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Phase 2a > MSK > Flashcards

MSK Flashcards

1
Q

What is osteoarthritis?

A

An age-related, dynamic reaction pattern of a joint in response to insult or injury

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2
Q

What joint tissue is most affected in OA?

A

Articular cartilage is the most affected

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3
Q

What are the main pathological features of OA?

A

o Loss of cartilage

o Disordered bone repair

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4
Q

What are the chemical mediators in OA?

A

Cytokines – IL-1, TNF-α, NO

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5
Q

What the risk factors for OA?

A
  • Age - >45 years
  • Gender - F>M
  • Genetics
  • Obesity
  • Occupation - manual labour, sport, farming etc.
  • Inflammatory arthritis
  • Trauma/abnormal biomechanics
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6
Q

Symptoms of OA

A
  • Pain – evening, exercise
  • Morning stiffness <30mins
  • Functional impairment – walking, ADL’s
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7
Q

Signs of OA

A 
•   Alteration in gait
•   Joint swelling – bony enlargement, effusion
•   Other joint abnormalities:
       o   Limited ROM
       o   Crepitus
       o   Tenderness
       o   Deformities
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8
Q

Radiological features in OA

A
  1. Joint space narrowing
  2. Osteocyte formation
  3. Subchondral sclerosis
  4. Subchondral cysts
  5. Abnormalities of bone contour
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9
Q

What joints are involved in hand OA?

A

DIP, PIP, CMC joints

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10
Q

What are the signs of hand OA?

A
  • Heberden’s nodes at DIP joints

* Bouchard’s nodes at PIP joints

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11
Q

Non-pharmacological management of OA

A 
o	Activity and exercise
o	Weight loss
o	Physiotherapy
o	Occupational therapy
o	Footwear
o	Orthoses
o	Walking aids
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12
Q

Pharmacological management of OA

A

o Topical – NSAIDs, capsaicin
o Oral – paracetamol
o Transdermal patches – lignocaine
o Intra-articular steroid injections

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13
Q

What is rheumatoid arthritis?

A

A chronic systemic inflammatory disease, characterized by a symmetrical, deforming, peripheral polyarthritis

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14
Q

Epidemiology of RA

A
  • 40-60yrs old
  • HLA DR4/DR1 linked
  • Smokers
  • 3x more women
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15
Q

Pathology of RA

A

Inflammatory cells infiltrate synovium -> angiogenic cytokines form new synovial blood vessels -> synovium proliferates and grows out over surface of cartilage producing a pannus -> pannus destroys cartilage and subchondral bone -> bony lesions

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16
Q

Main symptoms of RA

A 
o   Early morning stiffness/pain 
     >60 mins, eases with use
o   Loss of function
o   Deformity 
o   Pattern – symmetrical, most commonly wrists and 
     feet, rarely DIP's
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17
Q

Signs of RA

A 
o   Ulnar deviation 
o   Swan neck deformity 
o   Boutonnieres deformity
o   Z thumb
o   Rheumatoid nodules 
o   Joint inflammation
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18
Q

What are the 4 features of inflammation?

A

Red, heat, swelling, pain

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19
Q

Symptoms of extra-articular involvement in RA

A 
o   Eyes – dry eyes, scleritis
o   Neurological – Carpal tunnel 
o   Haematological – anaemia, splenomegaly 
o   Lungs – plural effusion 
o   Heart – pericarditis 
o   Kidneys – amyloidosis 
o   Skin – vasculitis
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20
Q

Investigations for suspected RA

A
  • RhF positive in approx. 70%
  • Anti-CCP is more sensitive and specific
  • Anaemia if chronic, raised inflammatory markers
  • X-rays
  • Use criteria – diagnostic ≥6
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21
Q

Features of RA on x-ray

A

o Soft tissue swelling
o Osteopenia (soft bones)
o Loss of joint space
o Erosion

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22
Q

Non-pharmacological management of RA

A
  • Physiotherapy, occupational therapy

* Surgery

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23
Q

Disease modifying drugs for RA

A
  • DMARDs (methotrexate) - 1st line
  • TNF-α inhibitor (infliximab) -2nd line
  • Rituximab - 3rd line
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24
Q

What drugs can be used for symptomatic relief in RA?

A

Steroids, NSAIDs

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25
Epidemiology of gout
o Men >40yrs o Rises in post-menopausal women o Chinese, Polynesian, Filipino – if westernised diet
26
What is uric acid a product of?
Nucleic acid/purine metabolism
27
Pathology of gout
Hyperuricaemia -> formation of sharp urate crystals in joints -> phagocyte activation -> inflammatory arthritis
28
Causes of gout
``` o Under-excretion: - Dehydration - Alcohol - Aspirin, diuretics - HTN - Obesity, DM o Over-production: - Hyperlipidaemia - Alcohol - Psoriasis - Excess meat, shellfish, offal, gravy, yeast ```
29
Signs and symptoms of gout
o First metatarsal joint of big toe most common o Inflammation – hot, red, swollen o Podagra: - Wakes up feeling like big toe on fire - Pain most severe in hours after attack - Can last days-weeks
30
Management of gout
o Anti-inflammatories – NSAID, colchicine o Prevention – allopurinol o Diet modification, stay active
31
Complications of gout
Repeated gouty attacks -> chronic gout – arthritis, tissue destruction, tophi, kidney stones
32
What is gout?
Joint inflammation caused by uric acid crystal deposits in the joint space
33
What is pseudogout?
Inflammation of a joint caused by deposits of calcium pyrophosphate crystals
34
Investigations for suspected crystal arthropathy
o Polarised light microscopy of synovial fluid o Bloods o X-ray
35
Management of pseudogout
o Acute attacks - cool packs, rest, aspiration, intra- articular steroids o Prevention - NSAIDs and colchicine may prevent o Methotrexate if chronic
36
What is osteoporosis?
A skeletal disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and increased risk of fractures
37
List 9 risk factors for osteoporosis
* Steroids * Hyperthyroidism, hyperparathyroidism, hypercalciuria * Alcohol and tobacco * Thin * Testosterone low * Early menopause/female * Renal/liver failure * Erosive/inflammatory bone disease * Dietary low calcium/malabsorption
38
Why does incidence of osteoporosis in women increase after menopause?
Lack of oestrogen increases bone resorption and decreases bone deposition
39
Why does calcium deficiency cause osteoporosis?
Deficiency of calcium -> increased bone resorption through PTH
40
Pathology of osteoporosis
Peak bone mass inadequate due to excessive bone resorption and inadequate formation of new bone during remodelling
41
Signs and symptoms of osteoporosis
* Asymptomatic | * Bone fragility -> fracture
42
What is the main investigation used to diagnose osteoporosis?
DEXA Bone Densitometry
43
How is a DEXA score interpreted?
o Produces ‘T score’: T > -1 = normal -1 < T > -2.5 = osteopenia T < -2.5 = osteoporosis
44
What tool can be used to assess fracture risk in osteoporosis?
FRAX
45
Pharmacological management of osteoporosis
``` • Anti-resorptive drugs: o Bisphosphates – alendronic acid o HRT – RF’s breast cancer, CVD o Denosumab - SC 2x yearly • Anabolic drugs – teriparatide ```
46
Non-pharmacological management of osteoporosis
• Lifestyle: o Quite smoking and reduce alcohol o Weight-bearing and balance exercise o Calcium and vit D-rich diet/supplements o Occupational health – fall prevention
47
List the 7 shared clinical features of spondyloarthropathies
1. Rheumatoid factor negative 2. HLA B27 association 3. Axial arthritis 4. Asymmetrical large-joint arthritis 5. Enthesitis – inflammed of insertion site of tendon/ligament into bone 6. ‘Sausage digit’ 7. Extra-articular manifestations – iritis, psoriaform rashes, oral ulcers, aortic valve incompetence, IBD
48
What is ankylosing spondylitis?
A chronic inflammatory disease of the spine and sacroiliac joints
49
Cause of ankylosing spondylitis
Unknown, HLA B27 association
50
Epidemiology of ankylosing spondylitis
M>F, <30yrs
51
Signs and symptoms of ankylosing spondylitis
o Low back pain – gradual onset, worse at night, radiates to hips/buttocks o Spinal morning stiffness relieved by exercise o Progressive loss of spinal movement -> decreased thoracic expansion o Kyphosis, neck hyperextension, spino-cranial ankylosis o Osteoporosis o Iritis -> blindness
52
Investigations for suspected ankylosing spondylitis
o Clinical examination o MRI – inflammation and destructive changes o X-ray o Bloods - RF -ve
53
Management of ankylosing spondylitis
o Exercise, physio o Drugs – NSAIDS, TNF α-blockers, steroid injections, bisphosphonates o Surgery – hip replacements ect.
54
What is psoriatic arthritis?
joint inflammation associated with psoriasis - about 10% of those with psoriasis
55
What are the 5 patterns of psoriatic arthritis?
DIPJ only, RA like, large joint oligoarthritis, axial, arthritis mutilans
56
Signs and symptoms of psoriatic arthritis
o Nail changes o Synovitis o Acneiform rashes o Joint inflammation
57
What changes would you see on x-ray for psoriatic arthritis?
Erosive changes, 'Pencil in cup' deformity
58
Management of psoriatic arthritis
NSAIDS, DMARD, methotrexate, anti-TNF agents
59
Name a DMARD
Sulfasalazine
60
What is reactive arthritis?
Arthritis and other clinical manifestations that occur as an autoimmune response to infection elsewhere in the body
61
Signs and symptoms of psoriatic arthritis
``` o Nail changes o Arthritis o Conjunctivitis o Psoriatic-like skin lesions o Circinate Balanitis ```
62
Investigations for suspected psoriatic arthritis
o Bloods – raised inflammatory markers, RF -ve o Culture stool, sexual health check o X-ray
63
Management of psoriatic arthritis
o NSAIDS, local steroid injections, DMARDs, methotrexate o Splint affected joints
64
What is osteomyelitis?
Inflammation of the bone or bone marrow - usually from infection
65
What are the three main mechanisms of getting osteomyelitis?
o Direct inoculation of infection into bone - surgery o Contiguous spread of infection to bone from adjacent soft tissues and joints o Haematogenous seeding
66
Where is the most common site for osteomyelitis in adults?
Vertebrae
67
Where is the most common site for osteomyelitis in children?
Long bones
68
What is the most common cause of osteomyelitis?
Staph. Aureus
69
Pathology of osteomyelitis, and difference between acute and chronic
Bacteria reaches bone -> proliferate -> alert immune cells -> immune cells break down bone -> immune system destroys all bacteria: o Acute – osteoblasts and osteoclasts repair damage over a number of weeks o Chronic – affected bone becomes necrotic and separates (‘sequestrum’)
70
Symptoms of osteomyelitis
o Dull pain at site – may be aggravated by movement | o Fever, rigors, sweats, malaise
71
Signs of osteomyelitis
Tenderness, warmth, redness, swelling
72
Investigations for suspected osteomyelitis
o Bloods – raised WCC, ESR, CRP o Imaging: - X-ray – thickening of cortical bone and periosteum, osteopenia - MRI/CT/bone scan – diagnostic, abscesses o Bone biopsy and cultures
73
Management of osteomyelitis
o Surgical – abscess, | o Antimicrobial therapy – tailored to cause
74
What is septic arthritis?
Invasion of a joint by an infectious agent resulting in joint inflammation
75
Causes of septic arthritis
Staph. Aureus, streptococci, Neisseria gonococcus
76
Risk factors for septic arthritis
RA, DM, immunosuppression, CKD, prosthetic joints, IVDU, >80yrs
77
Signs and symptoms of septic arthritis
o Painful, red, swollen, hot joint - usually monoarthritis o Fever o Knee > hip > shoulder
78
Investigations for suspected septic arthritis
o Joint aspiration o X-ray o Blood cultures BEFORE antibiotics
79
Give a differential diagnosis for septic arthritis
Crystal arthropathies
80
Management of septic arthritis
o Surgical – washout | o Antimicrobial therapy – tailored to cause
81
What empirical antibiotics should be given for an MSK infection
Flucloxacillin
82
What is SLE?
Multisystemic autoimmune disease characterised by presence of antinuclear antibodies
83
Epidemiology of SLE
Women of child-bearing age, Afro-Caribbean’s, HLA DR2/3
84
Causes of SLE
Genetics and environment, drug induced
85
What complement factors are lacking in SLE?
C3 and C4
86
Pathophysiology of SLE
Environmental trigger damages cells -> apoptosis -> release of nuclear antigens -> genetic factors mean individual cannot clear these effectively -> immune system recognises nuclear antigens as foreign -> ANA produced -> deposited in tissues -> inflammation
87
What type of hypersensitivity reaction is SLE?
Type 3
88
Signs and symptoms of SLE
``` • Fever • Joint pain • Weight loss • Malaise, fatigue, myalgia • Butterfly rash – UV triggered • Alopecia • Haematological disorders – anaemia, thrombocytopenia etc. ```
89
Investigations for suspected SLE
* Bloods - ESR raised, anti-dsDNA antibodies | * Urinalysis – proteinuria
90
Management of SLE
• Non-medical: o UV protection o Screen for comorbidities • Pharmacological: o NSAIDs – joint and skin symptoms o Severe – high dose steroids and rituximab
91
What are primary bone tumours?
Tumours that form from bone tissue and can be malignant
92
What are secondary bone tumours?
Tumours from metastatic disease
93
Signs and symptoms of bone tumours
* Rest pain * Night pain * Lump present * Loss of function * Neurological symptoms * Weight loss
94
Investigations for suspected bone tumour
* Blood tests – FBC, U+E, Ca2+, Alk Phos * Plain x-rays * Ultrasound * CT Scan * MRI Scan * Bone Scan * Biopsy
95
What are the 3 special signs sometimes seen on a plain x-ray that can signify bone cancer?
o Codman’s Triangle o Sunburst appearance o Onion-skin appearance
96
What system is used to grade bone tumours?
Enneking system
97
What is fibromyalgia?
A long-term condition that causes pain all over the body
98
Risk factors for fibromyalgia
* Female * Middle age * Low socioeconomic status * Life dissatisfaction
99
What other conditions are associated with fibromyalgia?
• Somatic syndromes – chronic fatigue, IBS, chronic headaches • RA, SLE
100
Features of fibromyalgia
* Chronic pain, >3 months, widespread * Profound fatigue * Morning stiffness * Paraesthesiae * Headaches * Poor concentration and low mood
101
Investigations for suspected fibromyalgia
All normal, diagnosis clinical
102
Management of fibromyalgia
* Encourage activity and staying in work if possible * CBT * Relaxation, rehabilitation and physiotherapy * Medications - mitriptyline/pregabalin
103
Associations with mechanical back pain
Heavy manual handling, stooping and twisting whilst lifting, exposure to whole body vibration, psychosocial distress, smoking and dissatisfaction with work
104
High risk activities for mechanical back pain
* Heavy manual handling (>20Kg) * Lifting above shoulder height * Lifting from below knee height * Incorrect manual handling technique * Forceful movements * Fast repetitive work; poor postures; poor grip
105
Management of mechanical back pain
``` • Analgesics or NSAIDs • Spinal manipulative therapy • Spinal injections • Spinal exercises, behavioural therapy and workplace adaptations ```
106
What is osteomalacia?
Normal amount of bone but its mineral content is low -> excess uncalcified osteoid and cartilage
107
How does Rickets occur?
When osteomalacia is present during growth
108
Causes of osteomalacia
* Vitamin D deficiency * Renal osteodystrophy * Drug-induced – anticonvulsants * Vitamin D resistance * Liver disease – cirrhosis * Tumour-induced
109
Signs and symptoms of Rickets
Growth retardation, hypotonia, knock-kneed, bow-legged
110
Signs and symptoms of osteomalacia
Bone pain, tenderness, fractures, waddling gait
111
Investigations for suspected osteomalacia
• Plasma – hypocalcaemia, hypophosphataemia, high PTH, low vit D (except resistance) • Bone biopsy – incomplete mineralisation • X-ray – loss of cortical bone
112
Management of osteomalacia
Oral calciferol
113
Cause of vertebral disc degeneration
Disease of aging
114
Pathology of vertebral disc degeneration
• Degenerative fibrocartilage and clusters of chondrocytes present • Fibrocartilage replaces the material of the nucleus pulposus as the disc changes with age
115
Presentation of vertebral disc degeneration
Chronic low back pain, sometimes radiating to the hips, or the buttocks
116
Investigations for suspected vertebral disc degeneration
CT, MRI
117
Management of vertebral disc degeneration
* Physical therapy * NSAIDs * Epidural steroids * Surgery
118
Complications of vertebral disc degeneration
Sciatica, alkylosis
119
What is vasculitis?
Inflammation and necrosis of blood vessel walls with subsequent impaired blood flow
120
How is vasculitis categorised?
By size of the vessels affected
121
Give an example of a large cell vasculitis
Giant cell arteritis
122
Give and example of a medium cell vasculitis
Polyarteritis nodosa
123
Give and example of a small cell arteritis
Granulomatosis with polyangiitis (GPA)
124
Is GPA ANCA positive or negative?
Positive
125
Signs and symtoms of GPA
Upper airways disease, sinusitis, pulmonary haemorrhage, glomerulonephritis, skin ulcers, CNS vasculitis, scleritis, pericarditis, saddle nose deformity
126
Management of GPA
o Severe – high dose steroids o Mild/moderate – moderate dose steroids + methotrexate
127
Is giant cell arteritis ANCA positive or negative?
Negative
128
Epidemiology of giant cell arteritis
o >50yrs old | o F>M
129
Symptoms of giant cell arteritis
``` o Headache o Scalp tenderness – hurts to brush hair o Jaw claudication o Acute blindness o Malaise ```
130
What is the diagnostic criteria for giant cell arteritis?
``` o >50yrs o New headache o Temporal artery tenderness or decreased pulsation o High ESR, >50mm/h o Abnormal artery biopsies ```
131
Management of giant cell arteritis
o Prompt prednisolone – dramatic response in 48 hr o Steroid sparing agents – methotrexate o Prophylaxis of osteoporosis
132
What is Padget's disease?
Increased bone turnover associated with increased osteoblasts and osteoclasts with resultant remodelling, bone enlargement, deformity and weakness
133
Signs and symptoms of Padget's disease
``` o Usually asymptomatic o Deep, boring pain o Bony deformation and enlargement o Pathological fractures o Osteoarthritis o Nerve compression -> hearing loss, vision loss o Hypercalcaemia ```
134
Epidemiology of Padget's disease
>40yrs
135
Which nerve is compressed in carpal tunnel syndrome?
Median nerve
136
What would be seen on joint fluid microscopy of a patient with Pseudogout?
Positively Birefringent Rhomboid Shaped Crystals
137
What would be seen on joint fluid microscopy of a patient with gout?
Negatively Birefringent Needle Shaped Crystals
138
What does anti-CCP stand for?
Anti-cyclic citrullinated peptide
139
Why is methotrexate contraindicated in pregnancy?
Folate antagonist
140
What is the most common composition of renal stones?
Calcium oxalate

Phase 2a (9 decks)

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