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3B > MSK > Flashcards

MSK Flashcards

1
Q

Osteoporosis aetiology

A

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
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2
Q

Osteoporosis aetiology (drugs)

A

AD’S TOP SHAG

Aromatase inhibitors 
Depo injection
Steroids
Thyroxine
OCP
PPI
SSRI's
Heparin
AED's
Glitazone
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3
Q

Osteoporosis clinical features and investigations

A 
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
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4
Q

FRAX score

A

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?
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5
Q

Osteoporosis management

A

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

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6
Q

Osteomalacia aetiology

A

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

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7
Q

Osteomalacia clinical features / investigations / management

A

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
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8
Q

Paget’s disease aetiology / pathophysiology / clinical features

A

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
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9
Q

Paget’s disease investigations / management / complications

A

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
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10
Q

Back pain DDx

A 
MSK
Fracture - Normal or osteoporotic
Ankylosing spondylitis
Myeloma
Bony mets
Disc prolapse
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11
Q

Back pain red flags

A

< 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

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12
Q

Describing paeds fractures

A

SALTER - Harris
(In relation to growth plate)

  1. Straight through
  2. Above
  3. Lower
  4. Through Everything
  5. cRush
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13
Q

NOF aetiology / presentation / initial management

A

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
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14
Q

NOF grading and blood supply

A

Intracapsular - Garden classification

  1. Incomplete
  2. Complete - No displacement
  3. Complete < 50% displacement
  4. Complete > 50% displacement

Extracapsular

  • Trochanteric
  • Subtrochanteric

Blood supply
- Medial circumflex artery < Femoral < External iliac

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15
Q

NOF management and complications

A

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
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16
Q

Scaphoid fracture

A

FOOSH

Anatomical snuffbox tenderness

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17
Q

Shoulder dislocation

A

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

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18
Q

Rotator cuff muscles

A

Supraspinatus - ABduction 0-15 degrees
Infraspinatus - External rotation
Subscapularis - Internal rotation
Teres minor - External rotation in ABduction

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19
Q

Frozen shoulder

A

Adhesive capsulitis

All ROM limited - Due to pain
External rotation first to be affected
More common in DM

Management - PT ± Surgery

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20
Q

Impingement

A

Supraspinatus tendonitis

Classically painful arc
Tender over acromion

Aetiology

  • Bursitis
  • Osteophytes
  • Degnerative bone disease

Management - PT

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21
Q

RA clinical features

A 
HOT SWOLLEN JOINT
Symmetrical 
DIP sparing
Z-thumb
Boutonnieres deformity
Swan neck deformity
Ulnar deviation
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22
Q

RA systemic disease

A

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
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23
Q

RA investigations

A

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

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24
Q

RA management

A

PT

DMARD + Prednisolone

  • Methotrexate
  • Sulfasalazine
  • Hydroxychloroquine

2x DMARD

Biologics - After 2x DMARD

  • Infliximab - Anti-TNF
  • Rituximab - Anti CD20
  • Tocilizumab - Anti IL6
  • Baricitinib - JAK inhibitor
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25
Q

Methotexate SE and monitoring

A 
Renal impairment - U&E
Hepatic impairment - LFT
Pulmonary fibrosis - LuFT + CXR
Bone marrow suppression
Teratogenic
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26
Q

Gout

A

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
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27
Q

Gout triggers and presentation

A

Diuretics
Dehydration
Alcohol
Chemotherapy - TLS

Presentation - 1st MTP joint ± Ankle, wrist, knee

  • Red
  • Hot
  • Swollen
  • Painful
28
Q

Gout investigations

A

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
29
Q

Gout management

A

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
30
Q

Pseudogout aetiology and clinical features

A

Calcium pyrophosphate dihydrate crystals

Haemochromatosis
HyperPTH
Acromegaly
Wilson's
Hypomagnesaemia
Hypophosphatasia

HOT SWOLLEN JOINT

31
Q

Pseudogout investigations and management

A

XR - Chrondrocalcinosis - Linear white lines

Joint aspiration + Light microscopy

  • Positively bifringent rhomboid crystals
  • Rule out septic arthritis

Management

  • NSAIDs / Colchicine
  • Intra-articular steroids
32
Q

Septic arthritis aetiology

A

Staph A
Young adults - N.Gonorrhoea

Risk factors

  • Immunocompromise
  • IVDU
  • Alcohol
  • DM
33
Q

Septic arthritis clinical features

A

HOT SWOLLEN JOINT
NWB
Fever
Frog leg - Shortened, flexed, externally rotated

KOSHER criteria - WENT

  • WCC > 12
  • ESR
  • NWB
  • Temperature > 38
34
Q

Septic arthritis investigations and management

A 
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
35
Q

Osteomyelitis aetiology

A

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
36
Q

Osteomyelitis clinical features / investigations / management

A 
Bone pain
Inflammation
Fever
NWB
Reduced ROM
Malaise
Fatigue
Back pain - Vertebral

Investigations

  • Septic screen
  • MRI

Management

  • ABCDE
  • Flucloxacillin - 6 weeks
  • Clindamycin if allergic
37
Q

Ankylosing spondylitis aetiology

A

Chronic progressive inflammatory arthropathy
Associated with HLA-B27

Typically males aged 20-40

38
Q

Ankylosing spondylitis clinical features

A

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
39
Q

Ankylosing spondylitis investigations

A

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

40
Q

Ankylosing spondylitis management

A

NSAIDs
PT - Regular exercise

Anti-TNF - After 2x NSAIDs…

  • Etanercept
  • Infliximab
  • Adalimumab
41
Q

Reactive arthritis aetiology and clinical features

A

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

42
Q

Reactive arthritis investigations and management

A

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
43
Q

Psoriatic arthritis

A 
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
44
Q

Fibromyalgia

A

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
45
Q

Dermatomyositis

Polymyositis

A

Idiopathic inflammatory myopathy

Associated with connective tissue disorders
Possible underlying malignancy - Ovarian, breast, lung

Polymyositis - Variation WITHOUT skin manifestations

46
Q

Dermatomyositis clinical features

A

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

47
Q

Dermatomyositis investigations and management

A

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

48
Q

Polyarteritis aetiology and clinical features

A

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
49
Q

Polyarteritis investigations and management

A 
ESR / CRP ^ 
FBC - Normocytic anaemia
HBV serology
Angiography
Biopsy
LFTs
Urinalysis - Haematuria

Prednisolone
DMARD - Azathioprine

50
Q

Marfan’s

A

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
51
Q

Ehlers Danlos

A

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
52
Q

Sjogren’s syndrome aetiology / clinical features

A

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
53
Q

Sjogren’s syndrome investigations / management / complications

A

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 ^

54
Q

Systemic sclerosis
Scleroderma
CREST

Clinical features

A

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
55
Q

Systemic sclerosis
Scleroderma
CREST

Investigations / Management

A

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
56
Q

SLE aetiology

A

AI - Type 3 hypersensitivity
HLA-DR2/3
Immune complex deposition - Skin, joints, kidney, brain

Risk factors

  • Females aged 20-40
  • AC / Asian communities
  • Isoniazid
57
Q

SLE clinical features

A

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

58
Q

SLE criteria

A

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

59
Q

SLE investigations and management

A

SOAP BRAIN MD

ANA +ve
Anti-dsDNA
Anti-Smith
Anti-Ro
Anti-La

Management

  • Hydroxychloroquine
  • NSAIDs
  • Prednisolone
  • DMARD - Methotrexate
60
Q

Takayasu’s arteritis aetiology and clinical features

A

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
61
Q

Takayasu’s arteritis investigations and management

A

ESR / CRP ^
CT angiography - Aorta

Prednisolone
Aspirin
Alendronic acid

62
Q

Antiphospholipid syndrome

A

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)

63
Q

Polymyalgia rheumatica

A

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

64
Q

Raynaud’s aetiology

A

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
65
Q

Raynaud’s clinical features / investigations / management

A

PD - Painful Digits

Digit pain / discomfort
Paraesthesia
Pallor
Discolouration - Red/blue - Well-defined
Dilated nailbed capillaries - Magnification

Management - Treat cause

  • CCB - Nifedipine
  • IV Prostacyclin

3B (23 decks)

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