MSK Flashcards
1
Q
Define osteoarthritis
A
‘wear and tear’ of the joints
Result of mechanical and biological events.
2
Q
Describe the pathophysiology of osteoarthritis
A
Destabilise normal process of degradation and synthesis of articular cartilage chondrocytes, extracellular matrix and subchondral bone.
Imbalance between cartilage damage and the chondrocyte response.
Involves the entire joint
3
Q
Name the commonly affected joints in osteoarthritis
A
Hips
Knees
DIP joints in hands
CMC joints at the base of the thumb
Lumbar spine
Cervical spine
4
Q
Name the 4 x-ray changes that would be seen in osteoarthritis
A
LOSS
Loss of joint space
Osteophytes - bone spurs
Subarticular sclerosis - increased density of the bone along the joint line
Subchondral cysts - fluid filled holes in the bone
5
Q
What are the causes of osteoarthritis
A
Multi-factorial disease
Genetic
Biological
Chemical
6
Q
Risk factors of osteoarthritis
A
Age > 50 years
Female sex
Obesity
Genetic factors - family history
Physically demanding occupation/sport
Post trauma/injury
7
Q
Describe the main symptoms of osteoarthritis
A
Joint pain and stiffness
Worse with activity and end of day
Reverse of the pattern in inflammatory arthritis
Results in - deformity, instability and reduced function of the joint
8
Q
Name the clinical signs of osteoarthritis
A
Bulky, bone enlargement of the joint
Restricted range of motion
Crepitus on movement
Effusions (fluid) around the joint
9
Q
By NICE guidelines what is the diagnosis of osteoarthritis
A
Diagnosis can be made with no investigations if
Patient over 45 + typical pain is associated with activity + no morning stiffness (or lasts under 30 minutes)
10
Q
Describe the management of osteoarthritis
A
Patient education + lifestyle change
Topical NSAIDs - 1st line knee
Oral NSAIDs
Weak opiates and paracetamol
Intra-articular steroid injections
Joint replacement
11
Q
Name 5 differential diagnosis of osteoarthritis
A
Bursitis
Gout
Pseudogout
Rheumatoid arthritis
Psoriatic arthritis
12
Q
Define rheumatoid arthritis
A
Autoimmune condition that causes chronic inflammation in the synovial lining of the joints, tendon sheaths and the bursa
13
Q
Describe the pathogenesis of rheumatoid arthritis
A
Inflamed synovial central pathogenesis
Synovial becomes hyperplastic, with infiltration of mononuclear
14
Q
Describe the antibodies of rheumatoid arthritis
A
Rheumatoid factor - present in 70% of patients (IgM)
Anti-CCP - positive around 80%. Often pre-date development
15
Q
Name the risk factors for rheumatoid arthritis
A
Genetics
Smoking (weak)
16
Q
Describe the clinical features of rheumatoid arthritis
A
Onset - rapid or gradual
3 joint symptoms
- Pain
- Swelling
- Stiffness
Associated systemic symptoms
Extra-articular manifestations and eye manifestations
17
Q
Describe the examination of rheumatoid arthritis
A
Joints - tenderness + synovial thickening
Hand signs of the disease
18
Q
Describe the hand signs of rheumatoid disease
A
Z-shaped deformity of thumb
Swan neck deformity - hyperextended PIP and flexed DIP
Boutonniere deformity - hyperextended DIP and flexed PIP
Ulnar deviation of the fingers at the MCP joints
19
Q
What are the investigations for rheumatoid arthritis
A
Joint aspiration (if suspected infection)
Rheumatoid factor
Anti-CCP antibody
Inflammatory markers - CRP,, ESR
Radiograph - x-ray, MRI
20
Q
Describe the management of rheumatoid arthritis
A
Short term-steroids (acute)
Modifying anti-rheumatic drugs + biological DMARDs
NSAIDs
Surgery
21
Q
What is used to monitor the success of rheumatoid arthritis treatment
A
C-reactive
DAS28
22
Q
Name 4 differential diagnosis of rheumatoid arthritis
A
Psoriatic arthritis
Infectious arthritis
Gout
Systemic lupus erythematosus
23
Q
Define gout
A
Crystal arthropathy associated with chronically high blood uric acid levels
24
Q
Describe the pathophysiology of gout
A
Urate crystals are deposited in the joint, causing it to become inflamed.
Characterised by hyperuricaemia and deposition of urate crystals causing attacks of acute inflammatory arthritis.
25
Describe the cause of gout
Hyperuricaemia - due to under-excretion of urate or over-production.
26
What are the risk factors for hyperuricaemia
Dietary factors (seafood, meat, beer)
Obesity, insulin resistance and hypertension
High cell turnover
27
Name the risk factors of gout
Male
Family history
Obesity
High purine diet
Alcohol - BEER
Diuretics
Cardiovascular disease
Kidney disease
Fructose
Aspirin
28
What are the clinical features of gout
Gouty tophi
Acute onset of:
- fever joint pain with:
- swelling
- effusion
- warmth
- erythema
- OR tenderness of the involved joints
29
What are the most affected joints in gout
The base of the big toe - metatarsophalangeal joint
The base of the thumb - the carpometacarpal joint
Wrist
30
Describe the investigations of gout
Bloods
Aspirated joint fluid
X-ray - if concern sepsis or recurrent arthritis
31
Define gouty tophi
Subcutaneous uric acid deposits are typically seen on hands, elbows and ears
32
How do you define between gout and pseudogout
Gout - needle-shaped and negatively birefringent of polarised light. Monosodium urate crystals.
Pseudogout - Rhomboid-shaped and positively birefringent. Calcium pyrophosphate crystals
Both - no bacterial growth
33
Describe what is seen on an aspirated joint fluid of gout including the type of crystal
Monosodium urate crystals
Needle-shaped and negatively birefringent of polarised light
No bacterial growth
34
Describe the x-ray seen in gout
No loss of joint space
Lytic lesions in the bone
Punches out erosions
Erosion can have sclerotic borders with overhanging edges
35
What is the clinical diagnosis of gout
Clinical + raised serum levels of blood test
36
Describe the management of gout
Acute flares
- NSAIDS (1)
- Colchicine (2)
- Oral steroids (3)
Prophylaxis
- xanthine oxidase inhibitors
Lifestyle changes
- losing weight
- staying hydrated
- minimising alcohol and purine-based food
37
Describe the differential diagnosis of gout
Critical - septic arthritis
Pseudogout
Trauma
Rheumatoid arthritis
Reactive arthritis
38
How are infectious prosthetics avoided
Surgery
- Laminar flow in surgery
- 10-sides
- Double gloving
IV Peri-operative antibiotics
Cemented implant - cement contains antibiotics
39
Describe the diagnosis of prosthetic infections
History
Examination
X-ray
FBC, ESR, CRP
Microbiology culture
40
What is the key investigation done in prosthetic infection
Aspiration
- confirms diagnosis
- identify organism (s) and antibiotic sensitivities
- MUST be done with patient off antibiotics for at least 2 weeks
41
Name the 3 aims of treatment in prosthetic infection
Eradicate sepsis
Relieve pain
Restore function
42
Name the treatment options for prosthetic infection
Antibiotics
Debridement & Implant retention (acute infection)
Excision Arthroplasty (poor functional outcome)
Exchange Arthroplasty
One-stage exchange (implantation of new prosthesis - cemented)
Two-stage exchange
43
Define pseudogout
Crystal arthropathy caused by calcium pyrophosphate crystals collecting in the joint
44
Name the risk factors for pseudogout
Advanced age
Injury
Hyperparathyroidism
Haemochromatosis
Family history
Hypomagnesemia
Hypophosphatasia
45
Describe the symptoms of pseudogout
Tender to be milder than gout or septic arthritis
Painful and tender joints
Osteoarthritis-like involvement of joints
Sudden worsening of osteoarthritis
Red and swollen joints
Joint effusion and fluctuance
46
Describe the joint aspiration results seen in pseudogout
Used to confirm diagnosis
Shows calcium pyrophosphate crystals
Rhomboid-shaped and positively birefringent of polarised light
No bacterial growth
47
Describe the x-ray of pseudogout
Chondrocalcinosis
Calcium deposits in the joint cartilage
LOSS
- loss of joint space
- osteophytes
- subarticular sclerosis
- subchondral cysts
48
Describe the management of pseudogout
Targeted at symptoms
Asymptomatic = no treatment
Symptoms
1. NSAIDs
Colchicine
Intra-articular steroid injection
Oral steroids
49
Name 5 differential diagnosis of pseudogout
Acute gouty arthritis
Acute septic arthritis
Milwaukee shoulder syndrome
Osteoarthritis
Rheumatoid arthritis
50
Define osteoporosis
Significant reduction in bone density
Systemic skeletal disease characterised by a low bone mass and abnormal bone architecture, which leads to compromised bone strength and a consequent increase in bone fragility and risk of fracture
51
What is T-score
Number of standard deviations the patient is from an average healthy young adult
52
What is the T-score of osteopenia
-1 to -2.5
53
What is the T score of osteoporosis
Less than -2.5
53
What is the T-score of severe osteoporosis
Less than -2.5 + fracture
53
Describe the pathophysiology of osteoporosis
Oversupply of osteoclasts or osteoblasts relative to the need for remodelling or cavity repair
54
Describe the cause of osteoporosis
Cause = low bone mass
Either
- low peak bone mass
- loss of bone mass with ageing
55
Name the risk factors of osteoporosis
Older age
Post-menopausal women
Reduced mobility and activity
Low BMI
Low calcium or vitamin D intake
Alcohol or smoking
Personal or family history of fractures
Chronic disease
Long-term corticosteroids
Certain medications
56
Name the clinical feature of osteoporosis
Asymptomatic until fracture occurs
57
What would a joint aspirate in septic arthritis show
Turgid fluid
Leucocytes ++
Gram stain - gram positive cocci
58
Name the causes of inflammatory arthritis
Rheumatoid arthritis
Seronegative spondylarthritis
- psoriatic
- ank spond
- reactive arthritis
- enteropathic - chrons & UC
Crystal arthritis
59
What are the 4 stages of gout if left untreated
1. Asymptomatic hyperuricemia
2. Acute/recurrent gout
3. Intercritical gout
4. Chronic tophaceous gout
60
What is the aim of chronic gout management
Treat to target
Reduce uric acid below < 300 umol/L
Allopurinol and increase every 2-4 weeks until target met
61
Define septic arthritis
Infection of a joint
May occur in a native (original) joint or a prosthetic joint replacement
62
What is the most causative organism septic arthritis
Staphylococcus aureus
63
Describe gonococcal arthritis
Occurs with disseminated gonococcal infection
64
Name 4 specific risk factors of septic arthritis
Any cause for bacteraemia
Direct/penetrating trauma
Local skin breaks/ulcers
Damaged joint
65
Name 4 general risk factors of septic arthritis
Immunosuppression
Elderly
Rheumatoid arthritis (or other immune driven disease)
Diabetes
66
Describe the clinical features of septic arthritis
90% monoarthritis
Knee > hip > shoulder
Presents with
- hot, red, swollen and painful joint
- fever
- stiffness and reduced range of motion
- systemic symptoms
67
Describe the investigations of septic arthritis
Joint examination fluid
Bloods
Imaging - plain x-ray, ultrasound
68
Describe the management of septic arthritis
Joint aspiration fluid - antibiotics guided by
Empirical antibiotics - 6 weeks minimum. 1st line = flucloxacillin
Other
- joint washout
- rest/splint/physio
- analgesia
- stop immune suppression temporality if possible
69
What antibiotics are given for septic arthritis caused by staphylococcus
Flucloxacillin
Erythromycin
Doxy/tetracycline
70
Name 4 differential diagnosis of septic arthritis
Gout
Pseudogout
Reactive arthritis
Hemarthrosis
71
Define reactive arthritis
Inflammatory arthritis that occurs after exposure to certain GI and GU infections.
72
Describe the pathophysiology of reactive arthritis
Involves synovitis in one or more joints in response to an infective trigger.
No infection inside the joint
73
Name the triggers of reactive arthritis
Gastroenteritis
Genitourinary infections - STI
- Chlamydia
- Gonorrhoea (normally causes septic)
74
Name 3 risk factors of reactive arthritis
Male sex
HLA-B27 genotype
Preceding chlamydia or GI infection
75
Name the clinical features of reactive arthritis
Fever
Peripheral and axial arthritis
Enthesitis
Dactylitis
Conjunctivitis and iritis
Skin lesions
76
Define Enthesitis
Inflammation where tendon is inserted into the bone
77
Define dactylitis
Swelling of an entire finger or toe
78
Define skin lesions
Circinate balanitis and keratoderma blennorrhagicum
79
Describe the investigations for reactive arthritis
Bloods
- ESR/CRP
- ANA
- Rheumatoid factor
Urogenital and stool cultures
Plain x-rays
Arthrocentesis with synovial fluid analysis
80
Describe the management of reactive arthritis
Treatment according to the hot joint policy
Joint aspiration
Pharmacology
- Treatment of triggering infection
- NSAIDs
- Steroid injection into the affected joints
- Systemic steroids (multiple joints)
81
What are the associations of reactive arthritis
Can't see, pee or climb a tree
Bilateral conjunctivitis - non infective
Anterior uveitis
Urethritis - non-gonococcal
82
Define giant cell arthritis
Type of systemic vasculitis affecting the medium and large arteries (extracranial branches of the carotid artery - usually affected)
83
Name 2 risk factors of giant cell arthritis
Age > 50 years
Female sex
84
Describe the clinical features of giant cell arthritis
Primary presenting feature = unilateral headache (severe, around temple)
Associated
- scalp tenderness
- jaw claudication
- blurred/double vision
- loss of vision if untreated
Temporal artery - may be tender, thickened. Reduced or absent pulsation
85
Name the investigations of giant cell arthiritis
Inflammatory markers - ESR
Biopsy - temporal artery biopsy
Duplex ultrasound
86
What is clinical diagnosis of giant cell arthiritis based off
Clinical presentation
Raised inflammatory markers
Temporal artery biopsy
Duplex ultrasound
87
Describe the management for giant cell arthiritis
Main steroids
- prednisolone - no visual symptoms or jaw claudication
- methylprednisolone - with
Other medications
- aspirin
- proton pump inhibitor
- bisphosphonates and calcium and vitamin D
88
Name 5 differential diagnosis of giant cell arthiritis
Polymyalgia rheumatica
Solid organ cancers/haematological malignancies
Chronic infections
Rheumatoid arthiritis
Amyloidosis
89
Define systemic lupus erythematosus
Inflammatory autoimmune condition disorder.
Systemic = affects multiple organs and systems.
Erythematosus = typical red malar rash across the face
90
Describe the pathophysiology of systemic lupus erythematosus
Anti-nuclear antibodies generate chronic inflammatory response.
Inflammation - immune complex mediated leads to tissue damage
Thrombosis - phospholipid antibodies
91
Who is systemic lupus erythematosus most common in
Women
Asian, African, Caribbean, Hispanic ethnicity
Young to middle-aged adults
92
Describe the causes of systemic lupus erythematosus
Genetic factors
Environmental factors
- Non infectious - drugs
- Infectious
93
Name 4 risk factors for systemic lupus erythematosus
Female sex
Age > 30 years
African descent in Europe or US
Drugs
94
Name the clinical features of systemic lupus erythematosus
Relapsing-remitting cause
Many symptoms
- arthralgia
- non-erosive arthiritis
- myalgia
- photosensitive malar rash
- SOB
- Hair loss
- Raynaud's phenomenon
- Oedema
95
Describe the haematological features of systemic lupus erythematosus
Anaemia
- haemolytic
- coombs positive
Neutropenia
Thrombocytopenia
Lymphopenia
96
Describe the investigations of systemic lupus erythematosus
Autoantibodies
FBC
CRP/ESR
C3&4
Urinalysis, urine protein: creatinine ratio
Renal biopsy
97
Describe the management of systemic lupus erythematosus
1st line
Can have no treatment
Hydroxychloroquine
Topical - sun avoidance
NSAIDs
Steroids
98
Name the differential diagnosis of systemic lupus erythematosus
Rheumatoid arthiritis
Antiphospholipid syndrome
Systemic sclerosis
Lyme disease
HIV
Infectious mononucleosis
99
Name some complications of systemic lupus erythematosus
Chronic inflammation
Antiphospholipid antibodies/syndrome
Anaemia
Interstitial lung disease
Neuropsychiatric SLE
100
What are the 2 main pathological features of osteoarthritis
Loss of cartilage
Disordered bone repair
101
Name the 3 cytokines which mediate osteoarthritis
ILA-1
TNF-a
NO
102
Describe erosive/inflammatory subset of osteoarthritis
Strong inflammatory component
DMAR therapy
103
Name the surgical options for osteoarthritis
Arthroscopy
Osteotomy
Arthroplasty
Fusion
104
What are the 4 Rs of orthopaedic principles
Resuscitate
Reduce
Retain
Rehab
105
Describe the steps of bone remodelling (direct)
1. Resting
2. Reabsorption
3. Formation
4. Mineralisation
106
Describe the steps of callus formation (indirect)
1. Bleeding
2. Soft callus
3. Bony callus
4. Remodelling
107
Define Sjogren syndrome
Autoimmune condition affecting exocrine glands (lacrimal and salivary glands) causing symptoms of dry mouth, eyes and vagina
108
Describe the types of Sjogren's syndrome
Primary - condition occurs in isolation
Secondary - occurs due to other diseases
- SLE
- Rheumatoid arthiritis
- Scleroderma
- Primary biliary cirrhosis
- Other autoimmune disease
109
What are the antibodies present in Sjogren's syndrome
Anti-SS-A antibodies (anti-Ro)
Anti-SS-B antibodies (anti-La)
110
Describe the epidemiology of Sjogren's syndrome
More common in women (maybe oestrogen)
Typically presents in middle age
111
Name the risk factors for Sjogren's syndrome
Female
SLE
Rheumatoid arthiritis
Systemic sclerosis
HLA class II markers
Age 40-70
112
Describe the clinical features of Sjogren's syndrome
Dry eyes and dry mouth (Sicca symptoms)
Arthritis
Rash
Neurological features
Vasculitis
ILD
Renal tubular acidosis
113
Describe the Schirmer Test
For Sjogren's syndrome
Folder filter paper under eye
Moisture from eye will travel down
After 5 minutes distance is measured
Less than 10mm = significant
114
Describe the investigations of Sjogren's syndrome
Positive - ANA, RF, Ro and La
Negative - immunoglobins
Abnormal salivary glands on ultrasound
Sialadenitis on lip biopsy
115
Describe the management of Sjogren's syndrome
Tear and saliva replacement
Pilocarpine
Vaginal lubricants
Hydroxychloroquine
116
Name the complications of Sjogren's syndrome
Eye problems
- Keratoconjunctivitis sicca
- Corneal ulcers
Oral problems
- dental cavities
- candida infections
Vaginal problems
- candida infection
- sexual dysfunction
117
Describe the clinical diagnosis of Sjogren's syndrome
Clinical features + presence of biopsy
May use - salivary biopsy
118
Define dermatomyositis/polymyositis
Autoimmune disorders causing muscle inflammation (myositis)
Poly - occurs without any skin features
Dermato - with skin features
119
Describe the causes of dermatomyositis/polymyositis
Paraneoplastic syndromes - underlying cancer
Viral infections e.g. Coxsackie or HIV
120
Name the risk factors for dermatomyositis/polymyositis
Genetic predisposition
Bimodal age distribution
Female sex
Black race
UV radiation
121
Name the clinical features of dermatomyositis/polymyositis
Muscle and skin
- rash
- muscle weakness (symmetrical)
- Interstitial lung disease
- para-neoplastic syndrome
122
Describe the investigations of dermatomyositis/polymyositis
1st line
- muscle enzymes (creatinine kinase)
Other
- antibody screen
- EMG
- Muscle/skin biopsy
- Screen for malignancy
123
What is clinical diagnosis of dermatomyositis/polymyositis based upon
Clinical features
Elevated creatinine kinase
Autoantibodies
Electromyography
Magnetic resonance imaging
Muscle biopsy
124
Name the management of dermatomyositis/polymyositis
1st line - corticosteroids
Other
- immunosuppressive drugs
- IV immunoglobulins
- Biological therapy
125
Define systemic sclerosis (scleroderma)
Autoimmune connective tissue disease involving inflammation and fibrosis of the connective tissues, skin and internal organs
126
Name the 4 main components of the pathophysiology of systemic sclerosis (scleroderma)
Vasculopathy
Excessive collagen deposition
Inflammation
Auto-antibody production
127
Name the clinical subsets of systemic sclerosis
Limited cutaneous - CREST
Diffuse cutaneous - CREST + internal organs
128
Describe crest in systemic sclerosis
Calcinosis
Raynaud's phenomenon
Oesophageal dysmotility
Sclerodactyly
Telangiectasia
129
Name the risk factors of systemic sclerosis
Family history
Immune dysregulation
130
Describe the clinical features of systemic sclerosis
Raynaud's phenomenon
Scleroderma
Sclerodactyly
Telangiectasia
Calcinosis
Oesophageal dysmotility
Systemic and pulmonary hypertension
Pulmonary fibrosis
131
Describe the investigations for systemic sclerosis
Autoantibodies
Nailfold capillaroscopy
132
Describe nailfold capillaroscopy
Examine peripheral capillaries
Suggests systemic sclerosis:
- abnormal capillaries
- avascular areas
- micro-haemorrhages
133
Describe the management of systemic sclerosis
Raynaud's
PPU
ACE inhibitors
Echo and pulmonary function tests
Treatment of the complications/symptoms
134
What are the options of management in systemic sclerosis in diffuse disease
DMARDs - methotrexate
Biological therapies
Steroids (may be considered)
135
Describe the non-medical management of systemic sclerosis
Avoid smoking
Gentile skin strength to maintain range of motion
Regular emollients
Avoid cold triggers for Raynaud's
Physiotherapy
Occupational therapy
136
Name 4 spondyloarthropathies
Psoriatic arthritis
Ankylosing spondylitis
Reactive arthritis
Enteric arthiritis
137
Name the clinical features of spondyloarthropathies
SPINEACHE
Sausage digits - dactylitis
Psoriasis
Inflammatory back pain
NSAID good response
Enthesitis - heel
Arthritis
Crohn's/Colitis/elevated CRP
HLA B27
Eye - uveitis
138
Define ankylosing spondylitis
Inflammatory condition affecting the axial skeleton (mainly the spine and sacroiliac joints), causing progressive stiffness and pain
139
Name the cause of ankylosing spondylitis
HLA-B27
140
Name 4 risk factors of ankylosing spondylitis
HLA-B27 (90%)
Endoplasmic reticulum aminopeptidase 1 and interleukin-23 receptor genes
Positive family history of AS
Male sex
141
Describe the clinical features of ankylosing spondylitis
Joint pain adult male in 20s - gradually developed over 3 months
Stiffness and pain in lower back (> 30 minutes in the morning)
Sacroiliac pain (in buttock region)
142
Name the main affected joints in ankylosing spondylitis
Sacroiliac joints
Vertebral column joints
143
Does movement improve or make worse ankylosing spondylitis
Improves with movement
Improve activity
Worsen with rest
144
Name the additional features which can be present with alkyalosing spondylitis
Chest pain
Enthesitis
Dactylitis
Vertebral fracture
Shortness of breath
145
Name the 5 associations with ankylosing spondylitis
5 As
Anterior uveitis
Aortic regulation
Atrioventricular block - heart block
Apical lung fibrosis
Anaemia of chronic disease
146
Name the key investigations of ankylosing spondylitis
Inflammatory markers - CRP, ESR
HLA B27 - genetic testing
X-ray of spine and sacrum
MRI of spine
Schober's test
147
Describe Schober's test of ankylosing spondylitis
Assesses spinal mobility
Standing straight - L5 15cm apart
Bend forward as far as possible - distance measured
< 20cm = indicated restriction in lumbar spine
148
Describe the x-ray changes in ankylosing spondylitis
Bamboo spine
Squaring of the vertebral bodies
Subchondral sclerosis and erosions
Syndesmophytes
Ossification
Fusion
149
Describe the medical management of ankylosing spondylitis
1st line - NSAIDs
2nd line Anti-TNF
150
Describe the additional management of ankylosing spondylitis
Physiotherapy
Exercise and mobilisation
Avoid smoking
Bisphosphates for osteoporosis
Surgery - occasionally required for severe joint deformity
151
Name 5 differential diagnosis for ankylosing spondylitis
Osteoarthritis
Diffuse idiopathic skeletal hyperostosis
Psoriatic arthiritis
Reactive arthiritis
Vertebral fracture
152
Define enteric arthiritis
Arthritis associated with inflammatory bowel disease
153
Name the cause of enteric arthiritis
HLA-B27
Endoplasmic reticulum aminopeptidase 1 and 2
154
What are the risk factors of enteric arthiritis
Family history
Smoking
155
Describe the clinical features of enteric arthiritis
Asymmetric lower limb arthiritis
Insidious onset of pain before the age 45
Morning stiffness
Pain worsening with rest and improving with movement
Awaking towards later portion of night
IBS symptoms
156
Describe the investigations for enteric arthiritis
Physical examination
Modified Schober test
Abdominal examination
Lab tests
Imaging - colonoscopy
157
Describe the management of enteric arthiritis
Treatment for IBD + treatment of arthiritis
158
Name 4 differential diagnosis of enteric arthiritis
Fibromyalgia
IBS
Reactive arthritis
Celiac disease
159
Describe the prognosis of enteric arthiritis
Remission is related to suppression of bowel disease
Can cause significant mortality
160
Define psoriatic arthiritis
Chronic inflammatory musculoskeletal disease associated with psoriasis
161
What are the 5 patterns of psoriatic arthiritis
Asymmetrical oligoarthritis - affect 1-4 joints, same side of body
Symmetrical polyarthritis - presents like rheumatoid arthiritis
Distal interphalangeal predominant pattern - primarily affects the DIP joints
Spondylitis - presents with back stiffness and pain
Arthritis mutilans - more severe form
162
Describe the pathophysiology of psoriatic arthiritis
May be maintained by adaptive immune system - both CD4+ and CD8+ cell play contributing role in both skin and the synovium
Angiogenesis and endothelial dysfunction
163
Name the causes of psoriatic arthiritis
Hereditary/genetic factors
Joint or tendon trauma
Infection - HIV, streptococcal infection
Smoking
Immune system dysfunction
164
Name the risk factors of psoriatic arthiritis
Psoriasis
Family history
165
Describe the clinical features of psoriatic arthiritis
Plaques of psoriasis on the skin
Nail pitting
Onycholysis
Dactylitis
Enthesitis
166
Describe the x-ray results in psoriatic arthiritis
Periostitis
Ankylosis
Osteolysis
Dactylitis
Digits
167
Describe the investigations in psoriatic arthiritis
X-ray
ESR/CRP
Anti-CCP
Lipid profile
Fasting blood glucose
Uric acid level
168
Describe the clinical diagnosis of psoriatic arthiritis
Screens for psoriatic arthiritis in patients with psoriasis
Involves questions about joint pain, swelling, a history of arthiritis and nail pitting
High score = referral to rheumatologist
169
Name the management of psoriatic arthiritis
Depends on severity
NSAIDs
Steroids
DMARDs
Anti-TNF medications
Ustekinumab
170
Name the differential diagnosis of psoriatic arthiritis
Rheumatoid arthiritis
Gout
Erosive arthiritis
Reactive arthiritis
Mycobacterial tenosynovitis
Sarcoid dactylitis
171
Name a diet change which would reduce the risk of gout
A diet rich in dairy products
Beer, larger and stout - all the same drink (not the answer)
172
Which of these is not an autoimmune connective tissue disease
Systemic Lupus Erythematosus
Ehler Danlos Syndrome
Primary Sjogren's syndrome
Systemic sclerosis
Dermatomyositis
Ehler Danlos Syndrome
173
Name a medication for the 1st line treatment of SLE
Anti-malarial
- hydroxychloroquine
- Methoprene
174
Define Marfan's
Autosomal dominant condition affecting the gene responsible for creating fibrillin
175
Describe the pathophysiology of Marfan's
Abnormal fibrillin protein leads to abnormalities in mechanical stability and elastic properties of connective tissue
176
Describe the cause of Marfan's
Mutation in fibrillin-1 gene
75% autosomal dominant
25% mutation occurs spontaneously
177
Name 2 connective tissue disorders
Marfan's
Ehlers Danlos
178
Name 2 risk factors in Marfan's
Family history of Marfan syndrome
Family history of aortic dissection or aneurysm
179
Name the clinical features of Marfan's
Tall
Long neck
Long limbs
Long fingers
High arch palate
Hypermobility
Pectus carinatum or pectus excavatum
Downward sloping palpable fissures
180
Name the associated conditions of Marfan's
Lens dislocation in the eye
Joint dislocation and pain
Scoliosis
Pneumothorax
GORD
Mitral/Aortic valve prolapse
Aortic aneurysms
181
Describe the investigations of Marfan's
Echo
Silt-lamp examination with intra-ocular pressure measurement
Imaging
182
What is the aim of treatment in Marfan's
Minimise blood pressure and heart rate
183
Describe the management of Marfan's
Lifestyle changes - avoid intense exercise and avoid caffeine and other stimulants
Preventative measures - beta blockers and angiotensin II receptor antagonists
Physiotherapy
Genetic counselling
184
What is the monitoring of Marfan's
Echo and ophthalmologist
185
Name the differential diagnosis of Marfan's
Aortic dissection
Bicuspid aortic valve
Ehlers-Danlos syndrome
XXY (Klinefelter) syndrome
186
What is the greatest risk in complication in Marfan's
Cardiac complications
Valve prolapse
Aortic aneurysm
187
Define Ehlers-Danlos Syndrome
Group of genetic conditions involving defects in collagen causing hypermobility in the joints and abnormalities in the connective tissue of the skin, bones, blood vessels and organs
188
Describe the 3 effects that the pathophysiology of Ehlers-Danlos syndrome causes
Biochemical abnormality
1. Ligament laxity
2. Inherent fragility of connective tissue
3. Impaired healing
189
Name the 4 types of Ehlers-Danlos syndrome
Hypermobile
Classical
Vascular
Kyphoscoliotic
190
Describe hypermobile Ehlers-Danlos syndrome
Most common
Less severe
Key features - joint hypermobility and soft and stretchy skin
191
Describe classical Ehlers-Danlos syndrome
Key features - stretchy skin that feels smooth and velvety
Severe joint hypermobility, joint, pain and abnormal wound healing
Lumps over pressure points
192
Describe Vascular Ehlers-Danlos syndrome
Most severe and dangerous
Blood vessels and particularly fragile and prone to rupture
Characteristic thin, translucent skin
193
Describe kyphoscoliotic Ehlers-Danlos syndrome
Poor muscle tone as neonate
Followed by kyphoscoliosis as grow
Joint dislocation common
194
Describe the inheritance pattern of hypermobile Ehlers-Danlos syndrome
Autosomal dominant
195
Describe the inheritance pattern of classical Ehlers-Danlos syndrome
Autosomal dominant
196
Describe the inheritance pattern of vascular Ehlers-Danlos syndrome
Autosomal dominant
197
Describe the inheritance pattern of kyphoscoliotic Ehlers-Danlos syndrome
Autosomal recessive
198
Name the risk factors of Ehlers-Danlos syndrome
Family history of joint hypermobility or EDS
Genetic mutations
199
Describe the clinical features of Ehlers-Danlos syndrome
Key = joint pain and hypermobility
Multisystem disorder (more symptoms).
200
Describe postural orthostatic tachycardia syndrome as a clinical feature of hypermobile Ehlers-Danlos syndrome
Results = autonomic dysfunction
Symptoms
- presyncope
- syncope
- headaches
- disorientation
- nausea
- tremor
201
Define presyncope
Light-headedness
202
Describe syncope
Loss of consciousness
203
Describe the investigations of Ehlers-Danlos syndrome
Clinical diagnosis
Genetic testing (except hypermobile EDS)
Beighton score
204
Describe Beighton score
Assesses hypermobility and supports of diagnosis
1 point for each side of the body - maximum 9
Place palms flat on floor with legs straight
Hyperextended knees
Hyperextended elbows
Bend their thumbs to touch their forearms
Hyperextended their little finger past 90 degrees
205
Describe the management of Ehlers-Danlos syndrome
No cure
Follow ups
Physiotherapy
Occupational therapy
Moderating activity
Psychology
Pain management
Joint dislocation
206
Describe how Marfan's is different to Ehlers-Danlos syndrome
Marfans
- High arch palate
- Arachnodactyly
- Increased arm span to body height ratio
207
Describe 5 differential diagnosis of Ehlers-Danlos syndrome
Marfan syndrome
Fibromyalgia
Chronic fatigue syndrome
Von Willebrand's disease
Corticosteroid excess
208
Describe the prognosis of Ehlers-Danlos syndrome
Many patients live healthy, unaffected lives and never come to clinical attention
Vascular - associated with shortened lifespan
209
Name a complication of Ehlers-Danlos syndrome
Premature osteoarthritis
210
Define fibromyalgia
Syndrome characterised by widespread pain in the body present for at least 3 months
211
Describe the epidemiology of fibromyalgia
Women 1.5 x more likely
Any age
Chance increases with age
212
Name the risk factors of fibromyalgia
Family history
Rheumatological conditions
Age 20-60 years
Female sex
Stressful events
Sleep problems
Infections
213
Describe neoplastic pain
In fibromyalgia underlying mechanism of pain originating from the CNS
214
Describe the clinical features in fibromyalgia
Chronic
- waxing and waning
- widespread body pain
Comorbid symptoms
- fatigue
- memory difficulties
- sleep and mood difficulties
215
Describe the investigations in fibromyalgia
Clinical diagnosis
> 3 months
Widespread body pain and associated symptoms
Some tests - to remove alternative causes
216
Describe the management of fibromyalgia
Therapies
Education
Exercise
Cognitive behavioural therapies
Tricyclic behavioural antidepressants
Gabapentinoids
Serotonin-noradrenaline reuptake inhibitors.
217
What is the goal of treatment in fibromyalgia
Decrease physical and mental symptoms
No cure
218
Define antiphospholipid syndrome
Autoimmune disorder caused by antiphospholipid antibodies
219
Describe the pathophysiology of antiphospholipid syndrome
Antibodies target the proteins that bind to the phospholipids on the cell surface, causing inflammation and increasing the risk of thrombosis
220
Name the 3 antiphospholipid antibodies
Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies
221
Describe the cause of antiphospholipid syndrome
Primary - no evidence of autoimmune disorder
Secondary - presence of autoimmune (40%
Infections - induction of antiphospholipid antibody formation e.g. HIV
Drugs which induce APLA production
222
Name the risk factors of antiphospholipid syndrome
History of:
Systemic lupus erythematosus
Other autoimmune rheumatological disorders
Other autoimmune disease
223
Describe the clinical features of antiphospholipid syndrome
Hallmarks - arterial or venous thrombosis and pregnancy-related complications
Other (involvement of):
- cutaneous
- Vascular
- neurological
- pulmonary
- renal
Catastrophic anti-phospholipid syndrome
224
Describe the investigations of antiphospholipid syndrome
Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta2-glycoprotein I antibodies
Antinuclear antibody, double-stranded DNA, and extractable nuclear antigen antibodies
FBC
Creatinine and urea
225
Describe the diagnosis of antiphospholipid syndrome
Clinical features + antiphospholipid syndrome
226
Describe the management of antiphospholipid syndrome
Long term warfarin
- target INR 2-3
- contraindicated in pregnancy
Low molecular weight heparin and aspirin
227
Name 2 differential diagnosis of antiphospholipid syndrome
Sneddon's syndrome
Inherited thrombophilia
228
Name the associations of antiphospholipid syndrome
Livedo reticularis
Libmann-Sacks Endocarditis
Thrombocytopenia
229
Name the complications of antiphospholipid syndrome
Venous thromboembolism
Arterial thrombosis
Pregnancy-related complications
Catastrophic phospholipid syndrome
230
Describe catastrophic antiphospholipid syndrome
Rare complication with rapid thrombosis in multiple organs within a few days
High mortality rate
231
Define paget's disease of bone
Involves excessive bone turnover due to increased osteoclast and osteoblast activity
232
Describe the pathophysiology of Paget's disease of bone
Excessive turnover is not coordinated
= patchy areas of high density (sclerosis) and low density (lysis)
= enlarged misshapen bones, structural problems and increased risk of pathological fractures
233
What does Paget's disease of bone particularly affect
Axial skeleton - bones of head and spine
234
Name 2 risk factors of Paget's disease of bone
Family history
Age > 50
235
Describe the clinical features of Paget's disease of bone
May be asymptomatic
Or present with:
- bone pain
- bone deformity
- fractures
- hearing loss
236
Describe the investigations in Paget's disease of bone
X-ray findings
Blood tests
- raised alkaline phopshatase
Bone biopsy (ultimate confirmatory test - rarely necessary)
237
Describe the x-ray investigations in Paget's disease of bone
Bone enlargement and deformity
Osteoporosis circumscripta
Cotton wool appearance of the skull
V-shaped osteolytic defects in the long disease
238
Describe the management of Paget's disease of bone
1st line - bisphosphonates
Other
- calcitonin
- analgesia
- calcium and vitamin D supplementation
- surgery
239
Describe the action of bisphosphonates in Paget's disease of bone
Interfere with osteoclast activity and restore normal bone metabolism
Improve symptoms and prevent further abnormal bone formation
240
Describe the monitoring Paget's disease of bone
Serum alkaline phosphatase (ALP)
Review symptoms
241
Name 2 differential diagnosis of Paget's disease of bone
Osteomalacia
Fibrous dysplasia
242
Describe the complications of Paget's disease of bone
Hearing loss
Heart failure
Osteosarcoma
Spinal stenosis and spinal cord compression
243
Describe Spinal stenosis and spinal cord compression as a complication of Paget's disease of bone
Deformity in the spine leads to spinal canal narrowing
Pressure on spinal nerves can cause neurological signs and symptoms
Treated with bisphosphonates
Surgical intervention may be necessary
244
Define osteomyelitis
Inflammation in a bone and bone marrow, usually caused by a bacterial infection
245
Define haematogenous osteomyelitis
When a pathogen is carried through the blood and seeded in the bone.
246
Name 2 modes of infection in osteomyelitis
Haematogenous osteomyelitis (most common)
Direct contamination of the bone
247
What is the most common cause of osteomyelitis
Staphylococcus aureus
248
Name the risk factors of osteomyelitis
Open fractures
Orthopaedic operations (prosthetic joints)
Diabetes
IV drug use
Immunosuppression
249
Name the clinical features of osteomyelitis
Can be non-specific/generalised symptoms
Fever
Pain and tenderness
Erythema
Swelling
Acute or chronic
250
Describe the investigations of osteomyelitis
X-ray
MRI (diagnosis)
Blood tests
Blood cultures
251
What x-ray changes would be seen on osteomyelitis
Periosteal reaction
Localised osteopenia
Destruction of areas of the bone
(Often do not show changes)
252
Describe the management of osteomyelitis
Combination of:
Surgical debridement of infected bone and tissues
Antibiotic therapy
- prolonged cause
253
Describe the pathophysiology of vasculitis
Narrowing of blood vessels due to filtration of media with inflammatory cells.
Myofibroblasts proliferate causes narrowing, stimulates the vascular smooth muscle cell remodelling.
Vessel wall infiltration, proliferation, and damage causes weakening and occlusion of blood vessels
254
Describe the mechanism of vasculitis
Primary or secondary phenomena
Primary = idiopathic autoimmune process.
Secondary = drugs, infection, other autoimmune disease.
Immune complex = ANCA mediated
255
Name the classifications of vasculitis
1. Vessel size
2. Consequence classification - hybrid classification of vessel size, pathophysiology and underlying cause
256
Name the 2 risk factors of polyarteritis Nodosa
Hepatitis B virus
Age 40-60 years
257
Describe the risk factors (4 weak) of granulomatosis with polyangiitis
Genetic predisposition
Infection
Environmental exposure
White ethnicity
258
Describe the clinical features (generic) of vasculitis
Joint and muscle pain
Peripheral nephropathy
Renal impairment
Purpura
Necrotic skin ulcers
GI symptoms
Systemic symptoms
259
Define purpura
Purple coloured non blanching spots caused by blood leaking from vessels under the skin.
260
Describe the investigations for vasculitis
Serological testing - ANCA (often negative)
Biopsy
Kidney (as no symptoms)
Cross-sectional imaging
261
What are the two phases of management in vasculitis
1. Induction of remission
2. Maintenance of remission
262
Describe the management of induction of remission in vasculitis
1st line = steroids
+/- immunosupressents
263
Describe management of maintanance of remission in vasculitis
Aiming to prevent life threatening relapses
May be lifelong
Aim to reach minimum effective dose
DMARDs
264
In vasculitis when would there be a prognosis of early mortality
With lung and renal involvement
265
Name 3 types of vasculitis
Giant cell arteritis
Wegener's granulomatosis
Polyarteritis nodosa
266
What vessel does polyarteritis affect
Medium
267
Describe the aetiology of polyarteritis nodosa
Idiopathic
Secondary to infection (hepatitis B)
268
Describe the key clinical features of polyarteritis nodosa
Renal impairment
Hypertension
Cardiovascular events
- MI
- Stroke
- Mesenteric arteries causing intestinal symptoms
Tender, erythematosus skin nodules
269
What type of vessel does granulomatosis with polyarteritis
Small vessels
270
What would be the lab finding in granulomatosis with polyarteritis
c-ANCA
271
Name a clinical finding in granulomatosis with polyangiitis
Saddle-shaped nose due to nasal bridge collapse (nasal bridge dip downwards)
272
Describe the key clinical features of granulomatosis with polyarteritis
Primarily affects - respiratory tract and kidneys
Nasal symptoms
- nose bleeds, crusting of nose and nasal secretions.
Respiratory symptoms
- ears, causing hearing loss.
- sinuses, causing sinusitis
Glomerulonephritis
273
What type of vessel does giant cell arteritis affect
Large vessels
274
What would be a lab finding in giant cell arteritis
Raised ESR
275
Name 3 key clinical features in giant cell arteritis
Unilateral headache
Scalp tenderness
Vision loss
276
Define polymyalgia rheumatica
Inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck
277
Describe the pathophysiology of polymyalgia rheumatica
Remains unclear
278
Describe the epidemiology of polymyalgia rheumatica
Often occurs with giant cell arteritis
More common in older white patients
279
Describe the aetiology of polymyalgia rheumatica
Not understood
No relevant antibodies
280
Name the risk factors (2) for polymyalgia rheumatica
Age > (or equal to) 50 years
Giant cell arteritis
281
Describe the onset clinical features of polymyalgia rheumatica
Rapid onset over days/weeks (present for 2 weeks before diagnosis)
282
Where would pain and stiffness be in polymyalgia rheumatica
Shoulders - radiating to the upper arm and elbow
Pelvic girdle (around the hips) - potentially radiating to the thighs
Neck
283
Describe the features of pain and stiffness in polymyalgia rheumatica
Worse in the morning
Worse after rest or inactivity
Interfere with sleep
Morning stiffness > 45 minutes
Somewhat improves with activity
284
Describe the investigations of polymyalgia rheumatic
Inflammatory markers
Additional investigations (differential diagnosis)
- ANA
- anti-CCP
- Urine Bence jones protein
- Chest x-ray
285
What is NICE guidelines on initiating steroids
Advice full investigations
286
Describe the clinical diagnosis of polymyalgia rheumatica
Clinical presentation + response to steroids + excluding differentials
287
What is the 1st line management in polymyalgia rheumatica
Steroids
Rapid improvement often occurs within 24-72 hours
288
What is the management of patients on long term steroids
Don't STOP
Don't - steroid dependence occurs after 3 weeks
Sick day rules
Treatment card
Osteoporosis prevention
Proton pump inhibitors
289
Name 5 differential diagnosis of polymyalgia rheumatica
Osteoarthritis
Rheumatoid arteritis
Systemic lupus erythematosus
Osteomalacia
Fibromyalgia
290
What are the two types of bone tumours
Primary
- arise from cells which constitute the bone
- divided into benign or malignant
Secondary
- metastasis
- most common site = spine
291
What cancers spread to bone
Kidney
Thyroid
Lung
Prostate
Breast
292
What are the risk factors of bone tumours
Genetic association
- PB1 and P53
- Mutations TSC1 and TSC2
Exposure to radiation or alkylating agents
Benign bone conditions (osteosarcoma)
- Paget's disease
- Fibrous dysplasia
293
What are the clinical features of primary bone tumours
Main symptom = pain
Not associated with movement
Worse at night
= red flag symptoms
Enlargement - may cause pathological fractures
294
What are the investigations of bone tumours
Plain film radiographs
MRI imaging
CT imaging
Bone biopsy
295
What staging system is used in bone tumours
Enneking staging system
296
Describe the management of bone tumours if they are from metastatic spread
Rarely treated with surgery
Systemic therapies
Often palliative
Prophylactic nailing
297
Name 4 differential diagnosis of bone tumours
Osteomyelitis
Multiple myeloma
Metabolic bone disease
Pathological fracture
298
Name the examples of benign primary bone tumour
Osteoid osteoma
Osteochondroma
Chondroma
Giant cell tumour (osteoclastomas)
299
