MSK Flashcards
What is gout?
An inflammatory arthritis associtated with hyperuricaemia and intra-articular negativley bifingent needle shaped monosodium urate crystals. Generally occurs in middle aged men
What causes gout?
Purine rich foods such as red meat, high alcohol intake (especially Beer), high fructose/saturated fat intake, high insulin levels, kidney disease and ischaemic heart disease
Describe the process leading to gout?
In purine metabolism hypoxanthine is converted to xanthine, xanthine is then converted to uric acid. Excess uric acid which is not secreted by the kidneys is sometimes converted to monosodium urate crystals
S&S of gout?
Extreme pain, swelling and redness of the first MTP joint (in the big toe), urate renal stones may also form and renal impariment may occur if gout is frequent
Treatment of gout?
High dose NSAIDS or Colchicine, intra-articular corticosteroids
Allopurinol (inhibits xanthine oxidase) and weight loss/dietary changes = long term prevention
What is psuedo gout?
Deposits of positivley bifingent rhomboid shaped calcium phosphate crystals. Generally occurs in older women
S&S of pseudogout?
Painful, hot and swollen joint (tends to be knee/wrist) and fever due to synovitis
What is an important test that should be done in pseudogout?
Joint fluid culture to exclude septic arthritis
Treatment of psuedo gout?
Aspirate joint, intra-articular corticosteroids and high dose NSAIDs/Colchicine
What is chronic tophaceous gout?
Occurs in those with persistantly high urate levels. Monosodium urate crystals form smooth white deposits (tophi) in the skin, joints and on the achille’s tendon. Tophi release proteolytic enzymes which errode bone.
What is osteoarthritis?
A non-inflammatory degenerative arthririts characterised by cartilage loss with inflammation of the articular and periarticular structures
What are the risk factors for osteoarthritis?
Joint hypermobility, increasing age, being female after menopause, diabetes, obesity, genetic predisposition and occupation (e.g. manual labour = small hand bones)
S&S of osteoarthritis?
Mechanical pain (with movement), gradual onset but progressive symptoms, <30mins morning stiffness, pain relieved by rest, Herberden’s nodes (DIP) and Bouchard’s nodes (PIP). SYSTEMIC FEATURES ARE ABSCENT AS IT IS NON-INFLAMMATORY
What is seen on X-rays/tests in osteoarthritis?
LOSS - Loss of joint space, Osteophytes, Subarticular sclerosis and Subchondral Cysts
What is Rheumatoid Arthritis?
An inflammatory autoimmune disorder causing symetrical deforming polyarthropathy
What are the risk factors for rheumatoid arthritis?
Being female, smoking, genetic predisposition (HLA-DR4/HLA-DRB1)
S&S of rheumatoid arthritis?
Slow, progressivley worsening painful/warm/swollen/tender joints, morning stiffness > 30mins, ulnar deviation, swan neck thumb, boutonniere deformity and fatigue
What is seen on X-rays/tests in rheumatoid arthritis?
LESS = Loss of joint space, Erosions (periarticular), Soft tissue swelling, Soft bones
What are the best markers of rheumatoid arthritis
Anti-CCP antibodies present = THE BEST and rheumatoid factor positive
What is the treatment specifically for rheumatoid arthritis?
DMARDs (such as methotrexate or sulfasalazine), may be accompanied by TNF-alpha antibodies. Monoclonal antibodies such as rituximab may also be used
What is osteoporosis?
A systemic skeletal disease characterised by a microarchitectural deterioration of the bone tissue leading to increased bone fragility and fracture risk
What are the primary causes of osteoporosis?
Menopause and increasing age
What are the secondary causes of osteoporosis?
SHATTERED = Steroids, Hyperthyroidism/Hyperparathyroidism, Alcohol/cigarettes, Thin (BMI <22), Testosterone (low), Estrogen (low), Renal/liver failure, Erosive/inflammatory bone disease, Diabetes mellitus
S&S of osteoporosis?
This tends to be asymptomatic until there is a fracture (often a proximal femur/vertebral crush/colle’s fracture), kyphosis seen in thoracic vertebral fracutures
What is a T-score?
A standard deviation gender-matched score of bone mass using DEXA. It is compared to the young adult average. -1 to -2.5 = osteopenia, >-2.5 = osteoporosis,
Treatment for osteoporosis?
Bisphosphonates, HRT/testosterone replacement, Denosumab (inhibits RANK ligand which normally stimulates osteoclasts), diet and lifestyle modification, weight bearing exercises
What is osteomalacia?
Defective mineralisation of bone leading to uncalcified osteoid/cartilage despite normal bone amount occuring AFTER the fusion of the epiphyses (if before it will be rickets).
What causes osteomalacia?
Malabsorption disorders (e.g. coeliac’s/chron’s), lack of sunlight, renal failure, liver disease/cirrhosis and tumours
S&S of osteomalacia?
Muscle weakness with waddling gait, bone pain worse on weight bearing, bone tenderness and fractures
S&S of rickets?
Growth retardation/hypotonia, knock-knees/bow-legs, widened epiphyses at the wrist
What is hypophosphataemia?
The main cause of osteomalacia. Low vitamin D = low calcium = increased PTH secretion = low phosphate (calcium will remain low due to lack of vitamin D)
What are the risk factors of SLE?
Epstein-Barr virus, genetic (linked to HLA genes), being a woman, being Afro-carribean or Asian
S&S of SLE?
Butterfly/photosensitive rash, reynaud’s phenomenom, glomerulonephritis with persisitant proteinuria, mouth ulcers, soft tissue swelling, small joint arthralgia, seizures
What is found in blood samples of SLE?
Raised ESR but normal CRP, Anti-nuclear antibody positive, anti-dsDNA positive (most specific but only positive in 60%), some will also be RF positive
Treatments for SLE?
Non-specific (can’t be cured), anti-CD20 e.g. rituximab, immunosuppresants e.g. azathoprine/methotrexate, hydroxychloroquine (for fatigue/arthralgia not controlled by NSAIDs), corticosteroids
What is antiphospholipid syndrome?
Thrombosis with or without reccurent miscarriages with positive blood tests for anitphospholipid antibodies
S&S of antiphospholipid syndrome?
CLOT = Coagulation defects, Livedo reticularis, Obstetric issues, Thrombocytopenia
How is antiphospholipid syndrome diagnoses?
A poitive on 2 of 3 of the following >12 weeks apart:
Anticardiloipin test (detects antibodies which bind to cardilolpinin a -vely charged posholipid)
Lupus anticoagulant test
Anti-B2-glycoprotein 1 test (detects proteins that bind to B2-glycoprotein 1)
Treatment for anti-phospholipid syndrome?
Long term warfarin. Oral aspirin and SC heparin in early pregnancy to prevent miscarriage
What is Sjorgen’s syndrome?
An antiinflammatory autoimmune condition characterised by the destruction of epithelial exocrine cells
What are the primary/secondarry causes of Sjorgen’s syndrome?
Primary = being female between 40-60 Secondary = connective tissue disorders such as RA/SLE
S&S/treatment of Sjorgen’s syndrome
Dry mouth/eyes
Treat with artificial saliva/tears and hydroxycholoquire/NSAIDs for pain and arthralgia
Test for Sjorgen’s syndrome?
Schirmer tear test, salivary gland biopsy and ANA/SSA antibodies present
S&S of Systemic sclerosis/scleroderma?
Raynaud’s phenomenom, CREST syndrome, flexion deformities (affects skin on hands, feet, face and fingers ONLY) pseudo colon obstruction, CKD, lung disease
What is CREST syndrome?
Calcinosis (calcium deposits in the SC tissues), Raynaud’s, Esophageal dysmobility/strictures, Sclerodactyly (thickening/tightness in skin on the fingers/toes), Telenagiectasia (spider veins)
What are seronegative spondlyoarthropathies?
Conditions with axial inflammation, asymmetrical peripheral arthritis, absence of RF and a strong association with HLA-B27
What is Ankylosing Spondylitis?
The abnormal stiffening and immobitility of the spine, ribs and sacroiliac joints due to new bone formation associated with Klebsiella/shigella/salmonella infection. It is worse and more common in men.
S&S of Ankylosing Spondylitis?
Gradual onset lower back pain which is worse at night, with morning stifness and relieved by exercise. Entesitis, anterior uveitis, loss of lumbar lordosis and increased kyphosis.
Think of this if seen in men under 30!!!
Tests for Ankylosing Spondylitis?
Patients will have normocytic anaemia, raised ESR & CRP and be HLA-B27 positive.
X-rays will show spinal bony spurs (syndesmophytes) and sacroiliac joint fusion/erosion
Treating Ankylosing Spondylitis?
NSAIDs at night, Methotrexate for peripheral arthritis, TNF-alpha-blockers to delay syndesmophyte formation
S&S of Psoratic Arthritis?
Asymmetrical oligoarthritis or symmetrical polyarthritis, dactylitis, spondylits, DIPJ involvment ONLY, arthritis mutalins
Tests for Psoratic Arthritis?
Central erosions with concave articulating bone seen on X-ray, skin and nail disease
Treatments for Psoratic Arthritis?
NSAIDs, DMARDs and Ciclosporin for severe disease, anti-TNF-al[pha agents
What is Reactive Arthritis?
Sterile infalmmation of the synovial membrane, tendons and fascia triggered by a distal infection e.g. salmonella, shigella, chlamidyia and gonorrhoea
S&S of Reactive Arthritis?
Reiter’s syndrome: urethritis, arthritis, conjunctivitis
Also painless penile ulceration, mouth ulcers and enthesitis
What is Arthritis Mutalins?
A complication of psoratic arthritis, there is periarticular osteolysis and bone shortening leading to telescopic fingers - pencil in cup x-ray changes
What are the main sites for secondary bone tumours to develop from?
Bronchus, breast, prostate, kidney, thyroid
S&S of bone cancer?
Fatigue, appetite loss, weight loss, fever, malaise, bone pain, increased fractures (weakened bones) and swelling
What % bone density must be lost before it shows as an osteolytic area on X-ray?
60%
What are the four common primary bone tumours?
Osteosarcomas, fibrosarcomas, chondrosarcomas and Ewing’s tumour
What is an osteosarcoma?
Occurs in the metaphyses of the long bones, produces immature bone and presents with a painless tumour and destroys surrounding bone/tissues before metastasising to the lung
What is an Ewing’s sarcoma?
Arises from the mesenchymal stem cells, presents as painful swelling/redness in teh area surrounding the tumour
What is a chondrosarcoma?
Occurs in the cartilage and presents with a deep, dull pain - the affected area is swollen and tender
What is acute vertebral disc disease?
A prolapse of the intervertebral disc leading to lower back pain (lumbago) commonly affecting the lower three discs in those age 20-40
Treatment for acute vertebral disc disease?
Analgesics (e.g. epidural corticosteroid injection), bed rest with a firm mattress, surgery if neurological impariment
What is chronic vertebral disc disease?
Degenerative changes in the lower discs and facet joints leading to long standing mechanical pain
Name some causes of mechanical back pain?
Heavy manual handling, stooping/twisting whilst lifting, whole body vibration, smoking, increasing age, fractures, osteoarthritis, stress, more common in females
What is lumbar spondylosis?
Degeneration of the lumbar discs causing circumferential bulging of the intervertebral ligaments, the bone becomes sclerotic and osteophytes form - usually affects L4/5 and L5/S1. Pain is episodic with progressive stifness
What is facet joint syndrome?
Osteoarthritis of the misaligned facet joints secondary to lumbar spondylosis. Leads to lumbar pain raditating from the buttock, the pain is worse on bending backwards/straightening from flexion
What is Paget’s disease?
A focal disorder of bone remodelling leading to weaker bone being formed. It most commonly affects the skull, legs, pelvis and spine
S&S of Paget’s disease?
Usually asymptomatic, leads to bone and joint pain, nerve decompression (may causes deafness and paraparesis), hydrocephalus, osteosarcoma and myocardial hypertrophy
Tests for Paget’ disease?
Increased serum alkaline phosphate with normal calcium and phosphorus, increased urinary hydroxyproline excretion, isotope bone scan
What is Fibromyalgia?
Widespread musculoskeletal pain after other diseases have been excluded - it is pain in at least 11 of the 18 tender points on examination and symptoms must be present for at least 3 months
S&S for fibromyalgia?
Widespread central non-nociceptive pain aggravated by stress, cold and activity. Generalised morning stiffness paraesthesia of the hands and feet as well as extreme pain and non-restorative sleep
What is vasculitis and what are the types (with examples of what they affect)?
Inflammation of the vessel wall
Small vessel = small arterioles, venules and capillaries
Medium vessel = medium/small arteries/arterioles
Large vessel = aorta and major tributaries
Name examples of the types of vasculitis?
Large = polymyalgia rheumatica, giant cell arteritis Medium = polyarteritis nodosa Small = microscopic polyangitis, essential cryoglobulinaemia
S&S of Polymyalgia Rheumatica?
Sudden onset pain/stiffness of the shoulders, neck, hips and lumbar spine. Pain is worse in the morning and may come with mild polyarthritis of the peripheral joints
Tests for Polymyalgia Rheumatica?
Raised ESR/CRP, ANCA negative, temproal artery biopsy.
S&S of Giant Cell Arteritis?
Severe headache with temproal pulsating, tender scalp, jaw claudication when eating, dysponea, sudden painless vision loss (EMERGENCY)
What is the diagnostic criteria for Giant Cell Arteritis?
Three of: Raised ESR, >50, new headache and temporal artery tenderness
This is also ANCA negative
S&S for Polyarteritis Nodosa?
Mononeuritis multiplex, abdominal pain, GI/SC haemorrhage, heamaturia/proteinuria, fever, weight loss
What gender is most affected in vasculitis? What are their ANCA statuses?
Large = female Medium = male Large/medium = ANCA -ve Small = ANCA +ve
What are polymyositis and dermatomyositis?
PM is a muscle disorder mainly affecting women. It cuases inflammation/necrosis of skeletal muscles and when it affects the skin is DM. The cause is often unknown but rubella and influenza are thought to stimulate it
S&S of Polymyositis?
Dysphagia, dysphonia, respiratory failure. Symmetrical progressive muscle weakening/wasting affecting the proximal shoulder muscles and pelvic girdle - this leads to dificulty squatting, going up stairs and raising hands above the head
S&S of Dermatomyositis?
Scaly erythematous plaques over the knuckles known as Gottron’s papules, Heliotrope rash, arthralgia, dysphagia, Reynaud’s phenomenom
Treatment of polymyositis and dermatomyositis?
Bed rest and a gentle programme, oral prednisolone, hydroxychloroquine for skin and ciclosporin/methotrexate upon relapse
What are common causes of Septic Arthritis?
Staph. aureus, N. gonorrhoea, Group A streptococci invading the joints (may be introduced by the bloodstream or directly by injection)
S&S of Septic Arthritis?
Warm, red and painful joint, fever, monoarthritis, decreased joint movement. THIS IS A MEDICAL EMERGENCY
Treatment for Septic Arthrits?
Antibiotics (2 weeks IV, 4 weeks oral) and joint aspiration
What are common causes of Osteomyelitis?
Staphylococcus from the bloodstream (commonly staph. aureus), fracture and sickle cell bone infarcts
S&S of Osteomyelitis?
Swollen, red and warm limb, fever, pain and loss of range of motion. It mainly affects the ends of the long bones - the bone begins to produce pus and necrose (pus blocks the blood supply)
Treatment for Osteomyelitis?
Antibiotics (vancomycin in gram +ve), drain the affected area, remove diseased bone, may require limb amputation
What is spinal stenosis?
Narrowing of the spinal canal. This can cause neurogenic claudication. Pain is worse
walking downhill and relieved leaning forward as this opens up the spine.
