MSK Flashcards
Osteoporosis aetiology
Loss of bone mineral density
Increased risk of fragility fractures - E.g. NOF
I’M SHATTERED
- Important - Myeloma
- Steroids
- Hyperthyroid / HyperPTH
- Age
- Thin - BMI < 25
- Testosterone
- Early menopause
- Renal/liver disease
- Erosive - RA/IBD
- Drugs - AD’S TOP SHAG
Osteoporosis aetiology (drugs)
AD’S TOP SHAG
Aromatase inhibitors Depo injection Steroids Thyroxine OCP PPI SSRI's Heparin AED's Glitazone
Osteoporosis clinical features and investigations
Back pain Kyphosis Impaired vision Impaired gait / balance Lower-extremity weakness
Diagnostic - FRAX score + DEXA = T-score > 2.5
Investigate cause
- Calcium profile - VITAMIN D
- TFTs
- ESR/CRP
- U&E, FBC, protein electrophoresis - Myeloma?
- FSH/LH
FRAX score
10 year risk of developing a fragility fracture
Age Sex BMI Previous fracture Parental fragility fracture Smoking status Glucocorticoids RA Secondary osteoporosis Alcohol intake BMD - DEXA - Optional?
Osteoporosis management
PT - Bone strengthening
OT - Falls prevention
Bisphosphonates
- PO - Alendronic acid
- IV - Zolendronic acid
- Bind to osteoblasts
- Send stop signals to osteoclasts
- S/E - Jaw osteonecrosis, oesophagitis, photosensitivity
Vit D - Ergocalciferol
Calcium - Calcitriol
RANK-L inhibitor - Denosumab
Oestrogen - Raloxifene
Osteomalacia aetiology
VItamin D deficiency
- Diet - Oily fish, liver, egg
- Malabsorption - IBD, etc.
- Lack of sunlight
Incomplete mineralisation of underlying bone matrix
“Soft bones”
Low vitamin D - Less calcium absorption from kidneys/gut
Before fusion of epiphysis = Rickets
- Knock knees
- Bow legs
- Hypocalcaemia
Renal failure
Drug induced - Anticonvulsants
Vit D resistant - Inherited
Liver disease - Cirrhosis
Osteomalacia clinical features / investigations / management
Hypocalcaemia - Tetany, PO anaesthesia, long QT
Hypophosphataemia - Weakness
Bone pain
Fractures
Calcium profile
- Calcium - LOW
- Phosphate - LOW
- Vit D - LOW
- ALP ^
- PTH ^
XR - Translucent bands
Management
- Ergocalciferol
- Calcium carbonate
Paget’s disease aetiology / pathophysiology / clinical features
Increased uncontrolled bone turnover
Rapid bone formation
Disorganised lamellar bone
RFs
- Age ^
- Male
- Northern latitude
- Family Hx
5% symptomatic
- Axial bone pain - Lower back and hips
- Bony deformities - Bowing of the tibia / Skull bossing
- Increased local temperature
- Hearing loss
Paget’s disease investigations / management / complications
Calcium profile - ALP ^
Tech-99 scan
XR - Calvarium thickening + Cotton wool sign
Rule out myeloma / bony mets
Management - Symptomatic
- Alendronic acid
- Calcitonin
Complications
- Deafness (SN) - CN8 compression
- Fractures
- HF
- Osteosarcoma
- Deformity
Back pain DDx
MSK Fracture - Normal or osteoporotic Ankylosing spondylitis Myeloma Bony mets Disc prolapse
Back pain red flags
< 20 or > 55
Eye symptoms - Anky spond?
Paraesthesia - Lower limb
Decreased anal tone
Urinary/faecal incontinence
Saddle anaesthesia
History of malignancy
B-symptoms
Worse at night
Worse lying down
Cardiorespiratory symptoms
Describing paeds fractures
SALTER - Harris
(In relation to growth plate)
- Straight through
- Above
- Lower
- Through Everything
- cRush
NOF aetiology / presentation / initial management
Previous hip fracture
Osteoporosis
Mobility / falls risk
Family history
Unable to weight bear
Leg shortened and externally rotated
Initial management
- Immobilise
- Analgesia - Morphine / Fascia-iliaca block
- ABCDE
- Cross-match / Group+Save
- Prep for surgery
NOF grading and blood supply
Intracapsular - Garden classification
- Incomplete
- Complete - No displacement
- Complete < 50% displacement
- Complete > 50% displacement
Extracapsular
- Trochanteric
- Subtrochanteric
Blood supply
- Medial circumflex artery < Femoral < External iliac
NOF management and complications
Intracapsular
- Comorbidities + Less mobile = Hemi
- Less comorbidities + More mobile = Total
Extracapsular
- Trochanteric - DHS
- Subtrochanteric - IM nail
Complications
- Second hip fracture
- AVN femoral head
- Pneumonia
- VTE
- Site infection
Scaphoid fracture
FOOSH
Anatomical snuffbox tenderness
Shoulder dislocation
Anterior - Most common
- Usually glenoid-humeral
- AC - Rare
- Head of humerus is medial - Under coracoid process
- Aetiology - Trauma / Joint laxity (ED)
Posterior
- More common in epilepsy
- Light bulb sign - Medial rotation of humeral head
Check axillary nerve sensation - Regimental patch
Rotator cuff muscles
Supraspinatus - ABduction 0-15 degrees
Infraspinatus - External rotation
Subscapularis - Internal rotation
Teres minor - External rotation in ABduction
Frozen shoulder
Adhesive capsulitis
All ROM limited - Due to pain
External rotation first to be affected
More common in DM
Management - PT ± Surgery
Impingement
Supraspinatus tendonitis
Classically painful arc
Tender over acromion
Aetiology
- Bursitis
- Osteophytes
- Degnerative bone disease
Management - PT
RA clinical features
HOT SWOLLEN JOINT Symmetrical DIP sparing Z-thumb Boutonnieres deformity Swan neck deformity Ulnar deviation
RA systemic disease
Eyes
- Anterior uveitis
- Episcleritis
Lungs
- Lower zone fibrosis - Methotrexate or RA nodules
- Pleural effusions
Neuro - Peripheral nerve entrapment
Cardio
- Pericarditis
- IHD risk ^
Felty syndrome
- RA
- Splenomegaly
- Neutropenia
- Leg ulcers
- Lymphadez
RA investigations
XR - LESS
- Loss of joint space
- Erosions
- Soft tissue swelling
- Softening of bone - Osteopenia
Rheumatoid factor Anti-CCP!!!!!!! ANA +ve CRP/ESR FBC - AoCD
Questionnaire - DAS28 score
RA management
PT
DMARD + Prednisolone
- Methotrexate
- Sulfasalazine
- Hydroxychloroquine
2x DMARD
Biologics - After 2x DMARD
- Infliximab - Anti-TNF
- Rituximab - Anti CD20
- Tocilizumab - Anti IL6
- Baricitinib - JAK inhibitor
Methotexate SE and monitoring
Renal impairment - U&E Hepatic impairment - LFT Pulmonary fibrosis - LuFT + CXR Bone marrow suppression Teratogenic
Gout
Hyperuricaemia
Deposition of urate crystals
Decreased uric acid excretion
- Diuretics
- Ciclosporin
- Tacrolimus
- Pyrazinamide
- CKD
Increased uric acid production
- Myelo/Lymphoproliferative disorder
- Cytotoxic drugs
- Psoriasis
Lesch-Nyhan syndrome - X-linked - HGPRTase deficiency
Male Diet - Red meat, seafood, alcohol, etc. Aspirin Obesity Family Hx
Gout triggers and presentation
Diuretics
Dehydration
Alcohol
Chemotherapy - TLS
Presentation - 1st MTP joint ± Ankle, wrist, knee
- Red
- Hot
- Swollen
- Painful
Gout investigations
XR
- Tophi
- Joint space widening
- Joint effusion
- Punched out erosions
Joint aspiration + Light microscopy
- Negatively bifringent needles
- Rule out septic arthritis
Urate levels
- Low during attack
- Any other time - HIGH
Gout management
Acute
- NSAIDs / Colchicine
± PPI
- Severe -Intra-articular steroid injection
Long-term
- Allopurinol - Xanthase oxidase inhibitor
- Febuxostat
Lifestyle changes
- Reduce alcohol intake
- Lose weight
Avoid food high in purines
- Liver
- Kidneys
- Seafood
- Oily fish
- Yeast products
Pseudogout aetiology and clinical features
Calcium pyrophosphate dihydrate crystals
Haemochromatosis HyperPTH Acromegaly Wilson's Hypomagnesaemia Hypophosphatasia
HOT SWOLLEN JOINT
Pseudogout investigations and management
XR - Chrondrocalcinosis - Linear white lines
Joint aspiration + Light microscopy
- Positively bifringent rhomboid crystals
- Rule out septic arthritis
Management
- NSAIDs / Colchicine
- Intra-articular steroids
Septic arthritis aetiology
Staph A
Young adults - N.Gonorrhoea
Risk factors
- Immunocompromise
- IVDU
- Alcohol
- DM
Septic arthritis clinical features
HOT SWOLLEN JOINT
NWB
Fever
Frog leg - Shortened, flexed, externally rotated
KOSHER criteria - WENT
- WCC > 12
- ESR
- NWB
- Temperature > 38
Septic arthritis investigations and management
Joint aspiration + MC&S XR - Loss of joint space Blood cultures ± Septic screen FBC ESR/CRP U&E LFT
Management
- ABCDE
- IV Flucloxacillin - 6-12 weeks
- Needle aspiration
- Arthroscopic lavage
Osteomyelitis aetiology
Common sites
- Children - Metaphysis of long bone
- Adults - Vertebrae
Aetiology
- Staph A
- E Coli
- Sickle cell - Salmonella
Risk factors
- Sickle cell
- IVDU
- Immunocompromise
- Cellulitis - Local spread
- Recent trauma / surgery
- DM
Osteomyelitis clinical features / investigations / management
Bone pain Inflammation Fever NWB Reduced ROM Malaise Fatigue Back pain - Vertebral
Investigations
- Septic screen
- MRI
Management
- ABCDE
- Flucloxacillin - 6 weeks
- Clindamycin if allergic
Ankylosing spondylitis aetiology
Chronic progressive inflammatory arthropathy
Associated with HLA-B27
Typically males aged 20-40
Ankylosing spondylitis clinical features
Lower back pain
Stiffness
- Worse in the morning
- Improves with exercise
- Painful at night
Decreased spine ROM
- Reduced lateral flexion
- Reduced forward flexion - Schober’s test
Reduced chest expansion
All the As
- Apical fibrosis
- Anterior uveitis
- Aortic regurgitation
- Achilles tendonitis
- AV node block
- Amyloidosis
- AI bowel disease
Ankylosing spondylitis investigations
All the S’s…
- Severity scoring system - BASDAI
- Schober’s test
- Spirometry - Restrictive
XR
- Sacroiliitis
- Syndesmophytes
- Squaring of lumbar vertebrae
- Spine - Bamboo + Dagger sign
Assess chest expansion
HLA-B27
Ankylosing spondylitis management
NSAIDs
PT - Regular exercise
Anti-TNF - After 2x NSAIDs…
- Etanercept
- Infliximab
- Adalimumab
Reactive arthritis aetiology and clinical features
Inflammatory arthritis
Exposure to GI/GU infections
Associated with HLA-B27
STI - Chlamydia - Reiter’s syndrome
Post-dysentery
- Campylobacter
- Shigella
- Salmonella
CAN’T SEE - Anterior uveitis
CAN’T PEE - Urethritis ± Balanitis
CAN’T CLIMB TREE - Arthritis
Reactive arthritis investigations and management
ESR/CRP ^
NAAT swab - Positive for chlamydia
Blood cultures
Rule out differentials
- Joint aspiration
- ANA/RF
Management
- NSAIDs
- Persistent - DMARD - Sulfasalazine
- Treat STI - Doxy
- Symptoms may last 4-6 months
Psoriatic arthritis
Asymmetrical oligoarthritis - Hands and feet \+ Psoriasis DIP joint disease Arthritis mutilans - Telescoping fingers Nail changes - Onycholysis and pitting
Investigations
- XR - Pencil in a cup (DIP erosion + periarticular bone formation)
- PSARC score
- ESR/CRP
- ANA/RF
Management - Treat as RA
- NSAIDs
- DMARDs
- IA steroids
- Anti-TNF
Fibromyalgia
Risk factors
- Women - 5x more likely to be affected
- Age 30-50
- Lower socioeconomic status
- Divorced
Clinical features
- Chronic pain at multiple sites - 11/18 points!
- Myalgia
- Headache
- Fibro-fog - Memory loss / Cognitive impairment
Management - Biopsychosocial
- Education
- PT - Aerobic exercsise
- CBT
- Pregabalin / Duloxetine / Amitriptyline
Dermatomyositis
Polymyositis
Idiopathic inflammatory myopathy
Associated with connective tissue disorders
Possible underlying malignancy - Ovarian, breast, lung
Polymyositis - Variation WITHOUT skin manifestations
Dermatomyositis clinical features
Symmetrical proximal muscle weakness
- Rising from chair
- Combing hair
- Climbing stair
Skin manifestations
- Gottron’s papules - Rough red papules over extensor surfaces of fingers
- Heliotrope rash - Orbital
- Photosensitivity
- Shawl rash
- Mechanic’s hands - Dry, cracked, scaly
- Nail fold capillary dilatation
GI - Dysphagia
Respiratory - Fibrosing alveolitis / Pneumonia
Raynaud’s
Dermatomyositis investigations and management
Better CAll Jo’S MuM
- CK ^
- ANA +ve
- Anti-Jo antibodies
- Serum aldolase ^
- Muscle biopsy - Perivascular or interfascicular inflammation
- Screen for malignancy!
Prednisolone
Suncream!
DMARD - Methotrexate
Polyarteritis aetiology and clinical features
Vasculitis of medium-sized vessels
Associated with Hep B
Clinical features
- Fever
- Arthralgia
- Weight loss
- Mononeuritis multiplex - Sensorimotor polyneuropathy
- Renal failure - Haematuria
- HTN - Diastolic > 90
- Testicular pain
- Livedo reticularis - Mottled skin discolouration
Polyarteritis investigations and management
ESR / CRP ^ FBC - Normocytic anaemia HBV serology Angiography Biopsy LFTs Urinalysis - Haematuria
Prednisolone
DMARD - Azathioprine
Marfan’s
AD - Connective tissue disorder
Loss of elastic tissue
Clinical features - TALL and THIN
- Long fingers
- High arched palate
- Retinal detachment
- Pectus excavatum
- Scoliosis
- Pes planus
- Cardio - AR, MVP, dissection
- Resp - Pneumothorax
- Dural ectasia - Ballooning of dural sac at LS level
Investigations
- TTE - Check for cardiac pathology
- Ophthalmic assessment
Management - Manage CV risk
- BB - Metoprolol
- Losartan
Ehlers Danlos
AD - Type III collagen
Increased elasticity
Clinical features
- Joint laxity - Hypermobility + Dislocations
- Skin thinning / splitting
- Bruising
- Neuro - SAH risk ^
- Tinnitus - Ossicle laxity
- Cardio - AR, MVP, dissection
Investigations - TTE - Cardiac pathology
Management
- Manage CV risk
- Screen for SAH
Sjogren’s syndrome aetiology / clinical features
AI - Exocrine glands affected
Primary or secondary to RA / Connective tissue disorders
Clinical features
- Dry eyes
- Dry mouth
- Dry vagina
- Parotiditis
- Arthritis
- RTA
- Raynaud’s
- Sensory neuropathy
Sjogren’s syndrome investigations / management / complications
Schirmer’s test - Tears
Anti-Ro
Anti-La
HLA-DR3
Management
- Artificial tears
- Artificial saliva
- Pilocarpine - May stimulate saliva production
Complications - Non-Hodgkin’s lymphoma risk ^
Systemic sclerosis
Scleroderma
CREST
Clinical features
AI - Multi-system
Diffuse cutaneous systemic sclerosis - Trunk and proximal limbs
- Resp - ILD and P.HTN
- Renal - HTN
- Poor prognosis
Scleroderma - Without internal organ involvement
- Tightening and fibrosis of skin
- Plaques or linear
CREST - Limited cutaneous systemic sclerosis - Face and distal limbs
- Calcinosis
- Raynaud’s
- oEsophageal dysmotility
- Sclerodactyly
- Telangiectasia
Systemic sclerosis
Scleroderma
CREST
Investigations / Management
ANA +ve
Anti-topoisomerase
Diffuse - Anti-Scl 70
CREST - Anti-centromere
U&Es
LuFTs
Barium swallow - Oesophageal dysmotility
Management
- Topical - Hydrocortisone
- Oral - Prednisolone
Symptom management
- Raynaud’s - CCB - Nifedipine
- GI - PPI
- Arthritis - NSAIDs / Steroid
SLE aetiology
AI - Type 3 hypersensitivity
HLA-DR2/3
Immune complex deposition - Skin, joints, kidney, brain
Risk factors
- Females aged 20-40
- AC / Asian communities
- Isoniazid
SLE clinical features
General
- Fatigue
- Fever
- Mouth ulcers
- Lymphadenopathy
Skin
- Malar - Butterfly rash
- Discoid rash - Scaly demarcated rash in sun-exposed areas
- Photosensitivity
- Raynaud’s
- Livedo reticularis
- Alopecia
Neuropsych
- Anxiety
- Depression
- Psychosis
- Seizures
MSK - Arthralgia / Arthritis
CV - Pericarditis / Myocarditis
Resp - Pleurisy / Fibrosing alveolitis
Renal - Proteinuria / Glomerulonephritis
SLE criteria
4 or more of SOAP BRAIN MD…
Serositis
Oral ulcers
Arthritis
Photosensitivity
Blood disorders - APLS Renal impairment ANA +ve Immunological - HLA-DR2 Neuro - Seizures
Malar rash
Discoid rash
SLE investigations and management
SOAP BRAIN MD
ANA +ve Anti-dsDNA Anti-Smith Anti-Ro Anti-La
Management
- Hydroxychloroquine
- NSAIDs
- Prednisolone
- DMARD - Methotrexate
Takayasu’s arteritis aetiology and clinical features
Chronic granulomatous vasculitis
Large vessels
Asian females - 20-40
Primarily the aorta and its branches - Granulomatous thickening
Systemic features - Malaise, headache, etc. Pulseless limb Intermittent claudication BP differences - Upper vs Lower Vascular bruits Fever Dizziness Myalgia HTN Renal artery stenosis
Takayasu’s arteritis investigations and management
ESR / CRP ^
CT angiography - Aorta
Prednisolone
Aspirin
Alendronic acid
Antiphospholipid syndrome
Aetiology - Primary or secondary to SLE
Clinical features
- Venous/arterial thromboses
- Recurrent miscarriages
- Thrombocytopenia
- Livedo reticularis
- Pre-eclampsia
- P.HTN
Investigations
- Platelets - LOW
- Anti-cardiolipin antibodies
Management
- Primary thromboprophylaxis - Low-dose Aspirin
- Secondary thromboprophylaxis - Warfarin
(INR target 3-4)
Polymyalgia rheumatica
Vasculitis of arteries supplying muscle
Older females / GCA
Clinical features
- Proximal pain and stiffness - Shoulders and hips
- B-symptoms
Investigations
- Corticosteroid trial - Rapid response
- ESR / CRP ^
Management - Prednisolone
+ Alendronic acid
+ Colecalciferol
+ Calcium carbonate
Raynaud’s aetiology
Exaggerated vasoconstriction of digital arteries
In response to cold or emotional stress
Connective tissue disorders - Scleroderma, RA, SLE Leukaemia Cryoglobulinaemia - Cold agglutins Vibrating tools OCP Cervical rib
Raynaud’s clinical features / investigations / management
PD - Painful Digits
Digit pain / discomfort Paraesthesia Pallor Discolouration - Red/blue - Well-defined Dilated nailbed capillaries - Magnification
Management - Treat cause
- CCB - Nifedipine
- IV Prostacyclin
