MSK Flashcards
what is the treatment for ankylosing spondylitis?
- NSAIDs and physiotherapy
- steroids during flares
- anti-TNF e.g. infliximab
first line appropriate management for septic arthritis?
aspirate the joint and send blood cultures, then immediate antibiotic treatment following determination of causative organism
what features would be seen on an XR of osteoarthritis?
LOSS of joint space, Osteophytes, Subchondral sclerosis, Subchondral cysts
what is the most specific investigation for RA?
anti-citrullinated peptide anti body (anti-CCP)
what is the drug colchicine used for?
reduces inflammatory responses e.g. acute gout
what is the drug allopurinol used for?
preventative gout drugs - long term and should not be given in a flare up as it can further exacerbate the joint
What is the mechanism of action for bisphosphonates?
Inhibit bone resorption through the inhibition of enzyme (Farnesyl Pyrophosphate synthase) which reduces osteoclast activity
what is the first line treatment for osteoporosis?
alendronic acid (oral bisphosphonate) and AdCal (vit D and calcium supplement)
what is the second line treatment for osteoporosis?
addition of denosumab
- monoclonal antibody which binds to RANK ligand, blocking osteoclast maturation/function/survival, thus reducing bone resorption
list 5 risk factors for septic arthritis
- PMH of other joint disease (e.g. RA)
- > 80 years old
- IVDU
- diabetes mellitus
- recent joint surgery
- penetrating trauma
- prosthetic joint
- recent intra-articular steroid injections
which primary cancers metastasise to bone?
breast, lung, kidney, thyroid, prostate
which antibody is most specific for SLE?
anti-dsDNA
which antibody is most sensitive for SLE?
antinuclear antibody (ANA)
which class of drugs is the first line medication for osteoporosis?
bisphosphonates (e.g. allendronic acid)
how should the first line medication for osteoporosis be taken?
allendronic acid should be taken once a week on an empty stomach and the patient should remain upright for at least 30mins following
which joints do Heberden’s nodes occur?
distal interphalangeal joints
which joints do Bouchard’s nodes occur?
proximal interphalangeal joints
name 4 characteristics of the hands in rheumatoid arthritis
- swan neck deformity
- Boutonniere deformity
- ulnar deviation
- “Z-thumb”
what is the Boutonniere deformity?
finger flexed at PIP, hyperextended at DIP, seen in RA
what is the treatment for acute gout?
high dose NSAIDs and corticosteroids, e.g. colchicine
describe the 3 phases of pathophysiology of Paget’s disease
- lytic phase: excessive osteoclastic resorption
- mixed phase: excessive resorption and diagnosed bone formation
- blastic (latent) phase: osteoblasts lay down excess disorganised, weak bone
blood results of Paget’s?
everything normal except raised ALP
give 4 complications of Paget’s disease
- skull thickening
- osteosarcoma
- fractures
- tibial bowing
- deafness
- high output cardiac failure
first line treatment for management of Paget’s?
bisphosphonates (e.g. alendronic acid)
proper term for temporal arthritis?
chronic granulomatous large vessel vasculitis, mainly affecting carotid artery and its branches
first line of action for large vessel vasculitis when presenting with vision loss and why?
urgent, high dose corticosteroids to prevent further blindness (due to lack of ophthalmic artery blood flow)
give the 4 diagnostic criteria for large vessel vasculitis (temporal)
- > 50 years
- temporal artery abnormality (e.g. tender/decreased pulse)
- abnormal biopsy
- elevated ESR (> 50mm/hr)
what condition associated with large cell vasculitis can cause stiffness in muscles in shoulder area and hips?
polymyalgia rheumatica
what type of hypersensitivity reaction is systemic lupus erythematosus?
type III
give 6 signs of SLE
- discoid rash
- pleuritis
- peritonitis
- myocarditis
- oral / mucosal ulcers
- alopecia
- lupus nephritis
- photosensitivity
- anaemia
- migraines
- seizures
what marker is used to monitor SLE?
ESR
how do you treat arthralgia / skin symptoms associated with SLE?
hydroxychloroquine (+- NSAIDs +- corticosteroids)
list some presentations of antiphospholipid syndrome
- recurrent miscarriages
- recurrent DVTs
- PEs
- livedo reticularis: blotchy pattern on skin
what would blood results show for someone with antiphospholipid syndrome?
prolonged APTT
give 3 antibodies associated with antiphospholipid syndrome
lupus anticoag, anti-cardiolipin, anti-beta2GP1
antiphospholipid syndrome could give a false positive result for which condition?
syphilis - due to anti-cardiolipin Ab
most common age and gender for fibromyalgia?
female; 30-60y
what four categories must be considered when presented with “back pain”?
- symptoms associated with cauda equina
- symptoms of spinal fracture
- cancer red flags
- symptoms of infection
2 risk factors for osteomalacia?
- decreased sun exposure (less vit D activation)
- decreased dietary vit D (less available for bone mineralisation)
which reflex is lost with a nerve root lesion at s1?
ankle jerk
list 5 presentations of cauda equina syndrome
- bilateral leg neuropathy
- new urinary / faecal retentions and/or incontinence
- perianal or perineal sensory loss
- poor anal tone PR
list 5 presentations of spinal fracture
- sudden onset
- high impact trauma
- structural deformity
- point tenderness over vertebral body
what condition does Shober’s test help diagnose?
ankylosing spondylitis
most common cause of osteomyelitis?
staph aureus EXCEPT in patients with sickle cell disease, otherwise salmonella
what would Ewing’s sarcoma show on an XR?
onion skin appearance, lytic bone lesions
what would an osteosarcoma show on an XR?
“sunray spiculation”, Codman’s triangle
XR of rheumatoid arthritis?
LESS:
- Loss of joint space
- Erosions
- Soft tissue swelling
- Soft bones (osteopenia)
risk factors for osteoporosis? (hint: SHATTERED)
- Steroids
- Hyperthyroid / Hyperparathyroid
- Alcohol / tobacco
- Thin - low BMI
- Testosterone
- Early menopause
- Renal / liver failure
- Erosive / inflammatory bone disease
- Dietary Ca2+ decrease / DMT1
is osteoarthritis symmetrical or asymmetrical?
asymmetrical
common presentations of Paget’s disease in a q?
hearing loss, pelvic pain, raised ALP
4 common presentations of fibromyalgia?
“pain all over”, headaches, poor concentration, sleep disturbances
features of cauda equina syndrome?
- can be progressive
- bilateral sciatica
- perianal or perineal sensory loss
- decreased anal tone on PR
- new urinary / faecal retentions / incontinence
list 4 causes of osteomalacia
- vit D deficiency
- renal failure
- inheritance
- liver disease
what is the first line treatment for neuropathic pain?
amitriptyline
Which is the genetic component most associated with ankylosing spondylitis?
HLA-B27
Which medication can cause recurrence of gout?
thiazide diuretics increase urate reabsorption in the proximal tubules, predisposing those to gout
which nerve root is responsible for the knee jerk reflex?
L4
what 2 infections are most likely to lead to reactive arthritis?
chlamydia and campylobacter jejuni
gram negative rod-shaped microorganisms that cause septic arthritis in IVDU?
pseudomonas aeruginosa
what does the joint pain presentation typically look like in reactive arthritis?
symmetrical and polyarticular
common presentations of reactive arthritis in a q?
- dactylitis: “sausage fingers” (inflammatory condition associated with spondyloarthropathies)
- DIPJ involvement
- presence of psoriasis or a 1st degree relative with
XR of pseudogout?
chondrocalcinosis -> calcification parallel to articular surfaces
Which antibody in the typical screen used in the diagnosis of Sjogren’s syndrome is most specific?
anti-La
is minimal change disease seen more commonly in adults or children?
children
why is methotrexate teratogenic?
it is a folic acid inhibitor -> crucial in neurodevelopment so inhibition will cause a miscarriage
which nerve is responsible for wrist drop and Saturday night palsy?
radial nerve
describe the crystals in pseudogout
positively birefringent rhomboid-shaped crystals
what is a normal DEXA T score?
-1 to +1
what is an osteopenic DEXA T score?
-1 to -2.5
what is an osteoporotic DEXA T score?
< -2.5 (severely: < -2.5 AND a known pathological fracture)
Name 3 genes associated with an increased risk of SLE
- HLA B8
- HLA DR2
- HLA DR3
Name 4 features of SLE that are required to make a clinical diagnosis
4 of … (remember as ‘A RASH POINTS AN MD’)
- Arthritis
- Renal disorder
- ANA+
- Serositis
- Haematological disorder
- Photosensitivity
- Oral ulcers
- Immunological disorder
- Neurological disorder
- Malar rash
- Discoid rash
What are 2 lifestyle changes that can be performed by the patient to reduce symptoms in SLE?
- Decrease sunlight exposure
- Wear high factor sunblock
- Decrease cardiovascular risk factors (Obesity, Smoking, Exercise, Cholesterol)
What medications should be given for an acute attack of SLE and what route should they be given?
IV cyclophosphamide and prednisolone
What causes the articular cartilage damage in osteoarthritis?
Apoptosis of chondrocytes leads to decreased cartilage production/increased cartilage breakdown 🡪 loss of cartilage, this causes clefts in the articular surface.
Name 2 joints that are commonly affected in Osteoarthritis
Interphalangeal joints
- Carpometacarpal joints
- Metatarsophalangeal joints
- Vertebra
- Hips
- Knees
Give 2 surgical treatment options for Osteoarthritis
- Arthroscopy / Arthroplasty
- Osteotomy
- Fusion
Give 3 characteristics of osteoarthritis that can be used to differentiate between rheumatoid arthritis.
- Pattern of joint involvement / Asymmetrical joints affected
- Absence of systemic features
- Morning stiffness <30mins
Give 3 risk factors for osteoarthritis.
- Joint hypermobility
- Insufficient joint repair
- Diabetes
- (increasing) Age
- Gender (female)
- Genetic predisposition
- Obesity
- Occupation
- Local trauma
- Inflammatory arthritis
give 4 differentials for a patient being HLA-B27 positive
ankylosing spondylitis, psoriatic, reactive and enteropathic arthritis
what scoring system is used for fractures involving the growth plate of bones in children?
Salter-Harris classification
what is the difference between T/Z scores in DEXA scans?
T: bone density compared to healthy 25 y/o of same sex
Z: bone density compared to healthy same age same sex
what is a FRAX score measuring?
the likelihood of a fracture in the next 10 years
what is a common side effect of alendronic acid?
oesophagitis
what is Sjogren’s syndrome?
immune destruction of exocrine glands
presentations of Sjogren’s syndrome?
arthritis, dry eyes, dry mouth
common test used to diagnose Sjogren’s syndrome?
Schirmer’s test - placing a small strip of paper in the eye to measure tear production
what XR sign is most commonly seen in psoriatic arthritis?
pencil in cup
RF for pseudogout?
parathyroidectomy, IV fluids -> can both derange calcium levels
what is the first sign on XR seen in ankylosing spondylitis?
sacroiliitis
features of ankylosing spondylitis?
- gradual onset back and buttock pain
- relieved slightly by exercise
- psoriasis
- dactylitis
- IBD
- eye involvement
name the causative molecules of gout and pseudogout
gout: monosodium urate
pseudogout: calcium pyrophosphate
state 4 causes of reduced urate excretion
elderly, post menopausal females, HTN, impaired renal function
state 3 causes of excess urate production
dietary, dehydration, genetic disorders
What is the treatment for gout if NSAIDs are contraindicated?
colchicine
what does DEXA stand for?
Dual Energy Xray Absorptiometry
fbc in osteoporosis?
normal calcium, phosphate and ALP
fbc in osteomalacia?
low calcium, low phosphate, high ALP
what parts of the skeletal system are inflamed in ankylosing spondylitis?
spine, rib cage, sacroiliac joints
what are vertebral syndesmophytes?
bony proliferations due to enthesitis between ligaments and vertebra
give 2 examples of something that would indicate a worse prognosis for those with ankylosing spondylitis
onset <16y, early hip involvement, poor NSAID response
what is the mechanism of action of NSAIDs (e.g. naproxen)?
non-selective inhibitors of COX1 and COX2 enzymes
Give two potential extra-articular manifestations of ankylosing spondylitis
5 A’s:
- anterior uveitis
- autoimmune bowel disease
- apical lung fibrosis
- aortic regurgitation
- amyloidosis
What bedside test can be used to assess mobility in the spine?
Schober’s test
Describe some aspects of how you perform Schober’s test and what is a positive result?
- Have the patient stand,
- locate L5 vertebrae
- mark a point 10cm above and 5cm below
- Ask the patient to bend over forwards as far as they can and measure the distance between the two points
- A distance of less than 20cm indicates reduced lumbar movement
Give three potential findings on X-ray of the spine of a patient with ankylosing spondylitis
bamboo spine, subchondral sclerosis, ossification, fusion of joints
give 1 topical and 2 oral management options of OA
- topical: NSAIDs
- oral: paracetamol, bisphosphonates
what is dermatomyositis?
- a rare disease that causes muscle weakness and skin rash.
- Symptoms include a red or purple rash on sun exposed skin and eyelids, calcium deposits under the skin, muscle weakness, and trouble talking or swallowing.
- “trouble going up stairs”
what is cut to release pressure on the median nerve?
transverse carpal ligament
top differential for pagets disease?
osteomalacia
name 3 bones paget disease affects
femur, skull, vertebrae, pelvis
DMARDS: what do they stand for? what does it target? give an example
- Disease Modifying Anti Rheumatic Drug
- inflammatory cytokines
- methotrexate
