MSK - Arthritides

Question 1

What is osteoarthritis and primary cause? / RFs?

Answer 1

Asymetrical degenerative synovial disease where cartilage destruction exceeds repair = pain and instability

‘wear and tear’ cause

Obesity, age, female, occupation, hereditary predisposition?postemnopausal?

Question 2

Secondary cause?

Answer 2

Altered joint architecture and stability = further damage.

Pre-existing condition s.e.g. Rh or septic arthritis,
developmental dyspasia o hip
Wilsons, acromegaly, haemochromotosis
Trauma

Question 3

Presentation of osteoarthritis?

Answer 3

Morning stiffness <30mins, joint pain with gradual nset, worse with activity and better with rest
High-use and weight bearing joints HIP, KNEE, DIP, PIP, 1st CMV, wrist

Late = night pain, instability, deformity and loss of function

Question 4

Osteoarthritis O/E?

Answer 4

SQUARING BASE OF THUMB, heberdens and bouchards nodes, effusion and erytherma

Question 5

Ix for osteoarthritis?

Answer 5

XRAY = LOSS
Loss of joint pasce
Osteophytes
Subarticular sclerosis
Subchondral cysts

Joint aspirationn = straw coloured aspirate with high viscosity

Question 6

what is the management of osteoarthritis?

Answer 6

Lifestyle + physio
Occ.therapy
Intra-articular steroids
Joint replacement 
Stepwise analgesia:
1) Oralparacetomol +- topical NSAID/capsaicin
2) Oral NSAID + PPI
3) Opiates

Question 7

WHat is rheumatoid arthritis (RA) and Rfs?

Answer 7

Autoimmune condition causing chronic > 6weeks inflammation of the synovial lining, tendon sheaths and bursa, Characterised by symetrical polyarthritis >4 + extraarcticular manifestations

HLADR4 (common)
HLADR1
Smoking
Dhx
Women more than men in middle age

Question 8

Articular presentation of RA?

Answer 8

small joints = wrist, ankle. MCP, PIP, MTP (knees, elbows, hips, shoulders)

DIP SPARING

rapid onset or chronic

Systemic = weight loss, fatigue, malaise

Question 9

Signs of articular RA?

Answer 9

Swan Neck = hyperextended PIP and flexed DIP
Boutonnieres = DIP extendsion and PIP flexion

Radial deviation of wrist
Ulnar deviation at CP
Z deformity on thumb

Question 10

Extra-articular presentation of RA?

Answer 10

RHEUMATOID NODULES
episcleritis/scleritis
Secondary Sjorens/sicca
Lymphadenopathy
Pulmonary fibrosis/pleuritis/bronchiolitis obliterans
Pericarditis
Carpel tunnel syndrome
Tenosynovitis/bursitis

Amyloidosis, Feltys syndrome and ACD

Question 11

What is Feltys syndrome?

Answer 11

RA, neutropenia and splenomgealy

Question 12

Ix for RA?

Answer 12

Serology for RF Abs, CCP Abs,
Bloods = elevated CRP, ESR, anaemia and low albumin

Xray = joint space narrowing, joint destruction, deformity, boney reosions at joint margimns , periarticular osteopaenia
Soft tissue swelling

ELAR score 6+ = RA

Question 13

Mx for RA?

Answer 13

SHort course steroids
NSAIDS/COX2 (PPIs)
Surgery
DMARDS

Question 14

Progression of DMARDS for RA?

Answer 14

hydroxychloroquine if mild

1) Methotrextae, leflunomide, sulfasalazine
2) 2 in combo
3) methotrexate + biologic e.g. anti-TNF (infliximab/adalimumab)
4) Methotrextae + rituximab

Question 15

Risk of rituximab and anti-TNF?

Answer 15

immunosuppression -> serious infections or TB/hep B reactivation

Rituximab can cause night sweats and thrombocytopaenia

Question 16

what are the seronegative spondyloathropathies?

Answer 16

No Rh factor
HLA-B27 association and Men>women

PEAR
Psoriatic athritis
Enterohepatic arthritis
Ankylosing sponylitis
Reactive athritis

Question 17

What is ankylosing athritis and RFs?

Answer 17

Inflammatory athropathy of axial skeleton and peripheral joints, tendos/ligamens and extraarticular sites

+ve FHx
HLA-B27
ERAP-1 or IL-23R genes

Early in males, usually early 20s

Question 18

What is reactive athritis?

Answer 18

Sterile, seronegative joint inflammatio n that develops in response to extra-articular infection

RFS: HLAD-B27 (70-80%)
?sexual behaviour and STIs

20-30 years M>F

Question 19

What is Reiters syndrome?

Answer 19

Triad of reactive arthritis, urethritis and conjunctivitis

Question 20

Articular presentation of AS?

Answer 20

> 3months inflammatory back pain, sacrolilac joints and axial spine>peripheral joints

Early = pain and stiffness
late = spinal fusion, kyphosis, loss of lumbar lordosis and eneck extesnion

Question 21

articular Presentation of Reactive athritis?

Answer 21

1-4 weeks post infection
GI = salmonella, shigella, yesinina, campylobacter
GU = chamydia trachomatic, gonorrhoea

Asymetrical, oligoarthritis and lower extremitis >upper

Question 22

Extraarticular presentation of AS?

Answer 22

Anterior uveitis >40%
Apical lung fibrosis and aortic regurgitation

Psoriasis
IBD symptoms

Question 23

Reactive Arthritis extra-articular presentation?

Answer 23

Reitiers = urethritis + conunctivitis

Keratoderman blenorrhagicum

Circinate balantis

oral ulcers
Cystitis/prostatis

Question 24

How to test for AS?

Answer 24

Schobers Test = lumbar mobility
Tragus to wall (increased in AS)

Stress tests e.g. Gaenslens = sacrolilac joint pain

Question 25

Xray features or psoriatic arthitis and Eneterohepatic arthritis?

Answer 25

``` P = pencil-in-cup appearance E = marginal syndesmophytes ```

Question 26

Ix for reactive arthritis?

Answer 26

Joint aspiration gram stain, culture and sensitivies to rule out septic joint and cyrstal athropathices

Question 27

Types of amyloidosis?

Answer 27

Primary = deposit of immunoglobulin light chains. Associated with MM, lymphoma, waldenstrons macroglobulinaemia Secondary = Serum amyloid A Association with RA, IBC< chronic infections e.g. TB

Question 28

Ix for amyloidosis?

Answer 28

Apple green birenfringence under polarised light - congo red stain

Question 29

Presentation of amyloidosis?

Answer 29

``` Periorbital purpura Carpal tunnel syndrome Hepatomegaly Nephrotic syndrome Peripheral neuropathy ``` Primary as well = macroglossia and restrictive cardiomyopathy

Question 30

What is septic arthritis and features?

Answer 30

Acute monoarthritis - very painful, erythermatous, swollen, restricted ROm and fever Caused by current infection S.Aureus >30, Neisseria gonorrhoea<30

Question 31

What is Gout and what causes it?

Answer 31

Acute monoarthritis, 1st MTP is podagra Precipitated by trauma or infection. Crystal is monosodium urate adn caused bu hyperuricaemia from increased intake, increased production and decreased excretion

Question 32

Specific causes of hyperuricaemia?

Answer 32

High pruine diet and alcohol, malignancy e.g. tumour lysis syndrome

Question 33

What is pseudogout?

Answer 33

Acute monoarthritis of large joints e.g. knee. Can be polyarticular if chronic Precipitated by illness of trauma. Calcium pyrophsophate crystals

Question 34

Causes of psuedogout?

Answer 34

Idiopathic, hyperPTH, hyperPO4, hypoMg, metabolic e.g. haemochromotosis, wilsons and acromegaly

Question 35

RFs and Ix for septic athritis?

Answer 35

IV drug use, DM< immunosuppression, Joint damage: RA, prosthetic joint or gout Aspirate = tubid yellow low viscosirt fluid. Raised WCC 90% neutrophils MC&S organsim Bloods for elevated WCC and CRP

Question 36

Gout RFs and Ix?

Answer 36

Alcohol, high purine diet, obesity, male and diabetes Aspirate -> yellow, turbid, low viscosity with raised WCC (neutrophils). Needle shaped vely birefringent crystals Bloods = elevated WCC, CRP and uric acid XR = rat bite erosions

Question 37

Pseudogout RFs and Ix?

Answer 37

Elderly and female Aspirate -> turbid yellow low viscosity fluid. WCC (neutrophils). Rhomboid shaped, +vly birefringent crystals Bloods = elevated WCC and CRP Xray = chondrocalconosis

Question 38

Mx for septic, gout and pseudogout?

Answer 38

SA = IV Abx for 2 weeks and 4 weeks oral and stop biologic therapies Got acute : NSAIDS +- PPI, colchicine, corticosteroids Gout prophylaxis: allopurinaol (dont give in acute) . febuxostat, probenecid Pseudogout: intra-articular coritcosteroids +-paracetomol Polyarticular = NSAIDS +-colchicine +-paracetomil

Question 39

What is osteomyelitis?

Answer 39

Infection of bone from haematogenous spread, contiguous spread and direct inoaculation Haematogenous = IVDU, immunosuppression, DM and Sickle cell Contiguus = cellulitis and localised infection Direct - penetrating injury, ulcers and surgery Leads to inflammation, necrosis and new bone formation. Mostly Staph A, Potts diease if TB

Question 40

presentation of ostemyelitis?

Answer 40

Nonspecific pain in affected area, fever, malaise, rigors, preceding skin lesion, sore throat trauma or operation O/E = localised erytherma, swellign and warmth, reduced ROM, and discharge from wound or affected area

Question 41

Ix for osteomyelitis?

Answer 41

Raised WCC and CRP/ESR No chnages onxray 1st 2 weeks then darkening and periosteal thickening Bone culture = +ve culture

Question 42

Causative organisms in osteomyelitis>

Answer 42

Here is a breakdown of most common causative organisms of Osteomyelitis by age group (Source BMJ Best practice): Infants: S aureus, Group B streptococci, Aerobic gram-negative bacilli (e.g., Escherichia coli), Candida albicans. Children 3 months – 5 years: S aureus, Kingella kingae (increased incidence in children <4 years), Group A streptococcus, Streptococcus pneumoniae, Haemophilus influenzae (if not vaccinated), Pseudomonas (from foot puncture wounds). Children > 5 years: Staph aureus, Group A streptococcus Adults: Staph aureus, Coagulase negative staphylococci, aerobic gram negatives, anaerobic gram positive Peptostreptococcus spp. Elderly: Gram negative bacilli