MSK

Question 1

Rheumatoid arthritis investigations

Answer 1

It is important to remember that Anti-CCP (cyclic citrullinated peptide) antibody is positive in approximately 40% of patients who test negative for Rheumatoid Factor. Therefore Anti-CCP is an important diagnostic test for RA.

Question 2

Rheumatoid arthritis presentation:

Answer 2

swollen, painful joints in hands and feet
stiffness worse in the morning
gradually gets worse with larger joints becoming involved
presentation usually insidiously develops over a few months
positive ‘squeeze test’ - discomfort on squeezing across the metacarpal or metatarsal joints

Question 3

Rheumatoid arthritis: x-ray changes

Answer 3

loss of joint space
juxta-articular osteoporosis
soft-tissue swelling
periarticular erosions
subluxation

Question 4

Rheumatoid arthritis: ocular manifestations

Answer 4

keratoconjunctivitis sicca (most common)
episcleritis (erythema)
scleritis (erythema and pain)
corneal ulceration
keratitis

Question 5

Rheumatoid arthritis management

Answer 5

DMARD monotherapy (methotrexate) +/- a short-course of bridging prednisolone

flares of RA are often managed with corticosteroids - oral or intramuscular

Question 6

Osteoarthritis

Answer 6

Mechanical - wear & tear*
localised loss of cartilage
remodelling of adjacent bone
associated inflammation

Question 7

Osteoarthritis X-ray?

Answer 7

Loss of joint space
Subchondral sclerosis
Subchondral cysts
Osteophytes forming at joint margins

Question 8

1st-line treatment for osteoporosis

Answer 8

oral bisphosphonate such as alendronate

(Denosumab 2nd line)

Question 9

Medications that may worsen osteoporosis (other than glucocorticoids):

Answer 9

SSRIs
antiepileptics
proton pump inhibitors
glitazones
long term heparin therapy
aromatase inhibitors e.g. anastrozole

Question 10

haematogenous osteomyelitis

Answer 10

results from bacteraemia
is usually monomicrobial
most common form in children
vertebral osteomyelitis is the most common form of haematogenous osteomyelitis in adults

risk factors include: sickle cell anaemia, intravenous drug user, immunosuppression due to either medication or HIV, infective endocarditis

Question 11

non-haematogenous osteomyelitis

Answer 11

results from the contiguous spread of infection from adjacent soft tissues to the bone or from direct injury/trauma to bone
is often polymicrobial
most common form in adults

risk factors include: diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease

Question 12

Microbiology osteomyelitis?

Answer 12

Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate

Question 13

Osteomyelitis investigations?

Answer 13

MRI is the imaging modality of choice, with a sensitivity of 90-100%

Question 14

Osteomyelitis management?

Answer 14

flucloxacillin for 6 weeks
clindamycin if penicillin-allergic

Question 15

Osteomalacia features?

Answer 15

bone pain
bone/muscle tenderness
fractures: especially femoral neck
proximal myopathy: may lead to a waddling gait

Question 16

Osteomalacia features?

Answer 16

bloods
low vitamin D levels
low calcium, phosphate (in around 30%)
raised alkaline phosphatase (in 95-100% of patients)
x-ray
translucent bands (Looser’s zones or pseudofractures)

Question 17

A child with hip pain, limp and recent infective illness

Answer 17

? transient synovitis

Question 18

Low serum calcium, low serum phosphate, raised ALP and raised PTH

Answer 18

osteomalacia

Question 19

Hydroxychloroquine complications?

Answer 19

may result in a severe and permanent retinopathy

Question 20

Proximal muscle weakness + raised CK + no rash

Answer 20

?polymyositis

Question 21

Drug causes of gout?

Answer 21

Drug causes
diuretics: thiazides, furosemide
ciclosporin
alcohol
cytotoxic agents
pyrazinamide
aspirin

Question 22

Gout presentation?

Answer 22

pain: this is often very significant
swelling
erythema

1st metatarsophalangeal (MTP) joint
ankle
wrist
knee

Question 23

radiological features of gout include:

Answer 23

joint effusion is an early sign

well-defined ‘punched-out’ erosions with sclerotic margins in a juxta-articular distribution, often with overhanging edges
relative preservation of joint space until late disease

eccentric erosions

no periarticular osteopenia (in contrast to rheumatoid arthritis)

soft tissue tophi may be seen

Question 24

acute management of gout?

Answer 24

NSAIDs or colchicine are first-line
the maximum dose of NSAID should be prescribed until 1-2 days after the symptoms have settled
gastroprotection (e.g. a proton pump inhibitor) may also be indicated

Question 25

Chronic gout management?

Answer 25

allopurinol is 1st line