MSK Flashcards
Ankylosing Spondylitis
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Ankylosing spondylitis is a HLA-B27 associated spondyloarthropathy. It typically presents in males (sex ratio 3:1) aged 20-30 years old. Chronic inflam, seronegative disease of skeleton leading to fusion and rigidy
CLINICAL FEATURES
- typically a young man who presents with lower back pain and stiffness of insidious onset
- stiffness is usually worse in the morning and improves with exercise
- the patient may experience pain at night which improves on getting up
- Anterior uveitus: eye pain, redness, photophobia
- Enthesitis: inflam where tendon or ligament attaches to bone.
- Tender sacroiliac joint
- reduced spinal mobility: lateral flexion and forward- Schober’s test
- fatigue, weakness, fever, weight loss
7 A’s:
Apical fibrosis
Anterior uveitis
Aortic regurgitation
Achilles tendonitis
AV node block
Amyloidosis
and cauda equina syndrome
peripheral arthritis (25%, more common if female)
INVESTIGATION
Plain x-ray of the sacroiliac joints is the most useful investigation in establishing the diagnosis. Radiographs may be normal early in disease, later changes include:
sacroiliitis: subchondral erosions, sclerosis
squaring of lumbar vertebrae
‘bamboo spine’ (late & uncommon)
syndesmophytes: due to ossification of outer fibers of annulus fibrosus
- If x ray neg but still suspect do MRI
- chest x-ray: apical fibrosis
-spirometry: restrictive
-HLA-B27
-Schobers test: reduced lateral fection, forward flexion, chest expansion
MANAGEMENT
NSAIDs and encourage regular exercise (physiotherapy)
If hifh disease activity desprite NSAID: Anti-TNF-alpha (infliximab or etanercept)
Corticosteroid injections (golimumab)
If peripheral joints affected: DMARDs (Methotrexate)
COMPLICATIONS
- Osteoporosis
- Cardiac involvement
- Hip involvement
- Pulmonary involvement
PROGNOSIS
active lifestyles= good prognosis
may progress to fusion of sacroiliac joints and vertebral column=bamboo spine
Crystal Arthropathy
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Gout and Psuedogout
Gout: acute inflam monoarthritis, due to monosodium urate crystals in joints
RF: male, obesity, alcholo, meat + seafood, high uric acid, post menopausal (as less oestrogen so same risk as men at that point)
Hyperuricaemia: renal failure (CKD), thiazide diuretics, tumour lysis syndrome
Pseudogout: deposition of calcium pyrophosphate inside joint space
RF: hyperparathyroidism, haemochromastosis, acromegaly
CLINICAL FEATURE
Gout: 1st MTP joint podagre (could be ankle, wrist, kness, metacarpal, on foot or hand), severe pain, swollen, red, stiff joint, asymmetrical, hot, tophi (elbows, knee, achilles tendons), worse after meal with high meats.
Have asymptomatic then symtpomatic until tophi and swollen joint ect
Pseudogout: knee or wrist (not 1st MCP) most common pain and swelling, sometimes wrist, shoulders, longer duration. Less pain with continued activity but pain if prolonged
INVESTIGATIONS:
Arthrocentesis with synovial fluid analysis:
- gout has needle shaped crystals and negative bifringencce
- pseudogout: rhomboid, positively bifringent
Acute episode of gout: after 2 weeks check serum urale levels as levels may be weird within the attack
X-ray
- gout: rat bite erosions (bony overhang): bone density and spacing is NORMAL
- pseudogout: chondrocalcinosis (cartilage white) so looks like no joint space or that there are bits in the space
Gram stain and cultures of aspirated fluid:
check for septic arthritis
10-50000 leukocyte in psueudo
2-10000 leukocytes in gout
100,000 in septic arthritis
MANAGEMENT
GOUT
Acute gout: NSAIDs (Naproxen) with prednisolone, then Colchicine (in caution with CKD or peptic ulcer)
4th intra-articular steroid injection
Offer allopurinol (once inflammation has settled and pt can made deciisons or if been 3 weeks since acute.
Recurrent gout (usually offered to all after first attack but strongly recommended if more than 2 in a year, renal issues, uric acid renal stones, on diuretics or have tophi): Allopurinol (lower uric acid levels plus NSAID/colchine
Allopurinol affects azathioprine metabolisation
Lifestyle for gout: low alcohol, lose weight, avoid liver, seafood, oily fish
PSEUDOGOUT
Intra articular corticosteroids- dexamethosone
NSAID
Colchine
Mono/oligoarticular: Intra articular dexamethosone + paracetomol
Polyarticular: NSAID or colchicine + paracetomol
Chronic/recurrent: joint replacement
Osteoarthritis
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Joint disease characterised by non-inflammatory degeneration of the joint complex
Joints commonly affected: Knee > hip > hands
RF:
- Obesity
- Excessive joint loading
- Family history
- History of joint injury
- Female
- Age >50
- Hypermobility of the joint
CLINCIAL FEATURES
- Pain during or after exertion, relieved by rest
- stiff after period of inactivity but only for a few mins (RA is long morning stiffness)
- Sparing of MCP but involves PIP and DIP (RA affects MCP)
- Bony deformities : Heberdens nodes (DIP), Bouchard node (PIP) (nodes form because of osteophytes formation), carpometocarpal joint -squaring at base of thumb, varus deformity,
- Malalignmant (valgum and varum deformaties)
- Crepitus
- Asymmetrical joint involvement
INVESTIGATION
CRP, ESP normal and RF and anti-CCP negative
X-Ray: LOSS
- loss of joint space (normally tilted)
- osteophytes (by ends of bone either side tiny protrusions
- subchondral sclerosis (whitening of bone end)
- subchondral cysts (darker colour in/slightly under the whitened sclerosis of bone ends)
- fragments/loose body
- bouchards node (see formations around the PIP)
- Heberdens (see formations around the DIP)
MANAGEMENT
- help with weight loss, local muscle strengthning exercises and general fitness
- walking aid for knee and hip
- topical NSAIDs are first-line analgesics
- second line: oral NSAID with PPI (avoid both if take aspirin)
- Only offer paracetomol or weak opiod if only used infrequently for short term pain or all other treatments are contraindicated
- intra articular steroids if pharmacological treatment is ineffective
- if all fail then arthroplasty - joint replacement
COMPLICATIONS
issues with daily living
effusion
NSAID related GI bleed
PROGNOSIS
most continue to have some pain
Osteomalacia
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
Softening of the bones secondary to low vitamin D levels which in turn leads to decreased bone mineral content
Rickets in contrast is disorder of impaired mineralisation of cartilaginous growth plates (Only in children)
Causes:
- Vitamin D deficiency: low dietary intake, reduced sunlight, reduced intestinal absorption in coeliac and chronic pancreatitis
- Defective Vitamin D metabolism: liver cirrhosis, CKD
- drugs, anticonvulsant
CLINICAL FEATURES
- Bone pain & tenderness
- Pathological fractures, esp at Femoral neck
- Proximal myopathy- May lead to waddling gait
- Fatigue
- hypocalcaemia: covulsion, arrythmia, tetany, paraesthesia
INVESTIGATIONS
bloods: low vit D, low calcium, low phosphate, raised alkaline phosphatase (ALP), raised PTH if secondary
X-ray: tranlucent bands (looser zones or psudofractures)
MANAGEMENT
- vitamin d supplement (loading dose initially)
- calcium supplementation maybe
Ergocalciferol + Calcium carbonate (if dietary calcium is inadequate)
COMPLICATIONS
- Pseudofractures
- Hypercalcaemia
- Secondary hyperparathyroidism
PROGNOSIS
dependent on cause and complicance
Osteomyelitis
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
Inflammatory condition of the bone caused by an infective organism. affects a SINGLE bone
- Most commonly Staphylococcus aureus
- Except in sickle cell disease patients, salmonella species is more common
Two types:
1) Haematogenous osteomyelitis: from bactaraemia usually monomicrobial (common in children). Risk factors:
- Sickle cell anaemia
- IV drug use
- Immunosuppression (HIV, meds)
- Infective endocarditis
If its in an adult then probably vertebral issue
2) Non-haematogenous osteomyelitis: more common in adults,, contageous spread of infection from soft tissues to bone or direct injury trauma to the bone. Polymicrobial. Risk factors:
- Diabetic foot ulcers/pressure sores
- DM
- Peripheral arterial disease
Risk facrors:
- Penetrating injury
- IV drug use
- Diabetes
- HIV
- Recent surgery
- Distant or local infection
CLINICAL FEATURES
- limp or reluctancy to weight bear (children)
- pain at infection site
- malaise, fever, fatigue, chills
- Inflammation, tenderness, erythema or swelling
- Native vertebral osteomyelitis: local back pain with systemic symptoms
INVESTIGATIONS
Bone MRI
Before ABx do Bone biopsy
Bloods: high WCC, ESR, CRP
MANAGEMENT
Abx therapy for 2-4 weeks → Flucloxacillin (IV)
2nd line Clindamycin
COMPLICATIONS
- Drug reactions
- Infection recurrence
- Fracture
PROGNOSIS
usually recover no long term issue
Osteoporosis
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- Skeletal disease characterised by low bone density and micro-architectural defects in bone tissue
- This leads to increased bone fragility and susceptibility to fractures
rf:
tobacco smoking
malnutrition (low vit D and calcium) low BMI
FHx
alcohol
Two common types
1) Primary osteoporosis
- Post menopausal osteoporosis (less oestrogen, increased bone reabsorption due to high osteoclast activity and decreased osteoblast
- Senile osteoporosis (loose bone mass as age)
- RA
2) Secondary
- Drug induces (long term corticosteroids, PPIs)
- Cushings syndrome
- Hyperthyroid
- Hyperparathyroid
- Hypogonadism
CLINICAL FEATURES
- Fragility fractures → Pathological fractures caused by everyday activities or minor trauma
- Back pain → Vertebral fracture is most common
INVESTIGATIONS
1st DEXA scan (gold standard) : obtain T score which is bone densiy as a standard deviation compared to reference population of healthy adults e.g -1 is one sd below norm
- Osteoporosis: T: -2.5
- Osteopenia -1.5 to -2.5
- Normal is over -1.0
Z score adjusts for age, sex, ethnicity
Dont need a DEXA IF following a fragility fracture in women ≥ 75 years, just clinically diagnose
Suspected osteoporotic vettebral fracture:
X-ray of spine
Calculate FRAX (10 year fragility fracture risk
Bloods: normal ALP, calcium, phosphate, PTH
Always check mens testosterone
MANAGEMENT
1st bisphosphonates (alendronate) inhibits osteoclast
(used in pain from bone mets and hypercalcaemia)
Side effects: oesophagitis/oesophageal ulcer (take tablet 30 mins before eating with lots of water and remain upright to avoid), ostenecrosis of jaw, atypical stress fracture
2nd line Risedronate
2nd line for post menopausal: Denosumab
Other:
- Calcium and vitamin d ergocalciferol supplementation (give before alendronate if required)_
- Teriparatide (PTH analogue)
- avoid glucocorticoids
COMPLICATIONS
Fractures
- Hip
- Rib
- Wrist
Polymyalgia rheumatica
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
Polymyalgia rheumatica (PMR) is a relatively common condition seen in older people characterised by muscle stiffness and raised inflammatory markers. Whilst it appears to be closely related to temporal arteritis the underlying cause is not fully understood and it does not appear to be a vasculitic process.
- Females
- Typically over 60 years of age
Causes:
- genetic prediscposition
- Associated with giant cell/temporal arteritis
CLINICAL FEATURES
- Bilateral morning stiffness and pain for >1 hour in shoulder/hip girdle region
- Worse at night
- Acute onset (less than a month)
- Systemic symptoms → fever, weight loss, malaise, depression
- Symptoms of giant cell arteritis
- Rapid response to steroids
- NO weakness, if felt due to muscle pain
INVESTIGATIONS
Elevated ESP and CRP
CK normal
RF and autoantibodies negative
MANAGEMENT
Prednisolone (CCS): shoudl respond well, if dont then alternate diagnosis.
If treatment resistant or relapsed: increase dose
Cortiocosteroid have risk of osteoporosis so give Alendronate (bisphosphonate) and ensure calcium and vitamin d levels are good
COMPLICATIONS
Corticosteroid related issues (e.g. Avascular necrosis of the femoral head)
Giant cell/temporal arteritis
unilateral vision loss, headache, jaw claudication, scalp tenderness, tender, palpable temporal artery.
High ESR, fundoscopy (swollen pale optic disk, blurred margins), temporal artery biopsy.
IV methyprednisolone before biopsy, urgent opthalmology review,
visual loss IV methylprednisione, no vision loss high dose oral prednisolone. If on CCS for long time bisphosphonates (alendronic).
Reactive arthritis
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
Arthritis that develops after an infection of urinary or gastro tract where the organism cant be recovered from the joint- sterile arthritis.
HLA-B27 associated seronegative spondyloarthropathies
Usually young men
post-STI chlamydia trachomatis (usually men more)
post-dysentering form is men or women (shigella, salmonella, campylobacter)
CLINICAL FEATURES
Can’t see, can’t pee, can’t climb a tree
- Arthritis developing 1-4 weeks after onset of infection (usually asymmetric and affects larger joints in lower extremity) → leads to painful, warm, swollen, red and stiff joints
- Lower back pain
- Conjunctivitis or Uveitis
- symptoms from preceding infection → Diarrhoea, dysuria, urethritis
- Dactylitis (Inflammation and swelling of digit)
- Fever, fatigue, weight loss
- Skin changes; circinate balanitis (vesicles on head of penis), keratoderma blenorrhagica (yellow/brown papules on palm and sole)
- Normal range of motion (in Reactive arthritis impaired flexion)
INVESTIGATIONS
high ESR and CRP
HLA-B27 positive
Negative ANA and RF
Arthrocentesis: cloudy yellow colour, culture negative, normal WBC, no crystals
MANAGEMENT
NSAIDs
- Naproxen
- Ibuprofen
- Diclofenac
If NSAIDs dont work: Corticosteroids (Prednisolone)
If refractory (doesnt respond to NSAID or CCS) then DMARDs (Sulfasalazine)
NO ABx
PROGNOSIS
Resolves spontaneously within a year, high rate of recurrence
Rheumatoid Arthritis
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
A chronic, systemic, inflammatory autoimmune disorder that primarily affects the joints
Usually affects women, 40-60
Risk Factors:
- HLA-DR1
- HLA-DR4
- Smoking
CLINICAL FEATURES
- Symmetrical pain and swelling
- MCP
- PIP
- MTP
- DIP SPARED UNLIKE OSTEOARTHRITIS
- Morning stiffness >30 min that improves with activity
- Rheumatoid nodules (non-tender, firm, subcutaneous nodules on skin)
- Hand deformities (late stage)
- Ulnar deviation
- swan neck deformity (MCP flexion, PIP extension, DIP flexion)
- Boutonniere finger deformity (PIP flexion, DIP extension - like pushing a button)
Episcleritis, scleritis- (Episcleritis is erythema only, whereas scleritis is erythema and pain)
- Pleural effusions
- Carpal tunnel syndrome
- Anaemia of chronic disease
- Constitutional symptoms → fever, fatigue, malaise, weight loss
- Pleuritic chest pain → pleuritis or pericarditis can occur
- Pyoderma gangrenosum
Feltys syndrome= RA, splenomegay and low WCC
INVESTIGATIONS
Rhemuatoid factor, more specific is anti-ccp
X ray of hands and feet:
- loss of joint space (equal loss unlike OA)
- juxta-articular osteoporosis/penia
- soft tissue swelling
- osteophytes and erosions
Ultrasonography:
- synovitia of wrist and fingers
Joint aspiration:
high WCC (polymorponuclear neutrophils
turbin, yellow, no crytals
Scoring system: DAS28
MANAGEMENT
- DMARDS:
1 option: methotrexate and prednisolone
Methotrexate must be co prescribed with folate
OR
2 option: Hydroxychloroquine (sulfasalazine)
If dont respond to at leasr 2 DMARDs: Infliximab (TNF-alpha inhibitor). (may cause reactive TB)
- NSAID
Ibuprofen
Naproxen
Diclofenac (not in CVD) - Flares
Give prednisolone (CCS)
PROGNOSIS
Patients treated aggressively and early have a good prognosis with most patients achieving good disease control
side effects of methotrexate
- Pneumonitis (cough, SOB, fever)
- Mucositis
- Pulmonary fibrosis
- Liver fibrosis
- Myelosuppression because its anti-folate
Septic Arthritis
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
Infection of the joint space
Haematogenous: spread from a distant site
- Abscess
- Wund infection
- Septicaemia
Direct contamination:
- Arthrocentesis or trauma (open would)
Common bacteria cause:
Staphylococcus aureus (gram +ve, coagulase positive)
- Young sexually active: Neisseria gonorrhoeae (gram -ve diplococci)
- Prosthetic join: staph epidermidis
Risk Factors:
- underlying joint disease (OA/RA)
- prosthetic joint
- age >80
- immunosuppression
- diabetes
- IV drug use
CLINICAL FEATURES
- Acute onset- Symptoms present for <2 weeks
- Unilateral hot, swollen, painful, restricted joint
- Fever
- Most commonly affected joint is the knee joint (followed by hip, wrist, shoulder, ankle)
Triad: fever, joint pain, restricted ROM
INVESTIGATIONS
Joint aspiration + culture (before ABx): yellow-green and turbid , high ECC (over 90 neutrophils), gram stain
Blood culture and bloods: high CRP, ESR
MANAGEMENTS
Joint drainage (Therapeutic arthrocentesis)
IV ABx: flucloxacillin (+) cefotaxime (-)
if allergic clindamycin
4-6weeks
PROGNOSIS
delayed can lead irreversible joint destruction and disability
Systemic Lupus Erythematous
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
Multisystem autoimmune disease that predominantly affects women of childbearing age (female, 20-40yrs, afro-caribbeans)
Type 3 sensitivity
CAUSE:
- HLA-DR2
- HLA-DR3
Associated with Anti-phospholipid syndrome
CLINICAL FEATURES
- Malar rash- Erythema over the cheeks and bridge of the nose, sparing the nasolabial folds
- Photosensitive rash after sun exposure (painful and pruritis for few days)
- Arthritis and arthralgia, distal symmetrical polyarthritis
- Oral ulcers
- Fatigue, fever, weight loss
- Raynauds phenomenon: colour changed of digits induced by the cold, go from white to blue red (nifedipine for this)
- Pericarditis or Myocarditis
INVESTIGATIONS
- Antinuclear antibody (ANA)- very sensitive, however may be positive in many other conditions so low specificity
- Anti-dsDNA
- ESR raises with disease activity
- CRP high if has an infection
- Low c3/4
- Drug induced lupus )procainamide or hydralazine): anti-histone antibodies
Urinalysis: proteinuria and renal involvement
MANAGEMENT
1st hydroxychloroquine: do visual acuity as can lead to retinopathy (baseline then annual screening) (retinopathy: reduced colour differention, central visual acuity, floars, Bulls eye maclopathy- red spot on macula surrounded by retinal pigment loss)
NSAIDS, no smoking, UV light
Topic steroids: for skin manifestitions
COMPLICATION
- anaemia
- leukopenia
- thrombocytopenia
- pericarditis
- myocarditis
- pleuritis
- pleural effusion
PROGNOSIS
- Cardiovascular disease
- Followed by infection and severe disease activity
Anti-phospholipid syndrome
increased risk of thrombus formation (recurrent PEs and DVTs) and recurrent miscarriages
CLINICAL FEATURE
- Clots (thrombosis)
- Livedo reticularis
- Obstetric complications (miscarriages)
- Thrombocytopenia
INVESTIGATIONS
- Prolonged APTT (paradoxical)
- Low platelets (thrombocytopenia)
- Anti-cardiolipin antibodies
MANAGED
low dose aspirin
life warfarin after thromboembolic event (INR 2-3 target) (pregnant should have LMWH instead)
