MSK Flashcards
What is Polymyalgia Rheumatica?
Risk factors?
Polymyalgia Rheumatica
- chronic, systemic rheumatic inflammatory condition
- not a true vasculitis (pathogenesis unknown)
Risk factors
- PMR and GCA share the same demographic characteristics (age >55, female)
- PMR more common with people who have had synovitis of proximal large joints, tenosynovitis, and bursitis
Clinical presentation of Polymyalgia Rheumatica?
joint presentation?
peripheral?
systemic?
Clinical presentation of Polymyalgia Rheumatica
- Aches/tenderness in PROXIMAL joints (shoulder, pelvic girdle, neck)
- Morning stiffness (45 mins)> struggle to role over or stand in morning
- Normally bilateral
- Sub-acute onset (<2 weeks) or rapid (< 1 month)
Peripheral MSK symptom (50%):
- Carpal tunnel syndrome
- Peripheral arthritis (knees and wrists), which is asymmetric +self limiting
- Swelling with pitting oedema of hands, wrists, feet, and ankles
Systemic symptoms (50%)
- fatigue (muscle weakness is NOT a feature)
- weight loss and anorexia
- low grade fever
- depression
Investigations for Polymyalgia Rheumatica?
(think about what you want to rule out
Polymyalgia Rheumatica
*important to exclude GCA, current infection or cancer , arthritis, thyroid disease, and statin-induced myalgia or myositis)
Bloods
- FBC
- ↑CRP, ↑ESR > 40 (can be normal)
- LFTs (↑ALP), ↓T-cells,
- CK (normal) -helps distinguish from myositis/myopathies
- Us and Es
- TSH (hypothyroid myopathy)
- Ca (cancer)
Treatment of Polymyalgia Rheumatica?
Treatment of Polymyalgia Rheumatica
- Trial of ORAL PREDNISOLONE with follow up 1 week to assess response (if no dramatic fall-consider differential)
- ↓Dose slowly e.g. 1mg/month (according to Sx + ESR)
- Continue Prednisolone for 2 years-provide blue steroid card)
- Gastric (PPI) and bone protection (bisphosphonates)
*If initial rapid relief needed: IV IV Methylprednisolone (not always required)
How often should you review Polymyalgia Rheumatica?
What should you review?
Polymyalgia Rheumatica
-Review 1 wk after dose change and 3 monthly after that
What to review
- review symptoms
- screen for GCA
- Side effects of steroids (weight gain, dyspepsia, weakness, thin skin, bruising
- FBC, U+E (if needed)
What is Ankylosing Spondylitis?
What happens over time?
Ankylosing Spondylitis
- chronic, inflammatory disease of SPINE + SACROILIAC JOINTS
- causing bony outgrowths and ENTHESITIS (bamboo fusion of the spine)
What is the aetiology of Ankylosing Spondylitis?
- Ankylosing Spondylitis has unknown aetiology
- 90% are HLA-B27 +ve
- MALE present earlier > Female (6:1 at 16yo, 2:1 at 30yo)
What is the clinical presentation of ankylosing spondylitis? (relieved by, radiation, assosiated symptoms
Ankylosing spondylitis
- Typically a young man with gradual onset lower back pain + stiffness
- Improves as day progresses and relieved by exercise
- Radiates from macro-iliac joints to hip/buttocks
- Associated symptoms: Enthesitis inflammation of tendons/ligaments (achilles tendon, plantar fasciitis)
What is the affect of ank spond on range of movement and on the shape of the spine?
Ankylosing spondylitis
Range of movement
-↓Lateral flexion + ↓Forward flexion (< 5cm = +ve Schober’s test)
Shape of spine
-Question mark deformity (loss of lumbar lordosis, exaggerated thoracic kyphosis and neck hyperextension)
what are the 7 extra articular manifestations of ank spond? (rule of A’s)
Ankylosing spondylitis
- anterior uveitis/iritis (results in blindness if untreated)
- aortic regurgitation
- apical fibrosis
- achilles tendon rupture
- av node block
- amyloidosis
- caudA equina
Investigations for ankylosing spondylitis?
Ankylosing spondylitis
Diagnosis is clinical (supported by imaging)
-X ray is 1st line
>sacroiliitis
>bamboo spine (fusing of supraspinous and interspinous ligaments)
Bloods
- 90% will be HLA-B27 +ve
- FBC (normocytic anemia)
- ↑↑ESR/CRP
Managment of Ankylosing spondylitis
Ankylosing spondylitis
-chronic condition with NO CURE
-Things that may help improve symptoms:
-exercise
-1st line NSAIDS (Iboprufen and Naproxen) with PPI
>switch is not working
>can also add para, codeine or corticosteroids on top
-TNF-a inhibitors (adalimumab, etanercept, golimumab) – for severe active AS if Sx poorly controlled with NSAIDs
(must be monitored by rheumatologist)
Surgery – Hip Replacement (↓pain, ↑mobility)
Classic complications of Ankylosing spondylitis? (what do you do about it)
Ankylosing spondylitis
-Loss of vision from anterior uveitis/iritis (acutly painful red eye U/L eye → refer to ophthalmology immediately SAME DAY!!
-osteoporotic spinal fractures – Bisphosphonates
Where in the back is spinal compression most common?
Name 3 causes of spinal compression?
Cord compression (most commonly thoracic 66%)
- Oncological
- extension of tumour from vertebral body
- metastasis - MSK
- crush fracture
- trauma/penetrating injury (Brown sequard syndrome)
- prolapsed disk (lumbar) - Inflammatory
- Rheumatoid arthritis (weakness of ligaments attaching to odontoid peg→ rupture→ atlas (C1) slips forward
Clinical presentation of cord compression
Clinical presentation of cord compression
- Back pain (90%)
- Localised, or band like, radiating to extremities along spinal root
- Worse lying flat, straining, coughing
- Parasthesia/weakness/pain in legs or saddle (symetrical)
- Bowel/bladder dysfunc: urinary retention (insidious), constipation or incontinence
Investigations for cord compression? (start top and work down)
How would reflexes be affected?
Investigations for cord compression
- Neurological assessment CNS AND PNS (all 4 limbs)
- Palpate spine for tenderness
- Palpate abdo to assess urinary retention (distended)
- Anal tone – ALWAYS CHECK
Reflexes
- Reflexes: ↑below compression, absent at level, normal above
- Clonus may be present
Management of spinal cord compression?
what is the prognosis?
Management of spinal cord compression
Full ABCDE assessment
-Stabilise + immobilise spine – lie flat
-Dexamethasone (16mg) w/ PPI cover (Omeprazole)
-URGENT MRI spine within 24 hrs of suspected SCC
Not all pts. present w/ back pain; if suspected ALWAYS DO MRI!! (Ct if C/I)
-Refer to neurosurgeons or oncologist
Prognosis: if motor function lost for 48 hours> recovery is unlikely
What is the prognosis of spinal cord compression?
What are the complications of spinal cord compression?
Spinal cord compression
-Prognosis: if motor function lost for 48 hours> recovery is unlikely
Complication
- Paraplegia (thoracic) and quadriplegia (above C3,4,5)
- Incontinence
- Paralytic Ileus – common
What is brown sequard syndrome?
how does it present?
Brown sequard syndrome
- Total hemisection of the spinal cord
- Ipsilateral weakness, proprioception,fine touch, vibration
- Contralateral loss pain and temp
Patient with graze on chin, weakess in upper limbs
Central cord syndrome
- Man in a barrel syndrome
- upper limbs>lower limbs
- cervical injury
What is osteoporosis?
What are the risk factors? (primary and secondary)
Osteoporosis
- reduced bone mass
- assymptomatic, can present with fragility fractures
Risk factors Primary -age -female -prolonged immobility(bone needs microdamage to repair)
Secondary (SHATTERED)
- steroids
- hyperthyroidism/parathyroidism (quickens bone turnover)
- alcohol/tobacco
- ↓Testosterone
- Thin (BMI < 22)
- Early menopause (protective oestrogen falls)
- Renal or liver failure
- Errosive/inflammatory bone disease
- Diet (↓Ca2+)
What are the investigations for osteoporosis? (bedside/bloods/imaging)
Osteoporosis Bloods -TFT -Calcium and phosphate -ALP -TSH (affect bone turnover) -Myeloma screen -Coelic screen
Imaging
- Xray (low sens and spec-although good to see fractures)
- Dexa scan (gold standard ∆)
Special
- FRAX sore (fracture risk assessment)
- high risk=treat
- mod risk=do DEXA
- low risk=lifestyle
Explain the findings of a DEXA scan
DEXA scan measures bone density
T > -1.0 (normal);
T -1 to -2.5 (osteopenia)
< -2.5 (osteoporosis)
Managment of osteoporosis? (conservative and medical-5)
Lifestyle measures
- Quit smoking, ↓Alcohol
- Weight bearing exercise → ↑Bone density
- Balance exercises (Tai Chi) → ↓Falls risk
Medical
-Bisphosphonates for pts. with T score < -2.5 (Alendronate is 1st line, not if eGFR < 35)
-Ca2+ supplements and Vit. D if deficient
Additional
HRT – can prevent osteoporosis in post-menopausal women
Testosterone – hypogonadal men
IV bisphosphonates or denosumab injection given if oral not tolerated
How do you take bisphosphonates?
What are the side effects of bisphosphonates?
Take bisphosphonates 30 mins before breakfast and stand
Common side effects of bisphosphonates (Alendronate)
- fever
- myalgia
- arthralgia
- GORD
- osophagitis (stop)
Adverse effects of bisphosphonates?
Adverse effects of bisphosphonates
- osteonecrosis of jaw
- hypophosphateamia/hypocalceamia
- atypical femoral fractures (e.g. thigh pain)
What are contraindications to bisphosphonates?
What do you do if they cant take?
Contraindications to bisphosphonates
- X osophagitis
- X memory problems (wont be able to take)
- X egfr<35
Options if cant take
- IV zolendronic acid (needs egfr >45)> once a year
- DENOSUMAB (1st line for RENAL FAILURE)>every 6 months
Differential for osteoporosis? (what would bloods show)
Osteomalacia (defect in mineralisation and ↓ bone quality)
- ↓Ca2+/↓Phos
- Increased ALP
What antibodies are seen in lupus?
Lupus
- ANA (if neg its not lupus!!)
- dsDNA
- anti smith
- anti-histone in DRUG induced
*also do a urine dip and check complement (low c4)
How does lupus present?
Lupus (RANCHeS)
RENAL impairment (ACR, egfr, creatinine)
AUTOIMMUNE (Anti-dsDNA, antiphospholipid antibodies, Coombs test in cases of heamolysis, antiSmith)
NEUROLOGICAL (seizures, psychosis, myelitis)
CUTANEOUS (rashes, ulcers, alopecia)
HAEMATOLOGICAL (heamolysis, leukopenia, thrombocytopenia)
SEROUS and SYNOVIAL (pleurisy, pericarditis, arthritis 90% patients)
Whats the treatment for Lupus?
- NSAIDS, steroids and hydroxychoraquine
- DMARDS and biologics if not
What antibodies are seen in myositis?
-Anti-Jo-1 antibodies are specific for polymyositis and dermatomyositis (PM/DM).
also strongly related to interstitial lung disease (ILD)
What is scleroderma (systemic sclerosis)?
What are the 2 types?
Scleroderma aka. Systemic sclerosis
- multisystem autoimmune disorder
- increase collagen and fibrosis
2 types:
- Limited cutaneous (ACA)
- common, milder and slower
- Puffy hands can be 1st sign
- CREST SYNDROME (Calcinosis, Reynaud’s, Esophgeal dysmotility, Sclerodactyly telangiectasia) - Diffuse cutaneous (SCL70)
- less common, rapid onset, high mortality
- can get ACCELERATED HTN (lung and kidney involvement)
Classic presentation of scleroderma? (classical and systemic)
Scleroderma C-Chalky nodules (calcinasis) R-Reynauds E-REFLUX/heartburn S-Sausage fingers (sclerodactyly)+ hardened skin T-Telangiectasia
Systemic
- Classic autoimmune (tired/weight loss)
- Lung involvement (fibrosis, pulmonary HTN)
- Renal involvement (glomerulonephritis)
- Cardiac involvement (pericarditis)
- ERECTILE DYSFUNCTION
What antibodies are assosiated with scerloderma?
Whats the treatment (3)
Centromere=limited
Anti-Scl 70 (more spesific to diffuse)
Treatment:
- Ace inhibitors for accelerated HTN
- Nifedipine/Losartan 1st line for Raynauds (prostaglandins if severe)
- Immunotherapy: Methotrexate (MTX) or Mycophenolate mofetile
SMALL VESSEL VASCILITIS
What are the ANCA+ve ones? (defining features?)
What are the ANCA-ve ones (defining features?)
SMALL VESSEL VASCILITIS
ANCA+
-Wegners/glanulomatosis polyangitis (nose bleeds/sinisitis) cANCA
-Churg strauss/eosinophilic (think asthma, eosinophils) pANCA
ANCA-
- Polyarteritis nodosum
- Goodpastures/antiglomerular basement membrane (anti-GBM with pulmonary heamorrgage and renal involvement-AKI)
- All others (HSP/bechets/SLE/sjogrens)
What are the treatment for vasculitis?
Treatment for vasculitis
- High dose steroids
- Biologics if not
What is a vasculitic screen
Vasculitic screen
- Biopsy and angiography is diagnostic for vasculitis
- Antibodies
- Urine dip
- Complement level
Management of Rheum arthritis during pregnancy?
Pregnancy and RA
Methotrexate is CI
-Give Hydroxychloroquine and/or Sulfasalazine with concomitant Folic Acid
What can happen if you stop steroids suddenly?
Whats the treatment?
-addrenal insufficiency (hypothalamus axis is surpessed)
HYPERKALEMIC HYPOTENSION
-Treatment is IV hydrocortisone.
What are sick day rules for people taking steroids?
‘Sick day rules’
-if acutely unwell double the usual dose of prednisolone or supplement IV hydrocortisone if unable to tolerate oral medication.
2 important things to prescribe for a post menopausal women with fracture?
Any post-menopausal woman with fracture must be put on Bisphosphonates and Calcium supplements
General features of vascilitis?
General features: fever/malaise/weight loss/skin changes/splinter heamorrgaes
What conditions are ACA (anticentromere antibodies) found?
ACA antibodies
-characteristic of CREST syndrome of scleroderma (also Anti-Scl)
Examples of medium vessel vascilitis?
MEDIUM VESSEL VASCILITIS
- Polyarteritis nodosa
- Kawasakis
Examples of large vessel vascilitis?
LARGE VESSEL VASCILITIS
- Takayasu (aortic arch syndrome)
- Giant cell arteritis
What is a classic sign of Polyarteritis nodosum?
What is PAN assosiated with?
Polyarteritis nodosum (spares the lung)
- rosey bead sign on renal artery
- associated with HepB
What antibodies are seen in Sjögrens?
Sjögrens
- anti-Ro and anti-La (these also pop up in Lupus)
- Raised Immunoglobulins/ ESR/RF as well
How would you describe Lupus rash?
Lupus rash
- Malar BUTTERFLY rash
- Discoid rash
- Photosensitivity – often causes disease flare (spare nasallabial folds)
