MSK Flashcards
Osteoporosis: Assessing patients following a fragility fracture
> 75yo vs <75
> 75 started on first-line therapy (an oral bisphosphonate),without the need for a DEXA scan.
<75DEXA scan
Signs of carpal tunnel
symptoms of a median nerve palsy in this context can be reproduced by tapping the area of the flexor retinaculum (Tinel’s sign), or by holding the wrist in flexion (Phalen’s sign) or extension (reverse Phalen’s)
Meralgia paraesthetica
affects
femoral cutaneous nerve (LFCN)
De Quervain’s tenosynovitis
sign
Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus
Rheumatoid arthritis: x-ray changes
loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
periarticular erosions
subluxation
Heberdens vs bouchards
Heberden’s nodes - swelling of the distal interphalangeal joints.
Bouchard’s nodes - swelling of proximal interphalangeal joints
drug induced lupus ab
ANA positive in 100%, dsDNA negative
anti-histone antibodies are found in 80-90%
Rheumatoid arthritis management
NICE recommendDMARDmonotherapy+/- a short-course of bridging prednisolone. In the past dual DMARD therapy was advocated as the initial step
choices for initial DMARD monotherapy:
methotrexateis the most widely used DMARD. Monitoring of FBC & LFTs is essential due to the risk of myelosuppression and liver cirrhosis. Other important side-effects include pneumonitis
sulfasalazine
leflunomide
hydroxychloroquine: should only be considered for initial therapy if mild or p alindromic disease
Rheumatoid arthritis management of flares
flares of RA are often managed with corticosteroids - oral or intramuscular
Osteomalacia labs
low vitamin D levels
low calcium, phosphate (in around 30%)
raised alkaline phosphatase (in 95-100% of patients)
Pagets labs
raised alkaline phosphatase (ALP)
calcium and phosphate are typically normal. Hypercalcaemia may occasionally occur with prolonged immobilisation
Methotrexate side effecst
Myelosuppression
Liver cirrhosis
Pneumonitis
Sulfasalzine side effects
Sperms low
Rash
Heinze body
Interstitial lung disease
Gout acute management
NSAIDS (PPI may be indicated) or colchicine (may be used with caution in renal impairment , side effect is diarrhoea)
Indications for urate lowering therapy
urate-lowering therapy to all patients after their first attack of gout
ULT is particularly recommended if:
>= 2 attacks in 12 months
tophi
renal disease
uric acid renal stones
prophylaxis if on cytotoxics or diuretics
When can urate lowering therapy be started
Commencement of ULT is best delayed until inflammation has settled as ULT is better discussed when the patient is not in pain
Medications of urate lowering therapy
Allopurinol first line - initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 360 µmol/l
Second line febuxostat
Which drugs should you consider stopping in gout
Thiazide
Chondromalacia patellae.
Runners knee adolescents and young adults
Cartilage under patella inflamed
Worsens with bending knee
Osgood schlatter
common cause of knee pain in growing adolescents but typically presents with localized pain and swelling at the tibial tuberosity (the bony prominence just below the kneecap)
Osteochondritis dessicans
condition where small fragments of bone and cartilage become detached from their surrounding tissue due to inadequate blood supply. This can cause joint pain and swelling; however, it typically affects children between 10-20 years old who are involved in high-impact sports like football or gymnastics
Red flags for back pain
Thoracic pain
Age <20 or >55 years
Non-mechanical pain
Pain worse when supine
Night pain
Weight loss
Pain associated with systemic illness
Presence of neurological signs
Past medical history of cancer or HIV
Immunosuppression or steroid use
IV drug use
Structural deformity
De Quervain’s tenosynovitis
sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed. It typically affects females aged 30 - 50 years old.
pain on the radial side of the wrist
tenderness over the radial styloid process
abduction of the thumb against resistance is painful
Finkelstein’s test: the examiner pulls the thumb of the patient in ulnar deviation and longitudinal traction. In a patient with tenosynovitis this action causes pain over the radial styloid process and along the length of extensor pollisis brevis and abductor pollicis longus
De quervains tenosynovitis mx
analgesia
steroid injection
immobilisation with a thumb splint (spica) may be effective
surgical treatment is sometimes required
Nomenclature extracellular vs intracapsular hip fracture
intracapsular (subcapital): from the edge of the femoral head to the insertion of the capsule of the hip joint
extracapsular: these can either be trochanteric or subtrochanteric (the lesser trochanter is the dividing line), intertrochanteric fracture
Pseudogout ix
joint aspiration: weakly-positively birefringent rhomboid-shaped crystals
x-ray: chondrocalcinosis
in the knee this can be seen as linear calcifications of the meniscus and articular cartilage
