MSK

Question 1

A patient presents with lower back pain. Give 5 differentials for each age:
15-30:
30-50:
>50:
Other:

Answer 1

15-30:
1) Postural/mechanical
2) Prolapsed disk
3) Trauma/fracture
4) Ankylosing spondylitis + Reactive arthritis
5) Spondylolisthesis
6) Pregnancy

30-50:
1) Postural
2) Prolapsed disc
3) Discitis
4) Spondyloarthropathies (Ankylosing spondylitis, psoriatic arthritis, Reactive arthritis)
5) Degenerative bone disease (OA, Spondylosis, Osteoporosis)

> 50:
1) Postural
2) Prolapsed disc
3) Malignancy
4) Myeloma
5) Degenerative joint disease (OA, spondylosis, osteoporosis)
6) Paget’s disease

Other:
1) Spinal stenosis
2) Spinal infection (Osteomyelitis, septic arthritis)
3) Cauda Equina
4) AAA

Question 2

What is the difference between spinal stenosis and spinal compression

Answer 2

Spinal Stenosis is the narrowing of the spinal canal which can lead to nerve compression.

Spinal Compression involves direct pressure on the nerves or spinal cord, and can be a result of stenosis or other conditions like disc herniation or tumours.

Question 3

What is encompassed within Spondyloarthropathies?

What do they all share?

Answer 3

Spondyloarthropathies are a group of HLA-B27 disorders that primarily affect the spine and are characterised by Enthesitis. They include:
Ankylosing spondylitis (15-30+30-50)
Psoriatic arthritis (30-50)
Reactive arthritis (15-30 + 30-50)

Question 4

What organisms primarily cause reactive arthritis

Answer 4

Chlamydia
Food borne (Shigella campylobacter)

Question 5

State 3 degenerative bone diseases

Answer 5

OsteoArthritis
Spondylosis (OA but for spine)
Osteoporosis (typically 50+)

Question 6

What are the most common malignancies found on a bone scan

Answer 6

the vast majority of tumours found in bone scans are not primary but metastasis from another tumour (Prostate, breast, thyroid, kidney)

Question 7

What is Paget’s disease of the bone?

What age group does it primarily affect?

Answer 7

Paget’s disease of the bone is a disease characterized by high turnover bone remodelling in a mosaic pattern leading to mis-shaped, fragile bones and bone pain

3 phases: (extra info)
1) Increased osteoclast activity => abnormal breakdown
2) Abnormal excessively increased osteoblast activity leading to disorganised, thickened bone
3) Cycle repeats leading to the high turnover bone remodelling

Question 8

Go over the Dermatomes yourself (image in answer)
State the myotomes and the reflexes they are involved in if applicable

Answer 8

L2 - Hip flexion + adduction
L3 - Knee extension
L4 - Knee extension + Foot dorsiflexion
L5 - Knee flex + foot inversion + Big tow dorsiflexion
S1 - Knee flexion + Foor plantar flexion

Knee reflex (L3,L4)
Ankle reflex (S1,S2)

Question 9

A joint that moves with ease suggests?

Answer 9

Inflammation as the cause (think RA for example which eases with movement)

Question 10

How would you structure and hx and exam in MSK?

Answer 10

Hx
Pain (Socrates)
Deformity
Loss of function/Impact on QoL
Neurology

Exam
Look
Feel
Move
Special tests
+/- neuro

Question 11

When conducting an examination in MSK, what routine neuro should you perform?

Answer 11

1) SLR (if backpain)
2) Sensory loss
3) Muscle weakness (power)

Question 12

You are asked to conduct a focused examination of the spine. Go through what you will do and what you are looking for

Answer 12

Important to note that the lower limb must be examined along with the spine
Look: Deformity such as kyphosis (ank.spon), lumbar lordosis, scoliosis

Feel: Spine and paraspinal muscles for tenderness !stepdeformity, muscle spasm

Move: Flexion, extension, !!!lateral rotation and flexion.

Special tests: Straight leg raise (ipsilateral sciatica) + Schober test

Neuro:
Inspection: LL Muscle wasting
Palpation: LL Muscle wasting and LL sensory
Motor: Power + Reflexes!!

Question 13

How is Schober test performed?

Answer 13

Mark at L5 and another 10cm above. Ask the patient to flex forward. If <+5 cm (total 15cm) => Ankylosing spondylitis

Question 14

What are the red flags in MSK

Answer 14

!!!Saddle Anaesthesia
!!!Urinary incontinence
!!! Night time pain
Weight loss/past hx of cancer
Ages <20, >55
Non-mechanical pain/pain at rest
Pain that worsens when supine
Immunosuppression (Drugs, transplant, HIV, IVDU)
Systemically unwell

Question 15

What screening tool is used in the evaluation of back pain? How would you explain what it involves?

How are the results interpreted?

Answer 15

The Keele STarT Back Screening Tool is a validated questionnaire used to classify patients with low back pain into categories of low, medium, or high risk for chronicity, based on their physical and psychosocial risk factors, to guide appropriate treatment strategies.

3 or less -> Avoid rest, advise on self-help and exercise
If 4+ -> we should look at questions 5-9
=> 3 or less => Physical therapy after 4 weeks
=> 4+ => Specialist referral

Question 16

What is the general workup of a patient presenting with lower back pain in primary care including relevant general management

Answer 16

-> means If present then do
1) Triage with hx and exam
2) Rule out fracture -> Xray -> manage (cast, external/internal fixation)
3) Rule out Cauda Equina? -> Immediate admission
4) Rule out Red flags? -> Conduct bloods (ESR, Ca2+, PO4, Alk Phos, PSA, CA125) + Xray
5) Neurological signs? -> Referral if not resolving within 4 weeks
6) Keele STarT Back Pain Scoring Tool
Final management based on score
In all: NSAID + Omeprazole or Codeine + Paracetamol
3 or less -> Avoid rest, advise on self-help and exercise
If 4+ -> we should look at questions 5-9
=> 3 or less => Physical therapy after 4 weeks
=> 4+ => Specialist referral

Question 17

What does physical therapy entail? Give 3 examples

Answer 17

Physiotherapy
Back exercises
Chiropractic
Osteopathy
Acupuncture

Question 18

What is Cauda Equina?

How does it present?

How is it managed?

Answer 18

Compression below L2 e.g. disc protrusion at L4/L5
This is a lower motor neuron lesion (upper motor neuron lesion) =>
Perianal anaesthesia
Asymmetrical LL weakness (Dorsiflexion-L4, Plantar flexion-S1, Eversion-S1)
Hypoflexion
Bowel/Bladder incontinence (sphincter)
Loss of ankle reflex (S1)

Immediate admission to A&E and surgical intervention

Question 19

A patient presents with a hx of thyroid cancer and new onset backpain worse on movement.
What is the most likely diagnosis?

Based on this what neurological symptoms may accompany this?

What imaging technique is best for this?

How is this managed?
If a patient is in the final stages of the disease, how is it managed?

Answer 19

Worse on backpain indicates that this isn’t due to inflammation
This is most likely spinal cord compression

Neurological signs:
In any case: LL weakness, urinary incontinence, constipation
Above L1 - UMN => increased tone and reflexes
Below L1 - LMN => reduced tone and reflexes

MRI (saggital view)

Management: Oral dexamethasone and referral for same-day assessment, surgery, and radiotherapy.
If final stage of disease, palliative care

Question 20

What is Scoliosis?

Give 5 causes

Give 3 specific examination findings

How would you manage in primary care?

Answer 20

Scoliosis is the lateral curvature of the spine

Causes:
1) Congenital (butterfly vertebra)
2) TB of spine
3) Neoplasm
4) Trauma
5) Neuromuscular (Cerebral palsy, neurofibromatosis)
6) Metabolic (bone dysplasia)

Exam:
1) Asymmetrical shoulder height
2) lateral curvature of spine
3) !!Unequal space between the trunk and the upper limb

Management: Referral to ortho. If pain then urgent referral

Question 21

What is postural scoliosis?

Answer 21

Scoliosis that disappears on bending.
It is not clinically significant

Question 22

What joints are you feeling during a shoulder exam? what would you be looking for?

Answer 22

Sternoclavicular joint
Acromioclavicular joint
Glenohumeral joint
Looking for crepitus, numbness, paraesthesia, swelling, tenderness, muscle wasting, ridges

Question 23

A patient presents with pain beginning at the shoulder and radiating down the arm anteriorly. Where is the pathology?

Answer 23

Shoulder joint

Question 24

Sources of shoulder tip pain?

Answer 24

Acromioclavicular joint
Cervical spine disorder
Irritation of the phrenic nerve/diaphragm => Referred pain(MI or inflammation e.g. cholecystitis, ectopic pregnancy, splenic rupture peritonitis)

Question 25

In a hx of shoulder problems, how would you assess for loss of function?

Answer 25

Inability to wear clothes, brushing hair, doing up bra

Question 26

What is the drop arm test and what does it test for?

Answer 26

Abduct arm to 90 degrees and ask patient to slowly bring down to their sides. Tests for rotator cuff tear

Question 27

What special tests should you perform in the shoulder test section. What does each test for

Answer 27

Empty can test (supraspinatus) Drop arm test (Rotator cuff tear) Lift off test (w/ resistance) (Subscapularis) Scarf Test (AC joint pathologies such as arthritis) Sulcus test (inferior instability) Apprehension test (Shoulder/anterior stability)

Question 28

A patient presents with painful limitation of movement in all directions. The pathology is likely to be caused by

Answer 28

Intraarticular disease

Question 29

A patient presents with painful limitation of movement in one plane. The pathology is likely to be caused by

Answer 29

Tendonitis

Question 30

A patient presents with painful weakness. The pathology is likely to be caused by

Answer 30

Tendon rupture or neurological signs

Question 31

A patient presents with a stiff, painful shoulder joint. What are your differentials

Answer 31

Rotator cuff injury/Tendonitis Shoulder osteoarthritis Adhesive capsulitis Prolonged immobilisation Polymyalgia rheumatica

Question 32

How does acute tendonitis present?

Answer 32

Holding shoulder immobile Unable to lie on affected side

Question 33

You suspect rotator cuff tear. What special test will you perform?

Answer 33

Drop arm test

Question 34

You suspect subacromial impingement. On examination, what would help you reach a diagnosis?

Answer 34

Painful arc test or internal rotation

Question 35

What is the painful arc?

Answer 35

Abduction from 60-120 degrees as this is the range that the rotator cuffs are responsible for

Question 36

How can a rotator cuff injury present (3)? What is the pathophysiology behind them all? What investigations will you perform? How are these managed in primary care + escalations

Answer 36

Rotator Cuff injury can present as either to all 3 of the folllowing: 1) Acute tendonitis: Due to excessive use/trauma in <40yo. Patient would be holding shoulder immobile and cannot sleep on that side 2) Rotator cuff tear: From trauma, Drop arm test +ve 3) Subacromial impingement: Painful arc +ve or pain on internal rotation Pathophysiology: Excessive use/trauma of the shoulder joint (controlled by the rotator cuff muscles) leads to acute tendonitis or tear which results in reduced space within the joint ending up with nerve impingement or subacromial impingement Investigations: X-ray, Dynamic USS, MRI Management: Rest->NSAIDs (+PPI) -> Physiotherapy -> Subacromial steroid injection -> Refer to Ortho

Question 37

A 55 year old with no history of trauma presents holding his shoulder immobile. He complains of being unable to sleep on that side lately. What could be the likely cause of this presentation? How is it treated?

Answer 37

With no history of trauma, it is more likely to be caused by inflammation around calcific deposits. Tx = Steroid injection

Question 38

What findings on X-ray would be consistent with rotator cuff injury? What findings on Dynamic USS?

Answer 38

X-ray -> calcification (of Supraspinatous), Glenohumeral joint cysts USS -> Impingement, tendonitis tears Remember what X-ray can see and what USS can see better

Question 39

Give 3 benefits and risks of steroid injections in joints

Answer 39

Benefits: - Reduce inflammation - Pain relief - Joint function (mobility) Risks: - Site infection or even septic arthritis - Cartilage damage and joint degradation - Increased blood sugar levels - Tendon weakening or rupture - Bleeding/haemorrhage (US-guided may help)

Question 40

What is the typical aetiology(ies) of shoulder osteoarthritis?

Answer 40

Trauma > chronic Or Crystal-induced inflammation (Gout/Haemochromatosis)

Question 41

What is the presentation of adhesive capsulitis? What pathologies are associated with adhesive capsulitis? Give the management escalations

Answer 41

Painfull stiff shoulder with global limitation of movement (intraarticular pathology that is !worse at night DM, Intrathoracic pathologies (Lung disease, Ischaemic heart disease, cervical pathologies) Management: Check HbA1c -> NSAIDs (+ppi) + Physiotherapy -> Local steroid injection -> Orthopaedic referral

Question 42

What is the typical aetiology of anterior dislocation What are complications of this? What examination findings are associated with this? How is this managed?

Answer 42

Fall on arm/shoulder in contact sports on an outstretched hand with !extended elbows (as opposed to Elbow dislocation) Complications: 1) Labral tear-> Apprehension test, Sulcus test +ve 2) Axillary nerve damage -> reduced sensation over regimental patch Management: Referral to A&E for Xray and reduction. Refer to ortho/physio if recurrent

Question 43

What is the typical aetiology and presentation of rupture of the head of the biceps.

Answer 43

Lifting -> pop -> Swelling and discomforty -> bulge on elbow flexion (Popeye's sign)

Question 44

Acromioclavicular joint problems present as

Answer 44

Shoulder tip pain Just a note, if you dont know how to treat something in ortho just say NSAIDs + PPI +/- steroid injection -> Refer to ortho

Question 45

What is cleidocranial dystosis

Answer 45

AD condition characterised by missing part or all of clavicle, delayed ossification of the skull, a/w short stature. No tx

Question 46

You perform a clinical exam on a patient coming with elbow pain. You note nodules over the olecranon. What are your ddx

Answer 46

1) Psoriasis 2) RA nodule 3) Gouty Tophus 4) Olecranon bursa 5) Trauma Note: When performing an elbow exam, dont forget to test for supination and pronation

Question 47

Define Epicondylitis and then Go through epicondylitis you already know it

Answer 47

Extensor tendon inflammation at the epicondyles due to repeated strain Tennis elbow = Lateral epicondylitis = pain on resisted wrist extension. Tenderness over lateral epicondyle Golfer's elbow = medial epicondyle = pain on resisted wrist pronation!!!. Tenderness over medial epicondyle Management: Rest and stop triggering movements +/- NSAIDs (+ppi) +/- Steroid injections (speeds up recovery but increased risk of recurrence) + physiotherapy

Question 48

What is the aetiology of olecranon bursa? Management?

Answer 48

Traumatic bursitis due to repeated pressure on elbow => pain and swelling over olecranon which may become infected => abscess Management: Conservative: Rest + Ice + analgesia Large/unresolving: Aspiration of fluid or steroid injection -> referral Infected -> antibiotics

Question 49

What is the most common distribution of numbness and paraesthesia in the upper limb? What pathology in the elbow may lead to this?

Answer 49

Ulnar distribution Ulnar Neuritis

Question 50

Ulnar neuritis typically begins with clumsiness -> weakness -> wasting of hand muscles -> reduced sensation over pinky + medial half of ring finger. What is the aetiology of Ulnar neuritis? How is it managed?

Answer 50

Narrowing of the ulnar groove from fracture or OA or RA leading to pressure on the ulnar nerve leading to ulnar neuropathy Managed via ruling out metabolic or autoimmune causes of mononeuritis and then referring for ! Nerve conduction studies and surgical decompression

Question 51

What is the aetiology of elbow dislocation? If you are looking at a person with elbow dislocation what would you see? Management?

Answer 51

Fall on an outstretched hand with !flexed elbow (in contrast to shoulder dislocation) Presentation: Swollen elbow with person holding it fixed in flexion! (in contrast to pulled elbow) Send to ED for reduction

Question 52

What is the aetiology of a pulled elbow? If you are looking at a child with a pulled elbow, what will you see? Would you do an Xray? How is this managed?

Answer 52

Children <5 due to traction injury causing subluxation of the radial head. Occurs when child is pulled up suddenly by the head. Child not using arm, elbow held in !extension + pronation (in contrast to elbow dislocation) X-ray is unhelpful. Reduce arm in clinic using

Question 53

What investigation is diagnostic for osteoporosis?

Answer 53

DEXA scan

Question 54

The DEXA scan can produce 2 score modalities. What are they? When should each be used?

Answer 54

T-score: Compares Bone Mineral Density of patient to the mean bone density of a 30 year old. For post-menopausal women and men >50. Z-score: Compares Bone mineral density of patient to age-matched normal control. Not used to diagnose osteoporosis. Used for children, premenopausal women, and men <50

Question 55

Osteoporosis most commonly affects the hips and mostly females due to menopause. The DEXA scan best tests for this. How would you diagnose Osteoporosis?

Answer 55

Osteopenia = T-score b/w -1 -> -2.5 Osteoporosis = T-score <-2.5

Question 56

Give 5 RF for osteoporosis

Answer 56

Low BMI Post-menopausal Age Steroid use Immobility Smoking Alcohol

Question 57

What does the DEXA scan stand for?

Answer 57

Dual-energy X-ray Absorbtiometry

Question 58

What is required to request a DEXA scan testing for osteoporosis

Answer 58

Qfracture or FRAX

Question 59

Give 5 causes for osteoporosis

Answer 59

Primary Osteoporosis: Menopause and old age (even men) Secondary Osteoporosis: 1) Endocrine: Hyperthyroidism, hyperparathyroidism, Hyperparathytoidism, hyperprolactinaemia, Cushing's, Hypogonadism (anorexia, androgen blockade - GnRH, LHRH, Antiandrogens). 2) GI - Coeliac, IBD, Chronic liver diease, Chronic pancreatitis 3) Rheumatological - RA, Reactive arthritis, psoriatic arthritis 4) Other: CF, Multiple myeloma, Immobility, Steroid use

Question 60

The DEXA scoring such as the T score is measured in standard deviations from the mean. Each St. Dev = 2-3x risk of a fracture. Define Fragility fracture What are the most common sites of a fragility fracture?

Answer 60

Fracture when falling from a standing height or Vertebral collapse Most common sites are Hip, wrist and vertebral

Question 61

A post-menopausal patient with low BMI presents with sudden onset severe lower back pain with no history of trauma. Their past history includes Rheumatoid arthritis for which she is taking long-term steroid for. What is your most likely diagnosis? How will you confirm it?

Answer 61

Osteoporosis, DEXA scan

Question 62

What lifestyle advice would you give to an osteopaenic/osteoporotic patient?

Answer 62

Lifestyle advice: 1) Nutrition: Maintain BMI >19 increased calcium in diet 2) Weight bearing exercises (+/- physiotherapy) 3) Smoking and alcohol cessation

Question 63

A post-menopausal patient with low BMI presents with sudden onset severe lower back pain with no history of trauma. Their past history includes Rheumatoid arthritis for which she is taking long-term steroid for. You conduct a DEXA scan and determine that the patient has a T-score of -1.5 consistent with osteopenia. How will you manage this patient?

Answer 63

Lifestyle advice: 1) Nutrition: Maintain BMI >19 increased calcium in diet 2) Weight bearing exercises (+/- physiotherapy) 3) Smoking and alcohol cessation Medical: Vit. D and calcium supplements Followup: Repeat DEXA in 2 years

Question 64

What do the Q-fracture and FRAX scores determine?

Answer 64

10-year probability of fracture (just like Qrisk)

Question 65

Give 2 examples of Bisphosphonates How are they supposed to be taken? What are the main side effects of bisphosphonates? What are the Contraindications?

Answer 65

Alendronate/Ibandronate Taken on an empty stomach in the morning >30 mins before eating. Sit upright for 30 minutes after taking SE: Osteonecrosis of the jaw, atypical femoral fracture (subtrochanteric/mid-shaft fracture) CI: Child-bearing age (teratogenic), CKD

Question 66

What is the medical management of osteoporosis along with its escalations

Answer 66

Women: 1) Bisphosphonates (Alendronate/Ibandronate) 2) Denosumab 3) Raloxifene (specific indication) 4) Teriparatide (technically 3rd line) Men: 1) Bisphosphonates 2) Teriparatide

Question 67

When is Denosumab indicated? How does it work?

Answer 67

Denosumab is indicated if bisphosphonates are CI (CKD, child-bearing) or not tolerated Monoclonal antibody targeting osteoclast activity => reducing bone resorption

Question 68

What is Raloxifene? When is it indicated for the tx of Osteoporosis?

Answer 68

It is a selective oestrogen receptor modulator Indicated if previous fragility fracture or further fracture despite being on bisphosphonates

Question 69

Teriparatide is the 3rd line drug for post-menopausal women and second line for men with a past history of fragility fracture. It is given if other treatments are not tolerated and specifi T-score and clinical criteria are met (not in the book). This drug requires consultant initiation. How is it administered? What is the maximum duration?

Answer 69

Daily injection but maximum duration is 18 months

Question 70

When is HRT indicated for the treatment of osteoporosis?

Answer 70

!Only indicated for osteoporosis if premature menopause or everything else is contraindicated

Question 71

A post-menopausal patient with low BMI presents with sudden onset severe lower back pain with no history of trauma. Their past history includes Rheumatoid arthritis for which she is taking long-term steroid for. You conduct a DEXA scan and determine that the patient has a T-score of -2.6 consistent with osteoporosis. What is the full management plan for osteoporosis?

Answer 71

Lifestyle advice: 1) Nutrition: Maintain BMI >19 increased calcium in diet 2) Weight bearing exercises (+/- physiotherapy) 3) Smoking and alcohol cessation Medical: Vit. D and calcium supplements + Women: 1) Bisphosphonates (Alendronate/Ibandronate) 2) Denosumab 3) Raloxifene (specific indication) 4) Teriparatide (technically 3rd line) Men: 1) Bisphosphonates 2) Teriparatide Followup: Regular monitoring

Question 72

What is Osteoarthritis

Answer 72

Metabolically active joint degeneration involving all components including cartilage, bone, synovium, capsule, muscle).

Question 73

Give 5 risk factors for osteoarthritis

Answer 73

1) Age 2) Female 3) Genetic predisposition 4) Obesity 5) Surgical intervention e.g. Post-meniscectomy (knee) 6) Occupation e.g. farming, athlete

Question 74

What is the typically presentation of a patient with osteoarthritis?

Answer 74

!gradual onset over years! Joint pain worse on movement Joint stiffness in the morning, relieved in <30 mins +/- exacerbations lasting weeks/months

Question 75

Where are Heberden nodes located? Where are Bouchard nodes located? What do these findings indicate

Answer 75

Heberden: Dorsal aspect, DIP Bouchard: Dorsal aspect, PIP They are bony growths indicating osteoarthritis

Question 76

You are asked to conduct a focused examination for osteoarthritis. Go over the findings you would be looking for

Answer 76

Note if this comes on exam, you should be looking for differentials as well and what findings are there => you would also be looking for things in RA for example Look -> Heberden Nodes (DIP), Bouchard Nodes (PIP) swelling of DIPs, Deformity. Feel -> Synovial thickening (=swelling), Effusions, Muscle wasting. Move -> Crepitus, weakness

Question 77

What investigations would you conduct to confirm the diagnosis of osteoarthritis

Answer 77

Bloods: FBC, ESR (>30 indicates inflammatory arthritis Imaging: X-ray

Question 78

You are investigating a patient with suspected osteoarthritis. You send bloods to the lab and the patient is getting their X-ray now. Blood results come back showing ESR >30. What would this mean?

Answer 78

This means that this is likely an inflammatory arthritis e.g. RA, psoriatic.

Question 79

What X-ray findings would indicate Osteoarthritis?

Answer 79

Joint space narrowing Subchondral sclerosis Subchondral cysts Osteophytes (bony growths)

Question 80

A patient is suffering from a chronic bone disease. Explain the multidisciplinary management available (and should be mentioned in any ortho case) for every patient.

Answer 80

1) Physiotherapist: Exercise, strapping, splints 2) Chiropody/Podiatry: Foot care and insoles 3) Orthopaedic: Surgery if needed 4) Occupational Therapist: Aids (e.g. handles) 5) Social work: Disability benefits and housing 6) Counselling: Chronic bone diseases are a/w mental health deterioration

Question 81

What is the conservative management of Osteoarthritis?

Answer 81

1) Reduce load on joint via a) Weight reduction b) Using a walking stick (on opposite leg) c) insoles via podiatry referral 2) Exercise: Swimming, cycling, Physiotherapy referral. Exercise is a/w reduced pain and disability 3) Complementary therapies (acupuncture, chiropractic). Not much evidence but only real evidence is chiropractic work with back pain. +/- analgesia (Topical NSAIDs > Oral NSAIDs > Opioids)

Question 82

A patient with a history of OA presents to the clinic. They are having an acute exacerbation of OA. How would this present? How is it managed?

Answer 82

Presents with increased intensity of pain and stiffness + swelling, warmth, tenderness + Further functional impairment (lasts weeks to months) Treated via joint aspiration (Steroid injections are not recommended according to NICE)

Question 83

Conservative management has proven to be unsuccessful for the treatment of OA in a patient. What management options are available?

Answer 83

Analgesia (if not already on it) Topical NSAIDs > Oral NSAIDs > Opioids. Aspiration if acute exacerbation Referral to rheumatology (if suspicion of co-existing inflammatory arthritis) or Orthopaedics (for hemi/total arthroplasty)

Question 84

What is the full management plan for Osteoarthritis

Answer 84

OA requires MDT management: 1) Physiotherapist: Exercise, strapping, splints 2) Chiropody/Podiatry: Foot care and insoles 3) Orthopaedic: Surgery if needed 4) Occupational Therapist: Aids (e.g. handles) 5) Social work: Disability benefits and housing 6) Counselling Conservative management: 1) Reduce load on joint via a) Weight reduction b) Using a walking stick (on opposite leg) c) insoles via podiatry referral 2) Exercise: Swimming, cycling, Physiotherapy referral. Exercise is a/w reduced pain and disability 3) Complementary therapies (acupuncture, chiropractic) Medical management: Analgesia (if not already on it) Topical NSAIDs > Oral NSAIDs > Opioids. Surgical management/Referral: Aspiration if acute exacerbation Referral to rheumatology (if suspicion of co-existing inflammatory arthritis) or Orthopaedics (for hemi/total arthroplasty)

Question 85

RA is typically triggered by environmental factors in patients with genetic predisposition. What genetic mutation is a/w rheumatoid arthritis?

Answer 85

HLA DR4

Question 86

RA is characterised by its variable course of disease with periods of exacerbations and periods of remission. How would you assess disease activity in a patient with RA?

Answer 86

DAS 28 (disease activity score -28 joints). This considers number of swollen joints, number of tender joints, ESR/CRP levels, and patient's global self-assessment

Question 87

What joints are typically affected in OA vs RA?

Answer 87

OA: Hip, knee, base of thumb => larger joints and typically asymmetrical RA: Starts with smaller joints

Question 88

What is the typical presentation of RA? (not exam findings)

Answer 88

Typically presents within months of onset (more acute than OA) Starts with symmetrical!! small joint involvement with pain + swelling Early morning stiffness (>30 mins) Pain on walking and doing daily activities => functional impairment (e.g. reduced grip strength => cannot hold kettle) Note: Joint deformity and damage typically present later

Question 89

Where are rheumatoid nodules found?

Answer 89

Extensor surfaces of arms (typically elbow)

Question 90

What is Felty Syndrome?

Answer 90

Combination of RA, splenomegaly and Leucopenia

Question 91

Give 15 exam findings and other features associated with Rheumatoid arthritis

Answer 91

Hands: 1) Involvement (swelling + tenderness) of MCP and PIP and NOT DIP (OA) 2) Ulnar deviation of fingers 3) Z-deformity of the thumb 4) Boutonnier's deformity (EM,FP) 5) Swan neck deformity (EP,FD) 6) Reduced grip strength 7) Bilateral carpal tunnel due to nerve entrapment 8) Palmer Erythema Extra-articular: 1) Anemia (Microcytic) 2) Felty Syndrome (RA + Splenomegaly + Leucopenia) Arms: Rheumatoid nodules (extensor surfaces) Eyes: Scleritis + Episcleritis Heart: 1) Pericarditis 2) Mitral regurgitation Lungs: Pleural effusions Shoulder: Adhesive capsulitis Spine: (Risk of cord compression) 1) Cervical spine subluxation 2) Atlantoaxial instability Legs and Feet: 1) Subluxation of metatarsal heads 2) Claw toes (pain walking => ask to walk for gait) 3) Baker's cyst 4) Patellar tap => Swelling over joint

Question 92

How would a Baker cyst rupture in a patient with RA present?

Answer 92

Baker cyst rupture mimics DVT => sudden onset severe unilateral leg pain with swelling, heat and tenderness.

Question 93

What is Boutinniere's deformity? What is the Swan neck Deformity?

Answer 93

Deformities of the hand associated with RA whereby Boutinniere's: Extended MCP, Flexed PIP Swan Neck deformity: Hyperextended PIP, flexed DIP

Question 94

A patient presents for the first time with signs and symptoms consistent with RA. You have conducted your Anti-CCP, RF, and ANA titre and all are positive. What is your next step?

Answer 94

Refer all suspected cases of RA to rheumatology as early detection significantly alters disease progression.

Question 95

A patient presets with joint pain in the hands. What are your differentials?

Answer 95

Rheumatoid arthritis Osteoarthritis (usually large joints) Psoriatic arthritis SLE Carpal tunnel syndrome Polymyalgia rheumatica

Question 96

What relevant investigations would you conduct for RA? For each, state the findings you are looking for

Answer 96

FBC - looking for microcytic anemia and leucopenia (Felty) Serology: Anti CCP, RF, ANA titre (+ve in RA) Xray: 1) Periarticular soft tissue swelling 2) Joint space narrowing 3) Erosions (From infl. of socket +/- collapsed head) 4) Juxtaarticular osteopenia (black in bones = reduced density)

Question 97

Give 4 ways to differentiate between osteoarthritis and rheumatoid arthritis

Answer 97

1) Morning stiffness: OA <30 mins, RA >30 mins 2) OA usually affects less joints but bigger joints. RA affects more joints but smaller joints 3) OA is localised to joints and surrounding tissue whereas RA is systemic and has many extra-articular features 4) RA never affects the DIP, OA has heberden nodules on DIPs 5) OA is develops over years whereas RA is over weeks/months 6) OA is a degenerative disorder, RA is an autoimmune disorder

Question 98

How is an acute flareup of RA managed?

Answer 98

Intra-articular injections of steroids

Question 99

IA injection of steroids is used to acutely manage flareups of RA. If someone comes in with many acute flareups a year, can they still receive steroid injections?

Answer 99

The maximum safe amount is 3x/year in any particular joint If someone is having more flareups, they probably need better medications to manage the symptoms.

Question 100

Give 3 examples of DMARDS used in the treatment of RA

Answer 100

Methotrexate (also used in psoriatic arthritis!) Sulfalazine Azathioprine Intramuscular gold Hydroxychloroquine Leflunamide Cyclophosphamide

Question 101

What is the medical management of RA including escalations? (Not acute)

Answer 101

a) NSAIDs + Paracetamol + PPi b) DMARDs: Methotrexate, Sulfalazine c) Biologics and JAK Inhibitors (Infliximab, Etanercept)

Question 102

Before starting DMARDs for RA, it is important to take baseline measurements within FBC (WCC, neutrophils, platelets), LFTs, and Urinalysis (haematuria, proteinuria) to be monitored throughout the course. Methotrexate is the first line drug in the tx of RA. What is the mechanism of action of methotrexate? What is the regimen used in RA? What are the side effects of methotrexate?

Answer 102

Methotrexate is a folic acid antagonist via inhibition of dihydrofolate reductase Given with a once a week dose (PO or IM) + folic acid supplements to be taken 1-2/week but not on the day that methotrexate is administered SE: Folic acid deficiency (mouth sores, GI upset), hepatotoxicity, BM suppression, B12/folate deficiency (megaloblastic anemia) Note: Teratogenic => consider contraception or other Sulfalazine

Question 103

When is Sulfalazine indicated for the treatment of RA?

Answer 103

Pregnancy or child-bearing age CI of methotrexate (liver failure, renal failure)

Question 104

When are biologics/JAK inhibitors indicated in the treatment of RA? Give 2 examples

Answer 104

Indicated if 2 or more DMARDs already used Infliximab Etanercept

Question 105

A patient with RA presents with carpal tunnel. Is it likely unilateral or bilateral? How is this managed surgically?

Answer 105

Bilateral Carpal tunnel release and Nerve decompression

Question 106

What are the options for surgical management of RA?

Answer 106

Orthopaedic referral for the following options 1) Joint fusion 2) Joint replacement (Arthroplasty) 3) Tendon transfer and repair 4) Carpal tunnel release + nerve decompression (carpal tunnel)

Question 107

What is the full management plan for a patient presenting with signs and symptoms consistent with rheumatoid arthritis?

Answer 107

First time? Refer to rheumatology directly Acute? IA steroid injection Conservative: MDT approach 1) Physiotherapist: Exercise, strapping, splints 2) Chiropody/Podiatry: Foot care and insoles 3) Orthopaedic: Surgery if needed 4) Occupational Therapist: Aids (e.g. handles) 5) Social work: Disability benefits and housing 6) Counselling Medical: a) NSAIDs + Paracetamol + PPi b) DMARDs: Methotrexate, Sulfalazine c) Biologics and JAK Inhibitors (Infliximab, Etanercept) Surgical: 1) Joint fusion 2) Joint replacement (Arthroplasty) 3) Tendon transfer and repair 4) Carpal tunnel release + nerve decompression (carpal tunnel)

Question 108

Define Gout What are the main causes of gout? Give 5

Answer 108

Crystal-induced arthritis due to hyperuricemia leading to the deposition of uric acid crystals causing inflammation Caused by: (Urea is a waste product of cells) 1) Drugs: Thiazide diuretics, Cytotoxic drugs (chemo) 2) Increased cell turnover: Lymphoma, leukemia, haemolysis, psoriasis 3) Reduced elimination: CKD, Hyperparathyroidism 4) Disorders of purine synthesis: Leisch-Nyhan Syndrome

Question 109

Give 10 RF for Gout

Answer 109

1) Gout 2) Obesity 3) Excess alcohol 4) High purine diet (Fish, seafood, meat, beer) 5) Family hx + Causes of Gout => Cancer tx => Leukemia, lymphoma, psoriasis => CKD, Hyperparathyroidism => Leisch-Nyhan Syndrome

Question 110

What are the top 3 triggers of acute gout exacerbation

Answer 110

Surgery/trauma Acute infection Dehydration

Question 111

How does acute gout present?

Answer 111

Painful, swollen distal joints (big toe, feet, ankle) with an erythematous base +/- fever

Question 112

How does chronic gout present?

Answer 112

Recurrent acute attacks tophi in pinna, tendons, and joints causing joint damage and deformity

Question 113

What is the top differential for acute gout that must be ruled out? How will you know? How is it managed?

Answer 113

Septic arthritis Patient would be systemically unwell. You can send synovial fluid for culture Septic arthtitis requires emergency admission for IV antibiotics + surgical washout of joint. Consider septic arthritis if the patient is young, ha a prosthetic, or recent surgery

Question 114

What investigations would you perform for a patient with gout (only include relevant) + what findings you expect.

Answer 114

Bloods: FBC (raised WCC), ESR (raised), Uric acid (raised) Microscopy of synovial fluid showing sodium monourate crystals under polarised light X-ray: Erosions if chronic (soft tissue swelling if acute but it is not typically performed) Note: Uric acid is its own standalone test

Question 115

How is an acute gout attack managed?

Answer 115

1) Colchicine (500mcg BD/QDS) 2) NSAIDs + PPI 3) Corticosteroid injection (IM, IA)

Question 116

How would you manage lifestyle factors to reduce the risk of another gout attack?

Answer 116

Educate about gout Physiotherapy referral for exercise Dietician referral to manage weight and lower purine diet Reduce alcohol intake to <14/week

Question 117

When is urate-lowering therapy indicated for gout? What options are available?

Answer 117

Indicated after 1 attack of gout 1) Allopurinol 2) Febuxostat 3) Sulfinpyrazone

Question 118

You schedule a followup 4-6 weeks after an acute gout attack. What does this review include?

Answer 118

Assess lifestyle factors (exercise, weight, purine diet, alcohol intake) Assess CVD RF and lipid profile Check serum Uric acid + eGFR !!Discuss Urate lowering therapy: 1) Allopurinol 2) Febuxostat 3) Sulfinpyrazone Schedule review in 1 year

Question 119

Allopurinol is typically started low and increased every 4 weeks until the aim of urate-lowering therapy is reached. What is the aim of urate lowering therapy?

Answer 119

Urate levels <300 micrimol/L (Prophylactic colchicine may be given during titration to prevent an attack)

Question 120

What is the full management protocol for Gout starting from presentation with a painful swollen 1st metatarsal with confirmed sodium monourate crystals under polarised light.

Answer 120

Question 121

Attacks of pseudogout are less severe than gout and may be difficult to differentiate between other typies of arthritis (not gout). What is the medical word for pseudogout? What is it associated with? What joints are mostly affected? What is the main finding on x-ray a/w pseudogout? How is the diagnosis of pseudogout confirmed?

Answer 121

Calcium Pyrophosphate deposition disease a/w OA, Hyperparathyroidism, and haemochromatosis Mostly affects knee, wrist and shoulder (ankle, toe and foot in normal gout). Chondrocalcinosis on Xray Rhomboidal/rod shaped crystals in synovial fluid under microscopy confirms diagnosis (gout is needle shaped)