MSK Flashcards
What is rheumatology
Medical management of musculoskeletal disease, mainly inflammatory
What are the three classes of inflammatory MSK
Autoimmune, crystal arthitis and infection
What are the two classes of non inlammatory MSK
Degenerative and non degenerative
Examples of autoimmune inflammatory MSK disorders
Rheumatoid arthitis, spondyloarthropathy (HLA B27) and connective tissue disease
Example of degenerative non inflammatory MSK disorders
Osteoarthritis
Example of non degenerative non inflammatory MSK disorders
Fibromyalgia
What is vasculitis
systemic inflammation of the blood vessels
What is the tell tale sign of bone pain
Pain at rest and at night
What are the causes of bone pain
Tumour, infection and fracture
What is the tell tale sign of inflammatory joint pain
Pain and stiffness in joints in the morning, at rest and wirth use
What are the causes of inflammatory joint pain
Inflammation or infection
What are the tell tale signs of osteoarthritis
Pain on use, at end of the day
What are the tell tale signsof neuralgic pain
Pain and paraesthesia in a dermatomal distribution, made worse by specific action
What is paraesthesia
Abnormal sensation, typically a tingling or prickling feeling
What causes neuralgic pain
Root or peripheral nerve compression
What is the tell tall sign of referred pain
Pain unaffected by local movement
Distal interphalyngeal arthritis cause
Osetoarthritis or psoriatic arthritis
Base of the thumb arthritis cause
Osteoarthritis
Proximal interphalangeal arthritis cause
Rheumatoid arthritis
Which arthrites does not affect the spine or hips
Rheumatoid
Which arthritis affects the shoulder
Rheumatoid
What are unique features of psoariatic arthritis
Enthesitis and dactylitis
Describe the chronicity of gout
Comes on quickly and is episodic but can become chronic over time
Describe the chronicity of reactive arthritis
Acute event, will peak and then slowly decline
Describe the chronicity of rheumatoid arthritis
Can be brought on by traumatic event (e.g bereavement), will fluctuate but gradually worsen over time
Describe the chronicity of palindromic rheumatoid arthritis
Episodic but does not go completely
What is enthesitis
Inflammation of a tendon
What is dactylitis
Inflammation of a digit
Is rheumatoid arthritis inflammatory or degenerative
Inflammatory
Is osteoarthritis inflammatory or degenerative
Degenerative
What causes swan neck deformity
Extensor tendons pulling in the distal phalyngeal joint
What is ankylosing spodylitis and spondyloathropathy
Fusing of the spine
What are the hand features of rheumatoid arthritis
Ulnar deviation, swan neck deformity and erosion on XRay
What are the hand features of osteoarthritis
Bouchards and Heberdens nodes on IPJs
Which other joint is distinctive of osteoarthritis
The knee
What are the features of connective tissue disease
Non erosive arthritis and butterfly rash
What are the features of SLE disease
Photo sensitivity and mouth ulcers
Where is gout most common
Big toe 1st MTPJ
What is the most severe form of gout
Chronic polyarticular tophaceous gout
What is ESR practically
Rate that red blood cells settle to the bottom of a test tube after centrifugation. High ESR due to high fibrinogen an acute phase protein
False positives for ESR
Old, female, obese, SE Asia, hypercholesterolaemia, high immunoglobulins, anaemia
Which disease causes high immunoglobulins
Myeloma
What is C-reactive protein (CRP)
Pentameric peptide made in response to IL-6 by the liver (High at 6hrs, peaks at 48)
When is CRP better than ESR
CRP rises and falls quickly so can see acute inflammation
Define autoantibodies
Immunoglobulins that bind to self antigens
Which two factors will be raised in rheumatoid arthritis
Rheumatoid factor (RF) and Cyclic citrullinated peptide (CCP)
Which two factors will be raised in SLE
antinuclear antibody (ANA) and dsDNA (double stranded DNA)
What does anti nuclear antibody do
Binds to antigens within cell nucleus
What has the blood serum been screened for to give a serum positive or serum negative response
Rheumatoid factor
What is HLA-B27 and which diseases is it associated with
Human leukocyte antibody- B27. Associated with seronegative spondylosing arthropathies
What is rheumatoid factor
Autoantibody against the Fc portion of IgG, made by B cells
Define osteomyelitis
Infection localised to bone
Why are gentamycin beads used
To avoid the systemic side effects but treat infection locally
What type of osteomyelitis do children get
Haematogenous
What type of osteomyelitis do adolescents and adults get
Contiguous (from trauma)
Why do older patients get osteomyelitis
DM/PVD/ arthroplasties
What are the three ways you can get osteomyelitis
Direct innoculation, contiguous spread of infection to bone and haematogenous seeding
Where is haematogenous seeding in children vs adults
Children- long bone Adults- vertebrae. Due to good blood flow at metaphysis in children and vertebra in old
What are risk factors for bacteraemia
Central lines, dialysis, sickle cell disease, urethral catheterisation, UTI
Why is osteomyelitis more common in the metaphyses of child long bone
More blood flow and slower blood flow, Endothelial basement membranes and phagocytic linings are missing
Which three bacteria are common in osteomyelitis
Staph aureus, coagulase negative staphylococci (S. epidermidis) and aerobic gram negative bacilli
Which bacteria is a cause of osteomyelitis in sickle cell disease
Salmonella
Which bacteria are causes of osteomyelitis in IV drug users
Pseudomonas aeruginosa and serratia marcescens
Which acute histopathological changes occur in osteomyelitis
Inflammatory cells, oedema, vascular congestion and thrombosis of small vessels
Which chronic histopathological changes occur in osteomyelitis
Sequestra of bone, involucrum, neutrophil exudates, lymphocytes and histiocytes
What are sequestra of bone
Necrotic bone sections
What are involucrum of bone
New bone growth sections
Symptoms of osteomyelitis
Dull pain at the site of osteomyelitis which comes on over several days and may be aggravated by movementq
What are the systemic signs of osteomyelitis
Fever, rigors, sweats and malaise
What are signs of acute osteomyelitis
tenderness, warmth, erythema and swelling
What are the signs of chronic osteomyelitis
Tenderness, warmth, erythema and swelling; draining sinus tract; non healing deep ulcers and fractures
Define septic arthritis
The infections breaks through the cortex and discharges
How is osteomyelitis seen on xray
cortical erosion, periosteal reaction, mixed lucency, sclerosis, sequestra, soft tissue swelling
Causes of avascular necrosis of the bone
Trauma, steroid, radiation, bisphosphonate use
Surgical treatment of OM
Debridement, hardware placement or removal
What is debridement
The removal of damaged tissue or foreign objects from a wound
What investigate is needed for TB OM
Biopsy essential
What determines how long the treatment should be in osteomyelitis
Vascular supply and microbial virulence
What type of bacteria most commonly causes prosthetic joint infection
Gram positive
What is listeria monocytogenes associated with
Meningitis and sepsis in pregnancy
What does DAIR procedure for infected prosthetics stand for
Debridement, antibiotics and implant retention
Is resistance of bacteria permanent
No the genes take energy to maintain so sometimes the bacteria will ditch the resistance
How long do contaminants of the lower limb take to grow
7 days
How long do contaminants of the upper limb take to grow
10 days
Where do propionibacteria infect
From the chest upwards. skin commensal.
What are the two main things important in prosthetic joint infection diagnosis
History and examination. Also XRays, blood tests and microbiology culture
What would you expect to hear in a prosthetic joint infection history
Slow to heal after the operation, recent dental work
Can you aspirate someone on antibiotics
No, they should have been off antibiotics for two weeks
When is antibiotic suppression used for prosthetic joint infection
When the patient is unfit for surgery and the organism has been identified
Does one or two stage exchange joint prosthesis infection tend to be more effective
Two stage as there is a delay between removal and implantation. There is a greater range of prosthesis as you are going into a clean area.
In a history what does PC stand for
Presenting complaint
In a history what does HPC stand for
History of presenting complaint
In a history what does PMH stand for
Past medical history
In a history what does DH stand for
Drug history
In a history what does SH stand for
Social history
In a history what does FH stand for
Family history
What does a gradual onset of knee pain suggst
Osteoarthritis
Investigations for osteoarthritis
Bloods and radiographs (standing AP and lat)
What are the four things you see on XRay for osteoarthritis
Joint space narrowing, subchondral sclerosis, subchondral cysts, osteophytes
What are osteophytes
Bony projections associated with cartilage degradation at joints
What is osteoarthritis treatment
Analgesia, physio, walking aids, therapeutic injection and arthroplasty
What is arthroplasty
Surgical reconstruction or replacement of a joint
What is classified as intracapsular in the hip
Above the line between the greater and lesser trochanters. The head and neck.
What is a type 1 intracapsular hip fracture
Fracture isnt all the way through the bone
What is a type 2 intracapsular hip fracture
Fracture is all the way through the bone but hasnt moved
What is a type 3 intracapsular hip fracture
Complete fracture and slight displacement
What is a type 4 intracapsular hip fracture
Complete fracture and complete displacement
How many degrees of mobilisation are normally lost with hip fracture
One degree
Being able to get out of bed into a chair reduces your chance of
Chest infection and blood clots
What is TARN
Trauma audit research network, collect data on hospital performance
What is a closed fracture
Where the skin is intact
What is an open fracture
Where the skin is not intact
What is a simple fracture
A fracture of the bone only, where the bone is broken into two sections
What is a comminuted fracture
A fracture where the bone is broken into more than two pieces
What is an intraarticular fracture
Involves the joint
What is an extraarticular fracture
Does not involve the joint
What kind of force is a spiral fracture associated with
Torsional
What is a segmented fracture
Where the bone is broken at two levels within the same bone
How is a fracture treated
Analgesia, examination (neurovascular before and after examination), reduce, immobilise, rehabilitate (RIR)
Name four methods of holding the fracture
Cast, splint, brace, halo
Name four methods of holding the fracture internally
Wires, screws, plates and nails
Name three types of external fixation frame
Monolateral, hybrid or circular frames
Define osteoporosis
A systemic skeletal disease characterised by low bone mass and microarchitectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture
What proportion of women over 50 will have an osteoporotic fracture
50%
What proportion of men over 50 will have an osteoporotic fracture
20%
What is a T score
Standard deviation score which compares your bone density with a gender matched young adult average
What are the most commonly used drugs for osteoporosis
Bisphosphonates
Name activities of daily living
Eating, bathing, dressing, toileting, transferring and continence
What determines bone quality
Bone turnover, architecture and mineralisation
What determines BMD
Peak bone mass and rate of bone loss
What determines bone strength`
Bone size, quality and BMD
What is the most important independent risk factor for fracture
Age
Where is most bone mass added during childhood
Mainly limbs
Where is most bone mass added during puberty
Spine
When does bone mass peak
25
What is a colles fracture
Distal forearm where broken end of the radius is bent backwards
Top three types of fracture in men and women over 60
1-hip 2-vertebrae 3-colles’
Is trabecullar or cortical bone remodelled more in bone remodelling
Trabecullar because it has a larger surface area
What is trabecullar bone also known as
Cancellous
What happens to trabecullae bone with age
Thinner (especially the horizontal non weight bearing), less connections, more porous, less strength
Why are horizontal trabecullae lost more than verticle
Mechanoreceptors detect stress and maintain strength in the weight bearing direction
What is the eular buckling theory
Loss of horizontal trabecullae leads to a 16x loss in bone strength
What are common causes of osteoporosis apart from menopause
Inflammatory disease, endocrine and medication
What DXA bone mass density is used for diagnosis of osteoporosis
T score below 2.5
What are the two classes of drugs used in treatment
Antiresorptive and anabolic
What does a T score of less than -1 suggest
Normal bone mass density
What does a T score of -1 to -2.5 suggest
Osteopenia
What does a T score of more than -2.5 suggest
Osteoporosis
What does a T score of more than -2.5 with fracture suggest
Severe osteoporosis
Why is inflammatory disease a cause of osteoporosis
Inflammatory cytokines increase bone resorption
Which hormones increase bone turnover
Thyroid and parathyroid
Which hormone causes bone resorption and induces osteoblast apoptosis
Cortisol
Which hormones reduce/control bone turnover
oestrogen and testosterone
What syndrome is associated with increased cortisol
Cushings
What effect does reduced skeletal loading have on bone
Reduced skeletal loading increases resorption
What affect do thyroid hormones have on osteoclasts
Drive their metabolism
What can cause excess cortisol
Excess treatment or endogenous like cushings
What can cause hypogonadism or menopause
Treatment for prostate disease, chemo, excess exercise
What is depoprovera
Progesterone only contraceptive
Why is alcohol a risk factor for osteoporosis
Directly poisons your osteoblasts
Why is smoking a risk factor for osteoporosis
Drives Vitamin D metabolism
FRAX criteria
Age, sex, weight height, previous fracture, parent fractured hip, current smoking, glucocorticoids, RA, secondary osteoporosis, more than 3 alcohol units, femoral neck BMD
What should you do if you have bad menopausal symptoms and osteoporosis
Take HRT until 60
Risks of HRT
Breast cancer, stroke, CVD, venous thrombo-embolic disease, vaginal bleeding
HRT reduces your risk of which cancer
colon
Whats the first line treatment for osteoporosis
Bisphosphonates such as alendronate
How do bisphosphonates act
Inhibit farnesyl pyrophophate synthase in the cholesterol pathway
How does denosumab act
Monoclonal antibody to RANK ligand
What is teriparatide
Synthetic PTH used as first line anabolic treatment
What is the index condition of crystal arthropathy
Gout
What is a homogenous solid
Ions bonded closely in ordered, repeating, symmetric arrangement
What are crystals in the kidney and liver called
Nephrolithiasis (stones)
Which type of crystals cause gout
Urate
Which type of crystals cause pseudogout
Calcium pyrophosphate
What is crystal arthropathy
arthritis caused by crystal deposition in the joint lining
Diagnosis of crystal arthropathy
Based on history, pattern, aspiration of joint to look for crystals, blood tests and XRays
How do gout crystals appear in synovial fluid
Negatively befringement needles
How do pseudogout crystals appear in synovial fluid
Positively befringement rhomboids
What type of arthritis is from acute inflammation from crystals
Gouty arthritis- gout attack
What type of arthritis is from long term deposition of crystals
Tophaceous gout
Why is the gender gap in gout reducing
Due to gout caused by medications such as diuretics
Which enzyme is needed to convert purines to uric acid
Xanthine oxidase
What are the two purines
Adenine and guanine
How is uric acid excreted
2/3 renal, 1/3 intestinal
What is the main cause of hyperuricaemia
underexcretion
What are causes of underexcretion of uric acid
Alcohol. obesity, diabetes. Renal impairment, HTN, metabolic hyperthryoid and drugs
Which drugs cause underexcretion of uric acid
Low dose aspirin, diuretics, cyclosporin, tacrolimus, ethambutol, pyrazinamide
What are causes of overproduction of uric acid
Metabolic syndrome (hyperlipidaemia), proliferative (myeloproliferative disease, cytotoxic drugs), psoriasis, lesch-nyhan syndrome, diet
What foods cause an overproduction of uric acid
Excess alcohol, meat, shellfish, offal, gravy, meat extract, yeast, fructose sweetened drinks
How do you treat an acute attack of gout
Antiinflammatories. NSAIDS, colchicine and steroids
Who are the main group that get pseudogout
Old women
How do you see gout on an XRay
Periarticular punched out erosions
Why do you get tophi in the early cartilage
Because the blood supply is slow
Define tophi
Onion like aggregates of urate crystals with inflammatory cells
Name a xanthine oxidase inhibitor used in the treatment of gout
Allopurinol
What is pyrophosphate arthropathy
Pseudogout
Define pyrophosphate arthropathy
Deposition of calcium pyrophosphate crystals on joint surface
What do calcium pyrophosphate crystals in a young person suggest
Metabolic disease. Haemachromatosis
What is present on xray in pseudogout
Chondrocalcinosis
Pseudogout is most common in which two joints
Knee and wrist
How to distinguish OA from pyrophophate arthropathy
Pattern of involvement, marked inflammatory component and superimposition of acute attacks
What causes an acute pyrophosphate arythropathy attack
Most are spontaneous but they can be caused by trauma, illness, surgery or fluids
When should you suspect metabolic disease in pyrophosphate arthropathy
Early onset (<55), polyarticular, frequent recurrance. Other clinical clues
Who gets calcium hydroxyapatite crystals
Older women
Which bone cancers are most common in the young
Euings sarcoma and osteosarcoma
What makes a lump a red flag
Tender, enlarging, deep to fascia, above 5cm in diameter
