MSK Flashcards
how do bisphoshonates?
decrease the demineralisation of bones and inhibit osteoclasts activity by reducing recruitment and promoting apoptosis
indications of bisphosphatones?
Pain from bone mets
Paget’s disease
hypercalcemia
prevention and treatment of osteoporosis
SE of bisphoshphatones?
oesophagitis, oesophageal ulcers (especially alendronate)
osteonecrosis of the jaw
increased risk of atypical stress fractures of the proximal femoral shaft in patients taking alendronate
acute phase response: fever, myalgia and arthralgia may occur following administration
hypocalcaemia: due to reduced calcium efflux from bone. Usually clinically unimportant
balancing Ca/ Vit D/ bisphospatones
Hypocalcemia/vitamin D deficiency should be corrected before giving bisphosphonates. However, when starting bisphosphonate treatment for osteoporosis, calcium should only be prescribed if dietary intake is inadequate. Vitamin D supplements are normally given.
criteria to stopping bisphosphatones
Some authorities recommend stopping bisphosphonates at 5 years if the following apply:
patient is < 75-years-old
femoral neck T-score of > -2.5
low risk according to FRAX/NOGG
Carpal tunnel syndrome
(examination findings)
weakness of thumb abduction (abductor pollicis brevis)
wasting of thenar eminence (NOT hypothenar)
Tinel’s sign: tapping causes paraesthesia
Phalen’s sign: flexion of wrist causes symptoms
Carpal tunnel syndrome
(causes)
idiopathic
pregnancy
oedema e.g. heart failure
lunate fracture
rheumatoid arthritis
Carpal tunnel syndrome
(MGT)
Mild- moderate
6-week trial of conservative treatments
* corticosteroid injection
* wrist splints at night
If symptoms severe, or persist with conservative management then for surgical decompression (flexor retinaculum division)
Frozen shoulder syndrome
(Adhesive capsulitis)
typical features?
symptoms usually develop over days
up to 20% of diabetics may have an episode of frozen shoulder
external rotation is affected more than internal rotation or abduction
both active and passive movement is affected
patients typically have a painful freezing phase, an adhesive phase and a recovery phase
bilateral in up to 20% of patients
the episode typically lasts between 6 months and 2 years
MGT of Frozen shoulder syndrome
(Adhesive capsulitis)
no single intervention has been shown to improve outcome in the long-term
treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids
Joint deformities in RA
In many cases, it is now possible to prevent these deformities by using disease-modifying anti-rheumatic drugs (DMARDs) and biologic drugs before the loss of bone (bony erosions) occurs.
Boutonniere deformity: The middle finger joint bends toward the palm while the outer finger joint may bend opposite the palm.
Swan-neck deformity: The base of the finger and the outermost joint bend, while the middle joint straightens.
Hitchhiker’s thumb: The thumb flexes at the metacarpophalangeal joint and hyperextends at the interphalangeal joint below your thumb nail. It is also called Z-shaped deformity of the thumb.
Claw toe deformity: The toes are either bent upward from the joints at the ball of the foot, downward at the middle joints, or downward at the top toe joints and curl under the foot.
Joint deformities in RA
In many cases, it is now possible to prevent these deformities by using disease-modifying anti-rheumatic drugs (DMARDs) and biologic drugs before the loss of bone (bony erosions) occurs.
Boutonniere deformity: The middle finger joint bends toward the palm while the outer finger joint may bend opposite the palm.
Swan-neck deformity: The base of the finger and the outermost joint bend, while the middle joint straightens.
Hitchhiker’s thumb: The thumb flexes at the metacarpophalangeal joint and hyperextends at the interphalangeal joint below your thumb nail. It is also called Z-shaped deformity of the thumb.
Claw toe deformity: The toes are either bent upward from the joints at the ball of the foot, downward at the middle joints, or downward at the top toe joints and curl under the foot.
Trigger finger
associations/ features/ management
Associated with abnormal flexion of the digits
more common in women
associated with RA and DM
Features
more common in the thumb, middle, or ring finger
initially stiffness and snapping (‘trigger’) when extending a flexed digit
a nodule may be felt at the base of the affected finger
MGT
steroid injection is successful in the majority of patients.
A finger splint may be applied afterwards
surgery should be reserved for patients who have not responded to steroid injections
Mallet finger
(basketball finger)
related to trauma (tendon tear or stretch)
(incomplete)
Dupuytren contracture
can affect one or more fingers (the ring finger and little finger are the fingers most commonly affected)
more common in older men with (60-70% +ve family history)
causes include
- manual labour
- phenytoin treatment
- alcoholic liver disease
- diabetes mellitus
- trauma to the hand
Rx consider surgical management when hand can not be placed flat on the table
how to check individuals prone to Azathiprine toxicity
thiopurine methyltransferase deficiency (TPMT) before treatment
SE of azathioprine
bone marrow depression
consider a full blood count if infection/bleeding occurs
nausea/vomiting
pancreatitis
increased risk of non-melanoma skin cancer
Azathioprine is generally considered safe to use in pregnancy.
Drugs that interact with azathioprine
Allopurinol
so lower doses of azathrioprine should be used
Which plasma autoantibody has the highest specificity for Rheumatoid Arthritis?
anti-CCP antibodies
Anti-cyclic citrullinated peptide antibody may be detectable up to 10 years before the development of rheumatoid arthritis. It has a key role in the diagnosis of rheumatoid arthritis, allowing early detection of patients suitable for aggressive anti-TNF therapy. It has a sensitivity similar to rheumatoid factor (around 70%) with a much higher specificity of 90-95%.
What is the first line recommended antibody test for patients with suspected rheumatoid arthritis?
Rheumatoid factor (RF)
NICE recommend performing x-rays of the hands and feet of all patients with suspected rheumatoid arthritis.
conditions associated with +Ve RF
Felty’s syndrome (around 100%)
Sjogren’s syndrome (around 50%)
infective endocarditis (around 50%)
SLE (= 20-30%)
systemic sclerosis (= 30%)
general population (= 5%)
rarely: TB, HBV, EBV, leprosy
MGT of OA
_ wt loss adv/ local muscle strengthening exercises
1st line
Paracetamol+ topical steroids (if hand/knee)
2nd line
NSAIDs/COX-2 inhibitors, opioids, capsaicin cream and intra-articular corticosteroids.
A proton pump inhibitor should be co-prescribed with NSAIDs and COX-2 inhibitors.
These drugs should be avoided if the patient takes aspirin
non-pharmacological treatment options include supports and braces, TENS and shock-absorbing insoles or shoes
if conservative methods fail then refer for consideration of joint replacement
MGT of osteoporosis following fragility fracture
MGT depends on age
if age is 75 or more
–> treat osteoporosis with oral bisphosphonate without a DEXA scan
if age is under 75
then arranged for a DEXA scan and use FRAX assessment to determine ongoing fracture risk
