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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
Q

Which joint do Heberden’s nodes present in?

A

DIPJs

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26
Q

Which joint do Bouchard’s nodes present in?

A

PIPJs

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27
Q

What is rheumatoid arthritis?

A

Chronic systemic autoimmune disorder causing a symmmetrical polyarthritis

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28
Q

What type of arthritis is rheumatoid arthritis?

A

Inflammatory?

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29
Q

What makes rheumatoid arthritis an inflammatory condition?

A

Synovial inflammation (synovitis)

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30
Q

What are the genetic associations of rheumatoid arthritis?

A

HLA DR1/DR4

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31
Q

How must a patient present to diagnose rheumatoid arthritis?

A

5 Ss

Slowly progressive
Symmetrical
Swollen
Stiff
Systemic symptoms (+pain)
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32
Q

What are the extra-articular manifestations of rheumatoid arthritis?

A

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

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33
Q

What is Caplan’s syndrome?

A

Pulmonary fibrosis with pulmonary nodules

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34
Q

What is Felty’s syndrome?

A

RA + splenomegaly + neutropenia

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35
Q

How is rheumatoid arthritis investigated?

A 
Bloods:
FBC
Rheumatoid factor
Anti-CCP
CRP/ESR
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36
Q

What does FBC show for rheumatoid arthritis?

A

Normochromic normocytic anaemia

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37
Q

Describe the ESR/CRP levels in rheumatoid arthritis.

A

Raised (inflammation)

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38
Q

Describe the levels of rheumatoid factor in rheumatoid arthritis.

A

Raised in 80% - low specificity, high sensitivity

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39
Q

Describe the levels of anti-CCP in rheumatoid arthritis.

A

Raised in 30% - low sensitivity, high specificity

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40
Q

What characterises a worse prognosis of rheumatoid arthritis?

A

Raised anti-CCP

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41
Q

What does an x-ray show for rheumatoid arthritis?

A

LESS

Loss of joint space
Erosion
Soft tissue swelling
Soft bones

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42
Q

How does rheumatoid arthritis present in the hands?

A

Boutonnière deformity of thumb
Ulnar deviation of MCP joints
Swan-neck deformity of fingers
Z-shaped deformity of thumb

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43
Q

What characterises gout under polarised light microscopy?

A

Yellow needle shaped monosodium urate crystals, strongly negative birefrigence

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44
Q

What characterises pseudogout under polarised light microscopy?

A

Blue rod/rhomboid calcium pyrophosphate dihydrate crystals. Weak positive birefringence.

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45
Q

What is gout?

A

Inflammatory arthritis associated with chronically high blood uric acid levels

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46
Q

Where does the majority of gout present?

A

60% occurs at 1st MTPJ of big toe

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47
Q

What are the risk factors for gout?

A 
Male
Obesity
High purine diet e.g. red meat, shellfish, beer
Alcohol
Diuretics
Existing cardio or kidney disease
FHx
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48
Q

What is the pathophysiology of gout?

A

Uric acid usually excreted out via kidneys but if there is excess uric acid and the kidneys can’t cope - converted into monosodium urate

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49
Q

How do the kidneys produce uric acid?

A

Purines > hypoxanthine > xanthine > uric acid

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50
Q

What enzyme is responsible for the conversion of hypoxanthine to uric acid?

A

Xanthine oxidase

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51
Q

How does acute gout present?

A

Sudden onset of severe pain, swelling and redness of metatarsophalangeal (MTP) joint of big toe

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52
Q

How many joints does acute gout usually affect?

A

Usually monoarticular

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53
Q

What differential is important to rule out in gout?

A

Septic arthritis - gout will have no bacteria in aspirate

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54
Q

Who does chronic polyarticular gout usually affect?

A

Patients with renal failure on long term diuretics

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55
Q

How does chronic tophaceous gout present?

A

Monosodium urate forms large, smooth, white deposits (TOPHI) in skin around the joints (particularly DIPJs/ear)

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56
Q

Until proven otherwise, what is the cause of any hot swollen red joint?

A

Septic arthritis

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57
Q

What is the 1st line treatment of acute attacks of gout?

A

High dose NSAIDs

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58
Q

What is the 2nd line treatment of acute attacks of gout?

A

Colchicine

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59
Q

What is the 3rd line treatment for acute attacks of gout?

A

Corticosteroids

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60
Q

How is gout prevented?

A

Avoid purine rich foods
Reduce alcohol consumption
Lose weight

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61
Q

What is allopurinol?

A

Xanthine oxidase inhibitor

62
Q

What medication is used to TREAT gout (rather than manage)?

A

Allopurinol

63
Q

How does allopurinol work?

A

Less uric acid production = less monosodium crystals

64
Q

When can you start a patient on allopurinol?

A

Must not start until 1 month after acute attack. Once started can be taken through any following attacks

65
Q

What is pseudogout?

A

Deposition of calcium pyrophosophate crystals on joint surface

66
Q

Why does pseudogout resemble acute gout?

A

Shedding of crystals into joint produces acute synovitis resembling acute gout

67
Q

What does an x-ray for pseudogout show?

A

Chondrocalcinosis = diagnostic for pseudogout

Linear calcification parallel to articular surfaces

68
Q

How is pseudogout managed?

A

Symptoms usually resolve on their own over a few weeks

Symptomatic management includes NSAIDs/colchicine/joint aspiration/corticosteroids

69
Q

What is osteoporosis?

A

Low bone mass = increased bone fragility and fracture risk

70
Q

What are the risk factors for osteoporosis?

A

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
Q

What is a protective factor for osteoporosis?

A

Oestrogen - post-menopausal women at greater risk (less oestrogen)

72
Q

What does an x-ray of osteoporosis show?

A

Fragility fractures

73
Q

How is osteoporosis investigated?

A 
X-ray
DEXA scan (gold standard) - calculate FRAX score
74
Q

What is the FRAX score?

A

Predicts risk of fragility fracture over next 10 years

75
Q

What do the FRAX scores mean?

A

> -1 = normal
-1 > -2.5 = osteopenia
< -2.5 = osteoporosis

76
Q

What lifestyle changes can be made to treat osteoporosis?

A

Quit smoking
Reduce alcohol consumption
Regular weight bearing exercise
Calcium and vitamin D supplements

77
Q

What is the medical treatment for osteoporosis?

A

Bisphosphonates e.g. alendronic acid, IV zoledronate/zoledronic acid
Denosumab
HRT for early menopause

78
Q

How should alendronic acid be taken?

A

Empty stomach, sitting upright for 30 minutes before moving or eating

79
Q

What are the side effects of bisphosphonates?

A

Reflux and oesophageal erosions

80
Q

What do bisphosophonates do?

A

Decrease osteoclast activity - slows down bone resorption and bone turnover

81
Q

What is denosumab?

A

Monoclonal antibody to RANK ligand - inhibits osteoclasts

82
Q

What are the seronegative spondylarthropathies?

A

Ankylosing spondylitis, psoriatic arthritis, reactive arthritis

83
Q

What are the common fearures of seronegative spondylarthropathies?

A

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
Q

What are seronegative spondylarthropathies?

A

Group of inflammatory diseases of the spine and sacroiliac joints

85
Q

What does ‘seronegative’ mean?

A

No rheumatoid factor

86
Q

What is ankylosing spondylitis?

A

Chronic inflammatory disorder of spine and sacroiliac joints

87
Q

What does inflammation in ankylosing spondylitis cause?

A

Pain and stiffness

88
Q

What happens after healing of inflammation in ankylosing spondylitis?

A

Inflammation heals with new bone formation - syndesmophytes

89
Q

How does ankylosing spondylitis present?

A 
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
Q

What are the effects on other organ systems in ankylosing spondylitis?

A

Chest pain - inflamed costosternal joints
Anterior uveitis
Enthesitis
Systemic symptoms (fatigue, fever, weight loss)
Dactylitis
Achilles tendonitis

91
Q

What is the clinical examination of ankylosing spondylitis?

A

Schober’s test

92
Q

What do bloods show for ankylosing spondylitis?

A

ESR/CRP raised

HLA B27 genetic test

93
Q

What does an x-ray show for ankylosing spondylitis?

A

Bamboo spine - late stages of disease

94
Q

What is the 1st line treatment of ankylosing spondylitis?

A

Exercise and physio

95
Q

What is the 2nd line treatment of ankylosing spondylitis?

96
Q

What is the 3rd line treatment of ankylosing spondylitis?

A

Anti-TNF e.g. infliximab/etanercept

97
Q

What is the 4th line treatment of ankylosing spondylitis?

A

Secukinumab - monoclonal antibody against IL-17

98
Q

Where should you look for hidden psoriasis?

A 
Behind ear
Inside ear
Scalp
Nails
Umbilicus
Genitals
99
Q

What is psoriatic arthritis?

A

Inflammatory arthritis associated with psoriasis (occurs in 10-20% of patients with psoriasis)

100
Q

What are the different patterns of disease for psoriatic arthritis?

A 
Symmetrical polyarthritis
Asymmetrical oligoarthritis
DIPJ arthritis
Spondylitic arthritis
Arthritis mutilans
101
Q

How does symmetrical polyarthritis present?

A

Similar to RA

102
Q

How does DIPJ arthritis present?

A

Dactylitis = characteristic

103
Q

How does spondylitic arthritis present?

A

Similar to ankylosing spondylitis

104
Q

What is arthritis mutilans?

A

Severe deformity where small bones in hands and feet are destroyed

105
Q

How is psoriatic arthritis investigated?

A

PEST scoring tool

X-ray

106
Q

What shows on x-ray for psoriatic arthritis?

A

‘Pencil-in-cup’ deformity

107
Q

How is psoriatic arthritis managed?

A

NSAIDs for pain
DMARDS e.g. methotrexate/sulfasalazine
Anti-TNF drugs e.g. infliximab

108
Q

What is reactive arthritis?

A

Sterile inflammation of synovial membranes, tendons and fascia

109
Q

What triggers reactive arthritis?

A

Infection at a distant site

110
Q

What infections can trigger reactive arthritis?

A

Gastroenteritis e.g. salmonella, shigella

STIs e.g. chlamydia (mainly), gonorrhoea

111
Q

What does reactive arthritis typically cause?

A

Acute monoarthritis (knee = most common)

112
Q

What differential must be excluded in cases of reactive arthritis?

A

Septic arthritis

113
Q

What are the classic symptoms of reactive arthritis?

A

Can’t see - conjunctivitis
Can’t pee - urethritis
Can’t climb a tree - arthritis

114
Q

What are the other symptoms of reactive arthritis?

A

Circinate balantis - painless ulceration of penis

Keratoderma blennorrhagia - feet

115
Q

How do you investigate reactive arthritis?

A

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
Q

How do you manage reactive arthritis?

A

Treat cause of infection with antibiotics
NSAIDs
Corticosteroid injections into affected joints
Consider systemic steroids if multiple joints affected

117
Q

How long does it take for most cases of reactive arthritis to resolve?

A

Most cases resolve within 6 months. If they don’t, consider DMARDs/anti-TNF drugs

118
Q

What joints does septic arthritis commonly affect?

A

90% monoarthritis

Knee > hip > shoulder

119
Q

How do you test for septic arthritis?

A

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
Q

What are the causes of septic arthritis?

A

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
Q

How is septic arthritis managed?

A

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
Q

What is SLE?

A

Multisystemic inflammatory autoimmune connective tissue disease

123
Q

Who is SLE most common in?

A

Pre-menopausal women

124
Q

What is the pathophysiology of SLE?

A

Autoantibodies attack normal healthy proteins causing a chronic inflammatory response

125
Q

What antibodies are associated with SLE?

A

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
Q

How does SLE present?

A

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
Q

How many of the SOAP BRAIN MD symptoms are needed to diagnose SLE?

128
Q

What conditions is SLE associated with?

A

Antiphospholipid syndrome and Raynaud’s phenomenon

129
Q

What are you at increased risk of if you have anti-phospholipid syndrome?

A

CLOTs

Coagulation defects - DVT, stroke
Levido reticularis - pink/blue mottling
Obstetric - recurrent miscarriages
Thrombocytopenia

130
Q

How do you investigate SLE?

A 
Bloods:
Raised ESR/normal CRP
Low complement (C3/4)
Normocytic anaemia of chronic disease
Autoantibodies - ANA/anti-dsDNA
131
Q

How is SLE managed?

A

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
Q

What are the different primary bone cancers?

A

Osteosarcoma
Ewing’s sarcoma
Chondrosarcoma
Chordoma

133
Q

When does osteosarcoma normally present?

A

10-25 years

134
Q

What is the most common bone affected in osteosarcoma?

135
Q

What is found on x-ray for osteosarcoma?

A

Sunray spiculation

136
Q

When does Ewing’s sarcoma normally present?

137
Q

What is the most common bone affected in Ewing’s sarcoma?

A

Femur and pelvis

138
Q

What does x-ray show for Ewing’s sarcoma?

A

Onion skin appearance

139
Q

When does chondrosarcoma normally present?

140
Q

What bone does chondrosarcoma normally affect?

141
Q

What shows on x-ray for chondrosarcoma?

A

Popcorn calcifications

142
Q

When does chordoma normally present?

143
Q

What bone is normally affected in chordoma?

A

Spine/skull

144
Q

What are the most common cancers that metastasise to bone?

A 
Breast
Bronchus (lungs)
Byroid (thyroid)
Bidney (kidney)
Brostrate (prostate)
145
Q

How do bone tumours present?

A 
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
Q

What are the back pain red flags?

A

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
Q

What are the cauda equina red flags?

A

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
Q

What is mechanical back pain often related to?

A

Very common - often traumatic or work related

149
Q

How does mechanical lower back pain present?

A

Lower back pain and stiffness worse on movement and improves with rest (opposite of inflammatory back pain)
Patient is systemically well

150
Q

How do you investigate mechanical lower back pain?

A

No need to investigate unless chronic (>3 months) or red flags present

151
Q

How long does it typically take for mechanical lower back pain to resolve?

A

90% resolve within 6 weeks

152
Q

How is mechanical lower back pain treated?

A

Advise patient to continue normal activities and take pain relief if needed

Phase 2a (25 decks)

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