MSK Flashcards
** Septic arthritis
- Septic arthritis – serious infection of ONE synovial joint space
- (75% knee>hip>ankle) → bone destruction in < 24hrs
- Staph.aureus (single site) or HiB (multiple site) or - Gonorrhoea (sexually active young pt.)
May result from adjacent osteomyelitis, haematogenous spread/ puncture wound
RF: steroids, RA, immunosuppressed, IVDU, prosthetic joint, DM
CF: Joint- swollen, erythematous, hot, tender, STUFF
Systemic: fever, rigors, vomiting, hypotension
IVX: ASPIRATE joint space then IV abx after, bloods + cultures, USS deep joints, bone scan and
TX: ABX, Flucoxacillin, refer to orthopaedics, physio and splint
** Temporal arteritis
also known as Giant cell arteritis
- Immune mediated granulomatous vasculitis of medium and large vessels
Typically in FEMALE pts > 55yo; If younger and FEMALE < 55 = Takayasu’s (aorta)
50% associated with Polymyalgia rheumatic
CF: Tends to be a RAPID onset < 1 month
Diffuse + constant HEADACHE (U/L ~ 85%) Superficial pain over temporal region ⇒ Scalp tenderness Jaw claudication – worse after eating Distended + throbbing temporal.a Acute transient visual loss (10%) ⇒ Amaurosis Fugax (curtain descending, 2o optic neuritis
IVX: ESR >50 !!!!!
CRP raised
Temporal artery biopsy - definitive dianosis = multinucleated giant cells - charatersitc skip lesions
Normocytic anaemia
Management: Steorids= Give immediatyely, HIGH DOSE 40MG PREDNISOLONE
+ Aspirin 75mg + PPI
- Urgent referral to opthalomolgy
Complication: stroke, TIA, optic neuritis
** Spinal Cord Compression
Spinal tumour, metastasis or crush fracture → direct spinal cord pressure or induction of vertebral collapse
1) Typically Thoracic (66%), also cervical and lumbar (33%) Often 1st presents in emergency department
Oncological, MSK trauma and inflammatory causes
CF: Back pain, noctural, aggravated by straining/coughing, motor pain and weakness, paraesthesia + saddle anaesthesia, bowel/bladder dysfunction.
IVX: Neuro exam, reflexes, clonus, palpate spine and abdo and ANAL TONE.
TX: A-E,
= Dexamethasone 16mg with PPI cover
URGENT MRI, radiotherapy and decompression surgery
Ifi motor function lost for 48hrs - unlikely recovery (paraplegia)
Osteoarthritis
Diagnostic?
X ray signs: LOSS
common sites
= PIPJ and DIPJ alongside base of thumb = squaring.
- Clinical syndrome characterised by destruction of joint cartilage + underlying bone (wear and tear) with a/ inflammation → eventual remodelling and disorganisation
Typical onset >45 yo, M=F, HIP AND KNEE
CF: Uilateral, large weight bearing joints- pain and crepitus worse at end of day.
stiffness after prolonged rest
Heberdens and Bouchards (hb pencil)
Diagnose: >45, no morning related stiffness longer than 30 mins
IVX: x-ray -LOSS Loss of joint space Osteophytes Subarticular sclerosis Subchondrial cysts
TX: exercise, weight loss + analgesic ladder
- Intrarticlar steroid injections
Hip/ Knee replacement
Osteoporosis
Number on dexa scan diagnositc?
Treatment + when to take
–Reduced bone mass
↑Risk of fragility fractures
Primary = age-related, FHx, prolonged immobility
Secondary (SHATTERED) = Steroids, Hyperthyroidism/ Parathyroidism, Alcohol + tobacco, Thin (BMI < 22), ↓Testosterone, Early menopause, Renal or liver failure, Errosive/inflammatory bone disease, Diet (↓Ca2+)
F > M
CF: Fragility fractres / asymtomatic
IVX: X ray + DEXA scan <2,5 is osteoporosis
Bloods: TFT, Ca, ALP, Po4
Osteoporosis is commonly associated with normal blood test values
Management
- lifestyle excises
- Bisphosphonates ALENDRONATE (standing 30 mins before breakfast)
Calcium Vit D
Rheumatoid Arthritis
Name of classification?
Treatment?
- Chronic, systemic, INFLAMMATORY JOINT DISEASE
RF: Smoking, Poor dental hygiene, FEMALE, Age > 50/60, HLA DR4/DR1 linked
CRITERIA for ∆ = ACR-EULAR RA classification (≥ 6 = ∆)
CF: relapsing remitting flares of small joints, worse in morning,
morning stiffness > 60 mins, fatigue, weight loss, bursitis
Late signs: Ulnar deviation, swan neck, RA nodules
Lung syx: fibrosing alveolitis, pleural effusion, vasculitis
Bloods: RH facture and anti-CCP
X RAY RANDS + FEET
TX: MDT rheumatologist, physio, podietry NSAIDS + prednisolone for flares - DMARDS: Methotrexate and + one other dmard e.g hydroxychloroquine \+ monoclonal antibody Surgery if pain/deformity
Annual review for complications
Polymyalgia Rheumaticia
Trouble doing what?
- Not a true vasculitis (pathogenesis unknown)
- -> PMR and GCA share the same demographic characteristics
CF: Sub-acute onset (<2 weeks proximal joints- shoulder and pelvic girdle aching and morning stiffness, fatigure, fever, weight loss, depression, carpal tunnel
Trouble lifting arms above head!!
IVX: CRP, ESR,
TX: IV METHYLPREDNISOLONE
Prednisolone 15mg o/d 2 years
Gastric PPI and bone protective bisphosphonate
(if markers dont decrease = not PA)
Review 3 monthly
Gout
- Deposition of Monosodium URATE crystals –> acute monoarthropaty and severe joint inflammation
- MTP bog toe
Causes: high purine diet, alcohol, CKD, Starvation, infection, M>F
CF: PAIN, localised, swollen, fever, malaise
IVX: aspiral synovial fluid - crystallography
BLoods: Serum urate >360, ESR
Joint X ray
Management: Self limiting 7-10 days NSAID + PPI or Colchine if NSAID intolerant / prednisolone
Long term: Allopurinol 2 weeks after acute attack
Vasculitis
Antibody?
Treatment?
Inflammatin of blood vessel walls
Infective causes
Non infective:
- Large vessel: GCA, takayasu arteritis in aorta
- Medium: Kawasaki, polyarteritis nodosa
- Small: ANCA +ve microscopic polyangitis
CF: systemtic ever, malaise, myalgia, purpira, HTN, end organ ischamia
IVX: Bloods- ESR, CRP, ANCA (anchor and vessesls), - rheumatoid factor
- Urine MSc
- Imaging: angiography + biopsy
Management: CYCLOPHOSPHAMIDE if ANCA +ve
TNF Blocker
Systemic Lupus Erythematosus (SLE)
Multi-system, autoimmune, inflammatory disorder characterised by formation of auto-Abs to various auto-Ag (e.g. ANA) → deposition of immune complexes –> tissue damage
CF: Malaise, Fatigue, Fever, MYALGIA + ARTHRALGIA ± Alopecia, Lymphadenopathy
Management: steroids + NSAID + DMARDS
Hydroxychloroquine (first line for mild SLE)
+ Suncream and sun avoidance for the photosensitive the malar rash
Fragility Fractures
Fragility fractures associated with osteoporosis are vertebral body, distal radius, NOF, pubic ramus, Neck of humerus
-
Ankylosing Spondylitis
Chronic, inflammaton of SPINE + SACROILIAC JOINTS → fusion of spine (bamboo)
- Males present earlier
CF: Typical young man with lower back pain + stiffness; gradual onset
Worse mornings. radiates to hips/buttucks
Relieved by exercise
Question mark ? deformity hunched back
+– Acute Iritis, Osteoporisis, Enthesitis (ligament inflammation)
IVX: X-ray /mri
Sacroilitits shows erosisons, Vertebral Ankylosis, syndesmophytes (bony growth inside a ligaments)
refer to Rheumatologist
Bloods: raised ESR, HLA +ve, normocytic anaemia
TX:
- Exercise, NSAIDS,
- IA Injections of corticosteroids
- TNF inhibitors for severe acute
- Surgery: Hip placement
Complication: Anterior Uveitis + cardiac complications such as heart block
Reactive Arthritis
? which syndrome?
Whats the triad?
Sterile inflammation - Sexually transmitted (chlamydia) - Post-dysteneric e.g. salmonella Triad of Reiters sydnrome typically 4 weeks post initial infeciton 1. Arthritis 2. Uveitis or conjunctivitis 3. Urethritis
Cant see cant pee cant climb a tree
IVX: ESR, CRP
Screen for chlamydial infection : MSI, NAATs
Stool culture if diarrhoea for salonella
Management: Split, NSAIDS, DMARD, Methotrexate
Usually resolves 3-12 months
Scleroderma
Increased Collagen deposition -> internal organ fibrosis –> Vasc Damage
limited vs diffuse
diagnosis
treatment
Reynaud’s – typically 1st symptom (90%)
Skin hardens – fingers (sclerodactyly)
- Inflammation 2. Microvascular dysfunction
- Fibrosis
Limited = CREST Calcinosis Raydnauds Esophogeal dysmotility Sclerodactyly Telangectasia
Diffuse version has cardio, lung and kidney issues too.
Diagnosis
- Nailfold Capillaroscopy
- ANA +ve, Anti-Scler 70 or anti-centromere
Treatment is very poor- try methotrexate
Sjorgrens syndrome
syx?
Diagnose with?
Dry mouth, Dry eyes, Fatigue and enlarged parotid gland
autoimmune
Anti-Ro and anti La ab + salivary gland biopsy.
Paegets disease
stereotypical patient?
Raised test>
- Deformity and mechanical weakness of bone
- Increased uncontrolled bone turn over
The stereotypical presentation is an older male with bone pain and an isolated raised ALP
IVX: RAISED ALP
Treatment: Bisphosphonates prevent further abnormal bone changes
+ NSAIDS for pain and Ca + Vit D when on bisphosphonates
Steroids Risk Long Term + prevention
D(ONT) STOP
Dependent after 3 weeks –> adrenal crisis
Sick day rules - increase dose on sick days
Treatment card- keep on them
Osteoprorisis prevention- bisphosphonates + ca + vit d
Proton pump inhibitor for gastric protection
WRIST BONES
some lovers try positions that they cant handle
(round anticlockwise)
scaphoid Lunate Triquitrum Pisiform Trapezium Trapzoid Capitate Hamate
Dermatomyosisits
An inflammatory disorder causing symmetrical, proximal muscle weakness and characteristic skin lesions
- anti-Jo1
Charcots foot
Caused by nerve damage in foot
Density change (areas of lucency and sclerosis) Destruction Debris (loose bodies and bone fragments) Distension (joint effusion) Dislocation (e.g. metacarpophalangeal joints).
GOUT findings
BIG toe
Negatively birefringent
Needle shaped
high uric acid
Pseudo-gout / Calcium Pyrophosphate findings
Knee or ankle
Positively birofringent rhomboid shapes
Hyperparathyroidism = RF due to the increased serum calcium
TX = nsaids and steroid injections
P = pseudo gout
P for positively birofringent
What are shiny corners on MRI on verterbae?
early radiological vertebral corner lesions are known as ‘shiny corners’ on MRI and are known as ‘Romanus’ lesions = indictaes Ank spon in young male –> syndesmosphytes
wrist fracture nerve damaged?
median nerve often affected = cant make okay sign
elbow fracture nerve damaged?
ulnar nerve
Methotrexate side effects?
GI diarrhoea, nausea
Mouth + duodenal ulcer (cant have with NSAIDs)
Liver cirrhosis
Pneumonitis
Polyarterius nodosa
classic examples?
- renal disease
- mesenteric angina
- orchitis
strong associated with Hep B
Wegnes - Granulomatosus with polyangitis
cANA
small vessel vasculitis with airway syx
e.g nasal crusting, pulmonary haemorrage, otitis media
pANCA
1) eosinonpilic granulomatosus with polyangitis
2) microscopic polyangiitis
1) polyp, asthma syx hypersensitivty
2) classic small vessel vasculitis eg haemoptysis
Colles Fracture
tx
FOOOSH
tx = closed reduction
Smiths
fall on hand facing in
tx = closed reductin
Hip fractuer management
Intracapsular non displaced vs displaced
Extracapsular
intertrochanteric vs subtrochanteric
Intracapsular non-displaced –> hip skrew
Intracapsular-displaced–> hemiarthroplasty
Extracapsular intertrochanteric –> dynamic hip skrew
Extracapsular subtrochanteric –> intermedullary femoral nail
Anke fracture management
weber A/B = Closed reduction
Immobilisation + Physiotherapy
Weber B/C with talar shift = Open Reduction Internal Fixation , Immobilisation
Physiotherapy
Mcmurrys
Lachmans
meniscus test
ACL
