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MSK Pathology Flashcards

1
Q

Fracture

A

Break in structural continuity of bone.

Aetiology:

  • Energy transfer (high force in normal, low force in abnormal)
  • Repetitive stress (stress fracture)
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2
Q

Fracture repair mechanism

A
  1. 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)
  2. Soft callus (10-14 days) - pain subsides:
    Collagen matrix -> cartilage/fibrous tissue
    - Stability: prevents shortening only
  3. Hard callus (cartilage -> woven bone)
    - Endochondral and membranous bone formation
    - Responds to load
    - Increased rigidity -> obvious callus
  4. Bone remodelling (woven bone -> lamellar bone)
    - Wolff’s Law: thicken in large load
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3
Q

Fracture Management

A

Reduction (restore alignment)
Hold (immobilise)
Rehabilitate

Surgery: platelet concentrates (IGF, PDGF, TGF-B, VEGF), bone graft (autogenous) and substitutes

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4
Q

Pathological healing of fracture

A

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
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5
Q

Tendon repair mechanism

A
  1. Haemostasis and inflammation
  2. Organogenesis: disorganised collagen and angiogenesis
  3. Remodelling: type I collagen
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6
Q

Tendinosis

A

DEGENERATION

Intrasubstance mucoid degeneration (collagen)

  • Chronic overuse or underload
  • Swollen, painful, nodules, asymptomatic
  • Management: load progressively
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7
Q

Tendinitis

A

INFLAMMATION (intrasubstance)

  • Abrupt overload
  • Swollen, tender, hot
  • Management: offload, pain relief
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8
Q

Enthesopathy

A

Inflammation at bone insertion

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9
Q

Traction apophysitis

A

Inflammation or stress injury to growth plate area

  • e.g. Osgood Schlatter’s - patellar tendon
  • Active adolescent with inflammation + pain
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10
Q

Avulsion +/- bone fragment

A

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
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11
Q

Tendon rupture/tear

A

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
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12
Q

Tendon laceration

A

Sharp object, often younger individuals

- Surgery early

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13
Q

Other tendon injury

A
  • Crush
  • Ischaemia
  • Attrition
  • Nodules
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14
Q

Ligament injury

A

Force exceeds ligament strength and ligament separates from bone

  • Abnormal position
  • Strongly contracted muscle
  • Chronic stress
  • Complete vs incomplete
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15
Q

Ligament repair mechanism

A
  1. Haemorrhage and inflammation
  2. Proliferative: disorganised collagen laid down
  3. Remodelling: stress -> more ligament-like collagen structure
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16
Q

Ligament injury Management

A

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
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17
Q

Peripheral nerve injuries

A

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
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18
Q

Peripheral nerve injury clinical features

A

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)
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19
Q

Peripheral nerve repair mechanism

A

Regenerate slowly

  1. Wallerian degeneration of distal axons
  2. Proximal axon budding (4 days)
  3. Regeneration (1mm/day)
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20
Q

Peripheral nerve injury management

A
  • Direct (no tissue lost)
  • Nerve graft

Rule of 3:

  • Clean/sharp -> immediate (3 days)
  • Blunt/contusion -> 3 weeks
  • Closed -> 3 months
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21
Q

Shoulder (glenohumeral) dislocation

A

Anterior most common
Posterior: epileptic fits, electrocution

  • Sporting injuries
  • Accidents
  • Falling on outstretched arm
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22
Q

Shoulder dislocation clinical features

A
  • Humeral head and acromion prominent
  • Shoulder flattened
  • Arm in slight abduction
  • Elbow flexed and forearm internally rotated
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23
Q

Shoulder dislocation investigations and management

A

X-ray, arthroscopy

  • Manipulation under sedation (Hippocratic and Kocher methods)
  • Immobilisation
  • Physiotherapy
  • Surgery
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24
Q

Subacromial impingement syndrome (SAIS)

A

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)

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25
Q

Subacromial impingement syndrome clinical features and investigation

A

Painful arc on abduction between 60-120 degrees

Clinical diagnosis or arthroscopy

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26
Q

Subacromial impingement syndrome management

A

Subacromial steroid injection
Physiotherapy
Arthroscopic subacromial decompression

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27
Q

Frozen shoulder

A

Aka adhesive capsulitis

  • Primary: idiopathic
  • Secondary: post-traumatic

Painful, stiff shoulder (all movements restricted)

Normal radiograph

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28
Q

Frozen shoulder management

A

Early

  • Steroid injection
  • Physiotherapy
  • Manipulation
  • Hydrodilatation

Late:
- Surgery

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29
Q

Rotator cuff tear

A

Traumatic or degenerative damage of subscapularis, supra-/infraspinatus or teres minor

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30
Q

Rotator cuff tear investigations

A

Examination
- Pain, weakness, crepitus, decreased ROM

USS - complete vs partial

MRI - muscle quality

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31
Q

Rotator cuff tear management

A

Acute: surgery
Chronic: surgery if symptomatic

Large tear: superior capsular reconstruction

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32
Q

Shoulder arthritis

A

Inflammation of the shoulder joint

  • Osteoarthritis
  • Inflammatory arthritis
  • Post-traumatic arthritis
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33
Q

Shoulder arthritis investigation and management

A

Examination: pain, stiffness, decreased ROM, swelling

X-ray: narrowed subacromial space

Total shoulder arthroplasty is curative

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34
Q

Elbow fractures and dislocations

A
  • Sporting injuries
  • Accidents
  • Fall on outstretched hand
  • X-ray
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35
Q

Tennis elbow

A

Lateral epicondylitis

- Overuse of the extensors of the wrist

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36
Q

Golfer’s elbow

A

Medial epicondylitis

- Overuse of the flexors of the wrist

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37
Q

Tendinopathy management

A
  • Rest
  • Analgesics
  • Physiotherapy
  • Steroid injection
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38
Q

Cubital tunnel syndrome

A

Entrapment of ulnar nerve posterior to medial epicondyle

Pain, tingling and wasting of intrinsic muscles supplied by ulnar nerve

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39
Q

Cubital tunnel syndrome investigation and management

A

Examination

  • Paraesthesia on palpation of ulnar groove (Tinel sign: exacerbation with percussion over nerve)
  • Froment’s sign: weakness of thumb pinch

Ulnar nerve release

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40
Q

Main causes of spinal injury

A
  • Road traffic accidents
  • Sporting accidents
  • Falls
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41
Q

Classification of spinal injury

A

ASIA

  • A: Complete
  • B: Incomplete (sensory preserved only)
  • C: Incomplete (motor preserved - muscle grade <3)
  • D: Incomplete (motor preserved - muscle grade >3)
  • E: Normal
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42
Q

Spasticity

A

Increased muscle tone due to upper motor neuron (CNS) lesion

- Above L1

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43
Q

Tetraplegia/Quadriplegia

A

Loss of motor/sensory function in cervical segments (cervical fracture)

  • Four limbs affected
  • Respiratory failure
  • Spasticity
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44
Q

Paraplegia

A

Loss of motor/sensory function in thoracic/lumbar/sacral segments (t/l/s fracture)

  • Lower limbs affected only
  • Trunk possibly affected
  • Spasticity
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45
Q

Central cord syndrome

A

Injury to central cervical tracts of spinal cord

  • Weakness in arms > legs
  • Perianal sensation preserved
  • E.g. arthritic neck, hyperextension
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46
Q

Anterior cord syndrome

A 
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
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47
Q

Brown-Sequard syndrome

A

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
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48
Q

Spinal cord and nerve root compression aetiology

A
  1. 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
  2. Cervical and lumbar spondylosis
    - OA at facet joints, discs, ligaments -> degenerative changes, osteophyte growths
    - ^Impair spinal movement (flexion, extension), compression
  3. Spinal stenosis
    - Lateral recess, central, foraminal
    - Symptoms: weakness, backache
  4. Abnormal movement
    - Spondylolysis: stress fracture
    - Spondylolisthesis: vertebra slips onto vertebra below
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49
Q

Cauda equina syndrome

A

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)
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50
Q

Cauda equina syndrome investigations and management

A
  • PR exam: loss of anal tone
  • Urgent MRI scan

Management: surgery <48 hours after onset

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51
Q

Investigation and management of spinal injury

A

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

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52
Q

Acute Osteomyelitis Pathology

A

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

  1. Starts at metaphysis
  2. Occludes blood vessels - stasis, congestion, necrosis
  3. Acute inflammation and suppuration
  4. Rupture - medulla, subperiosteal, joint
  • Involucrum: new bone formation
  • Resolution or not
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53
Q

Acute Osteomyelitis Organisms

A

Staph aureus

Group B strep
E. Coli
Strep pyogenes
Haemophilus influenza
Mycobacterium TB
Pseudomonas aeruginosa 
Salmonella 
Candida
Anaerobes
54
Q

Acute Osteomyelitis Aetiology/Risk Factors

A

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
55
Q

Acute Osteomyelitis Clinical Features

A
  • Localised peripheral bone pain/tenderness
  • Systemic: fever, malaise, fatigue
  • Swelling
  • Erythema
  • Weight loss

Vertebral

  • Localised back pain
  • Paravertebral muscle spasm
  • Nerve compression
56
Q

Acute Osteomyelitis Complications

A
  • Abscess
  • Sepsis
  • Metastatic infection
  • Pathological fracture
  • Septic arthritis
  • Altered bone growth
  • Chronic osteomyelitis
  • SCC
57
Q

Acute Osteomyelitis Investigations

A
  • 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
58
Q

Acute Osteomyelitis Management

A
  • Supportive
  • Antibiotics
  • Surgery: drainage, debridement, stabilise
59
Q

Chronic Osteomyelitis

A

Progressive inflammatory process resulting in bone destruction, involucrum (new bone) and sequestrum (necrosis) formation

  • Cavities +/- sinuses
  • Often mixed infection
  • Persistent/intermittent localised bone pain
60
Q

Septic arthritis

A

Infection of joint (usually monoarticular)

  • Acute synovitis + purulent joint effusion
  • Destruction of articular cartilage (bacterial toxin, cellular enzyme)
61
Q

Septic arthritis organisms

A
  • Staph aureus
  • Haemophilus influenzae (immunisation)
  • E. Coli (elderly, neonates)
  • Neisseria gonorrhoeae (STI)
  • Staph epididermis (joint replacement)
62
Q

Septic arthritis route and risk factors

A
  • Haematogenous, Local or direct
  • Underlying joint disease
  • Prosthetic joint
  • Joint surgery
  • Increasing age
  • DM
  • IVDU
  • Immunosuppression
63
Q

Septic arthritis clinical features

A
  • Hot
  • Painful
  • Swollen
  • Erythema
  • Decreased ROM
  • Cannot weight bare
  • Sometimes fever
64
Q

Septic arthritis investigations

A
  • Bloods: culture, FBC, CRP, ESR
  • Fluid microscopy (aspirate)
  • Imaging: x-ray, US (hip, shoulder), MRI
65
Q

Septic arthritis management

A
  • Supportive
  • IV empirical antibiotics
  • Referral to orthopaedics
  • Sepsis-6
66
Q

Tuberculosis

A

Mycobacterium tuberculosis

  1. Primary complex (lungs, gut)
  2. Haematogenous spread
  3. TB granuloma at MSK site

Extra-articular, intra-articular, vertebral (most common)

Risk Factor: HIV, AIDS

67
Q

Tuberculosis clinical features

A

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
68
Q

Tuberculosis Investigations

A
  • Bloods: FBC, ESR
  • Sputum/urine culture
  • Mantoux test
  • X-ray/MRI: narrowing of joint space, periarticular OA
  • Joint aspiration/biopsy and microscopy
69
Q

Tuberculosis Management

A

Rest and splintage

Anti-TB medication

  • Rifampicin
  • Isoniazid
  • Ethambutol
  • Pyrazinamide

Surgery

70
Q

Benign MSK tumours

A
  • 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
71
Q

Benign MSK tumour clinical features

A
  • Pain: progressive at rest, activity-related, night
  • Mass
  • Asymptomatic (incidental)
72
Q

Primary bone malignancy

A

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
73
Q

Primary soft tissue malignancy

A

Liposarcoma

  • Painless
  • Mass deep to deep fascia
  • Any fixed, hard/indurated, recurrent mass (>5cm)
74
Q

Other primary malignancy

A
  • Chondrosarcoma
  • Fibrosarcoma, malignant fibrous histiocytoma
  • Angiosarcoma
  • Ewing’s sarcoma, lymphoma, myeloma
75
Q

Secondary bone malignancy

A

Metastatic
- very common

Frequency: vertebrae, femur, pelvis, ribs, sternum, skull

Spread from: breast, lung, prostate, kidney, thyroid, GI, melanoma

76
Q

Secondary bone malignancy clinical features

A
  • Pain: persistent, increasing, non-mechanical (rest), nocturnal
  • Vague deep-seated mass
  • Weakness
  • Hypercalcaemia
  • Pathological fracture
77
Q

Investigation of bone and soft tissue tumours

A

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
78
Q

Management of bone and soft tissue tumours

A
  • Chemotherapy - early
  • Radiotherapy
  • Surgery: Mirel’s (fracture risk) >8, embolisation, resection, prophylactic fixation
79
Q

Rheumatoid arthritis

A

Chronic autoimmune systemic illness characterised by a symmetrical peripheral arthritis and other systemic features

80
Q

Rheumatoid arthritis pathology

A
  1. Autoantibodies (rheumatoid factors, ACPA) recognise joint/systemic antigens
  2. Several mechanisms (e.g. complement activation) activate immune cells: macrophages, T/B-cells, fibroblasts etc
  3. Neutrophils (inflammatory infiltration) in synovial fluid -> synovitis (pannus)
  4. Synoviocyte proliferation and neoangiogenesis
  5. Osteoclasts and synoviocytes destroy bone and cartilage
81
Q

Rheumatoid arthritis aetiology

A

Genetic

Environmental

  • Chronic infection
  • Smoking
  • Gut microbes
  • Mycoplasma
  • Viruses
82
Q

Rheumatoid arthritis clinical aspects

A
  • Pain
  • Swelling
  • Redness, heat
  • Morning stiffness
  • Poor function, decreased ROM, immobility
  • Systemic symptoms
83
Q

Rheumatoid arthritis 1987 Classification

A
  1. Morning stiffness
  2. Arthritis of 3 or > joints
  3. Arthritis of hand
  4. Symmetric arthritis
  5. Rheumatoid nodules
  6. Serum rheumatoid factor
  7. Radiographic changes
84
Q

Rheumatoid arthritis investigations

A
  • Serum rheumatoid factor (IgG, IgM)
  • ACPA: present -> seropositive
  • Imaging: x-ray, USS

Disease activity score
<2.4 remission
>5.1 biologic therapy

85
Q

Rheumatoid arthritis management

A

MDT

  • NSAIDS
  • DMARDs - methotrexate
  • Biologic DMARDs - anti-TNFa, anti B-cell/IL-6, JAK inhibitors
  • Corticosteroids
  • Surgery
86
Q

Crystal arthropathy

A

Deposition of mineralised material within joints and periarticular tissue

87
Q

Gout

A

Monosodium urate crystal deposition in joints, commonly big toe, feet and hands, due to hyperuricaemia.
- Overproduction or undersecretion of uric acid (made from purines)

88
Q

Gout risk factors

A
  • Male
  • Elderly
  • Diet: meat, seafood, alcohol
  • Obesity
  • Diabetes
  • Hypertension
  • Heart/renal disease
  • FH
  • Drugs: aspirin, diuretics
  • HGPRT deficiency
  • Hypothyroidism
  • Exercise, starvation, dehydration
  • Malignancy
89
Q

Gout symptoms and investigations

A
  • Pain
  • Inflammation
  • Swelling
  • Limited ROM
  • Aspiration and fluid microscopy
  • Blood test
  • X-ray
  • US
90
Q

Gout management

A
  • NSAIDs
  • Colchicine
  • Corticosteroids
  • lifestyle factors/prophylaxis

Hyperuricaemia (do not treat acute or asymptomatic)

  • Xanthine oxidase inhibitors
  • Uricosurics
91
Q

Pseudogout

A

Calcium pyrophosphate dihydrate formation in synovial fluid
- Elderly female

Aetiology

  • Idiopathic
  • Familial: genetic
  • Metabolic: mineral imbalance
  • Hypothyroidism
  • Hyperparathyroidism

Triggers

  • Trauma
  • Intercurrent illness
92
Q

Pseudogout symptoms

A
  • Swollen, warm, severe pain commonly of the knee
93
Q

Pseudogout investigation and management

A
  • Aspiration and fluid microscopy
  • Blood tests
  • X-ray

No cure/prophylaxis

  • NSAIDs
  • Colchicine
  • Corticosteroids
  • Joint drainage
94
Q

Polymyalgia Rheumatica

A

Inflammatory disorder

  • Close relationship with giant cell arteritis
  • Female, elderly
95
Q

Polymyalgia Rheumatica symptoms

A
  • Sudden onset shoulder +/- pelvic girdle stiffness
  • Anaemia: malaise, depression
  • Weight loss
  • Fever
  • Arthalgia/synovitis
96
Q

Polymyalgia Rheumatica investigation and management

A
  • ESR raised
  • Dramatic steroid response
  • Prednisolone
  • Bone prophylaxis
97
Q

Osteoporosis

A

Low bone mass and microarchitectural deterioration
- formation < resorption

  • Increased fractures - Q Fracture risk assessment
  • Reduced height
  • Stooped posture
98
Q

Osteoporosis aetiology and risk factors - general, hormonal, inflammatory

A
  • 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
99
Q

Osteoporosis aetiology and risk factors - Malabsorption, Gastroenterological, medications

A

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
100
Q

Osteoporosis investigation and management

A
  • DXA scan
  • Q Fracture assessment

Prevent fractures

  • Falls prevention
  • Decrease risk factors
  • Good Ca/Vit D status
  • Medications: biphosphonates, HRT, selective oestrogen receptor modulators
101
Q

Paget’s Disease

A

Localised disorder of bone turnover

  • Increased resorption followed by increased formation
  • Disorganised -> deformity, fracture

Aetiology: Genetic, Environmental

102
Q

Paget’s Disease symptoms

A
  • Bone/joint pain, deformity or fracture
  • Stiffness
  • Swelling
  • Neurological symptoms
  • Hearing loss
  • Osteosarcoma (rare)
103
Q

Paget’s Disease Investigation and Management

A
  • Serum alkaline phosphatase elevated
  • IV biphosphonate therapy
  • Supportive
  • Surgery
  • Calcium and vit D supplementation
104
Q

Rickets and Osteomalacia

A

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

105
Q

Osteogenesis Imperfecta

A

Defects in type 1 collagen (8 types)

  1. Milder form
  2. Lethal by age 1
  3. Progressive deforming, bone dysplasia and poor growth
  4. Similar to 1 but more severe

Genetic

106
Q

Osteogenesis Imperfecta symptoms

A
  • Fragility
  • Deformity (e.g. scoliosis, barrel chest)
  • Growth deficiency
  • Ligamentous laxity (flexible)
  • Defective tooth formation
  • Hearing loss
  • Blue sclera
  • Easy bruising
  • Fatigue
107
Q

Osteogenesis Imperfecta investigation and management

A

Clinical diagnosis

IV biphosphonates
Surgery
Counselling

108
Q

Osteoarthritis

A

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
109
Q

Osteoarthritis Aetiology and Risk Factors

A

Multifactorial

Primary

  • Increasing age
  • Female
  • FH
  • Obesity
  • Manual occupations

Secondary (biomechanical imbalance):

  • Abnormal anatomy
  • Previous trauma
  • Infiltrative disease
  • CT disease
110
Q

Osteoarthritis Clinical Features and Examination

A
  • 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
111
Q

Osteoarthritis Investigations and Management

A

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

112
Q

Dupuytren’s disease/ contracture

A

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
113
Q

Trigger Finger (stenosing tenosynovitis)

A

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
114
Q

De Quervain’s Tenovaginitis

A

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
115
Q

Ganglion cyst

A

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

116
Q

OA base of thumb

A

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
117
Q

Juvenile Idiopathic Arthritis Pathology and Clinical Features

A

Group of systemic inflammatory (autoimmune) disorders affecting children <16 years.

  • Multifactorial
  • Female
  1. <16 years
  2. Duration >6 weeks
  3. Arthritis: joint swelling or 2 of: limited ROM (limp), pain, warmth
118
Q

Pauci (oligo) articular JIA

A

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

119
Q

Polyarticular JIA

A

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)

120
Q

Systemic JIA (Still’s disease)

A

Inflammation in various parts of body
- Any age, F=M

  • Spiking fever
  • Evanescent, salmon pink, macular rash
  • Lymphadenopathy
  • Hepatosplenomegaly
  • Pericarditis
121
Q

JIA Investigations

A

Bloods

  • FBC
  • ESR/CRP
  • Anti-nuclear antibodies (ANA)
  • RF
  • Anti-cyclic citrullinated peptide antibodies
  • Ferritin (SJIA)

Imaging

  • US
  • X-ray

Eye screening

122
Q

JIA Management

A

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

123
Q

Seronegative Arthritis (spondylarthritis)

A

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
124
Q

Ankylosing Spondylitis

- Seronegative Arthritis

A

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

125
Q

Psoriatic arthritis
- Seronegative Arthritis

Subtypes

A

Form of arthritis that affects people who have psoriasis (severity not related to extent of psoriasis)

Subtypes:

  1. Distal interphalangeal predominant
  2. Symmetric polyarthritis
  3. Asymmetric oligoarticular
  4. Arthritis mutilans
  5. Spondylitis
126
Q

Psoriatic arthritis
- Seronegative Arthritis

Clinical features

A

Joints

  • Neck
  • UL
  • Spine
  • LL

Extraarticular:

  • Dactylitis
  • Onycholysis and pitting of nails
127
Q

Enteropathic arthritis

- Seronegative Arthritis

A

Peripheral and/or axial arthritis associated with:

  • Crohn’s disease
  • UC
  • Coeliac disease
  • Whipple’s (bacterial infection)

Enthesopathy common

128
Q

Reactive arthritis

- Seronegative Arthritis

A

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

129
Q

Management of seronegative arthritis

A

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)
130
Q

Reiter’s syndrome

A

Triad of urethritis, conjunctivitis and arthritis

Systems (9 decks)

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