MSK/Rheum Flashcards
investigation for ankylosing spondylitis?
- XRAY spine - sacroilitis, squaring of lumbar vertebrae, syndemophytes.
- inflammatory markers raised
- HLA-B27 (90% but also 10% in normal patient)
management of ankylosing spondylitis?
- exercise
- NSAIDs - first line.
- physio
- intra-auricular corticosteroids +/- DMARDS can be given (rarely)
- anti-TNF if very severe
lateral knee pain in runner?
iliotibial band syndrome
DEXA scan T-score:
> -1.0 = ?
-1.0 to -2.5 = ?
< -2.5 = ?
> -1.0 = normal
-1.0 to -2.5 = osteopaenia
< -2.5 = osteoporosis
clinical findings for ankylosing spondolytitis ?
reduced chest expansion, reduced lateral flexion and reduced forward flexion (Schober’s test)
Osteomalacia - inadequate levels of what?
Vit D, calcium or phosphate
Typical investigation findings in osteomalacia?
↓Calcium
↓Phosphate
↑ALP
↑Parathyroid hormone
X-rays: Looser lines (or zones) which are lucencies going part of the way through the bone
Management of osteomalacia?
A vitamin D level of < 25 nmol/L = deficiency, requires high dose treatment initially followed by maintenance treatment.
A vitamin D level of between 25-50 nmol/L = insufficiency, can be treated with long term maintenance therapy alone.
(may also require calcium supplements)
Adhesive capsulitis (Frozen shoulder) clinical presentation?
- external rotation is affected more than internal rotation or abduction
- both active and passive movement is affected
- episodes last 6m to 2y.
management of frozen shoulder?
- NSAIDs
- physiotherapy
- oral corticosteroids
- intra-articular corticosteroids
Bilateral shoulder and hip-girdle pain - most likely diagnosis?
polymyalgia rheumatica
Treatment for polymyalgia rheumatica?
prednisolone
Ligamentous injuries of the knee joint investigation?
MRI
pain worse on wrist extension against resistance with the elbow extended or supination of the forearm with the elbow extended = ?
Lateral epicondylitis
investigation for achilles tendon rupture?
ultrasound
Urethritis + conjunctivitis + arthritis + post infection = ?
reactive arthritis
Reactive arthritis management?
symptomatic: analgesia, NSAIDS, intra-articular steroids
sulfasalazine and methotrexate are sometimes used for persistent disease
Polymyalgia rheumatica clinical presentation?
- patient > 60 years old
- rapid onset (e.g. < 1 month)
- aching, morning stiffness in proximal limb muscles
- mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats
polymyalgia rheumatica investigations?
raised inflammatory markers - ESR >40mm/hr
Polymyalgia rheumatica management?
prednisolone
High twisting force applied to a bent knee + ‘pop’-crack sound + joint swelling and effusion + pain = ?
anterior cruciate ligament rupture
Tests for ACL rupture?
+ve anterior drawer test
lachman test +ve
lateral knee and joint line tenderness
Common causes of PCL rupture?
hyperextension injuries
dashboard trauma
direct force to tibia from the front
tests for PCL rupture?
posterior drawer test +ve
posterior sag test +ve
twisting injuries + delayed swelling = ?
meniscal tear
What is psuedogout?
a form of microcrystal synovitis caused by the deposition of calcium pyrophosphate dihydrate crystals in the synovium
Presentation of pseudogout?
- knee, wrist and shoulders most commonly affected
- joint aspiration: weakly-positively birefringent rhomboid-shaped crystals
- x-ray: chondrocalcinosis
Management of psuedogout?
- aspiration of joint fluid, to exclude septic arthritis
- NSAIDs or intra-articular, intra-muscular or oral steroids
What is polymyositis?
Inflammatory disorder causing symmetrical, proximal muscle weakness
Presentation of polymyositis?
- proximal muscle weakness +/- tenderness
- Raynaud’s
- respiratory muscle weakness
- interstitial lung disease(e.g. fibrosing alveolitis or organising pneumonia)
- dysphagia, dysphonia
Investigations for polymyositis?
- Elevated creatine kinase
- other muscle enzymes (lactate dehydrogenase (LDH), aldolase, AST and ALT) are also elevated in 85-95% of patients
- EMG
- muscle biopsy
- anti-synthetase antibodies
- anti-Jo-1 antibodies are seen in pattern of disease associated with lung involvement, Raynaud’s and fever
Management of polymyositis?
- high-dose corticosteroids tapered as symptoms improve
- azathioprine may be used as a steroid-sparing agent
What is paget’s disease of the bone?
A disease of increased but uncontrolled bone turnover - primarily a disorder of osteoclasts, with excessive osteoclastic resorption followed by increased osteoblastic activity.
Bones commonly affected in paget’s disease of the bone?
skull, spine/pelvis, and long bones of the lower extremities.
Clinical presentation of paget’s disease of the bone?
mostly asymptomatic (95%)
Bone pain + isolated raised ALP
bowing of tibia
bossing of skull
Investigations for paget’s disease of the bone?
Bloods - raised ALP
XRAY- osteolysis in early disease → mixed lytic/sclerotic lesions later
skull x-ray: thickened vault, osteoporosis circumscripta
Management of paget’s disease of the bone?
Biphosphonates (either oral risedronate or IV zoledronate)
Which classification system is used for hip fractures?
Garden:
Type I: Stable fracture with impaction in valgus
Type II: Complete fracture but undisplaced
Type III: Displaced fracture, usually rotated and angulated, but still has boney contact
Type IV: Complete boney disruption
Management of intracapsular non-displaced hip fracture?
Internal fixation or hemiarthroplasty if unfit
Management of intracapsular displaced hip fracture?
Arthroplasty (total hip replacement or hemiarthroplasty)
When would you consider total hip replacement over hemiarthroplasty in intracapsular hip fractures?
- patients were able to walk independently out of doors with no more than the use of a stick and
- are not cognitively impaired and
- are medically fit for anaesthesia and the procedure.
Management of extracapsular (stable intertrochanter) hip fracture?
dynamic hip screw
Management of extracapsular (reverse oblique, transverse or subtrochanteric fractures) hip fracture?
intramedullary device
What would you find on joint aspirated fluid in gout?
Needle shaped crystals - Negatively birefringent of polarised light
- Monosodium urate crystals
Management of gout?
Acute:
- NSAIDs (e.g. ibuprofen) - first-line
- Colchicine - second-line
- Steroids - third-line
Prophylaxis:
- allupurinol
When would you check uric acid levels in gout?
Serum uric acid can be checked after acute episode settles down (usually 2 weeks)
Tingling in 1st, 2nd and 3rd finger = ?
Carpal tunnel (median nerve)
Tingling in fingers 4 and 5 = ?
Cubital tunnel (ulnar nerve)
Most common cause of osteomyelitis + which part of bone usually affected?
Staph aureus
(salmonella in sickle cell patients)
Most commonly affected metaphysis of the long bones
Investigations for osteomyelitis?
MRI - diagnostic
raised inflammatory markers and WBC
blood cultures +/- bone marrow aspirate
Management of osteomyelitis?
flucloxacillin - 6 weeks
clindamycin if penicillin-allergic
What are the features of limited cutaneous systemic sclerosis?
C - calcinosis
R – Raynaud’s phenomenon
E – oEsophageal dysmotility
S – Sclerodactyly
T – Telangiectasia
What are the features of diffuse cutaneous systemic sclerosis?
CREST +
- cardiovascular problems e.g. hypertension, coronary artery disease
- lung problems e.g. pulmonary hypertension and pulmonary fibrosis
- kidney problems e.g. glomerulonephritis
Which antibodies are associated with diffuse cutaneous systemic sclerosis?
ANA + Anti-Scl-70
Which antibodies are associated with limited cutaneous systemic sclerosis?
ANA + anti-centromere
Management of diffuse systemic sclerosis?
steroids + immunosuppressants
Key X-ray findings in osteoarthritis?
L - loss of joint space
O - osteophytes
S - subchondral sclerosis (increased density of the bone along the joint line)
S - subchondral cysts (fluid filled holes in the bone)
Management of OA?
analgesia:
1st - paracetamol + topical NSAID/capsaicin cream
2nd - oral NSAIDs + PPI
3rd - opiates
Intra-auricular steroid infection
Joint replacement
What is SLE?
An inflammatory autoimmune connective tissue disease
Presentation of SLE?
Non-specific symptoms
Fatigue
Weight loss
Arthralgia (joint pain) and non-erosive arthritis
Myalgia (muscle pain)
Fever
Photosensitive malar rash.
Lymphadenopathy and splenomegaly
SOB
Pleuritic chest pain
Mouth ulcers
Hair loss
Raynaud’s phenomenon
Investigations for SLE?
FBC - normocytic anaemia of chronic disease
C3/C4 - decreased in active disease
CRP + ESR - raised
immunoglobulins - raised
ANA antibodies
Anti-dsDNA
anti-smith
Investigations for lupus nephritis?
urinalysis
urine protein:creatinine ratio
renal biopsy - diagnostic
which criteria is used to diagnose SLE?
SLICC Criteria or the ACR Criteria
Management of SLE?
- NSAIDs
- Steroids (prednisolone)
- Hydroxychloroquine (first line for mild SLE)
- Suncream and sun avoidance for the photosensitive malar rash
biologics for severe disease - rituximab, belimumab
or methotrexate
Which genes are associated with RA?
HLA DR4 (a gene often present in RF positive patients)
HLA DR1 (a gene occasionally present in RA patients)
Antibodies for RA?
rheumatoid factor
anti-CCP - more specific
Presentation of RA?
symmetrical distal polyarthropathy (joint pain, swelling and stiffness)
fatigue
weight loss
flu like illness
muscle aches / weakness
Worse with rest, improves with exercise
Which joints are commonly affected by RA?
- Proximal Interphalangeal Joints (PIP) joints
- Metacarpophalangeal (MCP) joints
- Wrist and ankle
- Metatarsophalangeal joints
- Cervical spine
- Large joints can also be affected such as the knee, hips and shoulders
Investigations for RA?
- Check rheumatoid factor
If RF negative -> check anti-CCP antibodies - Inflammatory markers such as CRP and ESR
- X-ray of hands and feet
- USS to confirm synovitis
XRAY changes in RA?
- Joint destruction and deformity
- Soft tissue swelling
- Periarticular osteopenia
- Boney erosions
Diagnostic criteria for RA?
American College of Rheumatology (ACR) / European League Against Rheumatism (ELAR)
> /= 6 = diagnosis of RA
Disease activity score for RA?
DAS28
What is the health assessment questionnaire (HAQ)?
used in RA to measure functional ability
Management of RA?
NSAID - acute flare
1st line - DMARDS (methotrexate, leflunomide or sulfasalazine)
Hydroxychloroquine - if very mild disease
2nd line - 2x DMARDS
3rd - methotrexate + biological therapy (TNF inhibitor)
4th - methotrexate + rituximab
Which DMARDs are safe in pregnancy?
Sulfasalazine and hydroxychloroquine
What should be co-prescribed alongside methotrexate?
Folic acid 5mg once weekly (on a different day than methotrexate dose)
Notable side effects of methotrexate?
Bone marrow suppression
leukopenia
highly teratogenic
Notable side effects of Lelunomide?
Hypertension
peripheral neuropathy
Notable side effects of Sulfalazine?
Male infertility (reduces sperm count)
Notable side effects of hydroxychloroquine?
nightmares
reduced visual acuity
Notable side effects of anti-TNF meds?
reactivation of TB / hep B
Notable side effects of Rituximab?
night sweats
thombocytopenia
Clinical features of temporal arteritis?
- typically patients >60y
- usually rapid onset (e.g. < 1 month)
- headache (found in 85%)
- jaw claudication (65%)
- temporary vision loss - amaurosis fugax
- tender, palpable temporal artery
- Fundoscopy - swollen pale disc and blurred margins
Investigations of temporal arteritis?
raised inflammatory markers:
- ESR > 50 mm/hr
- CRP may also be elevated
- temporal artery biopsy
(skip lesions may be present)
Management of temporal arteritis?
urgent high-dose glucocorticoids should be given as soon as the diagnosis is suspected and before the temporal artery biopsy (high-dose prednisolone if no eye involvement, IV methylprednisolone if vision loss)
Urgent ophthalmology review
Suspected temporal arteritis but biopsy normal, what is the next step in management?
Continue high dose steroids and repeat biopsy as skip lesions can occur and show normal appaerance
XRAY findings of perthes disease?
Flattened femoral head. Eventually in untreated cases the femoral head will fragment.
Management of perthes disease?
- Remove pressure from joint to allow normal development.
- Physiotherapy.
- Usually self-limiting if diagnosed and treated promptly.
Clinical presentation of perthes disease?
Hip pain (may be referred to the knee) usually occurring between 5 and 12 years of age.
Bilateral disease in 20%.
Clinical presentation of developmental dysplasia of the hip?
Usually diagnosed in infancy by screening tests.
May be bilateral, when disease is unilateral there may be leg length inequality.
As disease progresses child may limp and then early onset arthritis.
More common in extended breech babies.
management of developmental dysplasia of the hip?
Splints and harnesses or traction.
In later years osteotomy and hip realignment procedures may be needed.
In arthritis a joint replacement may be needed.
Screening test for developmental dysplasia of the hip?
USS until 3 months gives best results
Clinical presentation of slipped upper femoral epiphysis?
Typically seen in obese male adolescents.
Pain is often referred to the knee.
Limitation to internal rotation is usually seen. Bilateral in 20%.
Management of SUFE?
Bed rest and non-weight bearing.
Aim to avoid avascular necrosis. If severe slippage or risk of it occurring then percutaneous pinning of the hip may be required.
XRAY findings of SUFE?
X-rays will show the femoral head displaced and falling inferolaterally (like a melting ice cream cone) The Southwick angle gives indication of disease severity
What is dermatomyositis?
inflammatory disorder causing symmetrical proximal muscle weakness and characteristic skin lesions
What can dermatomyositis associated with?
can be idiopathic but can also be associated with malignancy - typically ovarian, breast or lung (screening is important post diagnosis)
Features of dermatomyositis?
Skin features - photosensitive, macular rash over back and shoulder, heliotrope rash in periorbital region. Gottron’s papules
proximal muscle weakness +/- tenderness
raynauds
resp muscle weakness
interstitial lung disease
dysphagia, dysphonia
Investigations for dermatomyositis?
- ANA positive (80%)
- anti-synthetase antibodies (30%) - anti Jo1 + anti SRP + anti-MI-2
Treatment of antiphospholipid syndrome?
primary thromboprophylaxis - low dose aspirin
secondary - lifelong warfarin (INR target 2-3)
Pseudogout joint aspiration findings?
+ve bi-fringent and rhomboid (p for pseudo)
Gout joint aspiration findings?
-ve and needle shapes (two N’s)
osteoporosis management?
1st line - vit D/calcium + bisphosphonate
2nd line - denosumab
