MSK

Question 1

Describe rheumatoid arthritis and its risk factors

Answer 1

A chronic systemic inflammatory disease with symmetrical, destructive polyarthropathy.

Female 2:1

Question 2

What is rheumatoid factor

Answer 2

IgM that binds to your own IgG
Not a sensitive or specific test
High titres are associated with more progressive disease

Question 3

Investigation of suspected rheumatoid arthritis

Answer 3

FBC, CRP, U&Es, LFTs - Baseline
Rheumatoid Factor 
Anti CCP antibodies
Plain radiographs of hands and feet 
Always refer to rheumatology - even if results -ve

Question 4

Radiographic changes in rheumatoid arthritis

Answer 4

SPADES
Soft tissue swelling
Peri-articular osteoporosis 
Absent osteophytes 
Deformity 
Erosions
Subluxation

Question 5

What pre-operative investigation needs to be performed on people with rheumatoid disease

Answer 5

A later upper cervical spine radiograph in gentle flexion

Atlanto-axial subluxation can compress the upper cervical cord

Question 6

Management of rheumatoid arthritis

Answer 6

Patient education 
Smoking cessation 
Physiotherapy + Hand exercise programme
Occupational therapy
Psychological interventions 

Treat to target strategy - remission or low activity
DMARD monotherpay +/- Prednisolone bridging
1st: Methotrexate, Sulfasalazine, leflunomide
+ basic analgesia
Monthly monitoring - CRP and DAS 28
At 6 months can step up to dual DMARD
If still severe - Consider offering Biological

Question 7

What scoring system is used for monitoring of rheumatoid disease

Answer 7

DAS 28

Disease Activity Score 28

Question 8

Presentation of septic arthritis

Answer 8

Acute monoarthropathy due to infection of the joint
Calor, dolor, rubor, tumor and loss of function
Systemic - Fever, malaise

Question 9

Aetiology of septic arthritis and its risk factors

Answer 9

Haematogenous spread due to bacteraemia
Direct inoculation - penetrating injury, surgery or injection
Spread from bone (osteomyelitis) or tissue (cellulitis)

Abnormal, damaged joints (e.g. RA, OA)
Prosthetic joints
Immunocompromised – DM, MTX, Steroids, CRF 
Elderly and very young
IV drug abuse

Question 10

Investigation of suspected septic joint

Answer 10

Full set of observations
- Joint aspiration with MC&S
Blood cultures
FBC, CRP, ESR, U&E, Glucose

Question 11

Management of septic arthritis

Answer 11

Immediate Abx pending culture results
Flucloxicillin 1g/6h IV (Clindamycin if allergic)
Vancomycin if MRSA positive
Cefotaxime 1g/8h I if gonococcal suspected
2 weeks IV abx then 4 weeks PO

Surgical washout

Question 12

Red flag symptoms for Spinal cord compression

Answer 12

Motor weakness
Loss of sensation
Saddle anaesthesia 
Urinary retention 
Loss of continence 
Systemic symptoms - Fever, Night sweats, Weight loss
Thoracic back pain:
- Sudden onset, <20 or >50yo
- High energy trauma or no mechanical cause
- Worse lying down, wakes up at night
Risk factors:
- Previous cancer
- IV drug user
- Immunosuppressed

Question 13

Management of metastatic spinal cord compression

Answer 13

Nurse flat
Urgent MRI whole spine - within 24hrs
Dexamethasone 16mg daily
Until Radiotherapy or surgery

Question 14

Describe temporal arteritis and its risk factors

Answer 14

In Giant Cell Arteritis (GCA) there is granulomatous inflammation of the aorta and large vessels

Elderly - > 55yo
Polymyalgia rheumatica - 50%
Other inflammatory disorders eg. SLE/RA

Question 15

Presentation of giant cell arteritis

Answer 15

Temporal headache
Scalp tenderness e.g. when combing hair
Jaw claudication
Visual disturbance: 
- Amaurosis Fugax or sudden blindness, unilateral 
- Diplopia or ptosis may occur

Question 16

Investigation and Immediate Management of giant cell arteritis

Answer 16

FBC - Low Hb, Plat elevated
CRP, ESR - elevated
Temporal artery biopsy within 7 days
- can be negative due to skip lesions

Prednisolone 60mg PO stat and daily
Aspirin 75mg
PPI cover - Omeprazole 20mg
If visual symptoms - Ophthalmology A&E
If none - safety net, review at 48hrs

Question 17

Long term management of giant cell arteritis

Answer 17

Patient education
Smoking cessation
Manage co-morbidities - DM, CV
Referal to Rheumatology - Shared care

! Steroid card !
Continue high dose prednisolone until symptoms, CRP and ESR have returned to normal, then reduce.
Reduce by 10 mg every 2 weeks until 20 mg daily,
Reduce by 2.5 mg every 2–4 weeks until 10 mg daily,
Reduce by 1 mg every 1–2 months,
Review one week after a change in dose
Mange relapse by returning to previous dose
- Or if Jaw claudication then 60mg and seek advice
Monitor BP, Glucose, CRP and ESR 3 monthly
Risk assess - Bisphosphonates for bone protection

Question 18

Presentation of Polymyalgia rheumatica

Answer 18

Over 50 years old with at least 2 weeks of:

• Bilateral shoulder and/or pelvic girdle pain.
• Stiffness lasting for at least 45 minutes after waking

Systemic symptoms: 50%
- fever, fatigue, anorexia, weight loss, and depression
Peripheral MSK signs: 50%
- Carpal tunnel syndrome.
- Peripheral arthritis (predominantly affecting the knees and wrists), which is asymmetric and self-limiting.
- Swelling with pitting oedema of hands, wrists, feet, and ankles.

Question 19

Investigation and diagnosis of polymyalgia rheumatica

Answer 19

Polymyalgia rheumatica (PMR) is diagnosed by:

• Identifying core features of the condition,
• Excluding conditions that mimic PMR,
• A positive response to oral corticosteroids.

Question 20

Management of Polymyalgia rheumatica

Answer 20

Patient education
Smoking cessation
Manage co-morbidities
Screen mental health

Trial of oral prednisolone 15 mg daily
- follow up after 1 week to assess clinical response.
After 3–4 weeks of treatment:
- Consider reducing the dose of prednisolone.
- Recheck ESR, CRP to assess response to treatment.
! Give Steroid card !
Review 1/52 after change in dose and at least every 3/12
Consider PPI
Assess Osteoporotic fracture risk

Question 21

Description and aetiology of compartment syndrome

Answer 21

Increased pressure in a closed fascial space causing muscle ischaemia

Long bone fractures
Plaster casts
Crush injuries
Vascular injuries
Anticoagulants
Burns

Question 22

Presentation of compartment syndrome

Answer 22

Pain out of proportion to apparent injury 
- exacerbated by passive stretching 
Redness, swelling 
Parasthesia 
Weakness of distal limb
Slow capillary refill
Pallor and absent pulses is alate sign

Question 23

Investigations for compartment syndrome

Answer 23

Urine dip - ?myoglobin in urine

FBC,
U&Es - monitor for AKI
CK - muscle damage
Clotting, G&S - for theatre

Manometre to measure pressure

Question 24

Management of compartment syndrome

Answer 24

Elevate the limb 
Oxygen 15L 
Contact senior surgeon immediately 
- Urgent Fasciotomy 
Analgesia + antiemetic 
Catheterise - monitor for AKI

Question 25

Radiological findings of osteoarthritis

Answer 25

LOSS
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis