MSK Flashcards
What is pagets disease?
- A disorder of uncontrolled bone turnover –> both formation and reabsorption due to excessive activity of both osteoblasts and osteoclasts
- Thought to primarily be disorder osteoclasts w excessive resorption followed by increased osteoblast activity. Osteoblasts make larger weaker bones.
- This excessive turnover is not coordinated –> leading to patchy areas of high density (sclerosis) and low density (lysis) –> results in enlarged and misshapen bones with structural problems that increase the risk of pathological fractures.
- It particularly affects the axial skeleton (the bones of the head and spine). Also long bones of lower extremities.
- 5% in UK, only symptomatic in 1 in 20.
What is the typical presentation of pagets disease?
- Typically affects older adults >50.
- Stereotypical presentation –> older male w bone pain, isolated raised ALP.
- Bone pain –> pelvic, lumbar spine, femur
- Bone deformity –> classical untreated features w bowing of tibia, bossing of skull. Hearing loss can occur when affects bones of ear.
- When spinal stenosis –> can be numbness, tingling, loss of movement in part of body
What are the investigations for pagets disease?
What would you expect to see on imaging? (3)
-Bloods –> raised ALP, normal calcium and phosphate.
X ray –> bone enlargement and deformity. ‘
-Osteoporosis circumscripta’ well defined osteolytic lesions appear less dense than normal bone.
-Cotton wool appearance –> poorly defined patchy areas of increase density (sclerosis) and decreased density (lysis).
-V shape defects in long bones –> V sape osteolytic bone lesions within healthy bone.
What is the management of pagets disease?
What is monitored?
- Bisphosphonates main treatment –> oral risedronate –> generally very effective. They interfere with osteoclast activity and seem to restore normal bone metabolism. They improve symptoms and prevent further abnormal bone changes.
- NSAIDs for bone pain
- Calcium and vitamin D supplementation, particularly whilst on bisphosphonates
- Surgery is rarely required for fractures, severe deformity or arthritis
- Monitoring involves check the serum alkaline phosphatase (ALP) and reviewing symptoms. Effective treatment should normalise the ALP and eliminate symptoms.
What are the possible complications of pagets?
- Osteogenic sarcoma (osteosarcoma) –> bone cancer w poor prognosis. Presents w increased focalbone pain, swelling or pathological fractuses. Risk increased in pagets disease, need to be followed up to detect. Seen on plain x ray.
- Spinal stenosis and spinal cord compression –> deformity in spine leads to spinal narrowing. When presses on spinal nerves –> neurological signs and symptoms. Diagnosed w MRI, often treated effectively w bisphosphonates.
- Others –> deafness (CN entrapment).
What is adhesive capsulitis?
What condition is associated w adhesive capsulitis?
- A condition in which the glenohumeral joint capsule becomes contracted and adherent to the humeral head.
- A common cause shoulder pain.
- This can result in shoulder pain and a reduced range of movement in the shoulder.
- Is more common in women, peak onset between 40-70yrs old (middle age females common) commonly symptoms in non dominant arm.
- Up to 20% diabetics can have episode
- Those who have previously been affected by adhesive capsulitis are more susceptible to developing the condition in the contralateral shoulder.
- Primary –> idiopathic
- Secondary –> associated w rotator cuff tendinopathy, subacromial impingement syndrome, biceps tendinopathy, previous surgery/trauma or known joint arthropathy.
What is the presentation of adhesive capsulitis?
What would you find on examination?
- Symptoms develop over few days ?
- Individual describe generalised deep and constant pain of shoulder (can radiate to bicep) , associated with joint stiffness and a reduction in function
- Can disturb sleep.
- Bilateral in up to 20% patients
- Episodes typically last between 6 months – 2 years.
- Loss or arm swing and atrophy of deltoid muscle
- Generalised tenderness on palpation common.
- Patient have limited range motion à principally affected external rotation (elbow 90 move arm out like holding sign) and flexion (arm towards sky) of shoulder. If normal ROM then consider DDx.
- Active AND passive movement affected.
- External rotation more affected then internal rotation or abductoion.
What are the investigations for adhesive capsulitis?
- Most diagnoses made clinically –> possible imaging e.g MRI to confirm when not sure such as atypical or persistent symptoms.
- Plain film radiographs are generally unremarkable, but importantly can be used to rule out acriomioclavicular pathology or atypical presentations of fractures.
- MRI can reveal a thickening of the glenohumeral joint capsule, can also can be used to rule out other conditions affecting the shoulder, such as subacromial impingement syndrome.
- More common in diabetic patients, therefore anyone presenting with adhesive capsulitis without any risk factors or precipitating events, HbA1c and blood glucose measurements may be useful.
What is the management for adhesive capsulitis?
- A self-limiting condition however recurrence is not uncommon.
- Recovery usually occurs over months to years and a proportion of patients will never recover full range of movement.
Initial management
- Education and reassurance –> encouraged to keep active; all patients should receive physiotherapy and advice concerning appropriate shoulder exercises.
- Management of pain initially begins with simple analgesics.
- Glenohumeral joint corticosteroid injections may be considered for those patients failing to improve.
Surgical Intervention – rarely needed
-For patients with no improvement following prolonged engagement with full conservative treatment efforts and when symptoms significantly affect quality of life, surgical intervention may be considered.
-A small proportion of patients will never regain a full range of motion but will regain movement beyond that required to perform activities of daily living.
-In some patients the progression of symptoms may persist beyond two years and adhesive capsulitis may recur in the contralateral shoulder.
What are the differential diagnosis for adhesive capsulitis?
- Acromioclavicular pathology (e.g. acriomioclavicular joint injury, acromioclavicular arthritis, glenohumeral arthritis) – a more generalised pain may be present with weakness and stiffness related to pain
- Subacromial impingement syndrome (rotator cuff tendinopathy, subacromial bursitis) – may present with preserved passive movement and history of repetitive overuse/external compression of subacromial space risk factors
- Muscular tear (rotator cuff tear, long head of biceps tear) – the weakness often persists when the shoulder pain is relieved
- Autoimmune disease (polymyalgia rheumatica, rheumatoid arthritis, systemic lupus erythematous) – may present with a polyarthropathy and systemic symptoms
