MSK Flashcards
What is a yellow flag
Psychosocial RF fro chronic pain + long term disability development
Fibromyalgia presentation
Widespread pain fatigue Fatigue + pain with small increases in physical exertion Easily woken and can't fall back asleep Poor memory Loww mood Headaches Parasthesiae Morning stiffness
Firbomyalgia Diagnosis
Chronic pain > 3m
Presence of pain at 11/8 tender sites
No joint inflammation
Widespread tenderness
Differential diagnosis for fibromyalgia
Hypothyrodism SLE Inflammatory arthiritis Hypercalcaemia Vit D def
Fibromyalgia management
Amitryptyline - Normal sleeping pattern
Pregabalin - Muscle relaxation
What is Anti-phospholipid syndrome
AI syndrome charecterised by thrombosis
Anti-phospholipid syndrome presentation
Stroke TIA MI DVT Misscarraige
Anti-phospholipid syndrome Ab can cause?
CLOT C - Coag defect L - LIvedo reticualris O - Obstetric issues T - Thrombocytopenia
Anti-phospholipid syndrome Ix
Anti-cardiolipin
Lupus anticoagulant
Anti - B2
Limited cutaneous scleroderma presentation
CREST C - Ca2+ deposition R - Raynauds E - Oesophageal dysmotility S - Sclerodactyly T - Telengectasia
Beak like nose
Systemic sclerosis Investigations
Serum Ab
- Anti-nuclear Ab
- Anti scl 70
X - ray
- Ca2+ deposits
Barium swallow
Bloods
What to avoid in Raynauds
Beta blockers
Smoking
Serum antibodies present in Sjrogren syndrome
Anti - Ro Ab
Anti - Lo Ab
Polymyositis presentation
Symmetrical muscle weakness + wasting Difficulty: - Squatting - Going upstairs - Hands above head
Presentation of mechanical back pain
Suddne onset
pain worse in evening
Morning stiffness
Excercise aggrevates pain
Back pain red flags
TUNA FISH T - Thoracic back pain U - Unexplained WL N - Nocturnal pain A - Age
F - Fever
I - Immunosuppressed
S - Spinal stenosis
H - Hx of malignancy
Clinical presentation of giant cell arteritis
Temporal branch - Severe unilateral headaches Opthalmic. A Visual disturbance Facial. A Claudication when chewing Scalp tenderness Weight loss fever Malaise
Giant cell arteritis investigations
Bloods - High ESR
Duplex US
Biopsy - Long sections due to skip lesions
Giant cell arteritis management
PO Prednisolone
Asprin
PPI
Steroid failure –> DMARDs
What is polymyalgia rheumatica
Inflammatry condition causing pain and stiffness in shoulders, neck and pelvic girdle
PMR Presentation
Bilateral shoulder pain - radiation to elbow Bilateral pelvic girdle pain Pain worse with movement Intefers with sleep Morning stiffness >45 mins Weight loss Upper arm tenderness Carpal tunnel syndrome Pitting oedema
c - ANCA positive conditions
Granulomatosis with polyangitis - wegners granulomatosis
What is polyarteritis nodosa
Necrotising vasculitis leading to aneurysms + thrombosis in medium sized vessels
- Assosciated with Hep B
Polyarteritis nodosa investigations
Bloods
- Increase WCC
- Increase ESR/CRP
ANCA -ve
Angiogram
- String of beads
- organ ischaemia
Microscopic polyangitis description
Necrotising vasculitis of blood vessels in lungs and kidney
Granulomatosis with polyangitis presentation
Chronic Sinusitis Cough Cardiac arrhythmias Non - caesiating granulomas Ulcers in resp tract - Bloody mucus Saddle nose deformity - Curvy nose Pulmonary nodules Decreased urine output Increase BP
Granulomatosis with polyangitis investigations
Bloods - Increase ESR
CXR Nodules
cANCA positive
Psoriatic arthiritis investigations
X-ray - Pencil in a cup Periostitis Ankylosis - bones join together Osteolysis Dactylisis - S.T swelling
Features of arthiritis mutilans
Osteolysis
Telescopic finger
Common triggers for reactive arthiritis
Gastroenteritis
Chlamydia
Reactive arthiritis presentation
Conjunctivitis
Urethritis
Arthiritis/ Enthesitis
Temporal arterities Tx
- 60mg Prednisolone
- 75mg Apsirin
- PPI
- Prophylactic Bisphosphonates
Common organisms causing reactive arthirtis
Campylobacter - Bloody diarrhoea
Salmonella
Shigella
Antibodies specific to SLE
Anti-dsDNA
Anti-Smith
Antibodies specific to Dermatomyositis
Anti-Jo-1
Antibodies specific to Systemic sclerosis
Anti-Scl-70
Conditions where Raynauds are present
SLE
Scleroderma
Sjrogrens
RA
Describe degeneritive joint disease
Worse with activity
Improved with rest
OA
Describe Inflammatory joint disease
Worse after rest
Improved with activity
RA
BMI Ranges
<18.5 - Underweight
18.5 - 24.9 - Healthy weight
25 - 29.9 - Overweight
30 - 39.9 - Obese
2 differentials is MSK diseases when the DIPJ is involved
OA
Psoriatic arthiritis
HLA - B27 positive diseases
AS
Reactive
Psoriatic
Spondyloarthropathies common generic sx
SPINEACHE S - Dactylitis P - Psoriasis I - Inflamm back pain N - NSAIDs good response E - Enthesitis A - Arthiritis C - Chrons / UC / CRP H - HLA-B27 E - Anterior uveitis
p - ANCA positive conditions
Polyareritis nodosa - Heart/Kidney/Skin/CNS
Microscopic Polyangitis
Eosinophilic granulomatosis with Polyangitis
Seropositive conditions
RA SLE Scleroderma Vasculitis Sjogren's
Seronegative conditions
AS
Psoriatic
Reactive
What is the sciatic stretch test
Sciatic stretch test -
+ve = Posteriot thigh/buttock pain
Suggestive of sciatic nerve irritation secondary to disc prolpase
Schober test
Restricted flexion of lumbar spine
- Distance should increase
What causes knee hyperextension
Cruciate ligament injury
What causes joint effusion
ACL rupture
Septic arthirits
Inflammatory arthirits - RA
Osteoarthirits
What does the Lateral collateral ligament test show
Varus
What does the Medial collateral ligament test show
Valgus
Thomas’ test
Loss of hip extension - suggests a fixed flexion deformity
+ve = Affected thigh rises off the bed (Contralateral hip flexion)
Trendelenburg’s test
Hip adbuctor weakness
Gluteus medias + minimus
+ve = Pelvis drops on the side of the raised leg
Contralateral hip abductor weakness
Rotator cuff muscles
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
Muscles for arm abduction
Supraspiantus
Deltoid
Trapezium
What is Jobe’s test
Supraspinatus assessment
- Impingement
- Tear in tendon
What does the painful arc test show
Subacromial impingement - Supraspinatus tendonitis
What does the lift off test show
Subscapularis
- Tendonitis
- Tear
- Subscapular nerve lesion
What does the ecternal rotation against resistance test show
Infraspinatus + teres minor
Pain = Infraspinatus tendonitis
Falls back to internal rotation
- Tear
- Muscle wasting
- LMN lesion (Axillary/Suprascapular)
What does the scarf test show
ACJ pathology
Primary bone tumours (3)
Osteosarcoma
Chondrosarcoma
E-wings sarcoma
Osteosarcoma
- Assosciation
- X - ray
Paget’s disease
Sunburst appearance
Codmans triangle
E - Wing’s sarcoma
- X - ray
Codmann’s triangle
Onion like apperance
Precipitants of gouty attack
Trauma surgery Diuretics Dehydration Alcohol Infection
Acute gout tx
High dose NSAIDs
Colchicine
Gout prophylaxis
- Avoid low dose aspirin
- Stop diuretics
Allopurinol
- Inhibits xanthase oxidase
Febuxostat
- For pt’s intolerant to allopurinol
SLE presentations
MD SOAP BRAIN
M - Malar rash
D - Discoid rash
S - Serositis/ Pericarditis
O - Oral ulcers
A - Arthralgia
P - Photosensitivity
B - Blood - Pancytopenia R - Renal - Glomerulonephritis A - ANA +ve I - Immuno - Anti - dsDNA N - Neuro - Seizures
SLE investigations
Bloods
- FBC
- U+E
- ANA
Antibodies
Biopsy - Kidney
IgG + complement deposition
Urinalysis
- Protein:Creatnine ratio
SLE mild tx
Hydroxychloroquine
SLE management
- NSAIDs
- Prednisolone
- Suncream and avoidance
- Methotrexate
- High dose prednisolone
- Rituximab - refractory
What is myeloma
Malignant disorder of plasma cells - Mature B lymphocytes
What is found in the urine of a patient with myeloma
Bence jones protein
Myeloma key features
C - Hypercalcaemia
R - Renal failure
A - Anaemia
B - Bone lesions
Paraproteinuria
Immunoparesis
Myeloma pathology
- Anaemia
- Bone disease
- Renal disease
- Hyperviscocity
Bone marrow infiltration –> Pancytopenia
- Easy bleeding/bruising/Increased infection
Increased RANKL
- Osteolytic lesions
- Hypercalcaemia - Pain (Bone/Abdo)
Light chain deposition
Blurred vision
SOB
Myeloma investigations
Bloods
BLIP B - Urine electrophoresis L - Light chain assay I - Immunoglobulins P - Protein electrophoresis
Bone marrow biopsy
Whole body MRI
Myeloma X ray findings
Punched out lytic lesions
Raindrop skull
Myeloma management
Chemo
High dose dexamethasone
Stem cell transplant
Myeloma supportive management
EPO transfusions - Anaemia
Hydration
Bishosphonates
AVOID NSAIDs
Secondary causes of OA
Joint disease
trauma
Haemochromatosis
Obesity
OA presentation
Joint pain
- Worse with movement
- improves with rest
Joint stiffness crepitus Muscle wasting Knee effusion Unstable joint
OA Investigations
Bloods
- ESR
- RF
X-ray
MRI
OA management
1st - Paracetamol
2nd - NSAIDs + PPI
3rd - Intra articualr joint injection
4th - surgery
Common causes of osteomyelitis
S.Aureus
H. Influnzae
E.Coli
Osteomyelitis presentation
fever local pain - worse on movement Malaise Sweats Erythema
Osteomyelitis investigations
Bloods
- Culture
- WCC
- CRP/ESR
X-Ray
MRI - Bone marrow oedema
Biopsy and culture
Osteomyelitis management
Immobolisation
Abx
- Flucloxacillin
Surgical debriedment
Secondary causes of osteoperosis
Steroids Hyperthyroidism Alcohol Testosterone low Early menopause Renal/Liver failure Rheumatoid arthiritis
Alcohols effect on osteoperosis
Inhibits osteoblasts
Cushing’s effect on osteoperosis
High cortisol increases bone resorption + induces osteoblast apoptosis
Glucocorticoids effect on osteoperosis
Increased bone turnover
Presintation of osteoperosis
Vertebral fractures
- back pain
- kyphosis
- loss of height
Colles fracture
Hip fracture
Proximal femur
Osteoperosis conservative management
Excercise Smoking cessation decrease alcohol Calcium rich diet Fall prevention programme
Osteoperosis pharmacological tx
- Bisphophonates
- HRT
- Denosumab
MAB to RANKL - PTH analgoue
Teriparatide
Pseudogout risk factors
Old age Hyperparathyroidism Haemochromatosis Hypophosphotaemia Wilsons disease
Feature of pseudogout on X ray
Chondracalcinosis
LOSS
Triggers of pseudogout attack
Trauma Intercurrent illness Surgery - parathyroidectomy T4 Replacemnt Blood transfusion
What antibodies are most associated with Limited cutaneous systemic sclerosis
Anti-centromere Ab
Rheumatoid arthiritis presentation
Joint pain
- worse in mornings
- worse after hot weather
Joint stiffness>30 mins
Joint tenderness
Joint swelling
Rheumatoid arthiritis X Ray findings
LESS L - Loss of joint space E - Erosions S - S.T swelling S - Soft bones
Rheumatoid Management
Symptomatic
- Paracetamol + NSAIDs
1st line - MXT
2nd line - Combination of DMARDs
3rd line - MXT + Etanercept
4th line - MXT + Rtuximab
Rheumatoid arthirits complications
- Respiratory
- Cardiac
- Nodules
Pulmonary fibrosis
Pleural effusions
IHD
Pericarditis
Pericardial effusions
Skin Lung Cardiac CNS Lymphadenopathy Vasculitits
Methotrexate adverse effects
Pulmonary fibrosis
Diarrhoea
Pancytopenia
Mouth ulcers
Sulfasalazine adverse effects
Male infertility
GI upset
Oral ulcers
Anti-TNF medications
Influximab
Etanercept
Rituximab
Rituximab adverse effects
Night sweats
Thrombocytopenia
Causes of septic arthirits
A.Aureus
Neisseria gonorrhoea
Pseudomonas aerginosa - IVDU
S. Epidermidis - Joint replacement
Septic arthirits management
Emperical - Flucloxacillin
Immobolisation
Joint drainge
NSAIDs
What do you do if a patient with R.A develops septic arthiritis
Stop immunosuppresion - DMARDs
What should you do if a patient currently taking steroids develops septic arthirits
Double the dose
Ankylosing spondylitis presentation
Lower back pain Pain worse at night Spinal morning stiffness >30mins stiffness relieved by excercise Sacroiliatic pain Pain wakes from sleep
Ankylosing sponylitis manageemnt
1st - Excercise
2nd - NSAIDs
3rd - Anti-TNF alpha blockers
4th - steroid injections
Presentation of fracture of the surgical neck of humerus
Axillary nerve
- Teres minor weakness
- Deltoid weakness
- Loss of sensation of regimaental patch
Rotator cuff movements
Subscapularis - Internal rotation Suprascapularis - Abduction External rotation - teres minor - Infraspiantus
Shoulder abduction - muscles involved
0 - 15 = Supraspinatus
15 - 90 = Deltoid
90 - 180 = Deltoid + serrartus anterior
Nerve assesed when adducting and abducting the fingers
Ulnar
Nerve assessed with thumb abduction against resistance
Median
