MSK Flashcards
Does an asymmetrical presentation indicate rheumatoid or psoriatic arthritis?
Psoriatic arthritis
1st line management of RA?
DMARD monotherapy (e.g. methotrexate) +/- a short course of bridging prednisolone.
What is the 1st line DMARD in RA?
Methotrexate
What should you consider in patients with suspected polymyalgia rheumatica that do not respond to steroids?
Consider an alternative diagnosis –> patients with polymyalgia rheumatica typically respond dramatically to steroids
What scoring system is used to measure disease activity in rheumatoid arthritis?
DAS28
What 2 Abs are seen in RA?
1) Rheumatoid factor (RF)
2) Anti-cyclic citrullinated peptide antibody (anti-CCP)
What is used to manage the acute flares of rheumatoid arthritis?
IM steroids e.g. methylprednisolone
What is Felty’s syndrome?
A complication of RA.
Characterised by RA + splenomegaly + low WCC.
What are 6 respiratory complications of RA?
1) Pulmonary fibrosis
2) Pleural effusion
3) Pulmonary nodules
4) Bronchiolitis obliterans
5) Methotrexate pneumonitis
6) Pleurisy
What is a cardiac complication of RA?
IHD –> RA carries a similar risk to type 2 diabetes mellitus
Features of a prolapsed lumbar disc?
Usually produces clear dermatomal leg pain associated with neurological deficits.
- Leg pain usually worse than back
- Pain often worse when sitting
Mx of prolapsed disc?
Similar to that of other MSK lower back pain: analgesia, physiotherapy, exercises
When is referral for MRI appropriate in a prolapsed disc?
iIf symptoms persist e.g. after 4-6 weeks)
Features of a prolapsed disc with S1 nerve root compression?
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
When can a diagnosis of osteoarthritis be made clinically (i.e. without imaging)?
In individuals aged ≥45y who present with activity-related joint pain and experience minimal morning joint stiffness lasting <30 minutes.
Stepwise Mx of osteoarthritis?
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
What is the key investigation in the diagnosis of polymyalgia rheumatica?
ESR and CRP (raised)
Is there true weakness of limb girdles in polymyalgia rheumatica on examination?
No - any weakness of muscles is due to myalgia (pain inhibition)
What are some poor prognostic factors in RA?
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
How does onset affect prognosis in RA?
Acute –> better prognosis
Insidious –> worse prognosis
What is De Quervain’s tenosynovitis?
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.
How does De Quervain’s tenosynovitis present?
With pain on the radial side of the wrist and tenderness over the radial styloid process.
Abduction of the thumb against resistance is painful
What test is used in examination of De Quervain’s tenosynovitis?
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.
Mx of De Quervain’s tenosynovitis?
Analgesia & steroid injection
How will the leg appear in a posterior hip dislocation (i.e. sitting in a car during an accident)?
Leg shortening & internal rotation.
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.
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
What is the most commonly associated condition with scleritis?
RA
1st line for lower back pain?
NSAIDs (co-prescribe PPIs for patients over the age of 45 years)
Muscle strength in polymyalgia rheumatica (PMR)?
Normal
Weakness is not considered a symptom of polymyalgia rheumatica.
Onset of PMR?
Rapid (<1 month)
What is a key investigation in patients with temporal arteritis?
Vision testing -> risk of permanent vision loss
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.
What does fundoscopy show in anterior ischemic optic neuropathy caused by temporal arteritis?
Fundoscopy typically shows a swollen pale disc and blurred margins
Temporal arteritis may result in temporary visual loss.
What is this called?
amaurosis fugax
What blood findings are there in temporal arteritis?
Raised inflammatory markers (ESR & CRP)
Investigations in temporal arteritis?
1) Inflammatory markers
2) Vision testing
3) Temporal artery biopsy
What may be present on a temporal artery biopsy in temporal arteritis?
Skip lesions
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
Steroid response in temporal arteritis?
There should be a dramatic response, if not the diagnosis should be reconsidered.
What are 4 causes of avascular necrosis of the hip?
1) long term steroid use
2) chemo
3) alcohol excess
4) trauma
What condition do Gottron’s papules indicate?
Dermatomyositis –> these are roughened red papules over extensor surfaces of fingers
What is dermatomyositis?
An inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions.
What is it important to screen for in dermatomyositis?
Underlying malignancy
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)
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
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
Levels of what are normally high in sarcoidosis?
ACE levels
Features of acute sarcoidosis?
- erythema nodosum
- bilateral hilar lymphadenopathy
- swinging fever
- polyarthralgia
How does trochanteric bursitis present?
With isolated lateral hip/thigh pain with tenderness over the greater trochanter
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
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.
What is broken down into uric acid?
Purines
Pathophysiology of gout?
1) Raised uric acid levels due to purine breakdown
2) Monosodium urate (MSU) crystals accumulate in joints
3) Inflammatory response
Repeated episodes of acute gout can lead to chronic gouty arthritis, what is this characterised by?
Tophi formation, joint damage & chronic pain
Where are gouty tophi typically seen?
Hands, elbow & ears
When diagnosing gout, when should uric acid levels be measured?
around 6 weeks following the first presentation of suspected gout
Which diuretics in particular can cause gout?
Thiazide diuretics (as associated with hyperuricaemia)
Medical management of ACUTE gout flares (1st, 2nd & 3rd line)?
1) NSAIDs
2) Colchicine
3) Oral steroids
Who is colchicine used in in an acute gout attack?
Those who cannot take NSAIDs e.g. renal impairment, significant heart disease
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.
What are 2 common side effects of colchicine?
1) Abdo symptoms
2) Diarrhoea
What 2 medications are used in the prophylaxis of gout?
1) Allopurinol
2) Febuxostate
What is the mechanism of allopurinol & febuxostate?
xanthine oxidase inhibitors –> lower uric acid level
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.
Who is offered urate-lowering therapy (e.g. allopurinol)?
Everyone is offered it after their FIRST attack
What crystal type is seen in pseudogout?
Calcium pyrophosphate
What is reactive arthritis usually triggered by? (2)
1) Urethritis
2) Gastroenteritis
How long are Abx given for in septic arthritis?
4-6 weeks (IV then oral)
if osteomyelitis is suspected, what investigation should be done?
MRI
which tb drug canc cause gout ?
Pyrazinamide
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
What Abx is given in septic arthritis in penicillin allergy?
Clindamycin
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
Juxta-articular osteoporosis/osteopenia is an early x-ray feature of what condition?
RA
What does joint aspiration show in RA?
1) High WCC (predominantly neutrophils)
2) Appearance is typically yellow and cloudy
3) Absence of crystals
What dermatological manifestation can be seen in reactive arthritis?
keratoderma blenorrhagica –> this is a waxy yellow/brown papules on palms and soles
At what age can a diagnosis of osteoarthritis be made without any investigations?
≥45 y/o
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.
What is the most common gene associated with rheumatoid arthritis?
HLA-DR4
What 2 antibodies can be seen in RA (and predict worse disease)?
1) Rheumatoid factor (RF)
2) Anti-cyclic citrullinated peptide (anti-CCP)
What scan can be done to visualise atlantoaxial subluxation?
MRI
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.
Complications of atlantoaxial subluxation?
emergency –> can cause spinal cord compression
What score is used to measure success of RA treatment?
DAS28
What drug treatment used in RA can cause retinopathy?
Hydroxychoroquine
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
What is the most common ocular manifestation of RA?
keratoconjunctivitis sicca (dry eye syndrome)
What 2 things are used to measure success of RA treatment?
1) CRP
2) DAS28 score
What is Caplan syndrome?
Development of massive fibrotic nodules in the lungs in patients with RA due to occupation coal dust exposure.
Which questionnaire measures functional ability in RA?
HAQ (health assessment questionnaire)
Felty’s syndrome is a rare complication of RA.
What triad of features is there?
1) RA
2) Neutropenia
3) Splenomegaly
What are the 4 most common DMARDs used in RA?
1) methotrexate
2) sulfalazine
3) luflonamide
4) hydroxychloroquine
Which 2 DMARDs used in RA are teratogenic?
1) methotrexate
2) leflonamide
Which 2 DMARDs used in RA are safe in pregnancy?
1) hydroxychloroquine
2) sulfalazine
What is required alongside sulfasalazine in pregnancy?
Extra folic acid
What is the ‘mildest’ DMARD? When would it be used?
Hydroxychoroquine
May be used in mild disease and palindromic rheumatism.
Which DMARD interferes with production of pyrimidine?
Leflunomide
Are RF autoantibodies or anti-CCP antibodies more sensitive and specific for RA?
Anti-CCP
What are 3 key side effects of hydroxychloroquine?
1) Retinal toxicity (reduced visual acuity)
2) Blue-grey skin pigmentation
3) Hair lightening (bleaching)
Which RA drug can cause retinal toxicity?
Hydroxychloroquine
Which RA drug can cause retinal toxicity?
Steroids
Which DMARD can cause peripheral neuropathy?
Leflunomide
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
Which RA drug can cause orange urine?
Sulfalazine
Which RA drug can cause reversible male infertility?
Sulfalazine
Why is phosphate high in CKD?
As kidneys fail to excrete it
Calcium, phosphate, ALP and PTH levels in osteomalacia?
Low calcium
Low phosphate
High PTH
High ALP
What is Charcot joint (AKA neuropathic joint)?
A joint that has been badly disrupted and damanged 2ary to a loss of sensation.
What are 2 key risk factors for Charcot joint?
1) alcoholism
2) diabetes
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
What is spastic paraparesis?
Describes an UMN pattern of weakness in the lower limbs.
What is a key cause of spastic paraparesis?
Demyelination e.g. MS
Mx of acute flare of RA?
IM steroids e.g. methylprednisolone
How long must the symptoms be present for for a PMR diagnosis to be made?
2 weeks
Where is pain & stiffness most common in PMR? (3)
1) Shoulders
2) Neck
3) Pelvic girdle
What antibodies are seen in SLE?
ANA
How long does treatment with steroids in PMR last?
1-2 years
What is used to diagnose osteoporosis/osteopenia?
DEXA scan –> T score of femoral neck
What is the ‘T score’ on a DEXA scan?
The number of standard deviations the patient is away from a healthy young adult
What T score is normal?
More than -1
What does a T score of -1 mean?
The bone mineral density is 1 standard deviation below the average for healthy young adults.
Impact of tamoxifen on:
a) breast
b) bone
c) endometrium
a) blocks oestrogen
b) stimulates oestrogen
c) stimulates oestrogen
Impact of tamoxifen on osteoporosis?
Protective
What T score defines severe osteoporosis?
Less than -2.5 + fracture
Is T score or Z score used for diagnosis of osteoporosis?
T score
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)
What QFracture score are patients considered for a DEXA scan?
Above 10%
What T score defines osteopenia?
-1 to -2.5
What T score defines osteoporosis?
Less than -2.5
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.
What is a SERM used to treat osteoporosis?
Raloxifene
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
What are the 2 tools used for risk assessment in osteoporosis?
1) DEXA scan
2) FRAX tool
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)
What should be started in all patients aged ≥75 following a fragility fracture?
Alendronate (without waiting for a DEXA scan)
What is initial management in RA?
Conventional DMARD monotherapy (usually methotrexate), often with short-term bridging corticosteroid.
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.
Management of cauda equina?
Surgical decompression
What tool is used to stratify the risk of a patient presenting with acute back pain developing chronic back pain?
STarT back tool
What spinal nerves form the sciatic nerve?
L4-S3
What is the 1st line management of ankylosing spondylitis?
NSAIDs + regular exercise + physiotherapy
1st line for back pain?
NSAIDs
