MSK Flashcards
1
Q
List the most commonly affected joints in osteoarthritis
A
Knee
Hip
Hands
Cervical/Lumbar spine
2
Q
What joints do osteoarthritis classically not affect
A
MCP joints
3
Q
Give the pathophysiology for osteoarthritis
A
Inflammatory response affecting the ENTIRE joint:
* Cartilage
* Subchondral bone
* Ligaments
* Menisci
* Synovium
* Capsule
Leads to:
* Loss of cartilage, sclerosis, eburnation of the subchondral bone
* Osteophytes
* Subchondral cysts
4
Q
List the factors associated with increased risk of OA
A
Increased age
Family history
Female sex
Obesity
Congenital articular deformities
Joint trauma
5
Q
List the local mechanical factors facilitating the progression of OA
A
Peripheral muscle weakness
Malalignment
Structural joint abnormalities eg. meniscal tear
6
Q
What enzymes are found in higher concentrations in OA cartilage
A
Metalloproteinases eg. collagenases
Catalyses collagen and proteoglycan degradation
Activated by nitric oxide
7
Q
List the secondary causes for OA
A
(antecedent insult to the joint)
Pre-existing joint damage:
* Rheumatoid arthritis
* Spondyloarthritis
* Septic arthritis
* Gout
* Overuse/ abnormal use
* Trauma
* Paget’s disease
* Avascular necrosis eg. corticosteroid therapy
Metabolic disease:
* Cartilage calcification
* Hereditary haemochromatosis
* Acromegaly
Systemic disease:
* Haemophilia (recurrent haemarthrosis)
* Haemoglobinopathies eg. SCD
* Neuropathies
8
Q
List the physical examination findings in OA
A
Swelling
Bone deformities
* Hand PIP joint enlargement (Bouchard nodes)
* Hand DIP joint enlargement (Bouchard nodes)
Malalignment of affected joints
Crepitus
9
Q
List the X ray signs in OA
A
Joint space narrowing
Subarticular sclerosis
Subchondral cysts
Osteophytes
10
Q
Give the clinical diagnostic criteria for OA
A
Activity-related joint pain
No morning joint-related stiffness / morning stiffness <30 mins
Age > 45 yrs
11
Q
List the pharmacological managements for OA
A
(Topical analgesics)
Capsaicin
NSAIDs eg. diclofenac, methylsalicyclate
12
Q
Give the management in OA if acute exacerbation/NSAIDs contraindicated, not tolerated
A
(Intra-articular corticosteroid injections)
methylprednisolone acetate
triamcinolone acetonide
13
Q
List the three subgroups of inflammatory arthritis
A
Rheumatoid arthritis - associated with antibodies
Spondyloarthritis - associated with HLA-B27
Crystal arthritis - associated with crystals
14
Q
List the causes of monoarthritis
A
Crystal arthritis
Septic arthritis
Palindromic rheumatism
Trauma/haemarthrosis
Juxta-articular bone tumour
14
Q
List the causes of oligoarthritis
A
Crystal arthritis
Septic arthritis
Palindromic rheumatism
Reactive arthritis
15
Q
List the causes of polyarthritis
A
Reactive arthritis
Psoriatic arthritis
Axial spondyloarthritis
Enteropathic arthritis
Post-viral
Lyme arthritis
16
Q
What age group does rheumatoid arthritis most commonly affect
A
40~60
17
Q
Give the general preponderance in rheumatoid arthritis
A
Female preponderance 3:1
18
Q
What does RA primarily affect
A
Small joints of hands and feet
Synovium of joints (synovitis)
19
Q
Give the genetic predisposition in RA
A
HLA-DRw4
20
Q
What joint does RA not affect
A
DIP
21
Q
Give the usual clinical presentation in RA
A
Bilateral, symmetrical pain and swelling of small joints in the hands and feet that has lasted for more than 6 weeks
* at least 3 symmetric joints involved
Morning stiffness lasting over 1 hour
22
Q
List the joint signs in RA
A
Hands and wrists
* Ulnar drift and palmar subluxation of the MCPs
* PIP joints:
* fixed flexion (buttonhole/boutonnière deformity)
* fixed hyperextension (swan-neck deformity)
Feet
* Broad foot, hammer-toe deformity
* Painful swelling of MTP joints
* Ankle often assumes valgus position
Shoulders
* Global stiffening
* Rotator cuff tear common
Cervical spine - Painful stiffness of the neck
Knees
* Synovitis
* Knee effusions
Hips
23
Q
List the extra-articular features in RA
A
Scleritis
Scleromalacia
Sjögren’s syndrome
* Dry eyes
* Dry mouth
Atlantoaxial subluxation (cervical cord compression)
Lymphadenopathy
Pericarditis
Lung
* Pleural effusion
* Interstitial lung disease
* Caplan’s syndrome
* Small airway disease
* Nodules
Splenomegaly (Felty’s syndrome)
Amyloidosis
Bursitis/nodules
Tendon sheath swelling
Tenosynovitis
Carpal tunnel syndrome
Nail fold lesions of vasculitis
Anaemia
Sensorimotor polyneuropathy
Leg ulcers
Ankle oedema
24
Give the triad in Felty syndrome
Rheumatoid arthritis
* Severe erosive joint disease and deformity
* Rheumatoid nodules
* Vasculitis (mononeuritis multiplex, necrotising skin lesions)
Reduced white blood cell
Splenomegaly
25
List the clinical manifestations in severe RA
Pericarditis
Pleuritis
Interstitial lung disease
Inflammatory eye disease
26
List the lab test features in RA
Rheumatic factor +ve
Anti-cyclic citrullinated peptide antibody (anti-CCP) +ve
ESR/CRP elevated
Blood count - normocytic normochromic anaemia
27
List the X ray signs in RA
Juxta-articular osteopenia
Soft tissue swelling
Joint deformity
Loss of joint space
Periarticular erosions
28
List the management approaches for RA
(Conventional synthetic disease-modifying anti-rheumatic drugs (DMARDs))
Methotrexate (1st line)
Leflunomide (MTX contraindicated/intolerated)
Hydroxychloroquine (pregnancy/non-erosive disease)
Sulfasalazine
29
What may be given for acute flare of RA
Intra-articular glucocorticoid injection
* methylprednisolone acetate
* triamcinolone acetonide
30
Give the options for severe RA / inadequate response to methotrexate
(Biologics)
TNF-a inhibitor:
* Anakinra (IL6 inhibitor)
* Abatacept
* Rituximab
Oral JAK inhibitor (e.g., tofacitinib, baricitinib, upadacitinib)
31
List the problems with corticosteroid use
Weight gain
Thin, easily damaged skin
Monitor for diabetes and hypertension
Accelerated cataract formation
Osteoporosis develops within 3 months on doses above 7.5 mg daily (monitor with DXA, vitamin D, bisphosphonate)
32
Give the adverse effect of hydroxychloroquine
Retinopathy
33
Give the mechanism for hydroxychloroquine
TNF and IL-1 suppressor
34
Give the mechanism for sufasalazine
TNF and IL-1 suppressor
35
Give the mechanism for leflunomide
Pyrimidine synthesis inhibitor
36
Give the mechanism for methotrexate
Folate antimetabolite
37
List the sufasalazine adverse effects
Nausea, mouth ulcers
Hepatotoxicity
Neutropenia/thrombocytopenia
Skin rash
38
List the Methotrexate adverse effects
Nausea, mouth ulcers, diarrhoea
Hepatotoxicity
Neutropenia/thrombocytopenia
Renal impairment
Pulmonary fibrosis
39
List the Leflunomide adverse effects
Diarrhoea
Hepatotoxicity
Neutropenia/thrombocytopenia
Alopecia
Hypertension
40
List the rituximab adverse effects
Hypo/hypertension
Pruritus and skin rash
Back pain
Toxic epidermal necrolysis
41
Give the hallmark in Spondyloarthritis
Enthesitis
41
What HLA antigen is spondyloarthritis associated with
HLA-B27
42
List the types of seronegative spondyloarthropathy
Axial spondyloarthritis (sacroiliac/spine)
Psoriatic arthritis
Reactive arthritis (sexually transmitted)
Post-dysenteric reactive arthritis
Enteropathic arthritis (CD/UC)
43
What age group does Ankylosing spondylitis. commonly affect?
20 years and older
44
List the hallmark clinical features in Ankylosing spondylitis
Inflammatory back pain
* Insidious onset
* Worse/stiff in the morning
* Improves with exercise
Alternating buttock pain
Waking up in the second half of the night with back pain
Resolution of symptoms with NSAIDs
45
List the Ankylosing spondylitis associated features
Family history of spondyloarthropathy
Anterior uveitis
Enthesitis
Psoriasis
Inflammatory bowel disease
Dyspnoea
Fatigue
Sleep disturbance
46
List the physical examination findings in Ankylosing spondylitis
Loss of lumbar lordosis and flexion
Tenderness at sacroiliac joints
Kyphosis in chronic cases
Peripheral joint involvement
47
List the X ray signs in Ankylosing spondylitis
Sacroiliitis
Syndesmophytes
Vertebral squaring
Erosion
Sclerosis
Bamboo spine
48
Give the first line management for Ankylosing spondylitis
NSAIDs
49
Give the management for ankylosing spondylitis when there is intra-articular inflammation/enthesitis
Hydrocortisone
50
Give the management for ankylosing spondylitis when there is peripheral joint involvement
Conventional DMARDs (sulfasalazine, methotrexate)
51
Give the inheritance mechanism in psoriatic arthritis
Paternal imprinting
(Inheritance of an allele from 16q chromosome from the father increases the risk of arthritis)
52
List the distinguishing features between psoriatic arthritis and rheumatoid arthritis
Presence of dactylitis
DIP involvement
Absent anti-CCP antibodies
Frequent mono/oligoarticular initial pattern of joint involvement
53
List the clinical features of psoriatic arthritis
Psoriasis
Prolonged morning stiffness in joints lasting > 30 mins
Morning first-step foot pain
Joint/digit swelling
54
List the X ray signs of psoriatic arthritis
Erosion in the DIP joint
Peri-articular new bone formation
Early disease: soft tissue swelling
Late disease:
* Osteolysis leading to arthritis mutilans
* Pencil-in-cup deformity
Characteristic asymmetric sacroiliitis
55
List the management options for psoriatic arthritis
DMARDs
NSAIDs
Physiotherapy
56
Give the pathology in reactive arthritis
Sterile synovitis after exposure to certain GI/GU infections
Bacterial DNA may be discovered in the synovial tissue
57
List the common associated species in Reactive arthritis
Chlamydia
* C trachomatis
* C pneumoniae
Salmonella enteritidis
Campylobacter jejuni
Shigella
Yersinia
58
List the classical triad in reactive arthritis
Post-infectious arthritis
Non-gonococcal urethritis
Conjunctivitis
59
List the presentations in reactive arthritis
Fever
Peripheral arthritis - asymmetrical, oligoarticular, affects large joints of the lower limb
Conjunctivitis
Axial arthritis
Enthesitis
Dactylitis
Nail dystrophy
Skin lesions:
* Circinate balanitis:
* Painless superficial ulceration of glans penis in uncircumcised
* Raised, red, scaly lesion in circumcised
* Keratoderma blenorrhagicum - Painless, red, raised plaques and pustules on skins of the feet and hand
60
Give the first line management in reactive arthritis
NSAIDs
Corticosteroid - Prednisolone
61
Give the management in reactive arthritis if persisting/chronic
Sulfasalazine
62
In what population does Enteric arthritis occur
Occurs in up to 10–15% of patients who have ulcerative colitis or Crohn’s disease
Remission of ulcerative colitis/total colectomy usually leads to remission.
But arthritis can persist in well-controlled Crohn’s disease.
63
What joints does Enteric arthritis affect
Predominantly affects lower-limb joints, asymmetrical
64
List the first line managements in Enteric arthritis
NSAIDs
65
Give the managements in enteric arthritis when there is intra-articular involvement
TNF-a inhibitors (treat both arthritis and IBD)
* Infliximab
* Adalimumab
66
List the two main types of crystal arthritis
Gout and hyperuricemia
Calcium pyrophosphate dihydrate deposition arthropathy
67
What joints do gout commonly affect
First toe (podagra)
Foot
Ankle
Knee
Fingers
Wrist
Elbow
68
List the complications of gout
Joint destruction
Nephrolithiasis
Tophi
Chronic arthritis
69
List the complications of hyperuricemia
Cardiovascular disease
Chronic kidney disease
70
What are urates
metabolite of purines (adenine, guanine), ionised form of uric acid
71
List the causes of hyperuricemia
Impaired excretion
* Chronic renal disease
* Thiazide diuretics
* Low-dose aspirin
* Hypertension
* Alcohol, exercise, starvation (increased lactic acid production)
* Lead toxicity
* Primary hyperparathyroidism and hypothyroidism
* Glucose-6-phosphatase deficiency (interferes with renal excretion)
Increased purine turnover:
* Myeloproliferative disorders eg. polycythaemia vera
* Lymphoproliferative disorders eg. leukaemia
* Others eg. carcinoma, severe psoriasis
72
List the clinical features in gout
Recurrent acute monoarthritis of the first metatarsophalangeal joint (podagra)
Acute onset of severe joint pain
Swelling, effusion, warmth, erythema, tenderness of involved joints
73
List the investigations and findings in gout
Arthrocentesis with synovial fluid analysis
* Elevated synovial WCC
* Needle shaped monosodium urate crystals
Serum uric acid level - elevated
74
List the ultrasound signs in gout
Tophi
Erosion
Double contour sign
75
How is gout diagnosis confirmed
Arthrocentesis showing strongly negative birefringent needle-shaped crystals under polarised light
76
List the first line managements in gout
NSAIDs
Corticosteroids
Colchicine
77
List the second line managements in gout
IL-1 inhibitor
* Anakinra
* Canakinumab
78
List the long-term prevention treatments for gout
(Uric acid-lowering drugs)
Allopurinol
Febuxostat
Probenecid/Sulfinpyrazone
Pegloticase
79
List the colchicine side effects
Diarrhoea
Nausea/vomiting
Colicky abdominal pain
80
List the dietary advices in gout
Reduce alcohol
Reduce total calorie and cholesterol intake
Avoid purine rich food
* Offal
* Red meat
* Shellfish
* Spinach
81
What metabolic conditions are Calcium pyrophosphate deposition associated with
Hyperparathyroidism
Hypomagnesaemia
Haemochromatosis
82
Give the hallmark in calcium pyrophosphate deposition
Deposition of CPP crystals in the mid-zone of articular hyaline and fibrocartilage
83
Give the presentations of calcium pyrophosphate deposition
Painful and tender joints
Osteoarthritis-like involvement of joints
Involvement of joints not typically involved in osteoarthritis (shoulders, wrists, MCP) in a patient with clinical osteoarthritis suggests CPP arthritis
84
List the major contraindications to arthrocentesis
Bacteraemia
Active infection overlying the joint
85
Give the investigations and findings in calcium pyrophosphate deposition
Arthrocentesis - positively birefringent rhomboid-shaped crystals
86
List the management options for calcium pyrophosphate deposition
Intra-articular corticosteroids
* Triamcinolone hexacetonide
* Dexamethasone
NSAIDs
Low dose colchicine
87
Give the predominant causative organism in septic arthritis
S aureus
88
When should non-gonococcal septic arthritis be suspected
Joint disease
Chronic systemic disease (impaired host defences)
Corticosteroids/immunomodulators
Recent intra-articular injections
Skin/soft tissue infection
IVDU
89
When should gonococcal septic arthritis be suspected
Sexually active
Localised septic arthritis
Arthritis-dermatitis syndrome (malaise, polyarthralgias, tenosynovitis, and dermatitis)
90
When should MRSA septic arthritis be suspected
Recent hospitalisation
Residence in nursing home
91
When should Gram -ve septic arthritis be suspected
Indwelling catheters/current UTI
Recent abdominal surgery
Advanced age
92
When should anaerobic septic arthritis be suspected
Penetrating trauma
93
When should Borrelia burgdorferi septic arthritis be suspected
Exposure to ticks
Lyme-endemic areas
94
List the risk factors for septic arthritis
Pre-existing joint disease (eg. RA/osteoarthritis)
Joint prostheses
IVDU
Immunosuppressive medication
HIV
Alcohol use disorder
Diabetes
Previous intra-articular corticosteroid injection
Recent joint surgery
Presence of other infections (eg. skin infections and cutaneous ulcers)
Exposure to ticks (Lyme disease)
95
List the presenting symptoms in septic arthritis
Hot, swollen, acutely painful joint with restriction of movement
Onset of joint pain typically 2 weeks or less
96
List the investigations for septic arthritis
Blood culture and sensitivities
Repeat aspiration to dryness
* Pain relief
* Therapeutic in removing source of infection
* Diagnostic / monitoring
97
List the antibiotics for septic arthritis
Staphylo/streptococci - Flucloxacillin
Gonococcal - Ceftriaxone
MRSA - Vancomycin + Ceftriaxone
Gram-ve - Ceftriaxone
98
List the antibiotic options for Lyme arthritis
Doxycycline 21 days
Amoxicillin 21 days
Azithromycin 17 days
99
List the antibodies found in Systemic Lupus Erythematosus
Anti-dsDNA
Anti-Ro (SS-A)
Anti-La (SS-B)
Anti-Sm
Anti-UI-RNP
100
List the antibodies found in Drug-induced lupus
Anti-histone
101
List the antibodies found in Primary Sjögren’s
Anti-Ro (SS-A)
Anti-La (SS-B)
Antinuclear antibodies
102
List the antibodies found in Polymyositis and Dermatomyositis
Anti-Jo-1 (antisynthetase)
103
List the antibodies found in Limited scleroderma and Diffuse cutaneous SSc
Limited scleroderma - Anti-centromeric
Diffuse cutaneous SSc
* Anti-topoisomerase-1
* Anti-RNA polymerase III
104
Give the pathophysiology in Systemic Lupus Erythematosus
Loss of immune tolerance due to:
* Failure of rapid clearance of cells through apoptosis that typically prevents nuclear antigen exposure to the immune system
* Loss of mechanisms that confer immune tolerance to nuclear antigens
High-affinity IgG antibodies to dsDNA and nuclear proteins
Evidenced by presence of antinuclear antibodies
105
What age group does Systemic Lupus Erythematosus commonly affect
Women in reproductive years
106
List the clinical features in Systemic Lupus Erythematosus
(Normal CRP, low complement)
General
* Fever
* Depression
* Fatigue
* Weight loss
Eye - Sjogren's
Skin
* Photosensitivity
* Butterfly rash
* Vasculitis
* Purpura
* Urticaria
Joints
* Aseptic necrosis of hip
* Arthritis in small joints
Raynaud's phenomenon
Chest
* Pleurisy/effusion
* Restrictive lung defect
Heart
* Pericarditis
* Endocarditis
* Aortic valve lesions
Abdominal pain
Glomerulonephritis
Anemia
* Normochromic normocytic
* Coombes+ve haemolytic
Leucopenia/lymphopenia
Thrombocytopenia
Nervous system
* Fits
* Hemiplegia
* Ataxia
* Polyneuropathy
* Cranial nerve lesions
* Psychosis
* Demyelinating syndromes
Myositis
107
List the causes of Drug-induced Lupus
Sulfasalazine
Procainamide
Isoniazid
Phenytoin
Carbamazepine
108
List the managements for mild to moderate serositis/arthritis in Lupus
1st line: Hydroxychloroquine (antimalarials)
NSAIDs
Corticosteroids
109
List the managements for severe lupus
Immunosuppressive agents
* Methotrexate
* Azathioprine
* Mycophenolate
* Cyclophosphamide
B-cell targeting agents
* Rituximab
* Belimumab
110
List the antibodies found in antiphospholipid syndrome
Lupus anticoagulant
Anticardiolipin antibody
Anti-β2-glycoprotein I
111
Give the diagnostic criteria for antiphospholipid syndrome
at least 1 of the clinical criteria of vascular thrombosis or pregnancy morbidity is present
presence of antiphospholipid antibodies on 2 or more occasions, 12 weeks apart
112
What is antiphospholipid syndrome associated with
Arterial/venous thrombosis
Recurrent miscarriages
113
Define Obstetric APS
Female patients with antiphospholipid antibodies and a history of pregnancy-related morbidity but no history of thrombosis
114
Define Incidental APS
Patients with antiphospholipid antibodies but no thrombotic or related obstetric complications
115
Give the managements for antiphospholipid syndrome
Long term anticoagulation
* Low molecular weight heparin (enoxaparin)
* Vitamin K antagonist (warfarin)
116
Define Catastrophic APS
Multiorgan impairment due to widespread thrombosis involving 3 or more organs
117
Give the management for Catastrophic APS
Low molecular weight heparin
Immunosuppressive therapy
* Prednisolone and plasma exchange / IV immunoglobulin
* Rituximab
* Eculizumab
118
What is scleroderma characterised by
Functional and structural abnormalities of small blood vessels
Fibrosis of skin and internal organs
Auto-antibodies
119
List the two subtypes of scleroderma
Limited cutaneous SSc (LcSSc)
* Less severe internal organ involvement
* Better prognosis
Diffuse cutaneous SSc (DcSSc)
120
List the clinical features of scleroderma
Tight skin over face, small mouth, beaky nose
Telangiectasia
Thickened skin
* DcSSc - all over the body
* LcSSc - limited to hands, feet, face
Oesophageal dysmotility/stricture
Raynaud's
Myocardial fibrosis
Lungs
* DcSSc - pulmonary fibrosis
* LcSSc - pulmonary hypertension
Scleroderma renal crisis
Intestine
* malabsorption
* hypo motility
* incontinence
121
What is the most common cause of death in scleroderma
acute hypertensive renal crisis
122
List the characteristics of scleroderma
Acute renal failure
Accelerated hypertension
Microangiopathic haemolytic anaemia
Histology = onion skin thickening of arterioles
123
List the three groups in idiopathic inflammatory myopathies and their distinguishing features
Polymyositis (autoimmune) - inflamed striated muscle causing proximal muscle weakness
Dermatomyositis (autoimmune) - characteristic rash
Inclusion body myositis (autoimmune and degenerative) - slowly progressive weakness of mainly distal muscles
124
Define antisynthetase syndrome
20~30% people with PM/DM have anti-tRNA synthetase antibodies
* anti-histidine-tRNA ligase (Jo-1)
* anti-signal recognition particle (SRP)
* anti-Mi-2
125
What do people with antisynthetase syndrome more likely to develop?
Pulmonary interstitial fibrosis
Raynaud’s phenomenon
Arthritis
Hardening, fissuring of skin over the pulp surface of hands
Poor outcome with respiratory and esophageal muscle involvement
126
List the malignancies most frequently associated with polymyositis
Non-hodgkin’s lymphoma
Lung cancer
Bladder cancer
127
List the malignancies most frequently associated with dermatomyositis
Non-hodgkin’s lymphoma
Pancreatic cancer
Ovarian cancer
128
List the presentations in idiopathic inflammatory myopathies
Increasing difficulties in performing tasks predominantly requiring proximal muscles
Fine motor tasks requiring distal muscles (sewing, knitting, writing) are affected
* Early in inclusion body myositis
* Late in polymyositis and dermatomyositis
Falling is common in inclusion body myositis
* Due to early quadriceps involvement
Weight loss, fatigue, generalised malaise
129
List the extra-muscular symptoms in idiopathic inflammatory myopathies
Arthralgia
Dysphagia
Shortness of breath
Palpitations
Syncope
Rash
Inflammatory arthritis/Raynaud’s phenomenon
Myocardial infarction symptoms
130
List the characteristic skin lesions in dermatomyositis
Heliotrope rash with eyelid oedema
Gottron’s papules - Erythema of knuckles with raised violaceous scaly eruption
Facial rash
Erythematous rash over the knees, elbows, malleoli, base of neck and chest
Nail fold changes eg. dilation of capillary loops of periungual area
131
List the laboratory investigations and findings in idiopathic inflammatory myopathies
+ve myositis-specific and associated autoantibodies
Elevated creatinine kinase (most sensitive)
Elevated aldolase, myoglobin, ALT, AST, LDH
132
List the EMG findings in idiopathic inflammatory myopathies
Spontaneous fibrillation potentials at rest
Polyphasic potentials on voluntary contraction
Repetitive potentials on mechanical stimulation of the nerve
133
List the MRI findings in idiopathic inflammatory myopathies
Muscle inflammation / atrophy
Muscle fatty replacement
134
Give the gold standard investigation in idiopathic inflammatory myopathies
Muscle biopsy
135
List the management options for idiopathic inflammatory myopathies
IV corticosteroids
Long term immunosuppression
* Methotrexate
* Azathioprine
* Mycophenolate
IV immunoglobulin
136
What genomic susceptibility is Sjogren’s syndrome associated with
HLA-B8/DR3
137
List the diagnostic features in Sjogren’s syndrome
Positive
* Anti-Ro (SS-A)
* Anti-La (SS-B)
* Antinuclear antibodies
Decreased tear and saliva production
Lymphocytic infiltration in labial salivary gland biopsy
138
List the characteristic symptoms in Sjogren’s syndrome
Dry eyes (keratoconjunctivitis sicca)
* Dry, itchy, burning, gritty eyes
* Redness of eyes
* Sensitivity to light and wind
Dry mouth (xerostomia)
* Dry mouth, burning, difficulty in chewing and swallowing
* Altered/decreased taste acuities
* Difficulty speaking for long periods
* Awake at night to drink
* Severe dental caries leading to teeth loss
* Increased bacterial and fungal infections
* Thicker and opaque saliva
* Enlarged and painful salivary glands
139
List the extraglandular presentations in Sjogren’s syndrome
Fatigue
MSK - Arthritis, arthralgia, myalgia
Vasculitis - Rash (anti-Ro, anti-La)
Renal tubular acidosis
Peripheral neuropathy
Facial pain
* Glossodynia (orofacial pain/burning mouth syndrome)
* Osteonecrosis of the jaw
* Trigeminal neuralgia
Venous thromboembolism
Aortic aneurysm/dissection
140
List the management options for sicca symptoms in Sjogren’s syndrome
Artificial tear substitutes
Ciclosporin eye drops
Cholinergic drugs (pilocarpine, cevimeline)
141
List the management options for xerostomia symptoms in Sjogren’s syndrome
Salivary substitutes
Cholinergic drugs (pilocarpine, cevimeline)
142
List the management options for MSK symptoms in Sjogren’s syndrome
Paracetamol
NSAIDs
Corticosteroid
Hydroxychloroquine
Methotrexate
143
List the management options for Vasculitis symptoms in Sjogren’s syndrome
Corticosteroids
IVIG
144
List the management options for Renal tubular acidosis symptoms in Sjogren’s syndrome
Potassium repletion and alkali
145
List the management options for Neuropathy symptoms in Sjogren’s syndrome
IVIG
146
List the common causes of a Trendelenburg gait
Painful hip joint problems - osteoarthritis
Weak hip abductors
* poliomyelitis
* hip replacement
Developmental hip dysplasia
147
What causes winging of scapula
Long thoracic nerve (C5–C7) injury
148
Describe Trendelenburg’s sign
Normally, the iliac crest on the side with the foot off the ground should rise.
The test is abnormal if the unsupported hemipelvis falls below the horizontal
149
List the types of systemic vasculitis
Large vessels
* Giant cell arteritis
* Polymyalgia rheumatica
* Takayasu’s arteritis
Medium vessels
* Polyarteritis nodosa
* Kawasaki’s disease
Small vessels - ANCA POSITIVE
* Granulomatosis with polyangiitis
* Microscopic polyangiitis
* Eosinophilic granulomatosis with polyangiitis
Small vessels - ANCA NEGATIVE
* Anti-GBM disease
* IgA vasculitis (Henoch–Schönlein)
* Cryoglobulinemic vasculitis
* Hypocomplementemic urticarial vasculitis (HUV, anti-C1q vasculitis)
* Cutaneous leukocytoclastic vasculitis
150
What age group and gender does Polymyalgia rheumatica tend to occur
Typically occurs in age ≥50
More common in women
151
What is Polymyalgia rheumatica associated with
15~20% of PMR patients have giant cell arteritis (GCA).
40~60% of GCA patients have PMR.
152
List the symptoms in Polymyalgia rheumatica
Difficulty rising from seated/prone positions
Acute onset of pain and stiffness in neck/shoulder/hip girdle, worse in the morning
Varying degrees of muscle tenderness
Shoulder/hip bursitis
Oligoarthritis
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List the investigations and findings in Polymyalgia rheumatica
Rapid response to corticosteroids within 24 to 72 hours
ESR/CRP Elevated
Thyroid function tests - Exclude hypothyroidism (arthralgia, stiffness)
FBC and serum protein electrophoresis - Exclude myeloproliferative disorders (fatigue, bony pain, elevated ESR)
Rheumatoid factor and anti-CCP antibodies - Exclude RA
154
Give one differential diagnosis for Polymyalgia rheumatica and its distinguishing features
Myositis
In polymyalgia rheumatica, there is normal creatinine kinase
155
List the management options in polymyalgia rheumatica
Low-dose corticosteroids
Short term NSAIDs
Methotrexate
156
List the presentations of Giant cell arteritis
Age >50 yrs
New onset headache
Limb, jaw, tongue claudication
Scalp tenderness
Acute visual symptoms (amaurosis fugax)
Unexplained raised ESR/CRP
Constitutional symptoms:
* Fever
* Fatigue
* Night sweats
* Weight loss
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How is Giant cell arteritis diagnosis confirmed
Ultrasonography
* Non-compressible halo sign (wall thickening)
* Stenosis/Occlusion
Temporal artery biopsy - Intramural inflammation characteristic of GCA
158
Give the typical demographic in Takayasu’s arteritis
Commonly affects women
Typically presents before <40
159
Define Takayasu’s arteritis
Vasculitis of large vessels that particularly affects the aorta and its primary branches.
160
List the typical symptoms in Takayasu’s arteritis
Claudication on exertion
Chest pain
Systemic symptoms:
* Fatigue
* Myalgia
* Weight loss
* Low grade fever
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List the physical signs in Takayasu’s arteritis
Cool extremities
Absent pulses (pulseless disease)
Differences in blood pressure >10mmHg on each arm
162
List the investigations and findings in Takayasu’s arteritis
Elevated ESR/CRP
Normocytic anaemia
Thrombocytosis
163
List the management options in Takayasu’s arteritis
1st line: Oral glucocorticoids
Immunosuppressants
* Methotrexate
* Leflunomide
* Azathioprine
* Mycophenolate
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What does Polyarteritis nodosa affect
Medium-sized vessels
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Give the characteristic pathology in Polyarteritis nodosa
Focal and segmental transmural necrotising inflammation with fibrinoid necrosis in medium sized vessels
166
List the clinical features for polyarteritis nodosa
Non-specific systemic symptoms
* Fever
* Weight Loss
* Weakness
* Myalgia
MSK - Arthritis, arthralgia, myalgia, muscle weakness
Nervous system
* Mononeuritis multiplex (sensory symptoms preceding motor deficits)
* CNS involvement (stroke, seizures, encephalopathy)
Skin
* Purpura
* Nodules
* Livedo reticularis
* Ulcers
* Bullous/vesicular eruptions
* Segmental skin oedema
Abdomen
* Pain (mesenteric artery disease)
* Appendicitis/cholecystitis/pancreatitis (ischaemia/infarction)
* Renal arteries vasculitis
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What is Polyarteritis nodosa associated with
HBV
In 7~38.5% of patients diagnosed with PAN, HBV infection is implicated as the underlying cause
168
List the investigations and findings in Polyarteritis nodosa
Elevated ESR/CRP
Raised fibrinogen (Acute inflammation)
FBC - Anaemia due to chronic inflammation/GI blood loss
Low complement levels
Normal/elevated creatinine kinase
Raised serum creatinine without haematuria/proteinuria (Renal ischaemia/infarction)
Abnormal LFT - HBV/ischaemic hepatitis
HBV serology - Positive in HBV-related PAN
ANCA -ve
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List the management for non-HBV-related PAN
Prednisolone and cyclophosphamide
170
List the management for HBV-related PAN
Short course high-dose oral prednisolone
Antiviral therapy - Lamivudine
Plasma exchange
171
List the findings in ANCA associated vasculitis
Renal impairment (immune complex glomerulonephritis)
Respiratory symptoms
* Dyspnoea
* Haemoptysis
* Sinusitis
Systemic symptoms
* Fatigue
* Weight loss
* Fever
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List the laboratory investigations and findings in ANCA associated vasculitis
Urinalysis for haematuria and proteinuria
urea and creatinine for renal impairment
Full blood count: normocytic anaemia and thrombocytosis
CRP: raised
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What may be seen on chest X ray in ANCA associated vasculitis
nodular, fibrotic or infiltrative lesions
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What is cANCA associated with
Granulomatosis with polyangiitis
Microscopic polyangiitis (40%)
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What do cANCA and pANCA target?
cANCA - Serine proteinase 3
pANCA - Myeloperoxidase
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What is pANCA associated with
Eosinophilic granulomatosis with polyangiitis
Microscopic polyangiitis
Ulcerative colitis (70%)
Primary sclerosing cholangitis (70%)
Anti-GBM disease (25%)
Crohn's disease (20%)
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What geographical regions is Behcet's syndrome commonly seen in
Commonly seen in Turkey, Israel, Mediterranean, and East Asia
178
What HLA type is Behcet's syndrome associated with
HLA-B51
179
Give the international diagnostic criteria for Behcet's syndrome
Oral ulcers + any two of:
* Genital ulcers
* Eye lesions (anterior/posterior uveitis, retinal vascular lesions)
* Skin lesions (erythema nodosum, pseudofolliculitis, papulopustular lesions)
* Positive skin pathergy test (skin needle prick injury leads to pustular formation within 24~48 hours)
* Oral ulcers (aphthous/herpetiform)
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List the management options for Behcet's syndrome
Corticosteroids
* Triamcinolone topical
* Prednisolone
Immunosuppressant
* Azathioprine
* Hydroxychloroquine
Colchicine
TNF-a inhibitor (infliximab)
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Give the clinical diagnostic criteria for Fibromyalgia
Chronic multifocal pain for longer than 3 months
With other symptoms
* Fatigue
* Memory problems
* Sleep and mood disturbances
Normal physical examination
182
What is Fibromyalgia associated with
(central sensitisation syndrome)
Irritable bowel syndrome
Tension headaches
Temporomandibular joint disorder
Interstitial cystitis
Vulvodynia
183
List the management options for Fibromyalgia
Tricyclic antidepressants
* Amitriptyline
* Cyclobenzaprine
SSRI
* Duloxetine
* Milnacipran
Gabapentinoids
* Pregabalin
* Gabapentin
184
List the hallmarks in Osteoporosis
Low bone mass
Micro-architectural deterioration of bone tissue
Enhanced bone fragility and increased fracture risk
185
List the biochemical markers of bone formation
Bone-specific ALP (Alkaline phosphatase)
Carboxyterminal (P1CP) and aminoterminal (P1NP) pro-peptides (Type 1 collagen propeptides)
Osteocalcin
186
List the biochemical markers of bone resorption
Serum/urine N-terminal (NTX) and C-terminal (CTX) cross-linked telopeptides
187
List the risk factors for osteoporosis
(SHATTERED)
Steroid use
Hyperthyroidism, hypercalciuria and hyperparathyroidism
Alcohol and smoking
Thin – BMI < 18.5
Testosterone ↓ - ↑ bone turnover, hypogonadism, Turner/Klinefelter
Early menopause - premature ovarian failure
Renal/liver failure
Erosive/inflammatory bone disease – RA/myeloma
Dietary calcium ↓ or malabsorption, T1DM
188
List the physical examination findings in osteoporosis
Low body mass index
Spinal kyphosis due to asymptomatic fracture
189
Give the gold standard investigation and findings in osteoporosis
Dual-energy X-ray absorptiometry (DXA)
* T-score ≤−2.5 = osteoporosis
* T-score ≤−1.0 to <−2.5 = osteopenia
* T-score >−1.0 = normal BMD
* Z scores ≤−2.0 is ‘low BMD for age’
190
List the laboratory investigations for Osteoporosis
Biomarkers of bone resorption (NTX, CTX) in conjunction with BMD
Normal serum calcium, serum phosphate, ALP and PTH
191
List the non-osteoporotic causes for fragility fractures
Metastatic bone disease
Multiple myeloma
Osteomalacia
Paget’s disease
192
Give the first line therapy in osteoporosis
Bisphosphonate + Calcium and vitamin D supplementation
Teriparatide
193
What geographical areas are Paget’s disease of the bone most often seen in?
Europe, particularly N. England
194
List the pathophysiology in Paget’s disease of the bone
Increased osteoclastic bone resorption
Followed by a compensatory increase in new bone formation
Increased local bone blood flow and fibrous tissue in adjacent bone marrow
Ultimately, formation exceeds resorption
However, the new woven bone is weaker than the normal bone. Leads deformity and leads to fracture risk.
195
List the three stages in Paget’s disease of the bone
1. Initial, short-lived burst of multinucleated osteoclast activity causing bone resorption.
2. Mixed phase of both osteoclastic and osteoblastic activity.
Increased levels of bone turnover lead to deposition of structurally abnormal bone.
3. Chronic sclerotic phase, bone formation outweighs bone resorption.
196
List the risk factors for Paget’s disease of the bone
Genetics
Infection by paramyxovirus
* Measles
* Respiratory syncytial virus
* Canine distemper virus
197
Where does Paget’s disease of the bone most commonly affect?
femur
198
List the presentations in Paget’s disease of the bone
Bone
* Pain
* Fractures
* Osteosarcoma
Bowed tibia
Skull enlargement
Arthritis
Neurological
* Nerve compression (CN2, 5, 7, 8 (deafness))
* Spinal stenosis
* Hydrocephalus (blockage of Sylvius aqueduct)
Hypercalcaemia (immobility)
High-throughput heart failure and myocardial hypertrophy
199
List the X ray findings for Paget’s disease of the bone
First stage: lytic changes, most commonly seen in skull (osteoporosis circumscripta cranii)
Second stage: maybe occasional fractures
Late stage: osteosclerotic changes. Thickened coarse trabeculae
200
List the laboratory investigations and findings in Paget’s disease of the bone
Elevated:
* Bone-specific ALP
* P1NP/P1CP
Serum 25-hydroxyvitamin D - Vitamin D deficiency
201
List the medical management options in Paget’s disease of the bone
Bisphosphonates
* Zoledronic acid
* Alendronic acid
* Risedronate sodium
If contraindicated: Calcitonin-salmon
202
Define Osteomalacia and Rickets
Osteomalacia - incomplete mineralisation of the bone matrix (osteoid) following growth plate closure in adults
Rickets - defective mineralisation of the epiphyseal growth plate cartilage in children, resulting in skeletal deformities and growth retardation
203
What is the primary cause of osteomalacia
Vitamin D deficiency
Vitamin D deficiency → hyperparathyroidism → hypophosphatemia
204
List the causes of osteomalacia
Acquired:
Nutritional deficiency (vitamin D, phosphates, calcium)
* Low dietary intake
* Malabsorption
* Lack of UV-B exposure
Anticonvulsants
Chronic kidney disease - metabolic bone disease
Paraneoplastic syndrome of renal phosphate wasting
Bisphosphonate toxicity
Inherited:
Vitamin D-dependent rickets
Hypophosphatasia (Inborn error of metabolism)
Hypophosphatemic rickets
Acquired/inherited
Fanconi’s syndrome
Renal tubular acidosis
205
What is Hypophosphatasia characterised by
Subnormal activity of tissue-non-specific ALP
Associated with development of osteomalacia and severe periodontal disease
206
List the risk factors for Osteomalacia
Increasing age
Poor dietary intake of vitamin D and calcium
Hx. limited sunlight exposure
Sunscreen use
GI malabsorption
Anticonvulsant use
Liver / renal impairment
207
List the common signs for Osteomalacia
Proximal muscle weakness
* Difficulty rising from a sitting position
* Waddling gait
Diffuse bony pain
Bone tenderness to percussion
Pseudofractures
Skeletal deformities
208
List the investigations and findings in Osteomalacia
Elevated ALP, PTH, FGF23
Low serum calcium, phosphate, 25-hydroxyvitamin D3
209
List the X ray findings in Osteomalacia
Decreased bone mineralisation
Looser’s pseudofractures (characteristic) - radiolucent lines with sclerotic borders running perpendicular to the cortex, most commonly in the femur and pelvis
210
List the managements for osteomalacia
Vitamin D
* Ergocalciferol
* Cholecalciferol
Calcium
* Calcium carbonate
* Calcium citrate
211
When should acute osteomyelitis be suspected
Unwell child with a limp or in an immunocompromised patient
212
When should chronic osteomyelitis be suspected
Patient with Hx. open fracture, orthopaedic surgery, discharging sinus
213
What is osteomyelitis most commonly caused by
Staphylococcus aureus
214
List the common organisms implicated in acute osteomyelitis
S aureus
Streptococci
Enterobacteriaceae
Anaerobic bacteria
215
When should native vertebral osteomyelitis be suspected
New onset neck pain and systemic symptoms
216
List the common organisms implicated in osteomyelitis by age
Infants
* S aureus
* Group B streptococci
* Aerobic gram-negative bacilli (Escherichia coli)
* Candida albicans
Children 3 months up to 5 years:
* S aureus
* Kingella kingae
* Group A streptococcus (S pyogenes)
* Streptococcus pneumoniae
* Haemophilus influenzae (unimmunised)
* Pseudomonas (foot puncture wounds)
Children >5 years:
* S aureus
* Group A streptococcus (S pyogenes)
Adults:
* S aureus
* Coagulase-negative staphylococci
* Aerobic gram-negative bacteria
* Peptostreptococcus species
Older adults - Gram-negative bacilli
217
List the common organisms implicated in osteomyelitis in patients with intravascular devices
S aureus
Candida species
218
List the common organisms implicated in osteomyelitis in patients who misuse intravenous drugs
S aureus
Pseudomonas aeruginosa
219
List the common organisms implicated in osteomyelitis in patients with sickle cell disease/from developing countries
Salmonella species
S aureus
220
List the suggestive features of native vertebral osteomyelitis
New/worsening neck/back pain AND
* Fever
* Elevated ESR/CRP
* Bloodstream infection / infective endocarditis
221
List the risk factors for native vertebral osteomyelitis
Elderly
Immunocompromised
Active IVDU
Have indwelling central catheters
Have undergone recent instrumentation
222
List the symptoms suggestive of acute osteomyelitis
Limb deformity
Limping/reluctance to bear weight in children
Fever
Bone pain
Local erythema and swelling
Reduced range of movement
Sinus/wound drainage
Recent incidental trauma
Malaise and fatigue
Infections (skin/ urinary tract)
223
List the symptoms suggestive of chronic osteomyelitis
Vague, non-specific bone pain
Low grade fever 1~3 months
Wound/sinus tract drainage
Lethargy and malaise
224
Give the gold standard investigation for osteomyelitis
Microbiology samples (blood culture/bone biopsy) prior to commencing antibiotics
225
Give the empirical antibiotics for acute osteomyelitis
IV flucloxacillin
* Penicillin allergy: IV vancomycin
226
Give the typical population in Osteosarcoma
Peak incidence between 13 and 16 years of age.
More common in males than females.
227
List the risk factors for Paget’s disease of the bone
Paget’s disease of the bone
Hx. radiotherapy
Chemotherapy
Bone conditions
* Fibrous dysplasia
* Bone infarct
* Chronic osteomyelitis
* Prosthetic implants
Inherited conditions
* Familial retinoblastoma syndrome
* Li-Fraumeni syndrome
* Rothmund-Thomson syndrome
228
List the symptoms in Osteosarcoma
Pain
Swelling
Limping
Limited range of motion
Pathological fractures
* Common in purely lytic tumours (telangiectatic osteosarcoma)
229
Give the first-line diagnostic test and findings in osteosarcoma
Radiolucent lesion
Areas of mottled radiodensity and ill-defined margins
Neoplasm is usually located in the metaphysis of a long bone
Codman’s triangle - reactive new bone formation under the periosteum
230
Give the definitive diagnostic test in osteosarcoma
Core needle / open biopsy
231
List the causes for True vs Functional Leg Length Discrepancy
True
* Idiopathic developmental abnormalities
* Fracture
* Trauma to the epiphyseal endplate prior to skeletal maturity
* Degenerative disorders
* Legg-Calvé-Perthes Disease
* Malignancy
* Infections
Functional
* Shortening of soft tissues
* Joint contractures
* Ligamentous laxity
* Axial malalignments
* Foot biomechanics
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