MSK and Rheumatology Flashcards
what is the structure of bone
cortical bone on the outside - osteon functional units
trabecular bone on the inside - BM structural mesh
what is the structure of osteon
it is concentric lamellae and a central haversian canal which supplies a single longitudinal osteon
what are volkmann canals
these are canals that allow communication between osteons
what is the inorganic component of osteon made from
hydroxyapatite (ca2(Po4)3) = stiff
what is the function of hydroxyapatite in the bone
to provide stiffness
what is the organic component of the osteon
collagen T1
what is the function of collagen T1 in the bone
to provide elasticity
what are the different types of joints
fibrous
cartilaginous
synovial
where do you find fibrous joints
in the skull sutures - immovable
where do you find cartilaginous joints
IV disc, pubis symphysis - partially movable
where do you find synovial joints
most joints of the body - freely movable
what are the different kinds of synovial joint
articular cartilage
joint capsule (inner lining of synovial membrane)
synovial cavity filles with synovial fluid
what connects bone to bone
ligaments
what connects bone to muscle
tendons
what is osteoarthritis
it is the most common form of arthritis, characterised by non inflammatory degenerative mechanical shearing
what are the risk factors of osteoarthritis
age - over 50
obesity
occupation/sports
genetic
what genetic factor predisposes you to osteoarthritis
COL2A1
what is the pathophysiology of osteoarthritis
there is imbalanced cartilage breakdown compared to repair due to increased chondrocyte metalloproteinase secretion. this causes degradation of collagen and cyst formation. The bone attempts to overcome this with type 1 collagen leading to abnormal bony growths (osteophytes) and remodeling
what are the symptoms of osteoarthritis
transient morning pain - worse as day goes on
Bouchard + Heberden nodes on fingers
inflamed joints
what are features of Bouchard and Heberden nodes
asymmetrical hard inflamed joints
typically found on the most stressed joints of the body
how do you diagnose osteoarthritis from an X ray
LOSS
loss of joint space
osteophytes
subchondral sclerosis
subchondral cysts
Normal bloods
how do you treat osteoarthritis
lifestyle changes - weight bearing and physio
NSAID and cortisol injections
last resort = arthroplasty - replacements
what is rheumatoid arthritis
an inflammatory autoimmune polyarthritis
is rheumatoid arthritis symmetrical or asymmetrical
symmetrical
what are risk factors for developing rheumatoid arthritis
women - 30-50 (3X more likely than men post menopause)
smoking
HLA DR4/ DRB1 gene
what is the pathophysiology of rheumatoid arthritis
there is an arginine to citrulline mutation in T2 collagen causing anti cyclic-citrullinated peptide formation. INF-a causes further proinflammatory recruitment to the synovium.
synovial lining expands and tumour like mass grows past the joint margins
there is destruction of subchondral bone and articular cartilage
what are symptoms of rheumatoid arthritis
often worse in the morning - eases as day goes on
Hand: boutonniere, swan neck and Z thumb ulnar finger deviation
Baker’s cysts and popliteal synovial sac bulge
symmetrical
hot
inflamed
what non bone symptoms do you get in rheumatoid arthritis
lungs - PE and pulmonary fibrosis
Heart - increased IHD risk
eyes - Episcleritis and dry eyes
spinal cord compression
kidney - CKD
rheumatoid skin nodules
how do you diagnose rheumatoid arthritis
Bloods: increased ESR/CRP, normocytic normochromic anemia
Serology: positive anti CCP and positive RF
X ray
what is seen on X ray in rheumatoid arthritis
loss of joint space
eroded bone
soft tissue swelling
soft bones
what other types of anaemias can be seen in rheumatoid arthritis
microcytic - NSAID use
Macrocytic - methotrexate use (inhibits folate)
what is seen in Felty syndrome
triad of rheumatoid arthritis, granulocytopenia, splenomegaly
what is the treatment for rheumatoid arthritis
methotrexate
NSAID analgesia
intra articular steroid injection
Biologics - INFLIXIMAB or rituximab
what is gout
it is hyperuricemia (sodium urate) causing crystal deposition along joints and intraarticularly
what is the most common inflammatory arthritis in the UK
Gout
what are risk factors for gout
high purine rich diet - meat, seafood, beer
CKD and diuretics
what is the pathophysiology of gout
purines (via xanthine oxidase) become uric acid which is normally excreted. However if there is a build up of uric acid its converted into monosodium urate which then deposits and crystals
what are the symptoms of gout
monoarticular - typically big toe
sudden onset
severe swollen
how do you diagnose gout
joint aspirate and polarised light microscopy
- see negatively bifringent needle shaped crystals
how do you treat gout
diet : reduce purines and increase dairy
NSAIDS
potentially steroid injection
Allopurinol for prevention
what can be given to prevent gout formation
Allopurinol - Xanthine oxidase inhibitor
what is pseudogout
calcium pyrophosphate crystals deposit along the joint capsule
what are risk factors for pseudogout
elderly
female
diabetes
metabolic diseases
osteoarthritis
what are symptoms of pseudogout
often polyarticular with knee commonly involved
swollen, hot, red joint
what is a differential diagnosis for pseudogout
septic arthritis
how do you diagnose pseudogout
joint aspiration and polarised light microscopy
- see positively birefringent rhomboid shaped crystals
how do you treat pseudogout
only acute management
NSAIDS
Colchicine
steroid injections
what is osteoporosis
it is a decrease in bone density by 2.5 + standard deviations below young adult mean volume
what are risk factors for osteoporosis
SHATTERED
steroids
hyperhyroid/hyperparathyroidism
alcohol and spoking
thin
testosterone low
early menopause
renal or liver failure
erosive and inflammatory disease
DMT1 or malabsorption
what is the T score
it is the young adult bone density score
0 = normal within 1 SD
1-2.5 = decreased bone marrow density - osteopenia
over 2.5 = osteoporosis
what are symptoms of osteoporosis
FRACTURES
- proximal femur
- Forked wrist - fall onto hands
- compression vertebral crush
how do you diagnose osteoporosis
DEXA scan - duel energy X ray absorptiometry
also FRAX score - fracture risk assessment tool
what is the treatment for osteoporosis
- Bisphosphonates - alendronate, risedronate
- mAB denosumab
HRT - oestogen and testosterone
oestrogen receptor modulator = raloxifene
recombinant PTH - teriparatide
what is the mechanism of action of bisphosphonates
they inhibit RANK-L signaling and therefore osteoclastic activity
how does Denosumab work
inhibits RANK-L
what is systemic lupus erythematosus
it is a hypersensitivity T3 reaction causing autoimmune systemic inflammation
Who is SLE most common in
females
afro-caribbean
20-40 (pre - menopausal)
what are the risk factors for developing SLE
female
HLA B8 / DR2 / DR3
Drugs - isoniazid
what is the pathophysiology of SLE
there is impaired apoptotic debris presented to TH2 causing B cell activation. this leads to antigen, antibody complex formation against self
what are symptoms of SLE
Butterfly rash
photosensitivity
glomerulonephritis
Seizures and psychosis
mouth ulcers
(+ Serositis, anaemia, joint pain, Raynaud’s and pyrexia)
how do you diagnose SLE
Bloods = anaemia w. raised ESR and normal CRP
Urine dip stick = haematuria, proteinuria
Serology = ANA Abs and Anti ds DNA Abs
low C3 and C4
how do you treat SLE
Lifestyle - low sunlight and stop triggering drugs
corticosteroids
hydroxychloroquine
NSAIDS
and azathioprine if severe
what is antiphospholipid syndrome
an autoimmune, hypercoagulable state caused by antiphospholipid antibodies. APS provokes blood clots (thrombosis) in both arteries and veins
- have aPL Abs
what can antiphospholipid syndrome cause in pregnancy
multiple miscarriages
what are symptoms of antiphospholipid syndrome
CLOTS
coagulopathy
Livedo reticularis - purple discoloration of skin
obstetric issues - miscarriages
thrombocytopenia
+ increased risk of arterial and venous thrombosis
what are the different types of antiphospholipid syndrome
primary - idiopathic
secondary - develop from other diseases such as SLE
how do you diagnose antiphospholipid syndrome
symptoms and
- lupus anticoagulant
- anticardiolipin antibodies (IgG/M)
- anti b2 glycoprotein -1 antibodies
how do you treat antiphospholipid syndrome
1st line = warfarin long term if patient has had a thrombosis
prophylaxis = give aspirin
what treatment is given in antiphospholipid syndrome if the patient is pregnant
Aspirin and heparin
what is Sjogren syndrome
it is an autoimmune exocrine dysfunction - DRY
what are the risk factors for developing Sjogren syndrome
Females
40-50
family history
HLAB8/DR3
what are symptoms of sjogren syndrome
dry eyes - Keratoconjunctivitis sicca
dry mouth - Xerostomia
Dry vagina
Raynauds
how do you diagnose Sjogren syndrome
Anti-RO and anti LA antibodies
ANA is often positive
Schirmer test - induce tears and place filter paper under the eyes to see how far the tears travel
how do you treat Sjogren syndrome
artificial tears, saliva and lubricant for sexual dysfunction
sometimes hydroxychloroquine is given
what is scleroderma (crest)
it is a systemic condition of which the most common type is limited cutaneous scleroderma (aka crest)
what does scleroderma cause
Calcinosis
Raynaud’s
Esophageal dysmotility
Sclerodactyly
Telangiectasia
what is calcinosis
it is when there are calcium deposits in the subcutaneous tissue
can lead to renal failure
what is raynaud’s
it is digit ischemia due to sudden vasospasm often precipitated by cold and is relieved with heat
what is sclerodactyly
local skin thickening or tightening on the fingers and toes and can lead to movement restriction
what is telangiectasia
it is spider veins - increases the risk of pulmonary hypertension
how do you diagnose scleroderma
anti centromere antibodies (ACAs) - 70%
ANA is often positive
how do you treat scleroderma
there is no cure
treat the symptoms the patient is experiencing
what is polymyositis or dermatomyositis
it is inflammation and necrosis of skeletal muscle, it is called dermatomyositis when skin is also involved.
what are risk factors for developing polymyositis
female
HLA B8 / DR3
what are symptoms of polymyositis/dermatomyositis
symmetrical wasting of the muscles of the shoulder and the pelvic girdle
hard to stand from sitting
hard to squat
hard to put hands on top of head
in dermatomyositis have Gottron Papules (scales) and Heliotrope (purple eyelid)
how do you diagnose polymyositis
muscle fibre biopsy necrosis is diagnostic
LDH and CK is raised
Anti - Jo1 and Mi2 ABs (2nd in dermatomyositis)
Bloods - serum creatinine kinase, aminotransferases, lactate dehydrogenase and aldolase are all increased
how do you treat polymyositis or dermatomyositis
bed rest and prednisolone for 1 month then taper down the dose
what is fibromyalgia
it is MSK equivalent of IBS: chronic widespread pain for over three months with all other causes ruled out
what pain pathway is affected in fibromyalgia
the non - nociceptive pathway is affected
what is non nociceptive pain
it is neuropathic pain and CNS processing of pain
what are risk factors for fibromyalgia
females
depression
stress
over 60
what are symptoms of fibromyalgia
stressed, depressed female of over 60
fatigue
sleep disturbance
morning stiffness
back and neck stiffness
pain
how do you diagnose fibromyalgia
there are no serological markers
there is no rise in ESR or CRP
there is pain in 11+ our of 18 regions palpated
clinically diagnosed
how do you treat fibromyalgia
educate the patients and physiotherapy
antidepressants for severe neuropathic pain - TCA, Gabapentin, Pregabalin, (opiates)
CBT
what antidepressants can be used in fibromyalgia
TCAs sch as amitriptyline
what is a differential diagnosis for fibromyalgia
polymyalgia rheumatica
what is polymyalgia rheumatica
large cell vasculitis presenting as chronic pain syndrome (affects muscles and joints)
what are risk factors for polymyalgia rheumatica
females
over 50
how do you diagnose polymyalgia rheumatica
increased ESR and CRP - diagnostic
temporal artery biopsy may show GCA
may have anaemia of chronic disease
how do you treat polymyalgia rheumatica
oral prednisolone
what is large vessel vasculitis
the spectrum of primary vasculitis that causes chronic granulomatous inflammation predominantly of the aorta and its major branches
what are the types of large vessel vasculitis
GCA
takayasu
what is medium vessel vasculitis
Medium vessel vasculitis (MVV) predominantly affects medium-sized and small arteries, defined as the main visceral arteries and their branches.
what are different types of medium vessel vasculitis
Polyarteritis nodosa
Buerger’s disease
Kawasaki disease
who does Buerger’s syndrome affect
male
smokers
20-40
what does Buerger’s disease cause
peripheral skin necrosis
thromboangiitis obliterans
who does kawasaki disease affect
children
causes coronary artery aneurysms
what is small vessel vasculitis
among a family of rare diseases characterized by inflammation of the blood vessels, which can restrict blood flow and damage vital organs and tissues
what are types of small vessel vasculitis
eosinophilic granulomatosis with polyangiitis
granulomatosis with polyangiitis
Henoch-Schönlein purpura
what is eosinophilic granulomatosis with polyangitis
rare autoimmune condition that causes inflammation of small and medium-sized blood vessels (vasculitis) in persons with a history of airway allergic hypersensitivity
- pANCA positive
what is granulomatosis with polyangiitis
rare condition where the blood vessels become inflamed. It mainly affects the ears, nose, sinuses, kidneys and lungs. Anyone can get it, including children, but it’s most common in adults and older people.
- cause of glomerulonerphitis
- cANCA positive
what is Henloch Schorilein purpura
it is IgA vasculitis leading to IgA deposition in the glomerular basement membrane as well as purpuric rash on the shins
what is the treatment for vasculitis
corticosteroids
- consider GI and bone protection such as PPIs and bisphosphates
what is Giant cell arteritis
it is an inflammation of the lining of your arteries
what are risk factors for giant cell arteritis
over 50
Caucasian
female
how does giant cell arteritis present
it presents with
unilateral temple headache
jaw claudication
temporal scalp tenderness
change in vision
what is the pathophysiology of giant cell arteritis
it affects the branches of the external carotid leading to inflammation affecting the temporal, ophthalmic and facial branches
how do you diagnose giant cell arteritis
there is an increase in EST +/- CRP
temporal artery biopsy is diagnostic
- see granulomatous inflammation of media and intima
how do you treat giant cell arteritis
with corticosteroids (prednisolone)
in giant cell arteritis biopsy why is it important to take a large chunk
as it has skip lesions so if you dont take enough it may look normal
what is a complication of giant cell arteritis
sudden painless vision loss in one eye
temporary = amaurosis fugax
may be permanent if nor delt with fast
what do you give for painless vision loss in giant cell arteritis
high dose IV methylprednisolone
what is polyarteritis nodosa
rare form of vasculitis in which the medium and/or smaller sized arteries become damaged and inflamed. It can sometimes be triggered by an infection
who is at risk of developing polyarteritis nodosa
males
associated with Hep B
what are the symptoms of polyarteritis nodosa
there are severe systemic symptoms
- mononeuritis multiples - ischemia or casa vasorum
- GI bleeds
- CKI/AKI
- skin SC nodules and haemorrhage
how do you diagnose polyarteritis nodosa
CT angiogram - beads on a string appearance due to microaneurysms
Biopsy - necrotising vasculitis
how do you treat polyartertitis nodosa
corticosteroids
control hypertension with ACE i
Hep B treatment AFTER corticosteroids
what is spondyloarthropathies
there are asymmetrical seronegative arthritis associated with HLAB27
- inflammatory
what are different types of spondyloarthropathies
Ankylosing spondylitis
psoariatic arthritis
reactive arthritis
+ IBD related arthritis
what are general features of spondyloarthropathies
SPINEACHE
sausage fingers
Psoriasis
inflammation - back pain
NSAIDs
enthesitis - plantar fasciitis
arthritis
crohns or collitis
HLAB27
Eyes - uveitis
what is Ankylosing spondylitis
abnormal stiffening of the joints (sacroiliac and vertebral) due to new bony formation
who is at risk for ankylosing spondylitis
young males
HLAB27 positive
what is the pathophysiology for ankylosing spondylitis
syndesmophytes (vertical abnormal bony growths) replace spinal bone damaged by inflammation and therefore makes the spine less mobile
- also causes inflamed tendons, eyes and fingers
at are symptoms of ankylosing spondylitis
young males with progressively worsening back stiffness
worse in the morning and at night
better with exercise
anterior uveitis
enthesitis
dactylitis
low natural lumbar lordosis
reduced lumbar flexion
what test shows reduced lumbar flexion
the Schober test
how do you diagnose ankylosing spondylitis
X ray - bamboo spine and sacroiliitis. Squared vertebral bodies and syndesmophytes
MRI - better screening tool
Bloods - ESR and EPR raised
how do you treat ankylosing spondylitis
Symptoms - exercise and NSAIDs
DMARD (improve disease) - TNA a blockers
what TNF a blocker is used in ankylosing spondylitis treatment
infliximab
what is psoriatic arthritis
a type of arthritis that affects some people with the skin condition psoriasis. It typically causes affected joints to become swollen, stiff and painful. Like psoriasis, psoriatic arthritis is a long-term condition that can get progressively worse.
what are moderate symptoms of psoriatic arthritis
moderate - inflamed DIPJ joints, nail dystrophy, dactylitis, enthesitis, rash on skin
what are severe symptoms of psoriatic arthritis
arthritis mutilaris - pencil in cup deformation where the osteolysis of the bone causes progressive shortening with the fingers telescoping in on themselves
how do you treat psoriatic arthritis
Symptoms - NSAIDs
DMARD - methotrexate. If this fails use anti-TNF and then if that fails use IL-12+23 inhibitor
what is reactive arthritis
it is sterile inflammation of the synovial membranes and tendons - reacting to distant infection usually GI or STI
what is the aetiology of reactive arthritis
Gastroenteritis = C. Jejuni, salmonella or shigella
STI = C. Trachomatis or N. Gonorrhoea
what are symptoms of reactive arthritis
Reiter’s triad
- Uveitis (cant see)
- Urethritis/Balanitis (cant pee)
- Arthritis + enthesitis (cant climb tree)
May have rash on sides of feet
what is the main differential diagnosis of reactive arthritis
septic arthritis
how do you diagnose reactive arthritis
joint aspirate
ESR and CRP raised
sexual health review
stool culture
how do you treat reactive arthritis
symptoms - NSAIDs (+ steroid injection)
Mostly single attack - if another attach = chronic
then give methotrexate and then anti TNF a
what is septic arthritis
it is a direct bacterial infection of the joint either due to direct access or haematogenous spread
how do you manage septic arthritis
as a medical emergency - acutely inflamed joint with fever can destroy joint in 24 hours
what organisms can cause septic arthritis
Most common = S. Aureus
H. influenza
N. gonarhoea
E.coli / pseudomonas
what are risk factors of septic arthritis
IV drug users
immunosuppression
recent surgery
trauma
prosthetic joints
inflammatory joint disease
how do you diagnose septic arthritis
urgent joint aspirate with MC+S and polarised light microscopy
increased ESR and CRP
consider blood culture
consider sexual health review
how do you treat septic arthritis
joint aspirate for drainage and then empirical antibiotics (flucloxacillin, vancomycin, IM ceftriaxone and azithromycin)
stop any methotrexate and anti TNF a treatment
if on steroids, double prednisolone dose
NSAIDs for analgesia
what is osteomyelitis
acutely inflamed infected BM, either haematogenous or local spread from infected joint or trauma.
what organisms can cause osteomyelitis
S. aureus
Salmonella in sickle cell patients
what are risk factors for osteomyelitis
IV drug users
Immunosuppression
PVD
DM
sickle cell anaemia
Inflammatory arthritis
trauma
what is the pathophysiology of osteomyelitis
there is direct infection, local spread or haematogenous spread leads to acute bone change leading to bone inflammation and bone ache. Overtime this could lead to chronic bone changes
what chronic bone changes are seen in osteomyelitis
Sequestra = necrotic bone embedded in pus
Involucrum = thick sclerotic bone placed around squestra to compensate: for support
what are the symptoms of osteomyelitis
Acutely = dull bony pain, hot and swollen area. worse with movement
Chronically = acute + deep ulcers
what are differential diagnosis for osteomyelitis
charcot joint - damage to sensory nerves due to diabetic neuropathy
how do you diagnose osteomyelitis
bone marrow culture and biopsy to ID the causative organism
Blood MC and S
X-ray = osteopenia
MRI = bone marrow oedema
increased ESR and CRP
what would be seen on a MRI in osteomyelitis
bone marrow oedema
What what would be seen on X ray with osteomyelitis
Osteopenia
how do you treat osteomyelitis
Immobilise plus antibiotics
- Vancomycin for MRSA and S.aureus
- Fusidic acid for s. aureus
- Flucloxacillin for salmonella
what do you have to rule out when diagnosing osteomyelitis
tuberculosis osteomyelitis with bone marrow biopsy (granuloma positive)
what are prosthetic joints commonly infected with
Coagulase negative staphs = S . Epidermis
what are primary bone tumours
Osteosarcoma
Ewing sarcoma
Fibrosarcoma
Chondrosarcoma
what are secondary bone cancers
due to metastasis
- breast
- lung
- prostate
- thyroid
- RCC
what types of metastasis causes osteolytic bone cancer
breast and lung
what types of metastasis causes osteoscerotic bone cancer
prostate cancer
what is the most common primary bone malignancy
osteosarcoma
what is osteosarcoma
a malignant tumour of bone in which there is a proliferation of osteoblasts.
where does osteosarcoma metastasize to
the lungs
how does osteosarcoma appear on X ray
sunburst appearing bone
what does Ewing sarcoma arise from
Mesenchymal stem cells
what age does ewing sarcoma often occur
15 years
what is chondrosarcoma
it is a cartilage cancer
what are the general symptoms of bone cancer
Local (dependent on tumour)
severe pain - worse at night
pathological fractures
low range of movement of long bone or vertebrae
weight loss
fatigue
fever
malaise
how do you diagnose bone cancer
skeletal isotope scan - shows changes before an X ray can
X ray = osteolysis
increased ALP, ESR and CRP
hypercalcaemia of malignancy
what is the treatment for bone cancer
chemotherapy
radiotherapy
bisphosphonates
what is osteomalacia
it is defective bone mineralisation
- after epiphysial fusion
what is osteomalacia due to
due to vitamin D deficiency and therefore reduced calcium and phosphate
what are causes of osteomalacia
hyperPTH - increased calcium release from bone
Vitamin D deficiency
CKD or renal failure
Liver failure - less reaction in Vit D pathway
Anticonvulsant drugs - increases Vit D metabolism
what is the vitamin D activation pathway
7 dehydrocholesterol - Cholecalciferol - 25-hydroxyvitamin D - 1,25 dihydroxy vitamin D
what are symptoms of osteomalacia
fractures
proximal weakness
difficulty in weight bearing
widespread bone pain and tenderness
what presentation do you have with defective bone mineralisation before epiphysial fusion
rickets
what are the symptoms of rickets
skeletal deformations
- knocked knees and bowed legs
- wide epiphyses
how do you diagnose osteomalacia
BM biopsy to see incomplete mineralisation
Bloods - Hypocalcaemia, increased PTH, low active vitamin D
X Ray - looser’s zones (defective mineralisation)
how do you treat osteomalacia
Vitamin D replacement - calcitriol
Increased dietary intake - D3 tablets, eggs
what is Paget’s disease
Focal disorder of bone remodelling where there are areas of patchy bone due to improper osteoblast/clast function
- areas of sclerosis and lysis
what are symptoms of Paget’s disease
Bone pain
Bowed tibia and skull
Neurological symptoms
- nerve compression of CN8
- hydrocephalus
how do you diagnose Paget’s disease
X ray - osteoporosis circus cipta and cotton wool skull (areas of lysis and sclerosis)
Urinary hydroxyproline - protein component of collagen
increased ALP
what is used as a marker of disease progression in Paget’s disease
urinary hydroxyproline
how do you treat pagets disease
Bisphosphonates
NSAIDs for pain relief
what is marfans syndrome
it is an auto dominant FB1 mutation which reduces connective tissue tensile strength
what are the symptoms of marfans syndrome
tall and thin
long fingers
pectus excavatum/carinatum
Aortic regurgitation murmur
abdominal aortic aneurysm
aortic dissection
how do you diagnose marfans syndrome
clinical features
FBN -1 mutation - genetic testing
what is Ehlers danlos
it is an auto dominant mutation affecting collagen proteins (about 13 subtypes)
what are symptoms of ehlers danlos
joint hypermobility
cardiovascular complications - mitral regurgitation, abdominal aortic aneurysm and aortic dissection
how do you diagnose Ehlers Danlos
clinical presentation
collagen mutations
Beighton score
what is the Beighton score
The Beighton score is a test that measures joint hypermobility (flexibility). It involves simple maneuvers, such as bending your pinky (little) finger backward to check the joint angle. The Beighton score uses a nine-point scoring system. The higher your score, the more flexible your joints are.
what is the presentation of lower back pain
its very common and often self limiting
- may be normal especially in those between 22-55
- can be trauma or work related
what are signs for serious lower back pain pathology
older age - myeloma
Neuropathic pain - spinal cord compression
what is lumbar spondylosis
it is the degeneration of IV disc. There is loss of compliance and it thins over time, progressively worsening
what age group is lumbar spondylosis common in
older patients
what are the most common lumbar involved in lumbar spondylosis
L4/5
L5/S1
when would you X ray in lumbar spondylosis
If serious pathology is suspected
how do you treat lumbar spondylosis
analgesia
physiotherapy
what is the cause of osteoarthritis
loss of cartilage and disordered bone repair
who does osteoarthritis affect the most
Females over males
Obese individuals
what joints does osteoarthritis affect the most
Large weight bearing joints
- knees
- hips
what is a herberdens node
Heberden’s nodes are small, pea-sized bony growths that occur on the joint closest to the tip of the finger, also called the distal interphalangeal joint.
what is a bouchards node
Bouchard’s nodes are one of the characteristic signs of osteoarthritis of the finger joints. They appear as bony bumps along the middle joint of a finger
what is the diagnostic criteria for rheumatoid arthritis
- rheumatoid factor positive
- finger/hand/wrist involvement
- rheumatoid nodules
- involvement of 3 or more joints
- stiffness in the morning
- erosions seen on X-ray
- symmetrical involvement
what biologics can be given in rheumatoid arthritis treatment
TNFa blockers: infliximab
B cell inhibitors: rituximab
what are causes of osteoporosis
Endocrine - cushings, parathyroid
Haematology - myeloma
GI - malabsorption
Latrogenic - use of steroids
what social treatments are used for osteoporosis
Lifestyle advice - quit smoking and alcohol
Calcium and vitamin D supplements
what type of hypersensitivity is SLE
type 3 hypersensitivity
what is antiphospholipid syndrome
an antibody mediated acquired thrombophilia characterised by thrombosis and recurrent miscarriages
what other disease is antiphospholipid associated with
Associated with SLE in 20-30% of cases
what is the diagnostic criteria for antiphospholipid disease
One or more clinical and one or more lab
clinical: vascular thrombosis, pregnancy morbidity
Lab: anticardiolipin antibody, lupus anticoagulant, anti-beta 2 glycoprotein 1 antibody
what lifestyle changes can be made in antiphospholipid disease
About smoking, exercise more and healthy diet
- prevent CVS issues
what other disorders is sjorgrens syndrome associated with
rheumatoid arthritis
SLE
Primary biliary cholangitis
Scleroderma
what is the pathophysiology behind Sjorens syndrome
there is immunologically mediated destruction of epithelial exocrine glands - especially lacrimal and salivary glands
what M3 agonist can be used in Sjorens syndrome
pilocarpine
what other diseases is raynauds phenomenon associated with
SLE
Systemic sclerosis
rheumatoid arthritis
dermatomyositis
what can raynauds phenomenon be caused by
Vibrational tools
smoking
beta blockers
what is the treatment for raynauds phenomenon
Lifestyle - protect the hands, stop smoking
Calcium channel blockers
what is systemic sclerosis
it is a multisystem autoimmune disease in which there is increased fibroblast activity, increasing collagen deposition and resulting in abnormal growth of connective tissue
what has the highest case specific mortality out of any autoimmune rheumatic disease
systemic sclerosis
what are the signs and symptoms of systemic sclerosis
skin involvement limited to the hands, face, feet and forearms
characteristic beak like nose and small mouth
microstomia
calcium deposits in the subcut tissue
eosophageal dysmotility or strictures
spider veins
Raynauds
GI, Renal and lung involvement
how do you diagnose systemic sclerosis
Limited - anti centromere antibodies
Diffuse - Anti-topoisomerase, anti scl-70 ANAs
ASR is normal
there may be anemia
what are the two types of systemic sclerosis
limited
diffuse
how do you treat systemic sclerosis
Lifestyle - avoid smoking, handwarmers
Medications - PPIs, antibiotics, ACEi, cyclophosphamide
what are symptoms of polymyositis
symmetrical progressive muscle weakness and wasting affecting the proximal muscles of the shoulder and pelvic girdle
- pain and tenderness are uncommon
- can lead to resp failure
what are symptoms of dermatomyositis
heliotrope (purple) discolouration of the eyelids
scaly erythematous plaques over the knuckles
arthralgia, dysphagia resulting from oesophageal muscle involvement and raynauds
what is Pagets disease
it is a localised disorder of bone remodelling
what is the pathophysiology behind pagets disease
Increased osteoclastic bone resorption followed by increased formation of weaker bone
it leads to structurally disorganised mosaic of bone
what is the demographic of people who get pagets disease
there is an increased incidence with age - rare under 40
it affects up to 10% of individuals by 90
what are the signs and symptoms of pagets disease
60-80% are asymptomatic
Bone pain
joint pain
deformities - bowed tibia and skull changes
neurological complications
nerve compression of 8th cranial nerve
Blockage of aqueduct of sylvius causing hydrocephalus
how do you diagnose Pagets disease
bloods - increased ALP, normal calcium and phosphate
Urinary hydroxyproline increase
X-ray - osteoarthritis
how do you treat Pagets disease
Bisphosphonates
NSAIDs
what is Rickets
When there is defective mineralisation at the epiphyseal growth plate
what are symptoms of rickets
Leg bowing and knock knees
- tender swollen joints
- growth retardation
- bone and joint pain
- dental deformities
- enlargement of end of ribs
who is at risk of septic arthritis
IV drug users
Immunocompromised
intra-articular injections
what is pseudogout caused by
deposition of calcium pyrophosphate crystals
what is gout caused by
deposition of monosodium urate crystals
what is the pathway of uric acid formation
- cell breakdown and diet causes purine bases to be produced
- this becomes hypoxanthine
- xanthine oxidase converts this to xanthine
- xanthine oxidase converts this into uric acid
what are the stages of gout progression
Stage 1: high uric acid levels building up round joints
stage 2: Acute gout were symptoms occur
stage 3: intercritital gout where there are periods of remission between attacks
stage 4: chronic gout, where pain is frequent and tophi form in the joints
what is the definition of hyperuricaemia
when there is over 420umol/L in males
when there is over 360umol/L in females
what are causes of gout
Diuretics - thiazides
High insulin levels
High fructose intake
Dysfunction of the URAT-1 transporter
Red meat
High saturated fat
High cell turnover rate
ALCOHOL
low dose aspirin
what are symptoms of gout
red, hot, swollen joint
Acute onset
what is the most common joint affected in gout
the big toe
what are the investigations done for gout
Bloods
U+Es and eGFR
Uric acid levels and 4-6 weeks later again
Gold standard is joint aspiration
what is the management plan for acute gout
1st line - NSAIDs or colchicine
2nd line - intra-articular steroid injection
lifestyle advice
what is the management plan for chronic gout
allopurinol - inhibits xanthine oxidase
2nst line - febuxostat
what are the three ways of infection entry into bone
Haematogenously
open wound
contiguously: skin into blood
what needs to be done when someone is admitted with suspected sepsis
- Administer oxygen
- Take blood cultures
- Give IV antibiotics
- Give IV fluids
- Check serial lactates
- Measure urine output
what are the stages in developing osteomyelitis
acute inflammation
subperiosteal abscess
sequestrum - necrotic bone attacked to healthy tissue
involucrum - layer of new bone growth outside of existing bone
Cloacae
what diseases are classed as seronegative spondyloarthropathies
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Inflammatory bowel disease arthritis
how does seronegative spondyloarthropathies present
sausage digits
psoriasis
inflammatory back pain
NSAIDs - good response
Arthritis
Crohns disease
HLA B27 positive
Uveitis - eye
Enthesitis
what is the most common form of back pain
mechanical
what are differentials for back pain
Congenital
trauma - fracture
infection - osteomyelitis
inflammation HLA B27
iatrogenic
miscellaneous
malignant - myeloma
what are red flags for lower back pain
cauda equina syndrome
cancer of the spine
spinal fracture due to trauma or osteoporotic collapse
spinal infection
what would you do if someone had red flag back pain
Bloods - look at inflammatory markers, FBS and ALP levels
DEXA scan and MRI
what is treatment for mechanical back pain
Paracetamol
NSAIDS
if severe then weak or strong opiates
Lifestyle advice
physiotherapy
in what age group is osteosarcoma common in
Children - metaphysis of long bones
What is osteochondroma
It is a benign cancer of the bone - overproduction of the bone which deposits on the metaphysis
what demographic is most likely to get osteochondroma
Men under 25
What cancers are most likely to cause secondary bone tumours
Prostate
Breast
Kidneys
Thyroid
Lungs
what investigations should be done if bone cancer is suspected
Bloods - FBC, U+E, ALP. PSA
Imaging - X ray and CT
how do you manage bone cancer
pain management
bisphosphonates
radiotherapy
chemotherapy
What is CRP
It is produced by the liver in response to infection
What condition normally presents with pain at the base of the thumb
Osteoarthritis
What are the four pillars of inflammation
Rubor
Dolor
Calor
Tumour
What are differential diagnosis for osteomyelitis
Soft tissue infection
Damaged joint
Avascular necrosis
Gout
How long is the treatment regime for osteomyelitis
6 weeks of Iv antibiotics are considered minimum
What are features of TB osteomyelitis
Slower onset
Patient has systemic non specific symptoms
Biopsy is essential for diagnosis
Treatment is longer - 6 months
What is ESR
Erythrocyte sedimentation rate - faster the sedimentation the more inflammation
How do you diagnose an infected joint
Aspirate the joint, fluid will look cloudy/turgid/gloopy in infection
What is the commonest cause of an infected joint
Staphylococcus aureus
If someone is on prednisone (steroids) what do you do to the dose if they get an infection
Double the dose
How many people with septic arthritis are over 65
45% of patients
What are common organisms causing septic arthritis
Neisseria. G
Gram negative bacilli
Anaerobes
Mycobacteria
Fungi
S. Aureus
What are signs of gonococcal arthritis
Inflammation around the tendon sheaths present in multiple joints
How do uou diagnose prothestic joint infections
Wound can leak pus
Red
Swollen
Painful joint
X Ray to show changes
FBC, ESR, CRP
Micro
What is a key diagnostic tool for prosthetic joint infection
Aspiration
How do you treat prosthetic joint infection
Antibiotics
Detriment and implant replacement
Excision arthroplasty
Exchange arthroplasty - one stage and two stage exchange
Who is pseudogout more common in men or women
Women
In gout will uric acid be high, low or normal in the bloods
In a flair up it will be normal/lower as it will be crystallised in joints
What foods can increase uric acid
Red meat
Shellfish
Offal
Why do sweetened soft drinks increase gout
As fructose shares the renal uric acid transporters
What are complications of gout
Tophi
Kidney disease - calculi, chronic urate nephropathy, acute urate nephropathy
What measured in rheumatoid arthritis can suggest aggressive disease
Anti CCP
- cyclic citrullinated peptide
What dose of methotrexate is given in rheumatoid arthritis
10-25mg/week
What are the theories as to why HLA B27 increases your chance of sponyloarthritis
- Molecular mimicking
- B27 mis folding theory
- HLA B27 heavy chain homodimer hypothesis
Why do you get a bamboo spine in analysing spondylitis
Because you have calcium depositing along the ligaments of the spine which eventually fuses them
What joints can be affected in anakylising spondylitis
Ribs
Spine
Hips
Pelvis - sacro-iliac joints
What are two subsets of ankylosing spondylitis
Non radiographic- only seen on MRI
Radiographic - seen on X Ray and MRI
What are two subsets of ankylosing spondylitis
Non radiographic- only seen on MRI
Radiographic - seen on X Ray and MRI
What are nail changes seen in spondyloarthritis
Pitting
Omucolysis - nail lifts from bed and thick white nail
What infections can cause reactive arthritis
Salmonella
Shigella
Yersinia
Chlamydia
Ureaplasma urealytioum
what are differential diagnosis for osteoarthritis
bursitis
gout
pseudogout
rheumatoid arthritis
psoriatic arthritis
avascular necrosis
internal derangements
what are the lung manifestations of rheumatoid arthritis
Pleural effusion
Fibrosing alveolitis
Pneumoconiosis
Interstitial lung disease
Bronchiectasis
what are heart manifestations of rheumatoid arthritis
pericarditis
pericardial rub
raynauds
pericardia effusion
what are eye manifestations of rheumatoid arthritis
dry eyes
episcleritis
scleritis
what are neuro manifestations of rheumatoid arthritis
peripheral sensory neuropathies
compression/entrapment neuropathies
cord compression
what are kidney manifestations of rheumatoid arthritis
amyloidosis
nephrotic syndrome
CKD
what are complications of gout
acute uric acid nephropathy
nephrolithiasis
what can be affected in pseudogout
knees
wrists
shoulders
ankles
elbows
hands
what are symptoms of pseudogout
Painful and tender joints
Osteoarthritis-like involvement of joints (wrists, shoulders)
Sudden worsening of osteoarthritis
Red and swollen joints
Joint effusion and fluctuance
Fever and malaise
what is the pathophysiology of osteoperosis
mismatch between osteoclastic bone resorption and osteoblastic bone formation
what are signs of osteoperosis
back pain
Kyphosis
Impaired vision
impaired gait
imbalance
low extremity weakness
vertebral tenderness
what are risk factors for ankylosing spondylitis
genetics
family history
male sex
what are the extra-articular manifestations of ankylosing spondylitis
osteoporosis
acute iritis/anterior uvitis
aortic valve incompetence
apical pulmonary fibrosis
what are the complications of ankylosing spondylitis
Osteoporosis
Cardiac involvement
Hip involvement
Iritis
Pulmonary involvement
Neurological involvement
what T cells play a primary role in psoriatic arthritis
CD8+ T cells
what are complications of psoriatic arthritis
cardiovascular disease
what percentage of reactive arthritis cases are HLA B27 positive
30-50%
what are the symptoms of septic arthritis
Hot, swollen, painful, restricted joint
Acute presentation
Fever
Large joint
Single joint
Prosthetic joint
Proportionality of symptoms (i.e. if already got RA the symptoms would be much greater)
Sexual activity
Erythema migrans
what are the possible complications of septic arthritis
Osteomyelitis
joint dystruction
what are the causes of osteomyelitis
S aureus (most common)
Streptococci
Enterobacter spp
H influenzae
P aeruginosa (IVDU especially)
Salmonella spp (sickle cell especially)
Haematogenous spread, direct inoculation or direct spread from nearby infection
what are clinical presentations of osteomyelitis
Limp/reluctance to weight bear
Non-specific pain at site
Malaise/fatigue
Local back pain associated with systemic symptoms
Paravertebral muscle tenderness/spasm
Local inflammation, tenderness, erythema or swelling
Fever
Spinal cord nerve root compression
what are complications of systemic lupus erythematous
Anaemia
Leukopenia
Thrombocytopenia
Raynaud’s phenomenon
What is the presentation of Ewing’s sarcoma?
Mass/swelling (normally in long bones)
Painful swelling
Redness in area surrounding tumour
Malaise
Anorexia
Weight loss
Fever
Paralysis +- incontinence (if affecting limb)
Numbness in limb
what is the presentation of chrondrosarcoma
dull deep pain
affected area is tender and swollen
normally in the pelvis, femur, humerus, scapula and ribs
how does osteosarcoma appear under X-ray
bone destruction and formation
soft tissue calcification produces a starburst appearance
how do you treat bone tumours
Analgesia and anti-inflammatory drugs
Local radiotherapy to bone metastases relieve pain and reduces risk of pathological fracture
Chemo
Hormonal therapy
Bisphosphonates (alendronate) symptomatic relief
what are risk factors of fibromyalgia
family history of fibromyalgia
rheumatological conditions
20-60 yrs
female sex
what are risk factors for recurrent lower back pain
female
age
pre-existing chronic widespread pain
psychosocial factors
what are main causes for mechanical lower back pain
Lumbar disc prolapse
Osteoarthritis
Fractures
Spondylolisthesis
Heavy manual handling
Stooping and twisting whilst
lifting
Exposure to whole body vibration
what is the management of mechanical lower back pain
Analgesia
Physio
Acupuncture
Avoid excessive rest
Re-education in manual handling
Comfortable sleeping position in medium hard mattres
what is vertebral disc degeneration
Prolapse of intervertebral disc leading to acute back pain
what are signs and symptoms of vertebral disc degeneration
sudden onset severe back pain
pain related to position and aggravated by movement
muscle spasm
radiation of pain depends on disc affected
how do you manage vertebral disc degeneration
Acute stage - bed rest, analgesia, epidural corticosteroid injection
Surgery in severe cases
physio at recovery stage
what is the aetiology of vasculitis
May be primary (this may be due to direct or indirect damage of endothelial cells of the vessel) or secondary to other conditions such as RA, SLE, hepatitis B & C, HIV, polymyositis and some allergic drug reactions.
what is vasculitis
Vasculitis means inflammation of the blood vessels through either WBC attacking the endothelial lining, or attacking healthy cells near the endothelium and indirectly damaging them
what is the pathophysiology of vasculitis
damaged endothelium exposes underlying collagen
this increases blood clotting restricting blood flow
the vessel becomes weaker making aneurysms more likely
as the vessels heal it becomes hard and stiff due to fibrin
what is the pathophysiology of pagets disease
increased osteoclastic bone resorption
formation of new weaker bone
increased local bone blood flow and fibrous tissue
non spreading but can become symptomatic in sites which were silent
