MSK Flashcards
1
Q
Does an asymmetrical presentation indicate rheumatoid or psoriatic arthritis?
A
Psoriatic arthritis
2
Q
1st line management of RA?
A
DMARD monotherapy (e.g. methotrexate) +/- a short course of bridging prednisolone.
3
Q
What is the 1st line DMARD in RA?
A
Methotrexate
4
Q
What should you consider in patients with suspected polymyalgia rheumatica that do not respond to steroids?
A
Consider an alternative diagnosis –> patients with polymyalgia rheumatica typically respond dramatically to steroids
5
Q
What scoring system is used to measure disease activity in rheumatoid arthritis?
A
DAS28
6
Q
What 2 Abs are seen in RA?
A
1) Rheumatoid factor (RF)
2) Anti-cyclic citrullinated peptide antibody (anti-CCP)
7
Q
What is used to manage the acute flares of rheumatoid arthritis?
A
IM steroids e.g. methylprednisolone
8
Q
What is Felty’s syndrome?
A
A complication of RA.
Characterised by RA + splenomegaly + low WCC.
9
Q
What are 6 respiratory complications of RA?
A
1) Pulmonary fibrosis
2) Pleural effusion
3) Pulmonary nodules
4) Bronchiolitis obliterans
5) Methotrexate pneumonitis
6) Pleurisy
10
Q
What is a cardiac complication of RA?
A
IHD –> RA carries a similar risk to type 2 diabetes mellitus
11
Q
Features of a prolapsed lumbar disc?
A
Usually produces clear dermatomal leg pain associated with neurological deficits.
- Leg pain usually worse than back
- Pain often worse when sitting
12
Q
Mx of prolapsed disc?
A
Similar to that of other MSK lower back pain: analgesia, physiotherapy, exercises
13
Q
When is referral for MRI appropriate in a prolapsed disc?
A
iIf symptoms persist e.g. after 4-6 weeks)
14
Q
Features of a prolapsed disc with S1 nerve root compression?
A
1) Sensory loss –> posterolateral aspect of leg and lateral aspect of foot
2) Weakness in plantar flexion of foot
3) Reduced ankle reflex
4) Positive sciatic nerve stretch test
15
Q
When can a diagnosis of osteoarthritis be made clinically (i.e. without imaging)?
A
In individuals aged ≥45y who present with activity-related joint pain and experience minimal morning joint stiffness lasting <30 minutes.
16
Q
Stepwise Mx of osteoarthritis?
A
Lifestyle –> weight loss, local muscle strengthening exercises and general aerobic fitness
1) Topical NSAIDs
2) Oral NSAIDs (+ PPI)
3) Intra-articular steroid injections (patients should be aware that they only provide short-term relief (2-10 weeks)
4) Joint replacement
17
Q
What is the key investigation in the diagnosis of polymyalgia rheumatica?
A
ESR and CRP (raised)
18
Q
Is there true weakness of limb girdles in polymyalgia rheumatica on examination?
A
No - any weakness of muscles is due to myalgia (pain inhibition)
19
Q
What are some poor prognostic factors in RA?
A
1) RF positive
2) anti-CCP Abx
3) poor functional status at presentation
4) X-ray: early erosions (e.g. after < 2 years)
5) extra articular features e.g. nodules
6) HLA DR4
7) insidious onset
20
Q
How does onset affect prognosis in RA?
A
Acute –> better prognosis
Insidious –> worse prognosis
21
Q
What is De Quervain’s tenosynovitis?
A
A common condition in which the sheath containing the extensor pollicis brevis and abductor pollicis longus tendons is inflamed.
It typically affects females aged 30 - 50 years old.
22
Q
How does De Quervain’s tenosynovitis present?
A
With pain on the radial side of the wrist and tenderness over the radial styloid process.
Abduction of the thumb against resistance is painful
23
Q
What test is used in examination of De Quervain’s tenosynovitis?
A
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.
24
Q
Mx of De Quervain’s tenosynovitis?
A
Analgesia & steroid injection
25
How will the leg appear in a posterior hip dislocation (i.e. sitting in a car during an accident)?
Leg shortening & internal rotation.
26
Why are chemotherapy patients at an increased risk of gout?
From increased urate production.
Cytotoxic drugs cause an increase in the breakdown of cells, releasing products that are degraded into uric acid.
27
Features of growing pains?
- never present at the start of the day after the child has woken
- no limp
- no limitation of physical activity
- systemically well
- normal physical examination
- motor milestones normal
- symptoms are often intermittent and worse after a day of vigorous activity
28
What is the most commonly associated condition with scleritis?
RA
29
1st line for lower back pain?
NSAIDs (co-prescribe PPIs for patients over the age of 45 years)
30
Muscle strength in polymyalgia rheumatica (PMR)?
Normal
Weakness is not considered a symptom of polymyalgia rheumatica.
31
Onset of PMR?
Rapid (<1 month)
32
What is a key investigation in patients with temporal arteritis?
Vision testing -> risk of permanent vision loss
33
What accounts for the majority of ocular complications in temporal arteritis?
Anterior ischemic optic neuropathy.
This results from occlusion of the posterior ciliary artery (a branch of the ophthalmic artery) → ischaemia of the optic nerve head.
34
What does fundoscopy show in anterior ischemic optic neuropathy caused by temporal arteritis?
Fundoscopy typically shows a swollen pale disc and blurred margins
35
Temporal arteritis may result in temporary visual loss.
What is this called?
amaurosis fugax
36
What blood findings are there in temporal arteritis?
Raised inflammatory markers (ESR & CRP)
37
Investigations in temporal arteritis?
1) Inflammatory markers
2) Vision testing
3) Temporal artery biopsy
38
What may be present on a temporal artery biopsy in temporal arteritis?
Skip lesions
39
What should be given as soon as the diagnosis of temporal arteritis is suspected and before the temporal artery biopsy?
Urgent high dose glucocorticoids:
If no visual loss --> high dose prednisolone
If evolving visual loss --> IV ethylprednisolone is usually given prior to starting high-dose prednisolone
40
Steroid response in temporal arteritis?
There should be a dramatic response, if not the diagnosis should be reconsidered.
41
What are 4 causes of avascular necrosis of the hip?
1) long term steroid use
2) chemo
3) alcohol excess
4) trauma
42
What condition do Gottron's papules indicate?
Dermatomyositis --> these are roughened red papules over extensor surfaces of fingers
43
What is dermatomyositis?
An inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions.
44
What is it important to screen for in dermatomyositis?
Underlying malignancy
45
What are some causes of carpel tunnel syndrome?
1) idiopathic
2) pregnancy
3) oedema e.g. heart failure
4) lunate fracture
5) rheumatoid arthritis (RA)
46
History of symptoms in carpel tunnel?
- pain/pins and needles in thumb, index, middle finger
- unusually the symptoms may 'ascend' proximally
- patient shakes his hand to obtain relief, classically at night
47
What 2 signs are seen in carpel tunnel syndrome?
1) Tinel's sign --> tapping causes paraesthesia
2) Phalen's sign --> flexion of wrist causes symptoms
48
Levels of what are normally high in sarcoidosis?
ACE levels
49
Features of acute sarcoidosis?
- erythema nodosum
- bilateral hilar lymphadenopathy
- swinging fever
- polyarthralgia
50
How does trochanteric bursitis present?
With isolated lateral hip/thigh pain with tenderness over the greater trochanter
51
What are the ocular manifestations of RA?
1) keratoconjunctivitis sicca (most common)
2) episcleritis (erythema)
3) scleritis (erythema and pain)
4) corneal ulceration
5) keratitis
52
Mx of a prolapsed disc causing sciatica?
Start treatment with NSAIDs and refer for physio.
A referral for sciatica is appropriate after 4-6 weeks of conservative treatment (analgesia and physiotherapy) has failed.
53
What is broken down into uric acid?
Purines
54
Pathophysiology of gout?
1) Raised uric acid levels due to purine breakdown
2) Monosodium urate (MSU) crystals accumulate in joints
3) Inflammatory response
55
Repeated episodes of acute gout can lead to chronic gouty arthritis, what is this characterised by?
Tophi formation, joint damage & chronic pain
56
Where are gouty tophi typically seen?
Hands, elbow & ears
57
When diagnosing gout, when should uric acid levels be measured?
around 6 weeks following the first presentation of suspected gout
58
Which diuretics in particular can cause gout?
Thiazide diuretics (as associated with hyperuricaemia)
59
Medical management of ACUTE gout flares (1st, 2nd & 3rd line)?
1) NSAIDs
2) Colchicine
3) Oral steroids
60
Who is colchicine used in in an acute gout attack?
Those who cannot take NSAIDs e.g. renal impairment, significant heart disease
61
What does aspirated joint fluid show in gout?
Monosodium urate crystals --> these are needle-shaped and NEGATIVELY birefringent of polarised light.
There should be no bacterial growth.
62
What are 2 common side effects of colchicine?
1) Abdo symptoms
2) Diarrhoea
63
What 2 medications are used in the prophylaxis of gout?
1) Allopurinol
2) Febuxostate
64
What is the mechanism of allopurinol & febuxostate?
xanthine oxidase inhibitors --> lower uric acid level
65
When is gout prophylaxis started after an attack?
Prophylaxis is not started until weeks after the first acute attack has resolved.
Once allopurinol or febuxostat is initiated, it is continued during an acute attack.
66
Who is offered urate-lowering therapy (e.g. allopurinol)?
Everyone is offered it after their FIRST attack
67
What crystal type is seen in pseudogout?
Calcium pyrophosphate
68
What is reactive arthritis usually triggered by? (2)
1) Urethritis
2) Gastroenteritis
69
How long are Abx given for in septic arthritis?
4-6 weeks (IV then oral)
70
if osteomyelitis is suspected, what investigation should be done?
MRI
71
which tb drug canc cause gout ?
Pyrazinamide
72
What criteria is used for the diagnosis of septic arthritis?
Kosher criteria:
1) Fever >38.5
2) Non-weight bearing
3) Raised WCC
4) Raised ESR
73
What Abx is given in septic arthritis in penicillin allergy?
Clindamycin
74
What makes up the Kocher criteria in kids?
1) Non-weight bearing - 1 point
2) Fever >38.5ºC - 1 point
3) WCC >12 * 109/L - 1 point
4) ESR >40mm/hr - 1 point
75
Juxta-articular osteoporosis/osteopenia is an early x-ray feature of what condition?
RA
76
What does joint aspiration show in RA?
1) High WCC (predominantly neutrophils)
2) Appearance is typically yellow and cloudy
3) Absence of crystals
77
What dermatological manifestation can be seen in reactive arthritis?
keratoderma blenorrhagica --> this is a waxy yellow/brown papules on palms and soles
78
At what age can a diagnosis of osteoarthritis be made without any investigations?
≥45 y/o
79
What does RF target in RA?
What does this cause?
RF targets the Fc portion of IgG.
This leads to immune system activation against patient's own IgG, and widespread inflammation.
80
What is the most common gene associated with rheumatoid arthritis?
HLA-DR4
81
What 2 antibodies can be seen in RA (and predict worse disease)?
1) Rheumatoid factor (RF)
2) Anti-cyclic citrullinated peptide (anti-CCP)
82
What scan can be done to visualise atlantoaxial subluxation?
MRI
83
What is palindromic rheumatism?
Self-limiting episodes of inflammatory arthritis, with pain, stiffness and swelling typically affecting only a few joints.
These episodes last a few days and then completely resolve.
84
Complications of atlantoaxial subluxation?
emergency --> can cause spinal cord compression
85
What score is used to measure success of RA treatment?
DAS28
86
What drug treatment used in RA can cause retinopathy?
Hydroxychoroquine
87
What respiratory complications can occur in RA?
- pulm fibrosis
- pulm nodules
- pleural effusion
- bronchiolitis obliterans
- complications of drug therapy e.g. methotrexate pneumonitis
- Caplan's syndrome - massive fibrotic nodules with occupational coal dust exposure
88
What is the most common ocular manifestation of RA?
keratoconjunctivitis sicca (dry eye syndrome)
89
What 2 things are used to measure success of RA treatment?
1) CRP
2) DAS28 score
90
What is Caplan syndrome?
Development of massive fibrotic nodules in the lungs in patients with RA due to occupation coal dust exposure.
91
Which questionnaire measures functional ability in RA?
HAQ (health assessment questionnaire)
92
Felty's syndrome is a rare complication of RA.
What triad of features is there?
1) RA
2) Neutropenia
3) Splenomegaly
93
What are the 4 most common DMARDs used in RA?
1) methotrexate
2) sulfalazine
3) luflonamide
4) hydroxychloroquine
94
Which 2 DMARDs used in RA are teratogenic?
1) methotrexate
2) leflonamide
95
Which 2 DMARDs used in RA are safe in pregnancy?
1) hydroxychloroquine
2) sulfalazine
96
What is required alongside sulfasalazine in pregnancy?
Extra folic acid
97
What is the ‘mildest’ DMARD? When would it be used?
Hydroxychoroquine
May be used in mild disease and palindromic rheumatism.
98
Which DMARD interferes with production of pyrimidine?
Leflunomide
99
Are RF autoantibodies or anti-CCP antibodies more sensitive and specific for RA?
Anti-CCP
100
What are 3 key side effects of hydroxychloroquine?
1) Retinal toxicity (reduced visual acuity)
2) Blue-grey skin pigmentation
3) Hair lightening (bleaching)
101
Which RA drug can cause retinal toxicity?
Hydroxychloroquine
102
Which RA drug can cause retinal toxicity?
Steroids
103
Which DMARD can cause peripheral neuropathy?
Leflunomide
104
Give the key side effects of the following RA drugs:
a) methotrexate
b) sulfalazine
c) leflunomide
d) hydroxychloroquine
e) anti-TNF
f) rituximab
a) bone marrow suppression, leukopenia, teratogenic
b) orange urine, male infertility
c) peripheral neuropathy, teratogenic, HTN
d) blue-grey skin, hair bleaching, retinal toxicity
e) reactivation of TB
f) night sweats & thrombocytopenia
105
Which RA drug can cause orange urine?
Sulfalazine
106
Which RA drug can cause reversible male infertility?
Sulfalazine
107
Why is phosphate high in CKD?
As kidneys fail to excrete it
108
Calcium, phosphate, ALP and PTH levels in osteomalacia?
Low calcium
Low phosphate
High PTH
High ALP
109
What is Charcot joint (AKA neuropathic joint)?
A joint that has been badly disrupted and damanged 2ary to a loss of sensation.
110
What are 2 key risk factors for Charcot joint?
1) alcoholism
2) diabetes
111
Features of Charcot joint?
- the joint is typically swollen, red and warm
- Charcot joints are typically a lot less painful than would be expected given the degree of joint disruption due to the sensory neuropathy
112
What is spastic paraparesis?
Describes an UMN pattern of weakness in the lower limbs.
113
What is a key cause of spastic paraparesis?
Demyelination e.g. MS
114
Mx of acute flare of RA?
IM steroids e.g. methylprednisolone
115
How long must the symptoms be present for for a PMR diagnosis to be made?
2 weeks
116
Where is pain & stiffness most common in PMR? (3)
1) Shoulders
2) Neck
3) Pelvic girdle
117
What antibodies are seen in SLE?
ANA
118
How long does treatment with steroids in PMR last?
1-2 years
119
What is used to diagnose osteoporosis/osteopenia?
DEXA scan --> T score of femoral neck
120
What is the 'T score' on a DEXA scan?
The number of standard deviations the patient is away from a healthy young adult
121
What T score is normal?
More than -1
122
What does a T score of -1 mean?
The bone mineral density is 1 standard deviation below the average for healthy young adults.
123
Impact of tamoxifen on:
a) breast
b) bone
c) endometrium
a) blocks oestrogen
b) stimulates oestrogen
c) stimulates oestrogen
124
Impact of tamoxifen on osteoporosis?
Protective
125
What T score defines severe osteoporosis?
Less than -2.5 + fracture
126
Is T score or Z score used for diagnosis of osteoporosis?
T score
127
Side effects of bisphosphonates? (4)
1) Reflux & oesophageal erosion
2) Osteonecrosis of jaw
3) Osteonecrosis of external auditory canal
4) Atypical fractures (e.g. atypical femoral fractures)
128
What QFracture score are patients considered for a DEXA scan?
Above 10%
129
What T score defines osteopenia?
-1 to -2.5
130
What T score defines osteoporosis?
Less than -2.5
131
How should oral bisphosphonates be taken?
Oral bisphosphonates are taken on an EMPTY stomach with a full glass of water.
Afterwards, the patient should sit UPRIGHT for 30 minutes before moving or eating to reduce the risk of reflux and oesophageal erosions.
132
What is a SERM used to treat osteoporosis?
Raloxifene
133
How can CKD lead to reduced bone mineral density?
1) CKD leads to the deficiency of the active form of vitamin D
2) This leads to hypocalcaemia
3) PTH levels rise in response (2ary hyperparathyroidism)
4) Causes reduced bone mineral density & increased fracture risk
134
What are the 2 tools used for risk assessment in osteoporosis?
1) DEXA scan
2) FRAX tool
135
What is required in patients who are going to take long-term steroids?
Immediate bone protection:
1) Calcium & vitamin D replacement (if low)
2) Bisphosphonates (alendronic acid is 1st line)
136
What should be started in all patients aged ≥75 following a fragility fracture?
Alendronate (without waiting for a DEXA scan)
137
What is initial management in RA?
Conventional DMARD monotherapy (usually methotrexate), often with short-term bridging corticosteroid.
138
Describe the sciatic stretch test
1) The patient lies on their back with their leg straight.
2) The examiner lifts one leg from the ankle with the knee extended until the limit of hip flexion is reached (usually around 80-90 degrees).
3) Then the examiner dorsiflexes the patient’s ankle.
139
Management of cauda equina?
Surgical decompression
140
What tool is used to stratify the risk of a patient presenting with acute back pain developing chronic back pain?
STarT back tool
141
What spinal nerves form the sciatic nerve?
L4-S3
142
What is the 1st line management of ankylosing spondylitis?
NSAIDs + regular exercise + physiotherapy
143
1st line for back pain?
NSAIDs
144
