MSK Flashcards
What is osteoarthritis?
- loss of cartilage
- disordered bone repair
- most common arthritis
What xray findings do you get with osteoarthritis?
LOSS
- loss of joint space
- osteophytes formation
- subchondral sclerosis
- subchondral cysts
Risk factors for osteoarthritis
- female
- obesity
Presentation of osteoarthritis
- mainly in large weight-bearing joints
- joint pain, worse with movement
- stiffness on rest
- limited joint movement
- bone swelling in fingers
What are the two types of bone swelling in fingers?
- Heberden = DIP
- Bouchard = PIP
Treatment for osteoarthritis
Biological
- paracetamol → work up analgesics ladder
- cortisol injections
- joint replacement
Social
- weight loss → required before surgery
- lifestyle advice
What is Rheumatoid Arthritis?
- autoimmune disease
- symmetrical, deforming, peripheral polyarthritis
- female 3x > male
What xray findings do you get with RA?
JOBS
- joint space loss
- osteopenia
- bone erosion
- soft tissue swelling
Presentation of RA
- pain in affected joints
- deformities of hand
- morning stiffness
- systemic presentations
Hand deformities in RA
- ulnar deviation
- swan neck
- boutonniere deformity
Systemic presentations in RA
- scleritis
- pleural effusions
- pericarditis
Diagnostic criteria for RA
RF RISES
- rheumatoid factor positive
- finger/hand/wrist involvement
- rheumatoid nodules present
- involvement of ≥ 3 joints
- stiffness in the morning for > 1hr
- erosions seen on xray
- symmetrical movement
> 4 symptoms for > 6 weeks
Investigations for RA
bloods
- RF = highly sensitive
- anti-CCP = more specific
- ESR
- xray
Treatment for RA
- methotrexate with folate
- DMARDs
- steroids
- biologics
- NSAIDs/opioids for pain management
What biologics are used to treat RA?
- TNFα blockers = infliximab
- B cell inhibitors = rituximab
What is felty syndrome?
- RA
- splenomegaly
- granulocytopenia
What is osteoporosis?
- decreased bone mass/density
- micro-architectural deterioration
- increased bone fragility
- increased susceptibilty to fracture
Causes of osteoporosis
- Cushing’s, PTH
- myeloma
- malabsorption
- steroids
Presentation of osteoporosis
- not clinically apparent until a fracture occurs
- risk assessment = FRAX and Qfracture
- DEXA scan → T scan
Treatment for osteoporosis
- bisphosphonates → oral alendronate/IV zoledronate
- mAbs → denosumab
- HRT
- lifestyle advice → quit smoking and alcohol
- Ca2+ and vitamin D
What is lupus
- Systemic Lupus Erythematosus
- inflammatory multisystem autoimmune disorder
- arthralgia and rashes
- type III hypersensitivity
- female 9x > male
- peak in 20-40yrcarditis, pls
Presentation of lupus
- joint pain
- malar, discoid, photosensitive rash
- serositis
- glomerulonephritis with proteinuria
- depression/psychosis
What serositis can be seen in lupus?
- scleritis
- pericarditis
- pleuritis
- oral ulcers
Diagnosis of lupus
- bloods → ESR raised, CRP normal
- ANA
- Anti-dsDNA
- serum C3 and C4
Treatment for lupus
- steroids
- hydroxychloroquine
- methotrexate
What is hyperuricaemia?
- high levels of uric acid
- > 420 M, >360 F
- asymptomatic
- 1 in 5 will develop gout
What is pseudogout?
- buildup of calcium pyrophosphate
- birefringent +ve, rhomboid
What is gout?
- buildup of monosodium urate
- birefringent -ve, needles
How does the buildup of uric acid lead to inflammation?
- uric acid builds up
- precipitates as uric acid crystals
- crystals deposit in joint spaces
- inflammation
Stages of gout progression
- high uric acid levels → builds up in blood → crystals form around joints
- acute gout → symptoms start → painful gout attack
- intercritical gout → periods of remission between gout attacks
- chronic gout → gout pain frequent and tophi form in joints
Signs and symptoms of gout
- red hot joint → painful, swollen
- acute onset
- most common joint = big toe
- also affects midfoot, ankle, knee, wrist
Investigations for gout
- bloods
- U&E and eGFR for renal function
- uric acid levels, now and 4-6 weeks later → confirm hyperuricaemia
GOLD STANDARD = joint aspiration to test for urate crystals
Management for acute gout
- NSAIDs or colchicine
- intra-articular steroid injection
lifestyle advice
Management of chronic gout
- allopurinol → inhibits xanthine oxidase
- febuxostat
consider coprescribing clolchicine with allopurinol for 6 months
Signs and symptoms of septic arthritis
LIFE THREATENING
- red hot swollen joints
- cold peripheries
- confusion
- high temperature
Causes and risks of septic arthritis
- IVDU
- immunocompromised
- intra-articular joints
- common bugs
What bugs cause septic arthritis?
- S.aureus
- Neisseria gonorrhoea
- gram -ve bacteria eg E.coli
- haemophilius influenza (kids)
What is the sepsis 6?
- give O2 to keep stats above 94%
- take blood cultures → CSF, urine, sputum
- give IV antibiotics
- give a fluid challenge
- measure lactate
- measure urine output
What antibiotics can be given to treat septic arthritis?
- flucloxacillin
- if penicillin allergic → clindamycin
- if MRSA → vancomycin
- if gonococcal arthritis or gram -ve infection → cefotaxime
Treatment for septic arthritis
Sepsis 6
What is osteomyelitis?
infection of the bone marrow
What are the 3 ways of entry for osteomyelitis?
- hematogenously
- open wound
- contiguously → skin into blood
Risk factors for osteomyelitis
- penetration injury
- IVDU
- diabetes/CKD
- HIV
- sickle cell disease
- RA
- children → URT/varicella infection
Presentation of osteomyelitis
- limp or reluctance to weight bear (kids)
- non-specific pain at site of infection
- low grade fever
- malaise and fatigue
Investigations for osteomyelitis
- FBC → raised WCC, ESR, CRP
- xray
- blood cultures
Management for osteomyelitis
- antibiotics
- supportive care
- surgery
What are the 3 seronegative spondyloarthropathies?
- ankylosing spondylitis
- reactive arthritis
- psoriatic arthritis
How do seronegative spondyloarthropathies present?
SPINACHEE
- sausage digits
- psoriasis
- inflammatory back pain
- NSAIDs (good response)
- Arthritis
- Crohn’s disease
- HLA B27
- Eye → uveitis
- enthesitis
What is ankylosing spondylitis?
- inflammation of sacroiliac joints
- loss of spinal movements
Investigations for ankylosing spondylitis
- bloods = HLA B27
- xray
Xray findings for ankylosing spondylitis
- eroded and sclerotic sacroiliac joints
- unclear margin between rims
- bone spurs aka syndesmophytes
- bamboo spine due to fusion
Treatment for ankylosing spondylitis
- NSAIDs
- physiotherapy
- steroid injections
- DMARDs → methotrexate, sulfasalazine
- TNF inhibitor or mAb → etanercept, infliximab, adalimumab
- ustekinumab = last line
Signs and symptoms of psoriatic arthritis
- painful swollen stiff joints
- psoriatic plaques
- dactylis
- telescopic fingers → pencil in cup on xray
occurs in 10-40% of people with psoriasis
Treatment for psoriatic arthritis
same as ankylosing spondylitis
What causes reactive arthritis?
- mainly due to infection
- think about if someone has an active sexual history
Signs and symptoms of reactive arthritis
- can’t see = uveitis
- can’t pee = urethritis
- can’t climb a tree = enthesitis
- keratoma blennorhagica
- circinate balantis
Investigations for reactive arthritis
- bloods = inflammatory markers
- imaging to determine extent of damage from enthesitis
What inflammatory markers can you see in reactive arthritis bloods?
- ESR
- CRP
- ANA
- rheumatoid factor
Treatment for reactive arthritis
- NSAIDs
- corticosteroids
- DMARDs → chronic arthritis
What is vasculitis?
group of autoimmune diseases that cause inflammation of the blood vessel walls
General constitutional symptoms of vasculitis
- malaise
- fatigue
- weight loss
- low grade fever
What is giant cell arteritis
- large vessel vasculitis
- affects aorta and/or its major branches eg carotid and vertebral arteries
Risk factors for giant cell arteritis
- almost exclusive in >50yrs
- North European
- females 2-3x > males
- history of polymyalgia rheumatica
Presentation of giant cell arteritis
- headache → new onset, typically unilateral over temporal area
- scalp tenderness
- jaw claudication
- visual disturbances
Investigations for giant cell arteritis
- increased ESR and/or CRP
- halo sign on US of temporal/axillary artery
GOLD STANDARD = temporal artery biopsy → giant cells, granulomatous inflammation
Management of giant cell arteritis
high dose glucocorticoids ASAP → prednisolone
Complications of giant cell arteritis
- blindess
- irreversible neuropathy
What are the common primary bone tumours?
- chondrosarcoma
- osteosarcoma
- Ewing sarcoma
Risk factors of primary bone tumours
- previous radiotherapy
- previous cancer
- Paget’s disease
- benign bone lesions
- male>female
Presentation of primary bone tumours
- common sites → long bones
- bone pain
- atypical bony or soft tissue swelling/masses
- pathological fractures
- easy brusiing
- mobility issues → unexplained limp, joint stiffness, reduced ROM
- inflammation and tenderness over bone
- systemic symptoms
What is bone pain like in primary bone tumours?
- worse at night
- constant or intermittent
- resistant to analgesia
- may increase in intensity
Investigations for primary bone tumours
- xray
GOLD STANDARD = biopsy
bloods
- FBC
- ESR
- ALP
- lactate dehydrogenase
- Ca2+
- U&E
CT chest/abdomen/pelvis
Management of primary bone tumours
- chemo
- radiotherapy
- surgery → limb sparing/amputation
What is multiple myeloma?
neoplastic proliferation of bone marrow plasma cells
Pathophysiology of multiple myeloma
- malignant plasma cells produce excess immunoglobulin
- multiple organ dysfunction esp kidneys
- 2/3 IgG, 1/3 IgA
Presentation of multiple myeloma
OLD CRAB
- old age
- calcium elevated → bones, stones, groans, moans
- renal impairment
- anaemia
- bone lytic lesions → bone/back pain
Investigations for multiple myeloma
- FBC → normocytic normochromic anaemia
- films → rouleaux formation (RBC aggregations)
- U&Es → raised Ca, urea, creatinine
- haematinics → raised ESR
- xray → pepper-pot skull, vertebral collapse, fractures
- serum/urine electrophoresis → bence jones protein band
- bone marrow biopsy → raised plasma cells
Diagnostic criteria for multiple myeloma
- monoclonal protein band in serum/urine
- raised plasma cells on BM biopsy
- end organ damage → hypercalcaemia, renal failure, anaemia
- bone lesions on skeletal survey
Treatment for multiple myeloma
- analgesia → bone pain
- bisphosphonates → reduce fractures and bone pain
- local radiotherapy → reduce focal disease
- transfusion → correct anaemia
- fluids/dialysis → renal failure
- Abs for infections
- chemo
What is osteomalacia?
- poor bone mineralisation leads to soft bones
- lack of Ca2+ in adults
What is rickets?
inadequate mineralisation of the bone and epiphyseal cartilage in growing skeleton of children
Pathophysiology of osteomalacia/rickets
- Ca2+ deficiency
- usually due to vitD deficiency
Presentation of osteomalacia
- widespread bone pain and tenderness → dull ache, worse on weight bearing
- fractures → NOF
- muscle weakness → waddling gait, difficulty with stairs
- gradual onset, persistent fatigue
Presentation of rickets
- knock-kneed, bow-legged
- tender swollen joints
- growth retardation
- bone and joint pain
- dental deformities
- enlargement of end of ribs → rachitic rosary
Diagnosis of osteomalacia/rickets
- xray → loss of cortical bone → defective mineralisation
- bloods → low Ca2+ and phosphate
- bone biopsies → incomplete mineralisation
Management of osteomalacia/rickets
vitamin D supplements
- rapid mineralisation of bone
- resolution of symptoms
- malabsorption → IM calcitrol
- renal disease → alfacalcidol
What is Paget’s disease?
disorder of bone turnover
Pathophysiology of Paget’s disease
- excessive bone turnover (formation and resorption)
- due to excessive osteoblast and osteoclast activity
- leads to patchy areas os high density (sclerosis) and low density (lysis)
- enlarged and misshapen bones → risk of fracture
Presentation of Paget’s disease
- bone pain
- bone deformity
- fractures
- hearing loss → if bones of ear affected
Investigations for Paget’s disease
xray
- bone enlargement and deformity
- osteoporosis circumscripta → well defined osteolytic lesions
- cotton wool appearance of skull → poorly defined areas of sclerosis and lysis
- v-shaped defects in long bones
bloods
- raised ALP
- normal Ca2+ and phosphate
Management of Paget’s disease
- bisphosphonates
- NSAIDs for bone pain
- Ca2+ and vitD supplements
Complications of Paget’s disease
- osteosarcoma
- spinal stenosis and cord compression
Causes of osteomalacia
- malnutrition
- drug induced
- defective 1-alpha hydroxylation
- liver disease
Osteosarcoma
- primary bone malignancy
- common in kids
- metaphysis of long bones
- associated with Paget’s disease
Ewing sarcoma
- v rare
- from mesenchymal cells
- originate from long bones
Osteochondroma
- bening
- very common in males under 25
- overproduction of bone → deposits on metaphysis
What are common sites of secondary bone tumours?
LEAD KETTLE PBKTL
- prostate
- breast
- kidneys
- thyroid
- lungs
Investigations for secondary bone tumour
bloods
- FBC
- U&E
- ALP
- PSA
imaging
- xray → lytic lesions
- CT scans → metastases
Management of secondary bone tumours
- pain management
- bisphosphonates
- radiotherapy
- chemo
What is fibromyalgia?
- chronic pain syndrome
- widespread over body → 11 out of 18 points
- > 3 months
- non-nociceptive pain
- no organic cause
Pathophysiology of fibromyalgia
- unknown
- possibly pain perception or hyper excitability of pain fibres
Presentation of fibromyalgia
- fatigue
- brain fog
- pain
- morning stiffness
Investigations for fibromyalgia
exclude all other differential with bloods and imaging
Management of fibromyalgia
- exercise
- relaxation
- neuropathic pain relief → TCA, gabapentin, pregabalin
- opiates
- CBT
Complications of fibromyalgia
- can really affect QoL
- anxiety, depression, insomnia
- opiate addiction
Pathophysiology of Sjogren’s syndrome
- chronic inflammatory autoimmune disorder
- destruction of epithelial exocrine glands esp lacrimal and salivary glands
Signs and symptoms of Sjogren’s
- dry eyes, mouth, vagina (mucous membranes)
- parotid gland enlargement
- joint pain
- Raynauds
- systemic features
What conditions is Sjogren’s associated with?
- RA
- SLE
- PBC
- scleroderma
Risk factors of Sjogren’s
- 1st degree relative = 7x increased risk
- female
- > 40
Investigations for Sjogren’s
Schirmer tear test
- tears travelling <10mm is significant
Rose bengal staining and slit lamp exam
RFs, ANA, anti-Ro, anti-La
Management of Sjogren’s
- artificial tears/saliva, vaginal lubricant
- humidifier, eye drops, mouth wash
- NSAIDs, hydroxychloroquine (halts progression)
- M3 agonist → pilocarpine
Complications of Sjogren’s
- conjunctivitis
- corneal ulcers
- dental cavities
- candida infections
- vaginal candidasis
- sexual dysfunction
What is Raynauds phenomenon
- intermittent spasm in arteries supplying fingers and toes
- usually precipitated by cold and relieved by heat
- can also be caused by vibrational tools, smoking, beta blockers
- associated with SLE, RA, systemic sclerosis, dermatomyositis
Treatment for Raynauds phenomenon
- protect hands
- stop smoking
- CCBs
What is systemic sclerosis?
- multisystem autoimmune disease
- increased fibroblast activity
- abnormal growth of connective tissue
- 2 types → limited and diffuse
Signs and symptoms of limited systemic sclerosis
- skin involvement limited to hands, face, feet and forearms
- characteristic beak like nose and small mouth
- microstomia
Signs and symptoms of diffuse systemic sclerosis
- skin changes develop more rapidly and widespread
- Raynaud’s phenomenon coincident with skin involvement
- GI, renal, lung involvement
Diagnosis of systemic sclerosis
- ANAs
- anaemia if renal involvement
- limited → ACAs
- diffuse → topoisomerase, anti-scl 70
Treatment for systemic sclerosis
- avoid smoking
- handwarmers
- GI → PPIs, Abs
- renal → ACEi
- pulmonary fibrosis → cyclophosphamide
What is polymyositis?
- muscle disorder of unknown aetiology
- inflammation and necrosis of skeletal muscle fibres
What is dermatomyositis?
polymyositis and skin involvement
Signs and symptoms of polymyositis
- symmetrical progressive muscle weakness and wasting
- affect proximal muscles of shoulder and pelvic girdle
Signs and symptoms of dermatomyositis
- heliotrope discolouration of eyelids
- scaly erythematous plaques over knuckles
- arthralgia, dysphagia
- Raynaud’s
Diagnosis of poly/dermato myositis
muscle biopsy
bloods → raised
- serum creatine kinase
- aminotransferases
- lactate dehydrogenase
- aldolase
immunology
- ANA
- anti jo1
- anti mi2
Treatment of poly/dermato myositis
- oral prednisolone
- stronger immunosuppressants
- symptomatic treatment of skin disease
What is antiphospholipid syndrome?
antibody mediated acquired thrombophilia
Risk factors for antiphospholipid syndrome
- diabetes
- female
- HTN
- obesity
- SLE
- oestrogen therapy for menopause
Presentation of antiphospholipid syndrome
- thrombosis
- recurrent miscarriages
- Livedo reticularis
- thrombocytopaenia
Investigations for anitphospholipid syndrome
- history of thrombosis/pregnancy complications
- antibody screen
Treatment of antiphospholipid syndrome
- long term warfarin
- LMW heparin and aspirin if pregnant
- lifestyles changes to avoid CVS issues
Complications
- VTE
- arterial thrombosis
- pregnancy complications
What is the most common type of back pain?
mechanical
Differential diagnoses for back pain
- congenital
- iatrogenic
- infection → osteomyelitis
- trauma → fracture
- malignancy → multiple myeloma, metastases
- lifestyle → posture/overuse
- inflammatoin
What types of inflammation can cause back pain
- HLA B27
- osteoporosis
- osteoarthritis
- pyelonephritis
What are the red flags for lower back pain
- cauda equina syndrome
- cancer of the spine
- spinal fracture → trauma/osteoporotic collapse
- spinal infection
Investigations for back pain
bloods
- inflammatory markers
- FBC → anaemia, WBC
- ALP levels
imaging
- DEXA scan
- MRI
Treatment for mechanical back pain
- analgesia ladder
- lifestyle advice
- physiotherapy
What is the analgesia ladder?
- PCM
- NSAIDs
- weak opiates
- strong opiates
- neuropathic pain treatment → gabapentin/tricyclic
Pathophysiology of granulomatosis with polyangiitis
- small vessel vasculitis
- affects respiratory tracts and kidney
- common in late teenage years/early adulthood
Presentation of granulomatosis with polyangiitis
- saddle-shaped nose
- epistaxis
- crusty nasal/ear secretions → hearing loss
- sinusitis
- cough, wheeze, haemoptysis
Investigations for granulomatosis with polyangiitis
- high eosinophils
- histology → granulomas
- presence of c-ANCA
Management of granulomatosis with polyangiitis
- nasal corticosteroid
- cyclophosphamide
complications of granulomatosis → glomerulonephritis
Pathophysiology of Marfan syndrome
- autosomal dominant
- affects gene involved in creating fibrillin
Presentation of Marfan syndrome
- tall stature
- long limbs
- long fingers
- hypermobility
- high arch palate
- pectus carinatum
Investigations for Marfan syndrome
- physical exam
- Ghent criteria
Management of Marfan syndrome
- avoid intense exercise/caffeine
- beta blockers/ARBs
- annual echo
Complications of Marfan sybdrome
- mitral/aortic valve prolapse with regurgitation
- aortic aneurysms
- lens dislocations
Pathophysiology of Ehlers-Danlos syndrome
- group of inherited connective tissue disorders
- faulty collagen
- varied presentation
Presentation of Ehlers-Danlos
- joint hypermobility
- easily stretched skin
- easy bruising
- chronic joint pain
- reoccurring dislocations
Investigations for Ehlers-Danlos
Beighton score → assesses hypermobility
Management of Ehlers-Danlos
- physiotherapy
- OT
- psychological support → chronic condition, pain
Complications of Ehlers-Danlos
- hernias
- prolapse
- aortic root dilation
- joint pain
- abnormal wound healing
