MSK Flashcards
What is rheumatoid arthritis?
An autoimmune condition in which autoantibodies attack and destroy the synovial lining of synovial joints
What are the symptoms of rheumatoid arthritis?
- Morning stiffness/pain lasting MORE than 30 mins
- Stiffness/pain EASES with use
Describe the physical examination results/signs of rheumatoid arthritis.
- Ulnar deviation
- Swan-neck deformity
- Boutonierre deformity
- Z thumb
- Active synovitis (red, hot, swollen joints)
- Pattern of joint involvement = symmetrical, mostly affecting wrists, hands and feet
What are the extra-articular manifestations of rheumatoid arthritis?
- Anaemia
- Neuropathy
- Vasculitis
- Lungs: Caplan’s syndrome (RA + pneumoconiosis = intrapulmonary nodules)
- Eyes: Sjogren’s syndrome (causing severe dry eyes), scleritis
- Felty’s syndrome: RA + splenomegaly + neutropenia
How is rheumatoid arthritis investigated?
Bloods:
- FBC may show anaemia
- ESR/CRP = raised
- Autoantibody screen (rheumatoid factor and anti-CCP)
X-ray shows characteristic changes -‘LESS’:
- Loss of joint spacing
- Erosion
- Soft tissue swelling
- Soft bones (osteopenia)
Describe the pharmacological management of rheumatoid arthritis
- 2 DMARDs, one being Methotrexate, other = Azathioprine or Sulfasalazine
- Analgesia
What is osteoarthritis?
Degenerative condition of articular cartilage
Describe the pathophysiology of osteoarthritis
- Loss of articular cartilage =exposure of underlying bone
- This leads to subchondral sclerosis/cysts and osteophyte formation
What are the risk factors for osteoarthritis?
- Age (50+)
- Obesity
- Previous injury/trauma
What are the symptoms of osteoarthritis?
- Morning stiffness/pain lasting LESS than 30 mins
- Pain after exercise/at the end of the day (after use)
Describe the physical examination results/signs of osteoarthritis
- Heberden’s nodes (DIPJs)
- Bouchard’s nodes (PIPJs)
- Base of thumb (1st MCPJ) and base of big toe (1st MTPJ)
- Hard, bony swelling
- Crepitus
- Pattern of joint involvement: asymmetrical, affecting joints which are used most (hands, feet, knees, hips)
How is osteoarthritis investigated?
Usually clinical diagnosis
X ray shows characteristic changes - ‘LOSS’:
L - Loss of joint spacing
O - Osteophytes
S - Subchondral sclerosis
S - Subchondral cysts
Describe the conservative management of osteoarthritis
Lifestyle advice: weight loss, low impact/non-weight bearing exercise
Describe the pharmacological management of osteoarthritis
- Analgesia
- Steroid injections
Describe the interventional management of osteoarthritis
Surgery: joint replacement
The ‘crystal arthropathies’ include which conditions?
Gout (much more common)
Pseudogout
What are the symptoms of gout/pseudogout?
5 cardinal signs of inflammation in joint:
- Calor (hot)
- Rubor (red)
- Dolor (painful)
- Tumor (swollen)
- Loss of function
How are gout/pseudogout investigated?
Joint fluid aspirate analysis
(MUST exclude septic arthritis by MC+S)
Crystals analysed by CPM (compensated polarised microscopy)
Which joint is most commonly affected in gout? Describe the joint distribution.
- 1st MTPJ
- Usually one joint affected (monoarthropathy)
Describe the chemical composition and structure of the crystals present in gout
- Monosodium urate
- Positive birefringence, needle-shaped crystals
What are the risk factors for developing gout?
- Male
- Diet high in purines (meat/seafood)
- Excess alcohol
- Drugs: diuretics
Describe the conservative management of gout
Lifestyle advice:
- Weight loss
- Reduce amount of purines in diet (meat, seafood etc.)
- Avoid alcohol (in excess)
Describe the pharmacological management of gout (both for acute attacks and prevention)
Treatment in acute attacks:
- NSAIDs
- Colchicine
Prevention:
- Stop diuretics
- Allopurinol
Which joint is most commonly in pseudogout? Describe the joint distribution
- Knee
- Usually more than one joint affected (polyarthropathy)
Describe the chemical composition and structure of the crystals present in pseudogout
- Calcium pyrophosphate
- Positive birefringence, rhomboid-shaped crystals
What are the risk factors for developing pseudogout?
- Elderly
- Dehydration
- Intercurrent illness/surgery/trauma
Describe the pharmacological management of pseudogout
NSAIDs
What is osteoporosis?
Progressive loss of bone mass and therefore bone strength, making bones fragile and more susceptible to fracture
Describe the pathophysiology of osteoporosis
Trabecular loss
Cortical thinning
What are the risk factors for osteoporosis?
‘ACCESS’
A - alcohol C - corticosteroids C - calcium low E - estrogen low S - smoking S - sedentary lifestyle
Which sites are most commonly affected by osteoporosis?
- Vertebrae
- Neck of femur
- Proximal humerus
- Distal radius
How is osteoporosis investigated?
DEXA scan for bone mineral density: T score (difference between normal healthy adult and the result of DEXA scan) < -2.5 = osteoporosis
Describe the conservative management of osteoporosis
Lifestyle advice - reduce risk factors:
- Reduce alcohol intake
- Adequate calcium and vitamin D intake (supplementation)
- Stop smoking
- Exercise
Describe the pharmacological management of osteoporosis
- Bisphosphonates, e.g. alendronic acid: inhibit action of osteoclasts, so inhibit bone resorption
- Calcium and vitamin D supplementation, e.g. Adcal D3
What are the side effects of the drugs used to treat osteoporosis?
Side effects of bisphosphonates:
- GI disturbance
- Oesophageal erosion
The ‘seronegative (or spondylo-) arthrpathies’ include which conditions?
- Ankylosing spondylitis
- Psoriatic arthritis
- Enteropathic arthritis
- Reactive arthritis
Ankylosing spondylitis most commonly affects…
Young males
What are the symptoms of ankylosing spondylitis?
- Lower back pain
- Alternating buttock pain
- Systemic features: fever, fatigue
Give some extra articular features of ankylosing spondylitis
A’s…
- Achilles tendinitis
- Apical pulmonary fibrosis
- Acute anterior uveitis
How is ankylosing spondylitis investigated?
Bloods:
- CRP/ESR raised
- Autoantibody screen (RF, anti-CCP) is negative
X-ray = Bamboo spine - ‘BOSS’:
B - blurring
O - ossification of spinal ligaments
S - sclerosis
S - syndesmophyte fusion
Enteropathic arthritis is associated with…
IBD
Describe the skin changes (signs) which may be present in enteropathic arthritis
- Erythema nodusum
- Pyoderma gangrenosum
What is reactive arthritis?
Inflammatory arthritis occurring 1-6 weeks after a GU/GI infection
Which bacteria most commonly cause reactive arthritis?
GI: Campylobacter, Salmonella, Shigella
GU: Chlamydia
Which syndrome is associated withe reactive arthritis?
Reiter’s syndrome: arthritis, urethritis, conjunctivitis
What is septic arthritis?
Inflammation of a joint caused by bacterial infection
What are the symptoms/signs of septic arthritis?
5 cardinal signs of inflammation:
- Rubor (red)
- Calor (hot)
- Dolor (pain)
- Tumor (swollen)
- Loss of function
Systemic features: fever
Mostly monoarthopathy
How is septic arthritis investigated?
Joint fluid aspirate analysis (MC+S)
Which bacteria are commonly associated with septic arthritis?
- Staph aureus (MOST COMMON)
- Group A and B streptococci
Describe the pharmacological management of septic arthritis
- Commence Abx (guided by MC+S) and stop any immunosuppression, e.g. DMARDs, temporarily
- Analgesia
Describe the interventional management of septic arthritis
Surgical joint washout if symptoms persist despite pharmacological therapy
What does SLE stand for and what is it?
SLE = systemic lupus erythematosus
Lupus is a chronic inflammatory autoimmune condition that causes inflammation of the joints, skin and other organs
Describe the pathophysiology of lupus
- Type 3 hypersensitivity reaction
- Causes deposition of immune complexes in different body tissues leading to inflammation
What are the symptoms and signs of lupus?
Symptoms:
- Fatigue
- Arthralgia/myalgia
- Chest pain
- SOB
- Photosensitivity
Signs:
- Pale mucous membranes (anaemia)
- Oral ulcers
- Malar rash
- Discoid rash
How is lupus investigated?
Bloods:
- FBC: anaemia
- ESR/CRP raised
- Autoantibody screen (many different ones present, e.g. ANA, anti-dsDNA, antiphospholipid antibodies
- Biopsies of kidney and skin - show deposition of IgG and complement
Describe the conservative management of lupus
Avoid sunlight
Describe the pharmacological management of lupus
- NSAIDs for pain
- Immunosuppression, i.e. steroids and DMARDs
Give some common complications of lupus
- CVD
- Depression
- Osteoporosis
