritis, pericarditis) Oral ulcers Arthritis Photosensitivity Blood (all are low - anaemia, leukopenia, thrombocytopenia) Renal (protein) ANA Immunologic (dsDNA etc.) Neurologic (psych, seizures) Malar rash - photosensitive, butterfly shaped Discoid rash ```
127
How many of the SOAP BRAIN MD symptoms are needed to diagnose SLE?
4/11
128
What conditions is SLE associated with?
Antiphospholipid syndrome and Raynaud's phenomenon
129
What are you at increased risk of if you have anti-phospholipid syndrome?
CLOTs Coagulation defects - DVT, stroke Levido reticularis - pink/blue mottling Obstetric - recurrent miscarriages Thrombocytopenia
130
How do you investigate SLE?
``` Bloods: Raised ESR/normal CRP Low complement (C3/4) Normocytic anaemia of chronic disease Autoantibodies - ANA/anti-dsDNA ```
131
How is SLE managed?
Sun cream and sun avoidance to prevent rashes NSAIDs for analgesia Hydroxychloroquine - first line for mild SLE Prednisolone Biological therapies if none of the above works
132
What are the different primary bone cancers?
Osteosarcoma Ewing's sarcoma Chondrosarcoma Chordoma
133
When does osteosarcoma normally present?
10-25 years
134
What is the most common bone affected in osteosarcoma?
Knee
135
What is found on x-ray for osteosarcoma?
Sunray spiculation
136
When does Ewing's sarcoma normally present?
Under 30
137
What is the most common bone affected in Ewing's sarcoma?
Femur and pelvis
138
What does x-ray show for Ewing's sarcoma?
Onion skin appearance
139
When does chondrosarcoma normally present?
50+
140
What bone does chondrosarcoma normally affect?
Pelvis
141
What shows on x-ray for chondrosarcoma?
Popcorn calcifications
142
When does chordoma normally present?
50+
143
What bone is normally affected in chordoma?
Spine/skull
144
What are the most common cancers that metastasise to bone?
``` Breast Bronchus (lungs) Byroid (thyroid) Bidney (kidney) Brostrate (prostate) ```
145
How do bone tumours present?
``` Persistent bone pain Pain is worse at night - nocturnal pain Rest pain Localised redness/tenderness/swelling Restricted joint movements Unexplained bone fractures Fatigue/weight loss/fever ```
146
What are the back pain red flags?
TUNA FISH ``` Trauma - osteoporosis? Unexplained weight loss - cancer? Neurologic symptoms - cauda equina? Age >50 (secondary bone cancer?) or <20 (ankylosing spondylitis?) Fever - infection? IV drug use - infection? Steroid use - infection? History of cancer - metastases? ```
147
What are the cauda equina red flags?
Urinary incontinence (occurs because of loss of sensation when passing urine) Urinary retention (loss of sensation of bladder fullness) Saddle anaesthesia Faecal incontinence Decreased anal sphincter tone Bilateral lower extremity weakness or numbness Progressive neurological deficity: - Major motor weakness - such as major motor weakness with knee extension, ankle eversion or foot dorsiflexion - Major sensory deficit
148
What is mechanical back pain often related to?
Very common - often traumatic or work related
149
How does mechanical lower back pain present?
Lower back pain and stiffness worse on movement and improves with rest (opposite of inflammatory back pain) Patient is systemically well
150
How do you investigate mechanical lower back pain?
No need to investigate unless chronic (>3 months) or red flags present
151
How long does it typically take for mechanical lower back pain to resolve?
90% resolve within 6 weeks
152
How is mechanical lower back pain treated?
Advise patient to continue normal activities and take pain relief if needed

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