MSK Flashcards
Which nerve is affected in carpal tunnel?
Which fingers do you get symptoms
Median
Thumb, index and middle
Polymyalgia rheumatic key features
Key Ix
Management?
- Usually pts > 60
- Usually rapid onset (e.g. < 1 month)
aching, morning stiffness in proximal limb muscles
also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats
ESR (inflam markers will be up)
Steroids
How to manage Carpal tunnel
Mild-moderate:
6 week trial of conservative treatments e.g.
corticosteroid injection, wrist splints at night.
If severe/conservative measures don’t help:
surgical decompression (flexor retinaculum division)
FRAX used risk factors for osteoporosis
Bones SPARC
BMI (low)
Smoking
Parental hip fracture
Alcohol XS
Rheumatoid arthritis
Corticosteroid use (more than 3 months at a dose of prednisolone 10mg daily)
What do DXA results mean?
> -1 = normal
-1-> -2.5 osteopoenia
< - 2.5 osteoporosis.
Osteoporosis management - lifestyle
Falls risk assessment, weight bearing and muscle strengthening exercises, adcal, calculate FRAX
When would you use bisphosphonates in osteoporosis
if 10y risk of fracture >1%
OR
hip or vertebral fracture
OR
T score <-2.5 or less at femoral neck
OR
T-score between -1 and -2.5 (osteopoenic) AND 10y probability of a hip fracture >3%
What can be used for osteoporosis above bisphosphonates if indicated
Denosumab
What is Tennis elbow?
How do you test for it?
lateral epicondylitis
Get pt to hold arm at 90 degrees whilst supinated then push wrist down into your hand (extend wrist) - will reproduce pain.
What is golfers elbow?
How do you test for this?
medial epicondylitis
Get pt to hold arm at 90 degrees whilst supinated then flex wrist (I’m pointing to ME)
What condition is anti phospholipid syndrome most commonly associated with
lupus
What happens to coag in anti phospholipid syndrome
Prolonged APTT
Features of anti-phospholipid syndrome?
Clots, recurrent miscarriages, low platelets
livedo reticularis
How to investigate anti phospholipid syndrome
Antibodies:
- Anticardiolipin antibodies
- Anti-beta2 glycoprotein I (anti-beta2GPI)
Lupus anticoagulant
FBC (thrombocytopenia)
Coag (prolonged APTT_
Anti phospholipid syndrome management
Aspirin
If pt develops a clot then warfarin
If they get another clot whilst on this increase target INR to 3-4 and consider adding aspirin
Other ank spond Features
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
What is cubital tunnel
When can symptoms be worse?
Little and ring finger affected
Ulnar nerve
Can be worse when leaning on the affected elbow. Often assoc w. trauma/ OA to the area
First line bisphosphonate for osteoporosis
Aledronate
When are bisphosphonates C/I?
eGFR less than 35
X ray changes in OA?
LOSS
Loss of joint space
Osteophytes forming at joint margins
Subchondral sclerosis
Subchondral cysts
Which autoantibody has the highest specificity for RA?
Anti CCP
In what other conditions might RF be positive
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
Classic radiograph features of osteosarcoma
Radiographs classically show Codman triangle (a triangular area of new subperiosteal bone) with an associated sunburst appearance.
Classic radiograph features of Ewing’s sarcoma
Onion skin
What condition is osteosarcoma associated with
Retinoblastoma
What is a fragility fracture
Fall from standing height or less
If pt over 75 falls and get a fragility fracture what do you do
Start bisphosphonates
When would you start bisphoshonates in women without screening
If over 50 and had a fragility fracture
meralgia paraesthetica - which nerve is affected?
Lateral cutaneous nerve of the thigh
Pseudogout microscopy
Positively bifringent crystals.
Gout timeline
Reaches maximum intensity within 24 hours, and resolves within 5-15 days.
What do gout crystals look like?
What do pseudo gout crystals look like?
What are the made of?
Gout:
Negatively bifringent
Needle shaped
Monosodium urate
Pseudogout:
Positively bifringent
Rhomboidal
Calcium pyrophosphate
Chronic Gout x ray appearances
Joint effusion is usually the earliest sign.
Later, x-rays show punched out lytic lesions, sclerotic margins and outlines of tophi.
Top are caused by MSU Crystal deposition
What is pseudo gout also called?
Calcium Pyrophosphate Deposition Disease
Main differences in management gout/pseudogout
Pseudogout - rate lowering therapies won’t work
Osteomalacia sx
-Bone pain
-Bone/muscle tenderness
-Fractures: especially femoral neck
-Proximal myopathy: may lead to a waddling gait
What blood results would you expect in osteomalacia?
What would XR look like?
Bloods:
- low vitamin D
- low calcium, phosphate (in around 30%)
- Raised alkaline phosphatase (in 95-100% of patients)
x-ray
translucent bands (Looser’s zones or pseudofractures)
How to treat osteomalacia?
Vit D supplement
What is Finkelstein’s test and what does it indicate?
Pulls the thumb of the patient in ulnar deviation and longitudinal traction.
Indicates De Quervain’s tenosynovitis. This is where the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed.
How to start allopurinol for gout?
Initial dose of 100 mg od. Titrate every few weeks to aim for a serum uric acid of < 360 µmol/
Colchicine cover (NSAIDS if can’t tolerate)
When should bisphosphonates be taken?
At least 30 mins before breakfast with lots of water, sit upright for 30 mins after
Knee pain and a history of lots of kneeling?
Infrapatellar bursitis
when would you start bisphosphonates without investigating?
If over 75 and sustained a fragility fracture
Reactive arthritis classic features and other name
Reiters syndrome.
Joint pain, conjunctivitis, urethritis
can’t see, pee or climb a tree
Which antibodies most common in Sjogrens
Anti-Ro
rheumatoid factor (RF) positive in nearly 50% of patients
ANA positive in 70%
anti-Ro (SSA) antibodies in 70% of
patients with PSS
anti-La (SSB) antibodies in 30% of patients with PSS
Common cause of lateral knee pain in runners?
Iliotibial band syndrome
Subacromial impingement examination signs
painful arc of abduction. With subacromial impingement, this is typically between 60 and 120 degrees.
What does CREST syndrome indicate and what does it stand for
Limited systemic sclerosis
Calcinosis
Raynaud’s phenomenon
oEsophageal dysmotility
Sclerodactyly
Telangiectasia
3 subtypes of systemic sclerosis
Limited systemic sclerosis (CREST)
Diffuse cutaneous systemic sclerosis
Scleroderma
Which antibodies are associated with systemic sclerosis and which subtypes
Antibodies
ANA positive in 90%
RF positive in 30%
anti-scl-70 antibodies associated with diffuse cutaneous systemic sclerosis
associated with a higher risk of severe interstitial lung disease
anti-centromere antibodies associated with limited cutaneous systemic sclerosis
Diffuse cutaneous systemic sclerosis features
- Trunk and proximal limbs mainly affected
- anti scl-70 antibodies
the most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)
other complications include renal disease and hypertension
poor prognosis
Which DMARD can cause oligospermia
Sulfasalzine
Also ILD and Heinz body anaemia
How to manage acute flare of RA
IM Methylpred
When would you give a TNF inhibitor in RA
If inadequate response to 2 DMARDs
