Msk Flashcards
What is osteoarthritis?
Asymmetrical degenerative synovial joint disease
Cartilage destruction exceeds repair causing pain and instability
What are the primary causes of osteoarthritis?
Obese Older Female Occupation Post menopausal
What is secondary osteoarthtiis?
Inflammatory -Rh Septic arthritis
Congenital -DDh
Metabolic
Altered joint architecture- and acquires more joint damage
What is the presentation of osteoarthritis?
Morning stiffness for approximately 15 minutes
Joint pain - Gradual onset, worse on activity, better with rest
High-use or weight bearing joints - hip, knee, or DIP, PIP , 1st CMC, wrist
(Late) - Night pain, instability , deformity, loss of function
What are the common examination findings for osteoarthritis?
Crepitus - bone surfaces grinding against each other
Effusion, erythema
Squaring (Base of thumb)
Heberden’s and bouchard’s nodes
What does a plain X-ray reveal in osteoarthritis?
Loss of join space (joint space narrowing)
Osteophytes
Subarticular sclerosis
Subchondral cysts
What is the first-line management for osteoarthritis?
oral paracetamol/topical NSAIDs, topical capsaicin (Stepwise analgesia
Oral NSAID + PPI
Opiates
Joint replacement
Intra-articular steroids
Lifestyle - physiotherapy
occupational therapy
What is co-prescribed with NSAIDs?
Proton pump inhibitor
What is rheumatoid arthritis?
Autoimmune, chronic (>6 weeks) and progressive inflammation of synovial lining, tendon sheaths and bursa
What genes are associated with rheumatoid arthritis?
HLA DR4, DR1
How is rheumatoid arthritis diagnosed?
Clinical diagnosis
Symmetrical polyarthritis _ extraarticular manifestations
What is polyarthritis?
> 4 joints
What is the presentation of rheumatoid arthritis?
Pain and stiffness in hands and wrists
- Worst in the morning, resolves over the course of the day
- Fatigue
What examination findings is seen in rheumatoid arthritis?
Swan-neck deformity
Ulnar deformation
Swelling and tenderness
Which joints are commonly affected in rheumatoid arthritis?
Wrist, ankle, MCP, PIP and MTP
What joints are commonly spared in rheumatoid arthritis?
Distal interphalangeal joints
What are the chronic signs seen in rheumatoid arthritis?
Z-deformity of the thumb - hyperextension of the IP joint and fixed flexion and subluxation of MCP joint
Ulnar deviation at the MCP
Radial deviation at the wrist
Swan-neck deformity - DIP is flexed
Boutonniere’s deformity - Permanent flexion of PIP joint and overextension of DIP joint
What are the extra-articular signs in rheumatoid arthritis?
Rheumatoid nodules
-Episcleritis, slceritis
Secondary Sjogren’s/Sicca
- Lymphandenopathy
- Pericarditis
- Carpal tunnel syndrome
- Pulmonary fibrosis/pleuritis/bronchiolitis obliterans
- Tenosynovitis, bursitis
Felty’s syndrome - triad of Rheumatoid arthritis, splenomegaly and neutropenia
What is Felty’s syndrome?
Felty’s syndrome - triad of Rheumatoid arthritis, splenomegaly and neutropenia
What investigations are performed in RH Arth?
Rheumatoid factor - IgM antibody
What is rheumatoid factor?
IgM antibody targeting the Fc portion IgG antibody- immune activation
What is the most sensitive marker for diagnosing rheumatoid arthritis?
Anti-CCP
What indicates aggressive and severe rheumatoid disease?
Positive antibodies and raised inflammatory markers (Associated with worse prognosis)
What are the urgent referral indications in rheumatoid arthritis?
Small joints of hands, feet and multiple joints
Sx >3 months
Persistent synovitis
What is the acute management for rheumatoid arthritis?
Short course steroids for acute flares
What is the management for rheumatoid arthritis?
NSAIDs and COX-2 inhibitors co-prescribed with PPI
DMARDs
Which DMADs are prescribed in rheumatoid arthritis?
Methorexate, Sulfasaazline
Anti-TNFs
Rituximab (Consider TB)
What are the four common forms of seronegative spondyloarthropathies?
Psoriatic arthritis
Enteropathic arthritis
Ankylosing spondylitis
Reactive arthritis
Common factors
Male > female
No Rh factor
HLA-B27
Which gene is implicated in seronegative spondys?
HLA-B27
What skeleton is affected in ankylosing spondylitis?
Axial skeleton
What is ankylosing spondylitis?
Chronic progressive inflammatory arthropathy of axial skeleton
-Peripheral joints, entheses (tendon/ligament attachments) and extra-articular sites
What is the presentation of ankylosing spondylitis?
Pain and stiffness of lower back and hips upon waking
Better on physical activity
Entheses - plantar asciitis
What extra-articular manifestations are present in ankylosing spondylitis?
Anterior uveitis
Apical lung fibrosis
Aortic regurgitation
+Psoriasis, IBD sx
What are the late changes seen in ankylosing spondylitis?
Kyphosis
Loss of lumbar lordosis
Neck extension
What specific tests are performed in ankylosing spondylitis?
Schober’s test - lumbar motility (Point-point reduced distance increase)
Tragus to wall
Stress tests - Gaenslen;s - sarcoiliac joint pain
What radiological investigations are performed in ankylosing spondylitis?
X-ray
MRI
What is revealed in an X-ray for ankylosing spondylitis?
SI joint - symmetrical bilateral sacroiliitis
Subchondral erosions, sclerosis
Bamboo spine
What is reactive arhtritis?
Sterile, seronegative joint inflammation in response to extra-articular infection
Why does reactive arthritis occur?
Initial activation of immune system by microbial antigen stimulates AI reaction affecting skin, eyes and joints
What is Reiter’s syndrome?
Arthritis, urethritis, conjunctivitis
What is the presentation of reactive arthritis?
Painful, swollen, unilateral joint inflammation
Associated with past infective history (Related symptoms)
What are the extra-articular manifestations of reactive arthritis?
Keratoderma blenorrhagicum
Reiter’s
Circinate balanitis - painless ulcers/plaques
Oral ulcers - painless cystitis/prostatitis
What is the presentation of septic arthritis?
Acute monoarthritis
Hot, swollen, erythematous joint with restriction of movement
What is the acute presentation of gout?
Acute mono-arthritis 1st MTP (Podagra)
What is the acute presentation of pseudogout?
Acute monoarthritis
Large joints - knee
Polyarticular (chronic)
What are the causes of septic arthritis?
Caused by current infection
Haematogenous spread of direct inoculation
Staph aureus >30 years
Neisseria gonorrhoea <30 years
What is the most common organism for causing septic arthritis in <30 years?
Neisseria gonorrhoea
What is the most common organism for causing septic arthritis >30 years?
Staph aureus
What factors can precipitate gout?
Trauma, infection
Monosodium urate crystals
- Hyperuricaemia - inceased intake (purine foods), increased production - tumour lysis syndrome or decreased excretion
High alcohol intake
What type of crystals are deposited in pseudogout?
Calcium pyrophosphate crystals
-HyperPTH, hypoPO4, hypoMg, metabolic
What are the risk factors for gout?
Alcohol High purine diet Obesity Male Diuretics
What are the risk factors for pseudogout?
RFs: Elderly, female
What crystals are seen in gout?
Negatively birefringent needle-shaped crystals
What crystals are see in psuedogout?
Positively birefringent rhomboid-shaped crystals
What XR findings are seen in gout?
Rat-bite erosions
What XR findings are seen in pseudogout?
Chondrocalcinosis
What is the management for septic arthritis?
Empirical IV Abx for 2 weeks + 4 weeks oral ABx
-Cover S.aureus and streptococcous
Stop any biologic therapies (12 months of forever for prosthetic joint)
What is the management for acute gout attacks?
NSAIDs
Colchicine (anti-mitotic)
Corticosteroids
What is the prophylactic treatment for gout?
Allopurinol
What is the management for psuedogout?
Intra-articular steroids
NSAIDs or colcichine
What is osteomyelitis?
Infection of bone due to haematogenous spread
- IVDU
- Immunosuppression
- Diabetes
Contiguous spread - cellulitis or localised infection
Direct inoculation - penetrating injury, ulcers, surgery
What is the most common cause of osteomyellitis?
Staph aureus
In patients w sickle cell disease which type of osteomyelitis is common?
Salmonella
What is the presentation of osteomyellitus?
Non-specific pain in affected area Fever Malaise Rigors Ski lesions, sore throat
Localised erythema, swelling and warmth
-Reduced ROM of affected join
Discharge associated with wound/ulcer
What are the investigations for osteymyelltiis?
Bloods - raised WCC, ESR/CRP
MRI - see darkening, periosteal thickening
Bone culture - Causative organism
What is the management for ostemyellits?
High dose IV ABx empirical Abx then adapt to cultured organism
Surgical debridement - biofilm
What is ankylosing spondylitis?
A seronegative chronic inflammatory arthropathy affects preferentially the axial skeleton and large proximal joints
What type of arthritis is associated with ankylosing spondylitis?
Seronegative
Which gene is associated with ankylosing spondylitis?
HLA-B27 gene
Which joints are predominantly affected in ankylosing spondylitis?
Spine and sacroiliac joints
Where does the inflammation begin in ankylosing spondylitis?
At the entheses (where ligaments attach to the vertebral bodies)
Which vertebrae are affected in ankylosing spondylitis?
Lumbar vertebrae
What shape are the vertebral bodies in ankylosing spondylitis?
Squaring
What are syndesmophytes in ankylosing spondylitis?
Bridging the margins between adjacent vertebrae + fusion
What is the long course of ankylosing spondylitis presentation?
Kyphosis, neck hyper-extension and spino-cranial ankyloses
What is the initial presentation of ankylosing spondylitis?
Lower back pain and sacroiliac pain
Disturbed sleep
Progressive loss of spinal movement
Pleuritic chest pain (Due to costovertebral joint involvement)
Heel pain (Due to plantar fasciitis)
Non-specific symptoms - Malaise and fatigue
Blindness due to acute iritis
Pain pattern
- Worse in the morning
- Better with activity
- Worse when resting
Describe the pain profile associated with ankylosing spondylitis
Better with activity
What are the examination features of ankylosing spondylitis?
Hyper-extended neck
Loss of lumbar lordosis
Flexed hips and knees
Reduced range of spinal movement (particularly hip rotation)
Reduced lateral spine flexion
Tenderness over sacroilliac joints
Later stages
- Kyphosis
- Spinal fusion
- Question-mark posture
What are the extra-articular manifestations of ankylosing spondylitis?
Anterior uveitis Apical lung fibrosis Achilles' tendinitis Amyloidosis Aortic regurgitation
What is the Schober’s test?
- Two fingers are placed on the patients back about 10 cm apart.
- The patient is instructed to bend over
- The distance between the two fingers should increase by >5 cm on forward flexion. Reduced movement Suggests ankylosing spondylitis.
What is the first-line investigation for ankylosing spondylitis?
Radiograph - Reveals Vertical syndesmophytes
And Bamboo spine appearance
What additional test should be performed in ankylosing spondylitis?
Lung function tests to assess for mechanical ventilatory impairment due to kyphosis
What is the first-line management for ankylosing spondylitis?
NSAIDs (Naproxen)
- Analgesia
- Intra-articular corticosteroid injection (peripheral joint)
- Sulfasalazine or methotrexate
What DMARDs are used for severe ankylosing spondylitis?
TNF-alpha inhibitors (Adalimumab and etanercept) for severe disease
What is reactive arthritis?
Characterised by sterile arthritis occurring after an extra-articular infection particularly urogenital (e.g., Chlamydia trachomatis) and gastrointestinal (e.g., Salmonella, Shigella, campylobacter).
What urogenital infection is commonly associated with reactive arthritis?
Chlamydia trachomatis
What is the epidemiology of reactive arthritis?
- 20x more common in males
* Age of onset: 20-40 years
What is the presentation of reactive arthritis?
Urethritis
Arthritis, low back pain (Due to sacroiliitis), painful heels and conjunctivitis
Arthritis
- Assymmetrical oligoarthritis
- Affects the lower extremiites
- Sausage shape digits
Circinate Balanitis
- Scaling red patches on the glans
- Painless
Signs of conjunctivitis
-Anterior uveitis- Painful red eye
Keratoderma blennorrhagia
-Brownish-red macules
found on the soles and palms.
What blood investigations are carried out in reactive arthritis?
Bloods • FBC • High ERS and CRP • HLA-B27 testing • ANA and Rheumatoid factor negative
What urine dipstick test would reveal reactive arthritis?
Urine
• Screen for chlamydia trachomatis
What would a plain X-ray reveal in reactive arthritis?
Evidence of asymmetrical sacroiliitis and enthesitis (Especially of the Achilles’ tendon).
What is the first-line management for reactive arthritis?
Symptomatic relief
-NSAID - Naproxen/ibuprofen/indomethacin
Corticosteroid- Prednisolone
Ongoing or chronic reactive arthritis
-Sulfalazine 500mg OD
Define rheumatoid arthritis
A chronic inflammatory systemic disease characterised by symmetrical deforming peripheral polyarthritis and extra-articular manifestations.
What are the common joints affected in rheumatoid arthritis?
• Polyarthritis: Swelling of small joints of the hand and wrists (MCP, PIPs and MTP joints).
Which antibody is associated with rheumatoid arthritis?
Anti-CCP Rheumatoid factor (IgM antibody)
What is the typical presentation of rheumatoid arthritis?
Symmetrical, swollen, painful and stiff small joints of hands and feet
-Morning stiffness
Joint pain -Polyarthritic involvement including large and small joints
Swelling
Morning stiffness >1 hour - improves motility
Impaired function
-Affects peripheral joints symmetrically
systemic symptoms: Fever,fatigue, weight loss, pericarditis, pleurisy
What are the early signs of rheumatoid arthritis?
- Spindling of fingers
- Swelling of MCP and PIP or MTP joints- Symmetrical.
- Warm, tender joints
- Reduction in range of movement
What are the late signs of rheumatoid arthritis?
- Symmetrical deforming arthropathy.
- Radial deviation of the wrist
- Swan-neck deformity1
- Boutonniere deformity2
- Z deformity of the thumb
- Trigger finger (Inability to straighten the finger, tendon nodule papule)
- Tendon rupture
- Wasting of small muscles of the hand
- Palmar erythema.