MSK conditions Flashcards
What are some red flags for joint pain?
Limping Not weight bearing Hot, inflamed or swollen joint Fever Systemic symptoms (tachycardia, tachypnoea)
What joint condition is acute, can deteriorate very quickly and needs to be immediately treated?
Septic arthritis
What investigation can be done if septic arthritis is suspected?
Joint aspiration and culture
How is septic arthritis treated?
Joint aspiration and culture to find specific abx
Drainage of the joint
Analgesia
Steroid injection to help pain possibly
What symptoms will someone with rheumatoid arthritis classically present with?
Symmetrical small joint pain (joints are tender and erythematous)
Stiffness of joints
Pain worse in the morning, gets better during the day
MCP joints most commonly affected
What investigations should you do if you suspect rheumatoid arthritis?
ESR/CRP (inflammatory markers)
Rheumatoid factor
anti-CCP antibody
Xrays
What are the classic features of rheumatoid arthritis that you might see on x ray?
Bony erosions Deformity (ulnar deviation) Loss of joint space Osteopenia or osteoporosis Soft tissue swelling
How would you manage rheumatoid arthritis?
Short course steroids (to induce remission) DMARDs (eg methotrexate) Biologics (tnf alpha blockers) NSAIDs Physiotherapy
What is ankylosing spondylitis?
A chronic inflammatory arthropathy that mainly affects the sacroliliac joints
Is ankylosing spondylitis mechanical or inflammatory?
Inflammatory
What is the difference between ankylosing spondylitis and axial spondyloarthropathy?
Axial spondyloarthropathy= only affects the axial skeleton
Ankylosing spondylitis= may have other symptoms like uveitis
What symptoms will someone with ankylosing spondylitis classically present with?
Recurrent back pain Pain worse in the morning Pain is worse with rest and improves with exercise Pain wakes people up at night Buttock pain Anterior uveitis
What criteria must someone meet for referral to rheumatology for ankylosing spondylitis?
Under age of 45 with back pain for longer than 3 months
Pain is inflammatory not mechanical
Pain is worse in the morning then improves
Pain wakes them up in the second half of the night
Pain is better with exercise
Pain if relieved within 48 hrs of NSAID use
Current or past psoriasis
Current or past arthritis
Who is more likely to get ankylosing spondylitis?
Male sex
Young adults
Those with family history
What investigations might be done for ankylosing spondylitis? What would the results be
Bloods- ESR and CRP may be raised
HLA B27
X rays of the sacroiliac joints- may see ankylosis, sclerosis (thickening of the bone), erosion, sacroilitis
MRI may be done to look for inflammation of the tissue where it may not be visible on x ray
How is ankylosing spondylitis managed?
Non pharmacological= exercises/stretches
Pharmacological= NSAIDs, if pain is still not managed add paracetamol/codeine, DMARDs, TNF alpha inhibitors
What is ankylosis?
Fusion of the joints
What are complications of ankylosing spondylitis?
Spinal fusion which results in severe disability
What symptom in ankylosing spondylitis warrants an immediate referral to rheumatology?
Anterior uveitis
What is meant by parenchymal lung tissue?
Functional lung tissue
What is sarcoidosis?
A chronic granulomatous disorder wherein there is an accumulation of lymphocytes and macrophages most often in the lungs, and they form non caseating granulomas
What symptoms will someone with sarcoidosis classically present with?
Non productive cough Dyspnoea that gets worse as the disease progresses Fatigue Lymphadenopathy Pain in the knees, ankles and wrists Uveitis
Who is most likely to get sarcoidosis?
Bimodal age distribution so in 30s or 50s
Slightly higher prevalence in black people
What are the first line investigations for sarcoidosis? What would you susepct to see?
ESR- raised
CRP- raised
Chest x ray- lymphadenopathy etc
Serum urea- raised if theres renal involvement
Serum creatinine- raised if theres renal involvement
LFTs- AST and ALT raised if theres liver involvement
Serum calcium- hypercalcaemia
ECG- to rule out cardiac involvement
What electrolyte balance is common in sarcoidosis and why?
Hypercalcaemia, macrophages and lymphocytes make calcitriol unregulated
What is the first line treatment for sarcoidosis
If symptoms are mild eg stage 1/2 or early stage 3 none is needed
Otherwise first line oral corticosteroids
What organ does sarcoidosis affect?
Most commonly the lung but it can affect any organ
How many stages to sarcoidosis are there and what are they briefly?
There are 4 stages (I-IV):
I- lymphadenopathy of the hilar nodes in the lung
II- lymphadenopathy and parenchymal (functional lung tissue) disease
III- parenchymal disease alone
IV- fibrosis
What is gout?
An acute inflammatory reaction to the deposition of urate crystals in a joint
What joint is most likely to be affected by gout?
The big toe
What symptoms will someone with gout classically present with?
Acute joint pain Severe pain (often the worst they have ever felt) Swelling Tenderness Tophi
Who is more likely to get gout?
Older people
Male sex
Those on certain drugs as aspirin, cyclosporin,
Those who consume meat, alcohol etc
What drugs might predispose someone to gout?
Aspirin
Cyclosporin
What is the first line investigation for gout? What will you expect to see
Arthrocentesis- you will see raised white cells (primarily neutrophils), needle shaped crystals and negative birifringence
What shaped crystals and birifringence will you see on arthrocentesis in gout?
Needle shaped crystals with negative birifringence
How is gout managed?
First line NSAIDs, colchicine and corticosteroids
If recurrent use allopurinol to reduce urate levels
What is pseudogout?
An inflammatory arthropathy due to the deposition of calcium pyrophosphate crystals
What type of crystals are deposited in pseudogout?
Calcium pyrophosphate
What are the 2 types of pseudogout and how do they differ?
Acute
Chronic- this mimics osteoarthritis
What symptoms will someone with pseudogout classically present with?
Acutely painful joint(s) Involvement of joints not typically associated with osteoarthritis eg wrists, shoulder Tenderness Effusion Sudden worsening of osteoarthritis
What are the first line investigations for pseudogout? What would you expect to see?
Arthrocentesis of joint with synovial fluid analysis- you would see rhomboid shaped crystals with positive birifringence
X ray of the joint- may show calcification of the cartilage and depositions along the cartilage line
What is osteoarthritis?
A condition affecting the whole joint where due to wear and tear there is destruction of cartilage, subchondral bone and ECM
What symptoms will someone with osteoarthritis classically present with?
Joint pain- usually involving hands, knees, hips
Antalgic gait
Hand features
Pain associated with activity
Lack of morning stiffness or morning stiffness that lasts under 30 mins
What joints in the hands are affected in osteoarthritis?
DIP and PIP
Base of thumb
What joint in the hands is spared in osteoarthritis?
MCP
What are some signs you might see on the hands on someone with osteoarthritis?
Squaring of the joint at the base of the thumb
Wasting of the thenar muscles
Involvement of DIP, PIP and base of thumb joints
Heberdens nodes on the DIPs
Douchards nodes on the PIPs
Ulnar or radial deviation
How will knee joints be affected in osteoarthritis?
Bilaterally
How will the hip be affected in osetoarthritis?
Pain due to weight bearing
Painful internal rotation when hip is flexed
Pain may cause an antalgic gait where the patient lurches towards the affected hip and spends less time weight bearing on it
Who is more likely to have osteoarthritis?
Those of older age
Those with family history
Those with physically demanding occupations
Female sex
What is the first line investigation for osteoarthritis and what would you expect to see?
Although diagnosis is mostly clinical and x ray of the joint may be done. You would see subchondral cysts and sclerosis, osteophytes, narrowing of the joint space
How is osteoarthritis managed?
Lifestyle advice: weight loss of they are obese, avoid repetitive movements eg pinching, weight bearing with the thumb
Pharmacologically use paracetamol and topical NSAIDs
Switch or oral NSAIDs if the pain is not managed or stronger analgesia eg codeine
Refer to physiotherapy for muscle strengthening exercises
In terms of signs in the hands how can you differentiate osteoarthritis from rheumatoid?
Osteo= DIP, PIP, base of thumb joint affected Rheumatoid= MCPs affected
What is osteomalacia
A metabolic bone disorder where there is incomplete mineralisation of the underlying mature organic bone matrix after the fusion of adult growth plates
What symptoms will someone with osteomalacia classically present with?
Diffuse bone pain- more the lower extremities
Proximal muscle weakness
Fractures (more easily than usual eg with small minimal movements)
Who is more likely to get osteomalacia?
Those with low vitamin D and calcium in their diet
CKD patients
Those with low exposure to the sun
What are the first line investigations for osteomalacia? What would you expect to see?
Serum calcium- low or normal Serum PTH- high Serum phosphate- high May also do Serum alkaline phosphatase- high Urea: creatinine ratio- raised
How is osteomalacia managed?
Calcium plus vitamin D
What is osteomyelitis?
Infection and inflammation of the bone
What symptoms will someone with osteomyelitis classically present with?
Acutely painful joint Low grade localised pain with a mild fever if chronic Inability to weight bear Trouble walking Erythema Tenderness Swelling Malaise Fatigue Fever
Who is more likely to get osteomyelitis?
Immunocompromised patients eg HIV CKD IV drug users Penetrating injury Recent fracture Recent surgery Recent URTI in children
How is a child with osteomyelitis likely to present?
Acutely
Limping or trouble weight bearing on a joint/ bone
They may have had a recent URTI
They may be unvaccinated against heamophilius influenzae B
What is it important to check in a child if you suspect they have osteomyelitis?
Have they been vaccinated against haemophilius influenzae B
In who is acute vs chronic osteomyelitis more common?
Acute= children Chronic= adutls
What are the first line investigations for osteomyelitis and what would you expect to see?
FBC- WCC may be raised
ESR- raised
CRP- raised
Blood culture- may be positive for infectious agent
What infectious agent most commonly causes osteomyelitis?
Staph aureus
How is osteomyelitis managed?
Antibiotic therapy
Consider surgery eg if the spine is involved then refer to spinal surgeons
Supportive therapy eg analgesia
What antibiotics are used in osteomyelitis first line for children and adults?
Adults= flucoxacillin Children= cefazolin
What is osteoporosis?
A bone disorder where there is reduced bone density and disruption to the architecture of bone making patients more susceptible to fragility fractures
How will someone with osteoporosis classically present?
They are usually picked up via screening tools and assessment but they may present with a fragility fracture or with kyphosis/ spinal/ back pain
Who is at risk of osteoporosis?
Older age Low vit d/ calcium Post menopausal women White ancestry Smokers Excessive alcohol intake Low BMI/ significant weight loss On long term corticosteroids
What is the first line investigation for osteoporosis? What would the result be?
DXA scan- would show up with a T score of less then -2.5
Before doing so you may also want to use a risk stratifying tool eg FRAX
May need an xray if they present with a fragility fracture
How is osteoporosis managed?
Lifestyle advice= exercise to improve muscle strength, quit smoking, more vitamin D and calcium in diet, more sunlight exposure, reduce alcohol intake
Pharmacological= bisphosphonates (alendronate or risendronate) once daily or higher dose once weekly (only for men), vitamin D and calcium supplements if levels are low
What are some complications of osteoporosis?
Fragility fracture- most commonly hip, knees, wrists
Who is eligible for osteoporosis screening?
Women above 65 Men above 75 Women and men above 50 who: - have had a previous fragility fracture - smoke - drink over 14 units of alcohol weekly - have used long term corticosteroids - a hx of falls
How often do osteoporosis patients need a review of their medication?
After 3-5 years of taking it
Remeasure their bone density and see if the medication needs to be continued
What is reactive arthritis?
An inflammatory arthritis that develops after an GI or genitourinary infection
What usually precedes an episode of reactive arthritis?
Genitourinary infection eg chlamydia
GI infection
What symptoms will someone with reactive arthritis classically present with?
A previous GI or genitourinary infection
Painful, swollen, red joints
Triad of conjunctivitis, post infectious arthritis and non gonococcal urethritis
Enthesitis- inflammation where tendon or ligament inserts into bone
Pain worse with rest and better with movement
Pain worse in the morning then gets better
Swollen digits
Who is more likely to get reactive arthritis?
Male sex
HLA-B27 phenotype
Preceding chlamydia or GI infection
What are the first line investigations for reactive arthritis? What would you expect to see?
ESR-raised
CRP- raised
ANA antibody- to rule out other arthritis
X ray of joint- may see enthesitis
Arthrocentesis- to rule out crystal arthropathy
How is reactive arthritis managed?
First line NSAID
If stronger treatment is needed use corticosteroids eg prednisolone
If chronic use DMARDs
What is rheumatoid arthritis?
An erosive, chronic arthritis that is diagnosed when there is evidence of synovial inflammation that isn’t caused by anything else
What symptoms will someone with rheumatoid arthritis classically present with?
Pain in the small joints of the hands and feet symmetrically
Swollen, stiff, hot joints
Stiffness worse in the morning and lasts for an hour
Extra articular features eg vascular lesions, uveitis, rheumatoid nodules
Joint pain worse with inactivity
Who is more likely to get rheumatoid arthritis?
50-55 year olds/ increasing age
Female sex
What are the first line investigations for rheumatoid arthritis?
Diagnosis can be clinical
May do rheumatoid factors, if this is negative anti CCP antibody, x ray of the joint to determine severity
To establish baseline and monitor effectiveness of treatment, on diagnosis do: FBC ESR CRP Renal function tests LFTs
How is rheumatoid arthritis managed?
First line conventional DMARDs (cDMARDs) eg oral methotrexate, leflunomide, sulfasalazine
While the DMARD is working a glucocorticoid may be given to relieve symptoms
What are some complications of rheumatoid arthritis?
CAD
ILD
Joint replacement
Workplace disability
What is swan neck deformity? Describe what happens at the joint involved and what it looks like
A feature of rheumatoid arthritis, the PIPs are hyperextended and DIPs are hyperflexed (it looks like the weird thing i can do with my fingers)
What are some clinical signs of rheumatoid arthritis?
Swan neck deformity
Ulnar deviation
Rheumatoid nodules
Where specifically are rheumatoid nodules seen?
On the extensor surfaces of tendons
What is septic arthritis?
Infection of one or more joints by pathogenic inoculation of microbes
What symptoms will someone with septic arthritis classically present with?
Painful, swollen, red joint
Unable to weight bear/ walk
Acute pain (< 2 weeks)
Fever
Who is more likely to get septic arthritis?
Open wound Immunocompromised Prosthetic joint Exposure to lyme disease Gonococcal infection
What are the first line investigations for septic arthritis? What would you see
Synovial fluid WCC- may be raised, lower in gonococcal
Synovial fluid microscopy- may be positive
Synovial fluid culture- may be positive
Blood culture- may be positive if spread haematologically
ESR
CRP
LFTs
U+Es
X ray of the joint
How is septic arthritis managed?
Follow local guidelines for sepsis
If possible do synovial fluid analysis before starting abx
Pathogen specific abx
Analgesia if needed
How can you tell someone might have septic arthritis when you examine them?
The joint will be extremely painful to move and they will be very reluctant to let you examine it
What is the first step in management when you suspect septic arthritis of a prosthetic joint and why?
Refer to orthopaedic surgery
They have to aspirate it in a sterile surgical environment and it may need more specialist care
What might you find septic arthritis co exists with when synovial fluid microscopy is undertaken? What will you see?
Crystal arthropathy- you might see urate or pyrophosphate crystals indicating gout and pseudogout respectively alongside the septic arthritis
