MSK

Question 1

how do bisphoshonates?

Answer 1

decrease the demineralisation of bones and inhibit osteoclasts activity by reducing recruitment and promoting apoptosis

Question 2

indications of bisphosphatones?

Answer 2

Pain from bone mets
Paget’s disease
hypercalcemia
prevention and treatment of osteoporosis

Question 3

SE of bisphoshphatones?

Answer 3

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

Question 4

balancing Ca/ Vit D/ bisphospatones

Answer 4

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.

Question 5

criteria to stopping bisphosphatones

Answer 5

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

Question 6

Carpal tunnel syndrome
(examination findings)

Answer 6

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

Question 7

Carpal tunnel syndrome
(causes)

Answer 7

idiopathic

pregnancy

oedema e.g. heart failure

lunate fracture

rheumatoid arthritis

Question 8

Carpal tunnel syndrome
(MGT)

Answer 8

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)

Question 9

Frozen shoulder syndrome
(Adhesive capsulitis)

typical features?

Answer 9

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

Question 10

MGT of Frozen shoulder syndrome
(Adhesive capsulitis)

Answer 10

no single intervention has been shown to improve outcome in the long-term

treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids

Question 11

Joint deformities in RA

Answer 11

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.

Question 11

Joint deformities in RA

Answer 11

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.

Question 12

Trigger finger

associations/ features/ management

Answer 12

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

Question 13

Mallet finger
(basketball finger)

Answer 13

related to trauma (tendon tear or stretch)

(incomplete)

Question 14

Dupuytren contracture

Answer 14

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

Question 15

how to check individuals prone to Azathiprine toxicity

Answer 15

thiopurine methyltransferase deficiency (TPMT) before treatment

Question 16

SE of azathioprine

Answer 16

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.

Question 17

Drugs that interact with azathioprine

Answer 17

Allopurinol
so lower doses of azathrioprine should be used

Question 18

Which plasma autoantibody has the highest specificity for Rheumatoid Arthritis?

Answer 18

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%.

Question 19

What is the first line recommended antibody test for patients with suspected rheumatoid arthritis?

Answer 19

Rheumatoid factor (RF)

NICE recommend performing x-rays of the hands and feet of all patients with suspected rheumatoid arthritis.

Question 20

conditions associated with +Ve RF

Answer 20

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

Question 21

MGT of OA

Answer 21

_ 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

Question 22

MGT of osteoporosis following fragility fracture

Answer 22

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