MSK Flashcards
1
Q
MSK symptoms?
A
Arthralgia
Arthritis
Mechanical problems
Periarticular pain
Enthesis (inflammation at the site of attachment of ligaments, tendons and joint capsules)
2
Q
MSK investigations?
A
Bloods
Autoantibodies
X-ray
Bone scintigraphy - the severity of bone disease
Ultrasound - assessment of soft tissue
MRI - articular disease and spinal disorders
DXA - Duel energy x-ray absorptiometry
Arthroscopy - direct means of visualising into a joint
3
Q
3 reasons for synovial fluid analysis?
A
Aspiration
Relieve pressure
Injection of inter-articular corticosteroid
4
Q
Differences between mechanical and inflammatory back pian?
A
Mechanical - often sudden onset, worse in the evening with morning stiffness absent and aggravated by exercise
Inflammatory - Gradual onset, morning stiffness and exercise relieves pain
5
Q
features of serious back pain?
A
Metastasis, multiple myeloma, osteomyelitis or spinal + root canal stenosis
- 20 to 50
- constant pain without relief
- Bone tenderness
- TB, HIV, Carcinoma and steroid use
6
Q
Difference between the cause of acute and chronic disc disease?
A
Acute - prolapsed intervertebral disc which results in lumargo and sciatica
- younger people
Chronic - Degenerative disease in the lower lumber discs of the facet joints - sciatic radiation to the butt and posterior thigh
7
Q
Clinical features of acute disc disease?
A
Sudden onset of severe back pain following strenuous activity
8
Q
Management of acute disc disease?
A
9
Q
Management of chronic disc disease?
A
NSAIDS
Physio
Weight reduction
Surgery - if level or nerve root identified
10
Q
What is the difference between spondylothesis and spinal stenosis?
A
Spondylothelosis - condition where the lower vertebra slip forward onto the bone directly beneath associated with mechanical back pain
Spinal stenosis - compression of the cauda equina - back and butt pain
11
Q
Osteoarthritis?
A
Degenerative disease of synovial joints and the commonest form of arthritis
12
Q
Pathology of osteoarthritis?
A
Progressive destruction and loss of articular surface
Exposed subchondral Bone - sclerosis - increase vascularity - cyst formation
In an attempt to repair - cartilaginous growths calcify at the margin of the joints (OSTEOPHYTES)
13
Q
What causes the destruction in osteoarthritis?
A
Metalloproteinases - collagenases that degrade protein and proteoglycans
IL1 and TNF-alpha - stimulate metalloproteinases and inhibit collagen production
Deficiency of growth factors
Osteoprotegerin - Binds to RANKL and stimulates osteoclastogenesis
14
Q
Clinical features of osteoarthritis?
A
Heberden Bouchard notes
Adducted thumb
Joint pain made worse by movement and better by rest
Gelling - stiffness at rest
Weigh bearing joining - knees, hips and vertebrae
Muscle wasting or surrounding muscle group
15
Q
Key X-ray features of osteoarthritis?
A
Osteophytes
Subchondral sclerosis
cyst formation
16
Q
Investigations to confirm osteoarthritis?
A
- -ve rheumatoid factor
- Normal FBS and ESR
- X-ray
- MRI - early cartilage changes
17
Q
Management of osteoarthritis?
A
Based on symptoms + disability
PHYSICAL CHANGES
MEDICATION
- Paracetamol + weak opioid
- Short course NSAIDS
- Intra articular corticosteroid injections
SURGERY
18
Q
3 types of inflammatory arthritis?
A
Rheumatoid
Spondyloarthritis - axial spondyloarthropathies, Reactive, psoriatic
Crystal - Gout and pseudogout
19
Q
Rheumatoid arthritis?
A
Chronic systemic autoimmune disorder causing symmetrical peripheral polyarthritis with prolonged morning stiffness associated with other autoimmune conditions
20
Q
Aetiology of rheumatoid arthritis?
A
Gender - women before menopause
Family histology
Genetics - HLA DR4/ DRB1
Smoking
21
Q
Pathology of rheumatoid arthritis?
A
Synovial inflammation - activated by inflammatory T cells activating macrophages, mast cells and fibroblasts
Rheumatoid factor - autoantibodies against the FC portions of IgG produced by B cells - forms complexes and causes complement activation
22
Q
Synovitis?
A
inflammation of synovium due infiltration by inflammatory cells - inflammation of joints, tendon sheaths and bursae
- Cytokines cause angiogenesis and activation of adhesion molecules and endothelial cells - leukocyte infiltration
PANNUS - synovium proliferates and grows over the surface of cartilage - causes a tumour like mass that destroyed articular surfaces of bone causing bony erosions
23
Q
Clinical features of rheumatoid arthritis?
A
Symmetrical peripheral polyarthritis with early morning stiffness lasting more than 30 mins
Swollen MCP and PIP causing spindle shaped fingers
KEY:
ULNER DEVIATION
Z SHAPED THUMB
SWANN NECK DEFORMITY
BOUTONNIERE DEFORMITY - PIP flexion and DIP hyperextension
24
Q
Non-articular manifestations of rheumatoid arthritis?
A
Muscle wasting
Rheumatoid nodules - elbow, finger, Achilles tendon - near joints affected by rheumatoid
Increased risk of infection
Pericardial effusion and pleural effusion
Episcleritis - inflammation of the white of the eyes
Ulcers
25
Investigations to diagnose rheumatoid arthritis?
**Bloods** - normocytic normochromic anaemia (chronic disease and drug therapy) (normal size and normal concentration of Hb)
- ESR and CRP increased
**Serum autoantibodies** - anti-citrullinated protein antibodies + rheumatoid factor
**X-ray** - soft tissue swelling, joint erosion and porosis of periarticular bone
**Synovial aspiration** - increased neutrophil count - if painful start thinking it might be septic
26
Management of rheumatoid arthritis?
No cure, just treat the symptoms and try to get back function of joint
- NSAIDs + COXIBS (selective NSAIDS for COX2 not protective COX1) - relive joint pain but doesn't slow down the progression of the disease
- CORTICOSTEROIDS - decreases disease activity
- DMARDs - inflammation of inflammatory cytokines
27
DMARDs drugs and which one is safe if pregnant?
**Sulfasalazine** - safe for preggo
**Methotrexate** - teratogenic
**Leflunomide** - longer-lasting and blocks T cell proliferation
28
Gold standard Biological DMARD?
**Infliximab** - TNF-alpha inhibitor
**Anakinra** - IL1 receptor blocker
**Rituximab** - lysis of B cell
**Tocilizumab** - IL6 receptor antibody
**Abatacept** - Blocks T cell activation
**Infliximab** - TNF-alpha inhibitor
29
What joint needs to be involved for axial spondyloarthropathy to be ankylosing spondylitis?
Sacroiliac joint
30
Axial spondyloarthropathy?
Inflammation of the spine mainly found in you male adults
31
Clinical features of ankylosing spondylitis?
Compensatory hyperextension of the neck
Exaggerated thoracic kyphosis
Loss of lumbar lordosis
vertebra fused together
Fixed flexion of the hips
Compensatory flexion of the knees
- Achilles tendonitis and plantar fasciitis - inflammation on heel and arch of foot
32
Investigations used to diagnose axial spondyloarthropathy?
**Bloods** - Increase ESR and normalish CRP
**X-ray**
- bamboo spine
- sclerosis/ erosions of sacroiliac joint
blurring of upper or lower vertebral arthritis at thoracolumbar junction
Syndesmophytes - new bony growths
Enthesitis
**MRI** - sacroilitis
33
Management of axial spondyloarthropathy?
Early diagnosis
Morning exercise
slow release NSAIDS at night
Infliximab
Phosphodiesterase type 4 inhibitor
34
What percentage of patients with psoriasis develop psoriatic psoriasis?
10%
35
Clinical features of psoriatic arthritis?
**Dactilytis** - sausage fingers
**Arthritis mutilans** - severe destruction of small bones in hands and feet due to severe inflammation
Sacroiliitis
mono- or oligoarthritis
36
what is a pencil in cup deformity on a x ray indicative of?
Arthritis mutilans
37
Management of psoriatic arthritis?
Analgesics or NSAIDS
Local intraarticular corticosteroid injections
Methotrexate or TNF-alpha inhibitor
PDE4
38
Enteropathic arthritis?
Large joint mono or symmetrical oligoarthritis occurring in 10 to 15% of patients with IBD
The worse the IBD the worse the pain and visa versa
39
Reactive arthritis?
Arthritis mostly found in young patients within 4 weeks of infections such as GI infections or STIs
mostly lower limb joints
40
GI infections that can cause reactive arthritis?
Salmonella
shigella
Yesenia
campylobacter
41
Clinical features of reactive arthritis?
Srthritis within 4 weeks of an infection in young adults
Circinate balanitis - skin ulcers around the penile meatus - ring-shaped dermatitis around glans penis
Red plaques/ pustules on skin
Uveitis
Enthesis - Achilles tendonsiits, plantar fasciitis
42
Reiter's syndrome?
Uveitis, reactive arthritis and conjunctivitis
43
Investigations used to diagnose reactive arthritis?
Bloods - increased ESR
Synovial aspirations - sterile with high neutrophil count
44
Management of reactive arthritis?
NSAIDs
Local corticosteroid injections
Antibiotics
45
what are the crystals found under joint fluid microscopy in gout and pseudogout?
Gout - sodium urate
Pseudogout - calcium pyrophosphate dihydrate
Neutrophils ingest the crystals and initiate pro-inflammatory reaction
46
Gout
Inflammatory arthritis caused by hyperuricaemia and intra-articular sodium urate crystals
47
Pathophysiology of gout?
Increased uric acid production and decreased excretion through kidneys and faeces
- urate is derived from the breakdown of purines by xanthine oxidase
48
clinical features of gout?
Acute sodium urate synovitis
Chronic interval / polyarticular / tophacus gout
Urate renal store formation
49
What is the most common location for gout?
1st metatarsophalangeal joint of the big toe - middle aged, swollen and painful
50
What can put elderly women at risk of developing gout?
Long term diuretics
51
Investigations used to confirm gout?
**Joint fluid microscopy** - needle-like crystals which are regularly birefringent under polarised light
**Increased serum uric acid**
**Increased urea and creatinine** if the kidneys are involved
52
Management of gout?
**NSAIDs and COXIB** - diclofenac and lumiracoxib
**Colchicine** - inhibits activation and migration of neutrophils to sites of inflammation
**DECREASE SERUM URIC ACID** - decrease alcohol, weight, sugar, purine rich food,
**ALLOPURINOL** - Inhibits xanthine oxidase and decrease sodium urate rapidly
**FEBUXOSTAT** - non-purine analogue inhibitor of xanthine oxidase
**ANAKINRA** - IL1 beat blocker
53
what factors can cause impaired uric acid excretion?
CKD
Thiazide or aspirin
Hypertension
Primary hyperparathyroidism
Increased lactic acid production
54
Factors that can increase production of uric acid?
Increase turnover of purines
Myeloproliferative disorder - polycythemia
Leukaemia
55
Pseudogout?
Calcium pyrophosphate dihydrate crystals in articular cartilage and periarticular tissue that produces an image of chondrocalcinosis
Affects elderly women and affects the knees and wrist
56
Investigations used to confirm pseudogout?
**X-ray** - chondrocalcinosis
**Joint fluid microscopy** - small brick-shaped crystals which are positively birefringent under polarised light
**Blood** - raised which cell count
57
Management of pseudogout?
Joint aspiration + colchicine
Local injection of corticosteroids
58
Most common cause of septic arthritis?
Staphy Aureus
59
What can cause septic arthritis?
Infection of the joint by direct injury or blood bourne infection
60
Risk factors of septic arthritis?
Prosthetic joints, pre-existing joint disease or recent intra-articular corticosteroid injection
61
Clinical features of septic arthritis?
Hot, painful, swollen joint + FEVER
20% involve more than 1 joint
Prosthetic joint - inflamed or visible discharge
62
Investigations used to confirm septic arthritis?
JOINT ASPIRATION AND SYNOVIAL FLUID ANALYSIS OF APPEARANCE AND NEUTROPHIL COUNT
- Opaque and 75000+ neutrophils
BLOODS - Increase ESR and CRP, bacterial culture and FBC
X-RAY
SWABS OF URETHRA, CERVIX OR ANORECTUM - looking for gonococcal infection
63
Management of septic arthritis?
**Flucloxacillin + oral fusidic acid** (gentamicin is given to immunosuppressants)
## Footnote
**Joint drainage**
**Immobilize the joint**
**NSAID**
64
Appearance and WCC when doing a synovial fluid analysis?
Normal
Inflammed
Septic
Normal - straw + \<3000 wcc/mm^3
Inflammed - Cloudy + \>3000 wcc/mm^3
Septic - opaque + 75000 wcc/mm^3
65
Most common cause of septic arthritis in young people?
Gonococcal infection - genital, rectal or oral infection
66
Meningococcal septic arthritis?
Migratory polyarthritis due to meningococcal septicaemia so **there is a deposition of immune complexes containing m. antigens**
67
Osteomyseltiits?
Infection of bone by bloodstream, open fracture or surgery
Staphy - Haemophilus influenza or salmonella
CLINICAL FEATURES: Fever, local pain, erythema and sinus formation
INVESTIGATIONS: CT, MRI, BONE SCAN, BLOOD CULTURE AND BONE DENSITY
MANAGEMENT: Flucloxicilin and fusidic acid
68
5 types of autoimmune rheumatic disease?
SLE
Antiphospholipid syndrome
Systemic sclerosis (scleroderma)
Polymyositis + dermatomyositis
Sjogren's syndrome
69
SLE?
An inflammatory multisystem disease characterised by the presence of serum autoantibodies against nuclear components
70
Pathophysiology of SLE?
Environmental trigger causes apoptosis - increase nuclear antigens and apoptotic bodies
Genetic susceptibility - not able to clear the apoptotic bodies and recognising the nuclear antigens as foreign
Autoantibodies (antinuclear antibodies and Anti ds-DNA) - form antigen-antibody complexes and they deposit in tissue and blood vessel walls causing inflammation
complement system causes pores to form and cells to burst
71
Aetiology of SLE?
Ultraviolet light
Genetics - HLA B8, DR3, A1
Oestrogen
Drugs - Procainamide (antiarrhythmic), isoniazid (TB antibiotic), hydralazine (heart failure)
EBV
72
Clinical features of SLE?
Fever, joint pain and rash
Organ specific symptoms
ULCERS - Malar rash, discoid rash and photosensitivity
SEROSA - pericarditis (can affect other layers of the heart), pleuritis
JOINTS - Arthritis in 2 or more joints
KIDNEY - abnormal urine protein
BRAIN - neurological disorders - seizure and psychosis
BLOOD - haematological disorders (anaemia, leukopenia, thrombocytopenia)
ANTIBODIES - Anti-nuclear antibodies, Anti-smith (ribonucleoproteins), Anti-dsDNA, Anti-phospholipids syndrome (targets proteins bound to phospholipids)
73
3 types and antiphospholipid autoantibodies?
Anticardiolipin
Lupus anticoagulant
Anti-Beta 2 Glycoprotein 1
74
Discoid lupus?
lupus where only skin is involved - facial rash with erythematous plaques
Coin shaped lesions
SCALP, EARS, BUTTERFLY AND LOWER LIP
75
Investigations to diagnose SLE?
**BLOODS** - normochromic normocytic anaemia, haemopoietic deficiencies, Increased ESR but noremal CRP, urea and creatinine/ low serum albumin if renal impairment
**SERUM AUTOANTIBODIES** - Antinuclear antibodies, anti-smith, anti-dsDNA and anti-phospholipids
**SERUM COMLEMENNT 3 AND 4**
**HISTOLOGY OF RENAL OR SKIN BIOPSY** - Deposition of IgG and complement
76
Management of SLE?
Dependant on severity and symptoms of the disease
**AVOID SUNLIGHT AND DECREASE CARDIOVASCULAR RISK**
**NSAIDs**
**CHLOROQUINE OR HYDROXYCHLOROQUINE** - anti-malarials and anti-inflammatory (mild and cutaneous)
**CORTICOSTEROIDS -** prednisolone - moderate to severe
**IMMUNOSUPPRESANTS** - severe with cerebral and renal impairment
**TOPICAL STEROIDS**
77
What are SLE patients at risk of developing?
Osteonecrosis of femoral head + mitral valve regurgitation
78
What is associated with anti-phospholipid syndrome?
Recurrent miscarriage
Recurrent thrombosis
Anti-phospholipid autoantibodies
hypercoagulable states and more likely to have clots
79
Clinical features of anti-phospholipid syndrome?
Arteries - stroke, TIA, MI
Veins - DVT and Budd-Chiari syndrome
Recurrent miscarriage
80
Management of antiphospholipid syndrome?
Long term warfarin
Pregnant - aspirin and heparin
Prophylaxis - aspirin and clopidogrel
81
Systemic sclerosis (scleroderma)?
Normal tissue is replaced with thick fibrous connective tissue - excessive collagen production
multisystem condition that has skin involvement and raynaud's phenomenon occurring early
82
Aetiology of scleroderma?
Increased vascular permeability so there is infiltration and activation of inflammatory cells and adhesion molecules - migrate to the extracellular matrix - fibroblasts are stimulated to produce more collagen
**UNCONTROLLED IRREVERSIBLE PROLIFERATION OF CONNECTIVE TISSUE AND THICK VASCULAR WALLS**
83
Limited cutaneous scleroderma?
**70%**
**Calcinosis** (hands)
**Raynaud's phenomenon**
**Oesophageal Involvement**
**Sclerodactyly** - thick and dough-like then hard a claw-shaped
**Telangiectasia** - wide blood vessels that cause thread-like patterns
MICROSTOMIA
84
Diffuse cutaneous scleroderma?
30%
Skin changes more rapidly and more widespread involvement
GI - GORD, dysphagia and malabsorption
Renal - AKD or CKD
Lung - lung fibrosis and pulmonary vascular disease
Heart - myocardial fibrosis and conduction disturbances
85
Investigations used to diagnose scleroderma?
Blood - normocytic normochromic anaemia, increase U and C, serum auto-antibodies
X-ray - calcium deposits around fingers
Barium swallow - showing oesophageal dysmotility
86
Autoantibodies associated with scleroderma?
Antinuclear antibodies
DCS - anti-topiosomerase 1 (SL70) and anti-polymerase 1 and 3
LCS - Anti-centromere
87
Management of scleroderma?
Vasodilators, warfarin and O2 - P. hypertension
ACEi - hypertension and KD
Cyclophosphamide, azathioprine or low dose prednisolone - Pulmonary fibrosis
88
polymyositis?
Inflammation and necrosis of skeletal muscle fibres due to molecular mimicry of proteins found on their surface '
- Perofrins form holes and granulozymes enter = apoptosis
- FAS ligands - signals a cascade of reactions leading to apoptosis
REPEATED ATTACKS LEADS TO NECROSIS
89
Dermatomyositis?
Complement mediated and autoantibodies against blood vessels - tissue ischaemia
Immune complexes using proteins of damaged cells travel to the BM of skin - cell damage
90
Clinical features of polymyositis?
Bilateral proximal muscle weakness of shoulders and hips
**Difficulty** - swallowing, going upstairs, raising arms and rising from a chair
**Involvement of pharynx and oesophagus** - dysphagia, dysphonia and respiratory failure
91
Clinical features of dermatomyositis?
**Heliotrope rash** - rash on upper eyelids
**Gottrons plaque** - red scaly rash on the back of fingers and knees that are photosensitive
associated with malignancy :(
92
Investigations used to diagnose poymyositis/ Dermatomyositis?
**MUSCLE BIOPSY** - inflammatory cell infiltration and necrosis of muscle cells
**ELEVATED SERUM MUSCLE ENZYMES** - creatine kinase, aldolase and aminotransferase
SERUM ANTIBODIES - **Anti-tRNA synthetase (anti -jo), Anti-mi2, ANA**
**ELECTROMYOGRAPHY** - Detect regions of dead muscle
**MRI** - muscle inflammation
ESR not raised
93
Management of polymyositis/ dermatomyositis?
Corticosteroids
Immunosuppressants
Anti-malarial medication
Exercise therapy
Avoid sun and wear protective clothing
94
Sjogren's syndrome?
Immunologically mediated destruction of **epithelial exocrine glands in particular lacrimal and salivary glands**
95
Clinical features of Sjogren's syndrome?
Keratoconjunctivitis sicca - dry eyes
Xerostoma - dry mouth
Difficulty eating dry biscuits and absence of pool of saliva when the lifting tongue
Associated of other autoimmune diseases
Arthritis
96
Investigations used to confirm Sjorgren's syndrome?
**SERUM AUTOANTIBODIES** - ANA, Anti-Ro
**LABIAL GLAND BIOPSY** -lymphocyte infiltration and destruction of acinar tissue
**+VE SCHIRMER TEST** - standard stip of filter paper placed on lower lid and if positive it will wet less than 10cm in 5mins
97
Management of Sjorgren's syndrome?
Artificial tears or saliva replacement solutions
98
Vasculitis?
Inflammation of blood vessels walls associated with other haematological conditions such as SLE, RA and allergic reactions
99
Systemic vasculitits?
Group of multisystem disorders in which:
vasculitis is the principle features
classification is based on the size of the vessel affected
Anti-Neutrophilic cytoplasmic autoantibodies
100
Polymyalgia and giant cell arteritis?
Abrupt stiffness and instance pain of muscles in shoulder, neck, hips and lumber
Giant cell arteritis is when inflammation occurs in the arteries of the head and neck - specifically the **superficial temporal artery** - headache and tender heads
GCA - can cause stroke or sudden loss of vision
101
Investigations used to confirm Polymyalgia and giant cell arteritis?
Increased ESR and CRP
Normochromic Normocytic anaemia
Temporal artery biopsy
102
Management of Polymyalgia and giant cell arteritis?
Corticosteroids - prednisolone
103
Takayasu arteritis?
Vasculitis of major vessels such as the aortic arch and other major vessels mostly affecting Japanese people
- linked to hypertension, absent peripheral pulse, stroke, cardiac failure
- Corticosteroids treatment
104
Polyarteritis Nodosa?
Vasculitis secondary to immune complex deposition after Hep B antigenaemia
Necrotising arteries resulting in microaneurysms, thrombosis and infarction
- fever, malaise, myalgia and weight loss
105
Moneuritis multiplex?
Painful asymmetrical asynchronous sensory and motor peripheral neuropathy involving isolated damage to at least 2 separate nerve endings
## Footnote
**simultaneous malfunction of 2 or more peripheral nerves in different areas of the body**
**e.g. abdo pain due to visceral infarction, MI/HF due to affecting cardiac ateries and even renal failure**
106
Investigation and management of polyarteritis nodosa?
Angiography for microaneurysms
Biopsy of affected organs
Corticosteroids and immunosuppressants
107
What organs are affected by microscopic polyarteritis?
Lungs and kidneys - Haemoptosis, haematuria, proteinuria and renal failure
- arthralgia and purpuric rashes
108
Investigations used to confirm microscopic polyarteritis?
Renal biopsy and serum ANCA
109
Eosinophilic granulomatosis with polyangiitis?
Asthma, eosinophilia and a systemic vasculitis affecting peripheral nerves and skin
110
Henoch-Scholein purpura?
Purpuric rash mainly on legs and butt of children
Vascular depositions of IgA dominant immune complexes and it comes before acute respiratory tract infection
Abdo pain, arthritis, haematuria and nephritis
111
Cryoglobulinaemic vasculitis?
Cryoglobulin - Ig and complement components protein that precipitates in cold and causes obstruction of finger and toes
purpura, glomerulonephritis and polyneuropathy
112
Behcet's disease?
Inflammation of blood vessels and tissue associated with recurrent oral ulceration, eye lesions -uveitis, genital lesions, GI ulcers and arthritis
Immunosuppressants or even thalamide - inhibits IL6
113
Osteoporosis?
Reduction in bone mass and micro-articular destruction of bone tissue - bone fragility and increased risk of fracture
bone mass density Is greater than 2.5 below the young adult mean value
114
Aetiology of osteoporosis?
Inadequate peak bone mass and ongoing bone loss
115
What would be seen on an x-ray of a patient with osteoporosis?
Fractures at:
Kyphosis and loss of heigh in thoracic and lumber vertebrae
Proximal femur
Distal radius (colles)
116
Investigations used to confirm osteoporoiss?
DXA - Dual-energy x-ray absorptiometry
X-ray - fractures
Normal serum biochem
Look at secondary causes of osteoporosis
117
FRAX?
10 year probability of hip fracture and major osteoporotic fracture combined for an untreated patient between 40 and 90 years old
118
Biphosphonates MOA?
Alendronate, Risedronate and Zolendronate
Inhibit osteoclasts and bone resorption
increase bone mass at hip and spine and decrease the risk of fracture
119
Denosumab MOA?
Human monoclonal antibody for RANKL which usually stimulates and activates osteoclasts
120
Selective oestrogen receptor modulator?
Activates oestrogen receptors on the bone while having no stimulatory effect on the endometrium - decrease the bone mass lost
## Footnote
***cramps, flushing, strokes and increase risk of thromboembolism***
121
Recombinant human parathyroid peptide 1 - 34 MOA?
Stimulates bone formation in severe osteoporosis
***Hypercalcaemia***
122
Other forms of management for osteoporosis?
**Oestrogen therapy** for post-menopause women
**Testosterone** for men with hypergonadism
**Strontium Ranelate** - post-menopausal
123
Osteonecrosis?
Death of bone and bone marrow due to reduced blood flow
Drugs - glucocorticoids, bisphosphonates (maxillofacial skull)
Alcohol
Sickle cell
Radiation
HIV
124
Paget's disease?
Increased osteoclast activity and get replaced with new weaker bone associated with latent infection in osteoclasts or being genetically susceptible
Increased local bone blood flow and fibrous tissue
125
Clinical features of paget's?
Pelvis, femur, lumber spine, skull or tibia
Pain in bone or nearby joint
Deformities - enlarged skull and bowing of the tibia
126
Investigations used to confirm paget's disease?
Increased **serum alkaline phosphatase**
Increased **urine hydroxyproline excretion**
X-ray - enlargement, distortion or osteolytic changes
**Radionuclide bone scan**
127
Management of paget's disease?
**Biphosphonates** - Zolendronide
Constant monitor of serum alkaline phosphatase and urine hydroxyproline excretion
128
Complications of paget's?
Nerve compression
Pathological fracture
High output cardiac failure
Osteogenic sarcoma
129
Osteomalacia/ Rickets?
Osteomalacia - adults - weak, soft and risk of fracture
Rickets- children - softening, impaired growth and malformation
Bone softening due to faulty bone mineralization - deficiency or impaired metabolism of it D, Calcium or phosphate
130
What can cause vit D deficiency?
Decreased intestinal absorption - Crohns or coeliac
Chronic kidney or liver disease
Decreased UV light exposure
Long term phenytoin or anticonvulsants because they use up the hydrolase enzymes
131
Clinical features of osteomalacia and rickets?
Diffuse bone and joint pain
Proximal muscle weakness
Bone fragility
Increased risk of low trauma fractures
Muscle spasms and numbness
132
Rickets specific symptoms?
Craniotabey - thin and soft cranial bones
Delayed closure of fontanelles
Genu varum
Prominent frontal bone
Protruding abdomen
Rachitic rosary - bumps on chest due to coastal widening between ribs and cartilage
133
Investigations used to confirm osteomalacia?
Decreased serum 2,5-dihydroxyvitamin D
Decreased calcium - increased PTH - decreased phosphate
Increase alkaline phosphatase
X-ray - looser zones (pseudofractures), Rickets - metaphyseal clubbing and fraying or genu varum
134
Fibromyalgia?
Chronic widespread muscle pain mostly in women alongside tenderness and sleep disturbances
135
Pathology of fibromyalgia?
Nociceptor detects pain (skin, joints and walls of organs) - from dorsal root ganglion they release substance P to second or the inhibitory centre releases serotonin or norepinephrine to cancel the stimulatory effect of substance P
If substance P strong enough then it goes to the brain
At the site - Epithelial cells and mast cells release nerve growth factor
136
function of nerve growth factor?
They affect nociceptors
- increase growth
increase sensitivity to pain
increase amount of substance P produced
137
Diagnosis of Fibromyalgia?
1. Pain in \>7 or \>5 areas of the body
2. Sensitivity score - \>5/12 or \>9/12
3. \> 3 months
Pain can't be due to other conditions
pain can also be associated with emotion
138
Management of fibromyalgia?
Exercise
Relaxation techniques and sleep hygiene
**Medication** - Amitriptyline, Serotonin-norepinephrine reuptake inhibitors, Anticonvulsants - pregabalin or gabapentin which slow down nerve impulses
