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MSK > MSK Clincal 2 > Flashcards

MSK Clincal 2 Flashcards

1
Q

What evidence of autoimmunity is there in rheumatoid arthritis

A

High serum levels of autoantibodies such as rheumatoid factors and anti-citrullated peptide antibodies

They recognise either joint antigens or systemic antigens

  • can be present for many years before the onset of clinical arthritis
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2
Q

The rheumatoid synovitis (pannus) is characterised by

A

inflammatory cell infiltration, synoviocyte proliferation and neoangiogenesis

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3
Q

Autoantibodies in seropositive rheumatoid arthritis

A

Rheumatoid factor

Anti citrullinated protein antibody

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4
Q

How does ACPA+ disease affect the prognosis of RA

A

Less favourable

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5
Q

Environmental factors that are associated with RA

A

Smoking and bronchial stress

Infectious agents - EBV, CMV, e.coli, mycoplasma, peridontal disease

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6
Q

What does repeated environmental insults in a susceptible individual lead to (in RA)

A

Formation of immune complexes triggers rheumatoid factor

Altered citrullination (change aminoacids) of proteins and breakdown of tolerance resulting in ACPA response

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7
Q

ACPA response in RA

A

Gingiva insult causes uptake Tcell activation in genetically susceptible individuals causing B cells and ACPA production (antibodies)

–> immune complexes

–> joint inflammation
(–>citrillinated human joint proteins
–> Immune complexes)

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8
Q

Systemic consequences of RA

A

Vasculitis, nodules, scleritis, amyloidosis = secondary to uncontrolled chronic inflammation

CV disease (altered lipid metabolism and increased endothelial activation)

Fatigue and reduced cognitive function

Liver (Elevated acute phase response; anaemia of chronic disease)

Lungs (interstitial lung disease, fibrosis)

Muscles - sarcopoenia

Bone - osteoporosis

Secondary sjorgen’s syndrome (multisystem autoimmune disease)

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9
Q

Male vs female prevalence of RA

A

1M: 3F

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10
Q

Drugs for symptomatic relief of RA

A

Analgesics +/- NSAIDs

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11
Q

Adverse effects of NSAIDs

A

GI irritation - indigestion, ulceration - consider PPI for gastroprotection

Bronchospasm in asthmatics

Renal impairment

Hypersensitivity reactions

Increased BP, fluid retention

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12
Q

Disease modifying anti-rheumatic drugs - DMARDS

A 
Methotrexate 
Sulphasalazine 
Leflunomide 
Hydroxychloroquine
Azathioprine 
Mycophenolate mofetil
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13
Q

Most effective DMARD

A

Methotrexate

Because faster onset of action (6 weeks to 3 months) compared to other

Can be given parenterally

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14
Q

Side effects of methotrexate

A

Nausea, stomatitis

Haematological toxicity

Hepatic toxicity
- LFTs, cirrhosis, hepatic fibrosis

Pulmonary toxicity

  • TERATOGENIC
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15
Q

What can be given to reduce side effects of methotrexate

A

Folic acid

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16
Q

Biologics in RA

A

Specifically target pro-inflammatory mediators

Anti-TNF
- infliximab

Anti B cell
- rituximab

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17
Q

Safety concerns with biologic DMARDs

A 
Serious infections 
Opportunistic infections (TB)
Malignancies/lymphoma 
Demyelination 
Administration reactions 
Hepatic side effects 
Autoantibodies and drug induced lupus
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18
Q

Treatment of RA

A

Disease modifying anti-reumatic drugs

  • methotrexate
  • sulfasalazine

Corticosteroids
- prednisolone

Biologics

  • anti TNF
  • anti B
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19
Q

Osteoporosis risk factors

A

Old age
Genetic predisposition
Nutritional factors - low body weight and poor calcium and vit D
Immobility
Diseases influencing bone turn over; thyrotoxicosis, malabsorption, inflammatory arthritis
Medications: steroids, warfarin, TCA, diabetic medications, anticonvulsants

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20
Q

Antiresorptive agents for use in osteoporosis

A

HRT - not into 60s as increases stroke risk

SERMS

Biphosphonates (alendronate, risedronate)

RANKL inhibitors

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21
Q

Side effects of bisphosphonates

A

Oesophagitis

Iritis/uveitis

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22
Q

What is denosumab and what are the indications

A

Monoclonal antibody against RANKL
- for when bisphosphonates not well tolerated as treatment for osteoporosis

Reduces osteoclastic bone resorption

Subcut injection every 6 months

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23
Q

Side effects of denosumab

A

Allergy/rash

Symptomatic hypocalcaemia when vit D deplete

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24
Q

Side effects of strontium

A

Increased clotting risk

Increased cardiovascular risks

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25
Q

Causes of osteomalacia

A

VITAMIN D DEFICIENCY

Primary - environmental due to not making enough e.g. No sunlight exposure or nutritional deficit if vegan and don’t eat fish oils, and egg yolk

Secondary - partial gastrectomy, small bowel malabsorption, pancreatic disease; chronic renal failure; anti-convulsants

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26
Q

Clinical features of osteomalacia

A

Mose assymptomatic

Bone pain (worse on weight bearing)

Bone tenderness

Proximal muscle weakness without atrophy

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27
Q

Aetiology of pagets disease

A

Viral - paramyoxoviruses

Genetic

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28
Q

Paget’s disease clinical features

A

Monostotic or polystotic

Axial skeleton and long bones are common sites

Some may experience bone pain (at night especially)

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29
Q

Which genes are implicated in susceptibility to RA and severity of disease

A

Class II makpr histocompatibility complex genes PTPN22 and peptiylarginine transferases

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30
Q

Impingement syndrome symptoms

A

Pain in shoulder that may radiate down arm - worse when activities above shoulder level

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31
Q

Impingement syndrome may lead to

A

Rotator cuff tendinitis/tear

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32
Q

Examination findings of impingement syndrome

A

Painful arc and positive hawkin’s test

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33
Q

Rotator cuff tear partial vs complete

A

Partial - able to abduct, painful and weak

Complete - passively able to abduct

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34
Q

Frozen shoulder

A

More common in diabetes

May present with acute, severe pain

Limitation of passive as well as active range of motion (hence not like rotator cuff tear)

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35
Q

Presentation of bicipital tendonitis

A

Resisted supination

Resisted forwards flexion of arm in supination

Pain in biceps tendon

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36
Q

Classification of clavicle fracture

A

Medial, middle and lateral thirds

Undisplaced/displaced

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37
Q

Common way to injure proximal humerus

A

Fall onto outstretched hand

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38
Q

Symptoms of shoulder dislocation

A

Axillary nerve - deltoid power and badge area sensation

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39
Q

Most common direction of dislocation for shoulder

A

Anterior 80-85%
Posterior 10%
Inferior

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40
Q

Treatment for shoulder dislocation

A

Acute - reduction under anaesthetic/sedation

Non-operative - physiotherapy

Operative

  • arthroscopic (key-hole) stablisation
  • open stabilisation +/- bone block
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41
Q

Presentation of medial epicondylitis

A

Pain worse on wrist flexion and forearm pronation against resistance

42
Q

Treatment medial epicondylitis

A

Tendinopathy at flexor tendon origin

NSAIDs
Physiotherapy
Steroid injection
Surgery

43
Q

Common name for medial epicondylitis

A

Golfer’s elbow

44
Q

Common name for lateral epicondylitis

A

Tennis elbow

45
Q

Presentation of lateral epicondylitis

A

Pain worse on resisted wrist extension and forearm supination

46
Q

Cubital tunnel syndrome presentation

A

Entrapment is of the ulnar nerve

  • parasthesia in ulnar 1 and 1/2 fingers
  • weakness in interosseus fingers of hand
  • symptoms worse on elbow flexion q
47
Q

Treatment of cubital tunnel syndrome

A

Night splint

Surgical release

48
Q

Where is the cubital tunnel

A

Between the olecranon process and medial epicondyle at elbow

49
Q

After a first time anterior shoulder dislocation in a 18 yr old male rugby player, the risk of recurrence is

A

90%

50
Q

Who gets dupuytrens

A

More common in males and earlier

Is an autosomal dominant trait with variable penetrance (may be sex linked onset)

30% sporadic

Associated conditions

51
Q

Conditions associated with dupuytrens

A

Diabetes

Alcohol

Tobacco

HIV

Epilepsy

52
Q

Functional problems associated with dupuytrens

A

Usually not painful

Loss of finger extension - active or passive

Hand in pocket

Gripping things

Washing face

53
Q

Treatment of dupuytren’s disease

A

Non operative - observe, radiotherapy (splints dont work)

Operative - PARTIAL FASCIECTOMY, dermofasciectomy, arthrodesis, amputation; percutaneous needle fasciotomy; collagenase

54
Q

Recurrence of dupuytrens after partial fasciectomy

A

50% at 5 years

55
Q

Who gets trigger finger

A

Women more frequently than men

40-60s

Ring>thumb>hand

Associated with RA, DM, gout

56
Q

Diagnosis of trigger finger

A

Patient history

Clicking sensation with movement of digit

Palpable lump in palm over a1 pulley; feel the triggering

57
Q

Treatment of trigger finger

A

Non-operative
Splintage
Steroids

Operative
Percutaneous release
Open surgery

58
Q

Symptoms of de quervain’s syndrome

A

Several weeks pain localised to radial side of thumb

Aggrevated by movement of the thumb

May have seen a localised swelling

Localised tenderness over tunnel

59
Q

Who gets de quervain’s syndrome

A

Females 6:1 m

50-60

Increased in post partum and lactating females

Activities with frequent thumb abduction and ulnar deviation –> washerwoman’s sprain

60
Q

What is affected by de quervain’s syndrome

A

1st dorsal extensor compartment

Fibro-osseos tunnel at distal radius

Thickening of localised segment

61
Q

Treatment of de quervain’s syndrome

A

Non-operative
- splints and steroid injection

Operative
- decompression

62
Q

Muscles affected by carpal tunnel syndrome

A

Lumbricals
Opponens pollicis
Abdctor pollicis brevis
Flexor pollicis brevis

63
Q

Who gets carpal tunnel syndrome

A

Female > M 3:1

Idiopathic

Inflammatory arthritis
Fracture
Pregnancy or other conditions with abnormal fluid homeostasis

64
Q

Symptoms of carpal tunnel syndrome

A

Numbness and tingling

Pins and needles

Night symptoms

Drop things

Occasionally pain

65
Q

Diagnosis of carpal tunnel syndrome

A

Both hands

Wasting of thenar eminence

Power of thenar muscles

Thumb abduction

Phalen’s test
Tinel’s test
Nerve conduction studies

66
Q

Describe phalen’s test

A

Ask the patient to hold hands in upside down prayer for 30 seconds/manually extend?

67
Q

Tinel’s test

A

…

68
Q

Treatment of carpal tunnel syndrome

A

Non-operative

  • underlying problem
  • splint
  • steroid injection

Operative

  • carpal tunnel release
  • open
  • endoscopic
69
Q

Diagnosis of cubital tunnel syndrome

A

Numbness and tingling in little and ring finger

Increased with activity (especially involving elbow bending)

Hand clumsiness

Occasionally pain around elbow

70
Q

Treatment of cubital tunnel syndrome

A

Non-operative

  • activity modificaiton
  • extension splint

Operative
- surgical decompression

71
Q

What is a ganglion

A

A myxoid degeneration from joint synovia

  • arise from joint capsule, tendon sheath or ligament
72
Q

Who gets ganglia

A

70% of all discrete swellings in the hand and wrist

More common in females

Wide age distribution but peak 20-40

Dorsal>volar

May be associated with recurrent injury around wrist

73
Q

Ganglia diagnosis

A

Lump

Firm non tender

Smooth

Occasionally lobulated

Normally not fixed to underlying tissues
NEVER fixed to skin

74
Q

Treatment for ganglia

A

Reassure and observe

Needle aspiration

Operative

  • excision
  • including the root
75
Q

Aetiology of meniscal injury

A

twisting movement on a loaded fixed knee

76
Q

clinical features of meniscal injury

A

painful “squelch”
slow swelling
painful to weight bear
“locked” knee

77
Q

Aetiology of ACL tear

A

forward momentum, leg fixed +/- rotation

78
Q

clinical features of ACL tear

A

“pop”
quick swelling
often able to weight bear

79
Q

collateral tears

A

lateralised pain
feel of “crack”, sharp pain
no or minimal effusion
bruising to one side

80
Q

in knee pain Xray is best examination for

A 
fracture 
loose bodies 
ligament avulsion
osteochondral defect 
degenerative joint disease
lipohaemarthrosis
81
Q

in knee pain ultrasound is best for

A

tendon rupture
some meniscal tears
swellings
cysts

82
Q

valgus deformity vs varus

A

> = varus

83
Q

main causes of swollen knee

A

bony swellings
synocial thickening
fluid collection

84
Q

fluid collection in the knee

A 
effusion = generalised
localised = inflamed bursa
85
Q

how to test for knee effusions

A

bulge test for small

patellar tap for large effusions

86
Q

how to differentiate a baker’s cyst from a DVT

A

both produce calf swelling, pitting oedema, pain (when cyst ruptures) and redness

Ultrasound

87
Q

tendon injury categories

A 
degeneration 
inflammation 
enthesiopathy (muscle origin commonly)
traction apophysitis
avulsion +/- bone fragment
tear/rupture
88
Q

mechanism of rupture of Achilles tendon

A

1) pushing off with weightbearing forefoot whilst extending knee joint (e.g. sprint starts)
2) unexpected dorsiflexion
3) violent dorsiflexion of plantar flexed foot (e.g. fall from height)

89
Q

repair of Achilles tendon rupture

A

conservative - cast for 10 weeks

operative - especially for younger active patients

90
Q

Most common site for Achilles tendon to rupture

A

musculotendinous junction

- medial head of gastrocnemius at musculotendinous junction with tendon

91
Q

Sacral dermatomes short cut

A

STAND on S1
SLEEP on S2
SIT on S3
SHIT on S4

92
Q

Roots of femoral nerve

A

L2,3,4

93
Q

path of the femoral nerve

A

Through the psoas; exits pelvis under inguinal ligament, lateral to femoral artery, vein and lymphatic channels in femoral triangle - VAN with Vein next to V of legs

supplies quadriceps

terminates in saphenous nerve

94
Q

saphenous nerve

A

termination of femoral nerve
- long fine sensory branch that accompanies femoral artery

goes in front of medial malleolus to supply great toe

95
Q

which nerve supplies sensory innervation to lateral aspect of thigh

A

lateral femoral cutaneous nerve

96
Q

roots of sciatic nerve

A

L4-S3

97
Q

what does the sciatic nerve supply

A

posterior thigh (hamstrings), part of adductor magnus and all lower leg and foot via terminal branches

98
Q

sciatic nerve is at risk from

A

posterior dislocation of hip, intra-muscular injections and during surgery

99
Q

divisions of sciatic nerve

A

tibial and common fibular

100
Q

roots of common fibular nerve

A

L4-S2

101
Q

when is the common fibular nerve at risk

A

as passes round lateral aspect of neck of fibula

102
Q

deficit of common fibular nerve causes

A

foot drop and slapping gait

MSK (12 decks)

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