MSK Clincal 2 Flashcards
What evidence of autoimmunity is there in rheumatoid arthritis
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
The rheumatoid synovitis (pannus) is characterised by
inflammatory cell infiltration, synoviocyte proliferation and neoangiogenesis
Autoantibodies in seropositive rheumatoid arthritis
Rheumatoid factor
Anti citrullinated protein antibody
How does ACPA+ disease affect the prognosis of RA
Less favourable
Environmental factors that are associated with RA
Smoking and bronchial stress
Infectious agents - EBV, CMV, e.coli, mycoplasma, peridontal disease
What does repeated environmental insults in a susceptible individual lead to (in RA)
Formation of immune complexes triggers rheumatoid factor
Altered citrullination (change aminoacids) of proteins and breakdown of tolerance resulting in ACPA response
ACPA response in RA
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)
Systemic consequences of RA
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)
Male vs female prevalence of RA
1M: 3F
Drugs for symptomatic relief of RA
Analgesics +/- NSAIDs
Adverse effects of NSAIDs
GI irritation - indigestion, ulceration - consider PPI for gastroprotection
Bronchospasm in asthmatics
Renal impairment
Hypersensitivity reactions
Increased BP, fluid retention
Disease modifying anti-rheumatic drugs - DMARDS
Methotrexate Sulphasalazine Leflunomide Hydroxychloroquine Azathioprine Mycophenolate mofetil
Most effective DMARD
Methotrexate
Because faster onset of action (6 weeks to 3 months) compared to other
Can be given parenterally
Side effects of methotrexate
Nausea, stomatitis
Haematological toxicity
Hepatic toxicity
- LFTs, cirrhosis, hepatic fibrosis
Pulmonary toxicity
- TERATOGENIC
What can be given to reduce side effects of methotrexate
Folic acid
Biologics in RA
Specifically target pro-inflammatory mediators
Anti-TNF
- infliximab
Anti B cell
- rituximab
Safety concerns with biologic DMARDs
Serious infections Opportunistic infections (TB) Malignancies/lymphoma Demyelination Administration reactions Hepatic side effects Autoantibodies and drug induced lupus
Treatment of RA
Disease modifying anti-reumatic drugs
- methotrexate
- sulfasalazine
Corticosteroids
- prednisolone
Biologics
- anti TNF
- anti B
Osteoporosis risk factors
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
Antiresorptive agents for use in osteoporosis
HRT - not into 60s as increases stroke risk
SERMS
Biphosphonates (alendronate, risedronate)
RANKL inhibitors
Side effects of bisphosphonates
Oesophagitis
Iritis/uveitis
What is denosumab and what are the indications
Monoclonal antibody against RANKL
- for when bisphosphonates not well tolerated as treatment for osteoporosis
Reduces osteoclastic bone resorption
Subcut injection every 6 months
Side effects of denosumab
Allergy/rash
Symptomatic hypocalcaemia when vit D deplete
Side effects of strontium
Increased clotting risk
Increased cardiovascular risks
Causes of osteomalacia
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
Clinical features of osteomalacia
Mose assymptomatic
Bone pain (worse on weight bearing)
Bone tenderness
Proximal muscle weakness without atrophy
Aetiology of pagets disease
Viral - paramyoxoviruses
Genetic
Paget’s disease clinical features
Monostotic or polystotic
Axial skeleton and long bones are common sites
Some may experience bone pain (at night especially)
Which genes are implicated in susceptibility to RA and severity of disease
Class II makpr histocompatibility complex genes PTPN22 and peptiylarginine transferases
Impingement syndrome symptoms
Pain in shoulder that may radiate down arm - worse when activities above shoulder level
Impingement syndrome may lead to
Rotator cuff tendinitis/tear
Examination findings of impingement syndrome
Painful arc and positive hawkin’s test
Rotator cuff tear partial vs complete
Partial - able to abduct, painful and weak
Complete - passively able to abduct
Frozen shoulder
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)
Presentation of bicipital tendonitis
Resisted supination
Resisted forwards flexion of arm in supination
Pain in biceps tendon
Classification of clavicle fracture
Medial, middle and lateral thirds
Undisplaced/displaced
Common way to injure proximal humerus
Fall onto outstretched hand
Symptoms of shoulder dislocation
Axillary nerve - deltoid power and badge area sensation
Most common direction of dislocation for shoulder
Anterior 80-85%
Posterior 10%
Inferior
Treatment for shoulder dislocation
Acute - reduction under anaesthetic/sedation
Non-operative - physiotherapy
Operative
- arthroscopic (key-hole) stablisation
- open stabilisation +/- bone block
Presentation of medial epicondylitis
Pain worse on wrist flexion and forearm pronation against resistance
Treatment medial epicondylitis
Tendinopathy at flexor tendon origin
NSAIDs
Physiotherapy
Steroid injection
Surgery
Common name for medial epicondylitis
Golfer’s elbow
Common name for lateral epicondylitis
Tennis elbow
Presentation of lateral epicondylitis
Pain worse on resisted wrist extension and forearm supination
Cubital tunnel syndrome presentation
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
Treatment of cubital tunnel syndrome
Night splint
Surgical release
Where is the cubital tunnel
Between the olecranon process and medial epicondyle at elbow
After a first time anterior shoulder dislocation in a 18 yr old male rugby player, the risk of recurrence is
90%
Who gets dupuytrens
More common in males and earlier
Is an autosomal dominant trait with variable penetrance (may be sex linked onset)
30% sporadic
Associated conditions
Conditions associated with dupuytrens
Diabetes
Alcohol
Tobacco
HIV
Epilepsy
Functional problems associated with dupuytrens
Usually not painful
Loss of finger extension - active or passive
Hand in pocket
Gripping things
Washing face
Treatment of dupuytren’s disease
Non operative - observe, radiotherapy (splints dont work)
Operative - PARTIAL FASCIECTOMY, dermofasciectomy, arthrodesis, amputation; percutaneous needle fasciotomy; collagenase
Recurrence of dupuytrens after partial fasciectomy
50% at 5 years
Who gets trigger finger
Women more frequently than men
40-60s
Ring>thumb>hand
Associated with RA, DM, gout
Diagnosis of trigger finger
Patient history
Clicking sensation with movement of digit
Palpable lump in palm over a1 pulley; feel the triggering
Treatment of trigger finger
Non-operative
Splintage
Steroids
Operative
Percutaneous release
Open surgery
Symptoms of de quervain’s syndrome
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
Who gets de quervain’s syndrome
Females 6:1 m
50-60
Increased in post partum and lactating females
Activities with frequent thumb abduction and ulnar deviation –> washerwoman’s sprain
What is affected by de quervain’s syndrome
1st dorsal extensor compartment
Fibro-osseos tunnel at distal radius
Thickening of localised segment
Treatment of de quervain’s syndrome
Non-operative
- splints and steroid injection
Operative
- decompression
Muscles affected by carpal tunnel syndrome
Lumbricals
Opponens pollicis
Abdctor pollicis brevis
Flexor pollicis brevis
Who gets carpal tunnel syndrome
Female > M 3:1
Idiopathic
Inflammatory arthritis
Fracture
Pregnancy or other conditions with abnormal fluid homeostasis
Symptoms of carpal tunnel syndrome
Numbness and tingling
Pins and needles
Night symptoms
Drop things
Occasionally pain
Diagnosis of carpal tunnel syndrome
Both hands
Wasting of thenar eminence
Power of thenar muscles
Thumb abduction
Phalen’s test
Tinel’s test
Nerve conduction studies
Describe phalen’s test
Ask the patient to hold hands in upside down prayer for 30 seconds/manually extend?
Tinel’s test
…
Treatment of carpal tunnel syndrome
Non-operative
- underlying problem
- splint
- steroid injection
Operative
- carpal tunnel release
- open
- endoscopic
Diagnosis of cubital tunnel syndrome
Numbness and tingling in little and ring finger
Increased with activity (especially involving elbow bending)
Hand clumsiness
Occasionally pain around elbow
Treatment of cubital tunnel syndrome
Non-operative
- activity modificaiton
- extension splint
Operative
- surgical decompression
What is a ganglion
A myxoid degeneration from joint synovia
- arise from joint capsule, tendon sheath or ligament
Who gets ganglia
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
Ganglia diagnosis
Lump
Firm non tender
Smooth
Occasionally lobulated
Normally not fixed to underlying tissues
NEVER fixed to skin
Treatment for ganglia
Reassure and observe
Needle aspiration
Operative
- excision
- including the root
Aetiology of meniscal injury
twisting movement on a loaded fixed knee
clinical features of meniscal injury
painful “squelch”
slow swelling
painful to weight bear
“locked” knee
Aetiology of ACL tear
forward momentum, leg fixed +/- rotation
clinical features of ACL tear
“pop”
quick swelling
often able to weight bear
collateral tears
lateralised pain
feel of “crack”, sharp pain
no or minimal effusion
bruising to one side
in knee pain Xray is best examination for
fracture loose bodies ligament avulsion osteochondral defect degenerative joint disease lipohaemarthrosis
in knee pain ultrasound is best for
tendon rupture
some meniscal tears
swellings
cysts
valgus deformity vs varus
> = varus
main causes of swollen knee
bony swellings
synocial thickening
fluid collection
fluid collection in the knee
effusion = generalised localised = inflamed bursa
how to test for knee effusions
bulge test for small
patellar tap for large effusions
how to differentiate a baker’s cyst from a DVT
both produce calf swelling, pitting oedema, pain (when cyst ruptures) and redness
Ultrasound
tendon injury categories
degeneration inflammation enthesiopathy (muscle origin commonly) traction apophysitis avulsion +/- bone fragment tear/rupture
mechanism of rupture of Achilles tendon
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)
repair of Achilles tendon rupture
conservative - cast for 10 weeks
operative - especially for younger active patients
Most common site for Achilles tendon to rupture
musculotendinous junction
- medial head of gastrocnemius at musculotendinous junction with tendon
Sacral dermatomes short cut
STAND on S1
SLEEP on S2
SIT on S3
SHIT on S4
Roots of femoral nerve
L2,3,4
path of the femoral nerve
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
saphenous nerve
termination of femoral nerve
- long fine sensory branch that accompanies femoral artery
goes in front of medial malleolus to supply great toe
which nerve supplies sensory innervation to lateral aspect of thigh
lateral femoral cutaneous nerve
roots of sciatic nerve
L4-S3
what does the sciatic nerve supply
posterior thigh (hamstrings), part of adductor magnus and all lower leg and foot via terminal branches
sciatic nerve is at risk from
posterior dislocation of hip, intra-muscular injections and during surgery
divisions of sciatic nerve
tibial and common fibular
roots of common fibular nerve
L4-S2
when is the common fibular nerve at risk
as passes round lateral aspect of neck of fibula
deficit of common fibular nerve causes
foot drop and slapping gait
