MSK Pathology Flashcards
Fracture
Break in structural continuity of bone.
Aetiology:
- Energy transfer (high force in normal, low force in abnormal)
- Repetitive stress (stress fracture)
Fracture repair mechanism
- Inflammation
Haematoma and fibrin clot released into area.
Lysosomal enzymes break down by-products of cell death and bring in new cells for repair
- Fibroblasts: collagen
- Mesenchymal and osteoprogenitor cells
- Macrophages: angiogenesis (if hypoxic) - Soft callus (10-14 days) - pain subsides:
Collagen matrix -> cartilage/fibrous tissue
- Stability: prevents shortening only - Hard callus (cartilage -> woven bone)
- Endochondral and membranous bone formation
- Responds to load
- Increased rigidity -> obvious callus - Bone remodelling (woven bone -> lamellar bone)
- Wolff’s Law: thicken in large load
Fracture Management
Reduction (restore alignment)
Hold (immobilise)
Rehabilitate
Surgery: platelet concentrates (IGF, PDGF, TGF-B, VEGF), bone graft (autogenous) and substitutes
Pathological healing of fracture
Reduction of inflammation
- NSAIDs
- Lose haematoma (surgery, open fracture)
- Poor vasculature
Delayed healing -> other management
Delayed union (>6 months)
- High energy trauma
- Distraction (large gap)
- Instability
- Infection
- Smoking
- Drugs: Steroids, Immunosuppressants, Warfarin, NSAIDs, Ciprofloxacin
Non-union
- Abundant callus
- Pain/tenderness
- Persistent fracture lines or sclerosis (ends seal off) on x-ray
Tendon repair mechanism
- Haemostasis and inflammation
- Organogenesis: disorganised collagen and angiogenesis
- Remodelling: type I collagen
Tendinosis
DEGENERATION
Intrasubstance mucoid degeneration (collagen)
- Chronic overuse or underload
- Swollen, painful, nodules, asymptomatic
- Management: load progressively
Tendinitis
INFLAMMATION (intrasubstance)
- Abrupt overload
- Swollen, tender, hot
- Management: offload, pain relief
Enthesopathy
Inflammation at bone insertion
Traction apophysitis
Inflammation or stress injury to growth plate area
- e.g. Osgood Schlatter’s - patellar tendon
- Active adolescent with inflammation + pain
Avulsion +/- bone fragment
Failure at bone insertion
- Load > failure strength when contracted
- e.g. Mallet finger - torn extensor tendon (forced flexion of extended finger)
- Management: conservative (retraction), operative
Tendon rupture/tear
Intrasubstance:
- Load > failure strength
- E.g. Achilles (violent dorsiflexion of plantar flexed foot): +ve Simmond’s, palpable tender gap
Musculotendinous:
- Sudden force of contraction
Management
- If ends can be opposed (US) -> conservative (splint, cast)
- If not or high re-rupture risk -> operative
Tendon laceration
Sharp object, often younger individuals
- Surgery early
Other tendon injury
- Crush
- Ischaemia
- Attrition
- Nodules
Ligament injury
Force exceeds ligament strength and ligament separates from bone
- Abnormal position
- Strongly contracted muscle
- Chronic stress
- Complete vs incomplete
Ligament repair mechanism
- Haemorrhage and inflammation
- Proliferative: disorganised collagen laid down
- Remodelling: stress -> more ligament-like collagen structure
Ligament injury Management
Depends on extent and patient
Conservative:
- Partial, stability, poor surgical candidate
- Light (compression, brace, stability) vs supportive (walker, cast)
Operative:
- Instability, expectation, compulsory (multiple)
- Direct repair (tied)
- Augment (taped)
- Replacement
Peripheral nerve injuries
Neuropraxia (Sunderland grade 1): nerve in continuity
- Stretched/bruised
Axonotmesis (Sunderland grade 2): endoneurium intact, disruption of axons
- Stretched, compression, direct blow
Wallerian degeneration follows
Neurotmesis (Sunderland grade 3,4,5): complete nerve division
- Laceration, avulsion
- Must be repaired
Peripheral nerve injury clinical features
Dysaethesiae:
- Anaesthesia
- Hypo/hyper-anaesthesia
- Paraesthesia (pins and needles)
Motor:
- Paresis (weakness)
- Paralysis +/- wasting
- Dry skin (sweat glands not activated)
Reflexes:
- Increased (UMN)
- Diminished (LMN)
- Absent
Strength: decreased Tone: increased (UMN) or decreased (LMN) Clonus (UMN) Babinski's sign (UMN) Atrophy (LMN)
Peripheral nerve repair mechanism
Regenerate slowly
- Wallerian degeneration of distal axons
- Proximal axon budding (4 days)
- Regeneration (1mm/day)
Peripheral nerve injury management
- Direct (no tissue lost)
- Nerve graft
Rule of 3:
- Clean/sharp -> immediate (3 days)
- Blunt/contusion -> 3 weeks
- Closed -> 3 months
Shoulder (glenohumeral) dislocation
Anterior most common
Posterior: epileptic fits, electrocution
- Sporting injuries
- Accidents
- Falling on outstretched arm
Shoulder dislocation clinical features
- Humeral head and acromion prominent
- Shoulder flattened
- Arm in slight abduction
- Elbow flexed and forearm internally rotated
Shoulder dislocation investigations and management
X-ray, arthroscopy
- Manipulation under sedation (Hippocratic and Kocher methods)
- Immobilisation
- Physiotherapy
- Surgery
Subacromial impingement syndrome (SAIS)
Pain and dysfunction of shoulder joint due to any pathology decreasing subacromial space or increasing size of subacromial contents (bursa, rotator cuff muscles and tendons)
Subacromial impingement syndrome clinical features and investigation
Painful arc on abduction between 60-120 degrees
Clinical diagnosis or arthroscopy
Subacromial impingement syndrome management
Subacromial steroid injection
Physiotherapy
Arthroscopic subacromial decompression
Frozen shoulder
Aka adhesive capsulitis
- Primary: idiopathic
- Secondary: post-traumatic
Painful, stiff shoulder (all movements restricted)
Normal radiograph
Frozen shoulder management
Early
- Steroid injection
- Physiotherapy
- Manipulation
- Hydrodilatation
Late:
- Surgery
Rotator cuff tear
Traumatic or degenerative damage of subscapularis, supra-/infraspinatus or teres minor
Rotator cuff tear investigations
Examination
- Pain, weakness, crepitus, decreased ROM
USS - complete vs partial
MRI - muscle quality
Rotator cuff tear management
Acute: surgery
Chronic: surgery if symptomatic
Large tear: superior capsular reconstruction
Shoulder arthritis
Inflammation of the shoulder joint
- Osteoarthritis
- Inflammatory arthritis
- Post-traumatic arthritis
Shoulder arthritis investigation and management
Examination: pain, stiffness, decreased ROM, swelling
X-ray: narrowed subacromial space
Total shoulder arthroplasty is curative
Elbow fractures and dislocations
- Sporting injuries
- Accidents
- Fall on outstretched hand
- X-ray
Tennis elbow
Lateral epicondylitis
- Overuse of the extensors of the wrist
Golfer’s elbow
Medial epicondylitis
- Overuse of the flexors of the wrist
Tendinopathy management
- Rest
- Analgesics
- Physiotherapy
- Steroid injection
Cubital tunnel syndrome
Entrapment of ulnar nerve posterior to medial epicondyle
Pain, tingling and wasting of intrinsic muscles supplied by ulnar nerve
Cubital tunnel syndrome investigation and management
Examination
- Paraesthesia on palpation of ulnar groove (Tinel sign: exacerbation with percussion over nerve)
- Froment’s sign: weakness of thumb pinch
Ulnar nerve release
Main causes of spinal injury
- Road traffic accidents
- Sporting accidents
- Falls
Classification of spinal injury
ASIA
- A: Complete
- B: Incomplete (sensory preserved only)
- C: Incomplete (motor preserved - muscle grade <3)
- D: Incomplete (motor preserved - muscle grade >3)
- E: Normal
Spasticity
Increased muscle tone due to upper motor neuron (CNS) lesion
- Above L1
Tetraplegia/Quadriplegia
Loss of motor/sensory function in cervical segments (cervical fracture)
- Four limbs affected
- Respiratory failure
- Spasticity
Paraplegia
Loss of motor/sensory function in thoracic/lumbar/sacral segments (t/l/s fracture)
- Lower limbs affected only
- Trunk possibly affected
- Spasticity
Central cord syndrome
Injury to central cervical tracts of spinal cord
- Weakness in arms > legs
- Perianal sensation preserved
- E.g. arthritic neck, hyperextension
Anterior cord syndrome
Injury to anterior 2/3 of spinal cord. Symptoms below level of lesion - Motor weakness - Loss of pain - Loss of temperature - E.g. anterior spinal artery syndrome, hyperflexion, anterior compression fracture
Brown-Sequard syndrome
Hemi-section of spinal cord
- Paralysis (corticospinal) and loss of proprioception and fine discrimination (dorsal)
- Loss of pain and temperature on opposite side (spinothalamic)
- E.g. penetrating injuries
Spinal cord and nerve root compression aetiology
- Annulus fibrosis rupture with protrusion/prolapse of nucleus
- Posterolateral
- Cervical - 5/6
- Thoracic (rare) - T11/12
- Lumbar - L4/5 > L5/S1 > L3/4
^cauda equina syndrome - Cervical and lumbar spondylosis
- OA at facet joints, discs, ligaments -> degenerative changes, osteophyte growths
- ^Impair spinal movement (flexion, extension), compression - Spinal stenosis
- Lateral recess, central, foraminal
- Symptoms: weakness, backache - Abnormal movement
- Spondylolysis: stress fracture
- Spondylolisthesis: vertebra slips onto vertebra below
Cauda equina syndrome
Compression of cauda equina
Aetiology:
- Central lumbar disc prolapse
- Tumours
- Trauma
- Spinal stenosis
- Infection (epidural abscess)
- Iatrogenic (surgery, manipulation, epidural)
Clinical features
- Severe low back pain
- Motor/sensory loss in legs
- Saddle anaesthesia
- Bowel/bladder dysfunction (urinary retention)
Cauda equina syndrome investigations and management
- PR exam: loss of anal tone
- Urgent MRI scan
Management: surgery <48 hours after onset
Investigation and management of spinal injury
Advanced trauma life support
ABC:
Manage shock
- Neurogenic: low BP/HR, hypothermia, loss of sympathetic tone -> vasopressors
- Spinal: transient depression of cord function below level of injury (flaccid paralysis, areflexia)
D:
- Assess neurological function using ASIA (myotomes, dermatomes)
Imaging:
- X-ray, CT, MRI
Unstable fractures must be fixated surgically using pedicle screws.
Long-term: physio, occy, psychological, urological/sexual counselling
Acute Osteomyelitis Pathology
Acute onset of infection in a bone.
- Primary: local and haematogenous spread
- Secondary: open injury
Long bones: femur, tibia, humerus
Other: vertebrae
Intra-articular metaphysis joints: hip, elbow
- Starts at metaphysis
- Occludes blood vessels - stasis, congestion, necrosis
- Acute inflammation and suppuration
- Rupture - medulla, subperiosteal, joint
- Involucrum: new bone formation
- Resolution or not
Acute Osteomyelitis Organisms
Staph aureus
Group B strep E. Coli Strep pyogenes Haemophilus influenza Mycobacterium TB Pseudomonas aeruginosa Salmonella Candida Anaerobes
Acute Osteomyelitis Aetiology/Risk Factors
General
- Diabetes
- RA
- Immunocompromised
Primary
- Feet (diabetes, PVD)
- Pressure ulcer
- Any infection (e.g. UTI)
- Urological procedure history
- SCD, haemodialysis
Secondary
- Open fracture/trauma
- Surgery
Acute Osteomyelitis Clinical Features
- Localised peripheral bone pain/tenderness
- Systemic: fever, malaise, fatigue
- Swelling
- Erythema
- Weight loss
Vertebral
- Localised back pain
- Paravertebral muscle spasm
- Nerve compression
Acute Osteomyelitis Complications
- Abscess
- Sepsis
- Metastatic infection
- Pathological fracture
- Septic arthritis
- Altered bone growth
- Chronic osteomyelitis
- SCC
Acute Osteomyelitis Investigations
- Bloods: ESR/CRP, FBC, U&Es, Culture
- Imaging: x-ray (normal until 2 weeks), MRI, US, isotope bone scan, labelled WC scan
- Microbiological: bone biopsy, swab
Acute Osteomyelitis Management
- Supportive
- Antibiotics
- Surgery: drainage, debridement, stabilise
Chronic Osteomyelitis
Progressive inflammatory process resulting in bone destruction, involucrum (new bone) and sequestrum (necrosis) formation
- Cavities +/- sinuses
- Often mixed infection
- Persistent/intermittent localised bone pain
Septic arthritis
Infection of joint (usually monoarticular)
- Acute synovitis + purulent joint effusion
- Destruction of articular cartilage (bacterial toxin, cellular enzyme)
Septic arthritis organisms
- Staph aureus
- Haemophilus influenzae (immunisation)
- E. Coli (elderly, neonates)
- Neisseria gonorrhoeae (STI)
- Staph epididermis (joint replacement)
Septic arthritis route and risk factors
- Haematogenous, Local or direct
- Underlying joint disease
- Prosthetic joint
- Joint surgery
- Increasing age
- DM
- IVDU
- Immunosuppression
Septic arthritis clinical features
- Hot
- Painful
- Swollen
- Erythema
- Decreased ROM
- Cannot weight bare
- Sometimes fever
Septic arthritis investigations
- Bloods: culture, FBC, CRP, ESR
- Fluid microscopy (aspirate)
- Imaging: x-ray, US (hip, shoulder), MRI
Septic arthritis management
- Supportive
- IV empirical antibiotics
- Referral to orthopaedics
- Sepsis-6
Tuberculosis
Mycobacterium tuberculosis
- Primary complex (lungs, gut)
- Haematogenous spread
- TB granuloma at MSK site
Extra-articular, intra-articular, vertebral (most common)
Risk Factor: HIV, AIDS
Tuberculosis clinical features
Long Hx
Bone TB:
- Pain (esp at night)
- Swelling
- Decreased ROM
- Abscesses
General TB:
- Low grade pyrexia
- Night sweats
- Fatigue
- Weight loss
Advanced bone TB:
- Neurological complications (e.g. carpal tunnel syndrome, paraplegia, paralysis)
- Muscle wasting
- Ankylosis and deformity
Tuberculosis Investigations
- Bloods: FBC, ESR
- Sputum/urine culture
- Mantoux test
- X-ray/MRI: narrowing of joint space, periarticular OA
- Joint aspiration/biopsy and microscopy
Tuberculosis Management
Rest and splintage
Anti-TB medication
- Rifampicin
- Isoniazid
- Ethambutol
- Pyrazinamide
Surgery
Benign MSK tumours
- Osteoid osteoma (small, self-limited)
- Osteoblastoma (larger, >aggressive)
- Endochondroma, osteochondroma
- Fibroma
- Haemangioma, aneurysmal bone cyst
- Lipoma (soft tissue) - <5cm
- Giant cell tumours
- Simple bone cyst
- Fibrous cortical defect
Benign MSK tumour clinical features
- Pain: progressive at rest, activity-related, night
- Mass
- Asymptomatic (incidental)
Primary bone malignancy
Osteosarcoma
- Pain: increasing deep boring ache, worse at night
- Loss of function: difficulty weight bearing, reduced ROM, stiffness
- Deep swelling
- Pathological fracture
- Joint effusion
- Deformity
- Neurological complications
- Systemic symptoms
Primary soft tissue malignancy
Liposarcoma
- Painless
- Mass deep to deep fascia
- Any fixed, hard/indurated, recurrent mass (>5cm)
Other primary malignancy
- Chondrosarcoma
- Fibrosarcoma, malignant fibrous histiocytoma
- Angiosarcoma
- Ewing’s sarcoma, lymphoma, myeloma
Secondary bone malignancy
Metastatic
- very common
Frequency: vertebrae, femur, pelvis, ribs, sternum, skull
Spread from: breast, lung, prostate, kidney, thyroid, GI, melanoma
Secondary bone malignancy clinical features
- Pain: persistent, increasing, non-mechanical (rest), nocturnal
- Vague deep-seated mass
- Weakness
- Hypercalcaemia
- Pathological fracture
Investigation of bone and soft tissue tumours
History and examination
- General health
- Measurements, changes and characteristics of mass (location, shape, consistency, mobility, tendermess)
- Neurovascular deficits
Investigation
- Bloods: FBC, LFTs, U&E
- X-ray
- MRI: size, extent, relations
- Bone scan
- CT cap: staging
- Biopsy
Management of bone and soft tissue tumours
- Chemotherapy - early
- Radiotherapy
- Surgery: Mirel’s (fracture risk) >8, embolisation, resection, prophylactic fixation
Rheumatoid arthritis
Chronic autoimmune systemic illness characterised by a symmetrical peripheral arthritis and other systemic features
Rheumatoid arthritis pathology
- Autoantibodies (rheumatoid factors, ACPA) recognise joint/systemic antigens
- Several mechanisms (e.g. complement activation) activate immune cells: macrophages, T/B-cells, fibroblasts etc
- Neutrophils (inflammatory infiltration) in synovial fluid -> synovitis (pannus)
- Synoviocyte proliferation and neoangiogenesis
- Osteoclasts and synoviocytes destroy bone and cartilage
Rheumatoid arthritis aetiology
Genetic
Environmental
- Chronic infection
- Smoking
- Gut microbes
- Mycoplasma
- Viruses
Rheumatoid arthritis clinical aspects
- Pain
- Swelling
- Redness, heat
- Morning stiffness
- Poor function, decreased ROM, immobility
- Systemic symptoms
Rheumatoid arthritis 1987 Classification
- Morning stiffness
- Arthritis of 3 or > joints
- Arthritis of hand
- Symmetric arthritis
- Rheumatoid nodules
- Serum rheumatoid factor
- Radiographic changes
Rheumatoid arthritis investigations
- Serum rheumatoid factor (IgG, IgM)
- ACPA: present -> seropositive
- Imaging: x-ray, USS
Disease activity score
<2.4 remission
>5.1 biologic therapy
Rheumatoid arthritis management
MDT
- NSAIDS
- DMARDs - methotrexate
- Biologic DMARDs - anti-TNFa, anti B-cell/IL-6, JAK inhibitors
- Corticosteroids
- Surgery
Crystal arthropathy
Deposition of mineralised material within joints and periarticular tissue
Gout
Monosodium urate crystal deposition in joints, commonly big toe, feet and hands, due to hyperuricaemia.
- Overproduction or undersecretion of uric acid (made from purines)
Gout risk factors
- Male
- Elderly
- Diet: meat, seafood, alcohol
- Obesity
- Diabetes
- Hypertension
- Heart/renal disease
- FH
- Drugs: aspirin, diuretics
- HGPRT deficiency
- Hypothyroidism
- Exercise, starvation, dehydration
- Malignancy
Gout symptoms and investigations
- Pain
- Inflammation
- Swelling
- Limited ROM
- Aspiration and fluid microscopy
- Blood test
- X-ray
- US
Gout management
- NSAIDs
- Colchicine
- Corticosteroids
- lifestyle factors/prophylaxis
Hyperuricaemia (do not treat acute or asymptomatic)
- Xanthine oxidase inhibitors
- Uricosurics
Pseudogout
Calcium pyrophosphate dihydrate formation in synovial fluid
- Elderly female
Aetiology
- Idiopathic
- Familial: genetic
- Metabolic: mineral imbalance
- Hypothyroidism
- Hyperparathyroidism
Triggers
- Trauma
- Intercurrent illness
Pseudogout symptoms
- Swollen, warm, severe pain commonly of the knee
Pseudogout investigation and management
- Aspiration and fluid microscopy
- Blood tests
- X-ray
No cure/prophylaxis
- NSAIDs
- Colchicine
- Corticosteroids
- Joint drainage
Polymyalgia Rheumatica
Inflammatory disorder
- Close relationship with giant cell arteritis
- Female, elderly
Polymyalgia Rheumatica symptoms
- Sudden onset shoulder +/- pelvic girdle stiffness
- Anaemia: malaise, depression
- Weight loss
- Fever
- Arthalgia/synovitis
Polymyalgia Rheumatica investigation and management
- ESR raised
- Dramatic steroid response
- Prednisolone
- Bone prophylaxis
Osteoporosis
Low bone mass and microarchitectural deterioration
- formation < resorption
- Increased fractures - Q Fracture risk assessment
- Reduced height
- Stooped posture
Osteoporosis aetiology and risk factors - general, hormonal, inflammatory
- Female
- Elderly
- White, Asian
- FH
- Lifestyle: eating disorders, sedentary, excessive alcohol, smoking
Hormones:
- Low sex
- High TH
- High/low PTH
- High adrenal (Cushing’s)
- Low pituitary
- High prolactin
Inflammatory:
- Rheumatic: RA, ankylosing spondylitis, polymyalgia rheumatica, SLE
- UC, Crohn’s, IBD
Osteoporosis aetiology and risk factors - Malabsorption, Gastroenterological, medications
Malabsorption:
- GI surgery
- CF
- Coeliac disease
- Whipple’s
- Short gut syndrome
- Ischaemic bowel
Cerebral palsy
Multiple myeloma
Gastroenterological:
- LD
- Primary Biliary Cholangitis
- Alcoholic/viral cirrhosis
Medications:
- Steroids
- PPI
- Antiepileptic
- Aromatase inhibitors
- GnRH inhibitors
- Warfarin
Osteoporosis investigation and management
- DXA scan
- Q Fracture assessment
Prevent fractures
- Falls prevention
- Decrease risk factors
- Good Ca/Vit D status
- Medications: biphosphonates, HRT, selective oestrogen receptor modulators
Paget’s Disease
Localised disorder of bone turnover
- Increased resorption followed by increased formation
- Disorganised -> deformity, fracture
Aetiology: Genetic, Environmental
Paget’s Disease symptoms
- Bone/joint pain, deformity or fracture
- Stiffness
- Swelling
- Neurological symptoms
- Hearing loss
- Osteosarcoma (rare)
Paget’s Disease Investigation and Management
- Serum alkaline phosphatase elevated
- IV biphosphonate therapy
- Supportive
- Surgery
- Calcium and vit D supplementation
Rickets and Osteomalacia
Severe nutritional vitamin D or calcium deficiency
- Rickets = children
- Osteomalacia = epiphyseal growth plates fused
- Soft weak bones (deformity)
- Bone pain
- Poor growth
- Muscle weakness
Blood test, x-ray or DEXA scan
Diet and vitamin supplements
Osteogenesis Imperfecta
Defects in type 1 collagen (8 types)
- Milder form
- Lethal by age 1
- Progressive deforming, bone dysplasia and poor growth
- Similar to 1 but more severe
Genetic
Osteogenesis Imperfecta symptoms
- Fragility
- Deformity (e.g. scoliosis, barrel chest)
- Growth deficiency
- Ligamentous laxity (flexible)
- Defective tooth formation
- Hearing loss
- Blue sclera
- Easy bruising
- Fatigue
Osteogenesis Imperfecta investigation and management
Clinical diagnosis
IV biphosphonates
Surgery
Counselling
Osteoarthritis
Progressive, degradative loss of articular cartilage and remodelling of the underlying bone
- Primary: unknown cause
- Secondary: known cause
Biomechanical mediators elevated
- IL-1
- TNF-a
- MMPs
Osteoarthritis Aetiology and Risk Factors
Multifactorial
Primary
- Increasing age
- Female
- FH
- Obesity
- Manual occupations
Secondary (biomechanical imbalance):
- Abnormal anatomy
- Previous trauma
- Infiltrative disease
- CT disease
Osteoarthritis Clinical Features and Examination
- 45+ with activity-related joint pain (relieved by rest)
Plus either; - no morning stiffness
- morning stiffness <30 mins
Commonly: knee, hip, spine, hands and feet
Examination:
- Bouchard (PIPJ) and Heberden (DIPJ) nodes
- Fixed flexion deformity or varus misalignment of knee
- Reduced ROM and crepitus
Osteoarthritis Investigations and Management
Blood tests
X-ray (LOSS)
- Loss of joint space
- Osteophytes
- Subchondral sclerosis
- Subchondral cysts
Education
MDT
Non-pharmacological: heat, exercise, weight loss, aids and devices
Pharmacological: oral analgesia, topical NSAIDs, intra-articular corticosteroid
Referral for surgery: osteotomy, arthrodesis, arthroplasty
Dupuytren’s disease/ contracture
Pathology:
Growth factors -> myofibroblasts -> collagen production, intracellular contractile elements
Aetiology: sporadic, FH (auto dom)
Clinical diagnosis - cannot straighten
Management:
- Observe
- Radiotherapy
- Operate (fasciectomy)
- Collagenase
- Arthrodesis
- Amputation
Trigger Finger (stenosing tenosynovitis)
Swelling in tendon catches on pulley of tendon sheath
- Ring > thumb > middle
- Local trauma
Clinical diagnosis - clicking sensation with movement, lump/feel triggering over pulley
Management:
- Splintage
- Steroid injection
- Operative
De Quervain’s Tenovaginitis
Swelling in extensor tendons around base of thumb
- Female
- Frequent thumb abduction and ulnar deviation
- Symptoms: pain (radial wrist, worse on movement), localised swelling and tenderness
Positive Finklestein’s test
Management:
- Splint
- Steroid injection
- Operative
Ganglion cyst
Fluid-filled swelling that usually develops near a joint/tendon
- Myoxid degeneration from joint synovia
Clinical diagnosis: firm, non-tender, smooth, mobile lump
Management: reassure, observe, aspirate, excision
OA base of thumb
Common: 1 in 3 women
Clinical:
- Pain (opening jars)
- Stiffness
- Swelling
- Deformity - dorsal subluxation, metacarpal adduction, MCPJ hyperextension
- Loss of function
X-ray
Management:
- Lifestyle
- NSAIDs
- Splint
- Steroid injection
- Surgery: Trapeziectomy, fusion, joint replacement
Juvenile Idiopathic Arthritis Pathology and Clinical Features
Group of systemic inflammatory (autoimmune) disorders affecting children <16 years.
- Multifactorial
- Female
- <16 years
- Duration >6 weeks
- Arthritis: joint swelling or 2 of: limited ROM (limp), pain, warmth
Pauci (oligo) articular JIA
4 or less joints affected (asymmetric)
- Early age onset
- Limp
- No systemic features
- Asymptomatic uveitis
Type 1: LL>UL
Type 2: LL»UL
Type 3: UL + LL
Polyarticular JIA
4 or more joints affected in first 6 months (symmetric)
- Systemic features
- Anaemia
- Nodules (RF +ve)
- Growth deformities
RF +ve: late onset
RF -ve: biphasic onset (2-4, 6-12)
Systemic JIA (Still’s disease)
Inflammation in various parts of body
- Any age, F=M
- Spiking fever
- Evanescent, salmon pink, macular rash
- Lymphadenopathy
- Hepatosplenomegaly
- Pericarditis
JIA Investigations
Bloods
- FBC
- ESR/CRP
- Anti-nuclear antibodies (ANA)
- RF
- Anti-cyclic citrullinated peptide antibodies
- Ferritin (SJIA)
Imaging
- US
- X-ray
Eye screening
JIA Management
MDT:
- Physio, OT, orthotics, ophthalmologist
Uveitis: topical steroids, DMARDs, biologics
1st line: analgesia, NSAIDs
2nd line: methotrexate, anti-TNF, IL-1/6 antagonist
Steroids: local, systemic
Surgery: synovectomy, replacement
Seronegative Arthritis (spondylarthritis)
Rheumatoid arthritis that tests negative for RF and ACCP
- Autoimmune inflammatory disease
Arthritis (asymmetric) of large joints in hands and feet and spine
Extraarticular features:
- Enthesitis
- Uveitis
- IBD
- Secondary amyloidosis
- Osteoporosis
Ankylosing Spondylitis
- Seronegative Arthritis
Predilection for axial skeleton and entheses
- Male, 20-30s
- Back pain
- Morning stiffness
- Decreased lumbar ROM
- Decreased chest expansion
Extra-articular:
- Cardiac: aortic incompetence, heart block
- Restrictive resp disease
- Cauda equina
Imaging: x-ray, MRI
Psoriatic arthritis
- Seronegative Arthritis
Subtypes
Form of arthritis that affects people who have psoriasis (severity not related to extent of psoriasis)
Subtypes:
- Distal interphalangeal predominant
- Symmetric polyarthritis
- Asymmetric oligoarticular
- Arthritis mutilans
- Spondylitis
Psoriatic arthritis
- Seronegative Arthritis
Clinical features
Joints
- Neck
- UL
- Spine
- LL
Extraarticular:
- Dactylitis
- Onycholysis and pitting of nails
Enteropathic arthritis
- Seronegative Arthritis
Peripheral and/or axial arthritis associated with:
- Crohn’s disease
- UC
- Coeliac disease
- Whipple’s (bacterial infection)
Enthesopathy common
Reactive arthritis
- Seronegative Arthritis
Arthritis after distant infection
- Urogenital
- Respiratory
- GI
- Systemic
Usually mono or oligo (204) arthritis
- Dactylitis
- Enthesitis
Extra-articular:
- Skin and mucous membrane: urethritis, conjunctivitis, iritis, KB (heel), CB
Management of seronegative arthritis
MDT: physio, OT
Medication:
- NSAIDs (not enteropathic)
- DMARDs
- Biologics: anti-TNF, anti-IL-17/23
- Steroids
- Biphosphonates
- Antibiotics (reactive)
Surgery
- Stabilisation/replacement
- Bowel resection (enteropathic)
Reiter’s syndrome
Triad of urethritis, conjunctivitis and arthritis
