MSK/rheum Flashcards
What is gout
- Crystal arthropathy
- Chronically high blood uric levels
- Gouty tophi= subcutaneous deposits of uric acid
Gout S+S
- Severe pain
- Heat
- Swelling
- Redness
- Rapid onset
-Tophi
Gout RF
- Male
- Obesity
- High purines = meat, seafood
- Alcohol
- Diuretics
- Cardio or kidney disease
- FHx
Joints affected in gout
- Base of big toe = metatarso-phalangeal joint
- Wrists
- Base of thumb = carpometacarpal
Gout Ix
- serum urate = >360 micromol
- Aspiration = needle shaped crystals, negatively bifringent, monosodium urate crystals
Gout Mx
Acute flare
- NSAIDs 1st line
- Colchicine 2nd line
Gout prophylaxis
- Allopurinol
- Lifestyle changes
Psudogout S+S
- Older adult
- Hot
- Swollen
- Stiff joint = knee, shoulders, wrists, hips
Pseudogout aspiration
- Calcium pyrophosphate crystals
- Rhomboid shaped
- Positively bifringent
Mx pseudogout
- NSAIDs
- Colchicine
- Aspiration
- Steroid injections
- Oral steroids
why is osteoarthritis thought to occur
imbalance between cartilage damage and chondrocyte response
XR changes OA
LOSS
- Loss joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
S+S OA
- joint pain and stiffness
- Worse with activity and end of day
- bulky enlargement
- Resitrcted ROM
- Crepitus and effusions
Hand signs OA
- Heberdens = DIP
- Bouchards = PIP
- squaring base of thumb
Dx OA
- > 45, typical pain and no morning stiffness = OA
Mx OA
- Self care
- Topical and oral NSAIDs
- Weak opiates for short term
- Injections
- replacement
pattern of RA
symmetrical polyarthritis
gene assocaited with RA
HLA DR4
how many RA pateitns in RF seen in
70%
antibodies that are more specific than RF
- Anti CCP antibodies = 80% of patients
S+S RA
- pain, stiffness and swelling
- tender and synovial thickening
- systemic symptoms
- worse in morning, better on activity
when to refer for RA
- Small joints of hands or feet
- More than 1 joint affected
- Delay of 3 months or longer between onset and advice seek
Hand signs in RA
- Z shaped thumb
- Swan neck
- Boutonniere
- Ulnar deviation
eye manifestations related to RA
- dry eye syndrome
- episcleritis
- scleritis
- keratitis
- cataracts
- retinopathy
Dx RA
- RF
- Anti CCP
- Inflam markers
- X rays
XR changes RA
- Periarticular osteopenia
- Bony erosions
- Soft tissue swelling
- Joint destruction and deformity
Mx RA
- monotherapy with methotrexate, leflunomide, sulfasalazine and short course pred
- Combo with multiple cDMARDs
- Biologics = methotrexate
RA tx in pregnancy
- hydroxycholorquine and sulfasalazine safest
SE methotrexate
- bone marrow suppression, teratogenic, leukopenia
SE leflunomide
- HTN and peripheral neuropathy
SE sulfasalazine
- orange urine and male infertitlity
SE hydroxychloroquine
- retinal toxicity, blue grey skin pigmentation, hair bleaching
what are the seronegative spoldyloarthopathies
- Ankylosing spondylitis
- Psoriatic arthritis
- Reactive arthritis
HLA B27
Signs of psoriatic arthrtis
- symmetrical polyarthritis
- Psoriatic plaques
- Nail pitting
- Oncholysis
- Dactylitis
- Enthesitis
XR psoriatic
- Erosive changes = pencil in cup
- periostitis
- ankylosis
- osteolysis
- dactylitis
Mx psoriatic arthritis
- NSAIDs
- Steroids
- DMARDs = methotrexate
- Anti TNF
- monoclonal abs = ustekinumab
RF for reactive arthritis
- preceeding chlamydia or GI infection
S+S Reactive
- acute synovitis in 1 or more joints
- typically knee
- conjunctivitis
- urethritis
- circinate balanitis
- cant see cant pee cant climb a tree
Ix and Mx reactive
- Rule out septic = joint aspiration
- Treat infection
- NSAIDs
- Steroids
Main joints affected in AS
- Sacroiliac joints
- Vertebral column joints
S+S AS
- Young men in 20s
- Pain and stiffness in lower back
- Sacroiliac pain
- Improves with movement
- worse at night
- > 30 mins to improve in morning
- enthesitis, dactylitis, SOB
AS associations
- Anterior uveitis
- Aortic regurgitation
- AV block
- Apical lung fibrosis
- Anaemia chronic disease
Schobers test
- 10cm above L5 and 5 cm below this
- Length <20cm when touching toes = AS
Ix AS
- Inflammatory markers
- HLA B27
- X ray
- MRI
AS XR changes
- Bamboo spine
- Squaring vertebral bodies
- Subchondral sclerosis
- Syndesmophytes
- Ossification
- Fusion
AS Mx
- NSAIDs 1st line
- Anti TNF 2nd line
- 3rd line = IL17 monoclonal abs or JAK inhibs
Patho of SLE
- ANA generate a chronic inflammatory response
- ANA = autoantibodies against proteins within the nucleus
S+S SLE
- fatigue
- weight loss
- arthralgia and myalgia
- non-erosive arthritis
- photosensitive malar rash
- LN
- hair loss
- Raynauds
- SOB
Ix SLE
- Autoantibodies = ANA and Anti dsDNA
- FBC
- CRP and ESR
- Urinalysis
- Renal biopsy
Complications SLE
- Cardiovascular disease
- Infection
- Anaemia
- Pericarditis
- Pleuritis
- ILD
- Lupus nephritis
Mx SLE
- Hydroxychloroquine
- NSAIDs
- Steroids
- Severe = DMARDs and biologics
presentation PMR
- rapid onset
- 2 weeks before diagnosis consideres
- pain and stiffness in shoulders, pelvic girdle, neck
- worse in morning and rest
- > 45 mins to ease
- some imprvement on activity
associated features PMR
- systemic
- muscle tenderness
- carpal tunnel
- peripheral oedema
IX for PMR before steroids
- FBC
- U+E
- LFT
- Calcium
- Serum protein electrophoresis
- TSH
- CK
- RF
- urine
Mx PMR
- 15mg prednisolone daily
- follow up after 1 week
- 15 mg until fully controlled
- 12.5mg for 3 w then
- 10mg for 4-6w then
- reduce by 1mg every 4-8 w
Dont STOP for steroids
- Dont = dont stop immediate = adrenal crisis
- Sick day rules = increase
- Treatment card
- Osteoporosis prevention
- PPI
presentation GCA
- unilateral headache
- Scalp tenderness
- jaw claudication
- blurred or double vision
- Loss of vision
Dx GCA
- Clinical presentation
- Raised inflammatory markers
- TA biopsy
- duplex USS
Mx GCA
- 40-60mg prednisolone if no vision or jaw, 500-1000mg if visual or jaw
- aspirin
- PPI
- bone protection
T scores for OP
Normal = > -1
Openia = -1 to -2.5
Oporosis = <-2.5
Severe = -2.5 + fracture
Mx OP
- Reversible RF
- Calcium 1000mg and Vit D 400-800
- ## Bisphosphonates = alendronate, zole
SE Bisphosphonates
- reflux and oesophageal erosions
- atypical fractures
- osteonecrosis jaw or auditory canal
S+S osteomalacia
- fatigue
- bone pain
- musle weakness and aches
- pathological fractures
Ix osteomalacia
- Serum 25-hydroxyvitamin D = <25 def
- Low Ca and P, high ALP and PTH
- XR = osteopenia
- DEXA
Tx omalacia
- colecalciferl
- 50,000IU once weekly for 6 w or 4000 IU daily for 10
Pagets patho
- Excessive bone turnover
- increased osteoclast and blast activity
- patchy areas of sclerosis and lysis
S+S pagets
- bone pain
- deformity
- fractures
- hearing loss
- raised ALP
XR pagets
- bone enlargement
- OP curcumscripta
- cotton wool skull
- V shaped osteolytic defects in long bones
Mx pagets
- Bisphosphonates
- NSAIDs
complications pagets
- hearing loss
- HF
- osteosarcoma
- spinal stenosis
Polymyositis
- no skin features
- proximal weakness, symmetrical
- dermatomyositis
- CK raised
- steroids
Dermatomyositis
- same as pol but skin
- Gottron papules
- helitrope rash
- periorbital eodema
- photosensitive rash on back
Antiphospholipid syndrome
- increase risk of thrombosis
- pregnancy complications
- mx = APL antibodies
- long term warfarin
- pregnancy = LMWH and aspirin
Sjogrens
- dry eyes, dry mouth, dry vagina
- joint pain and stiffness
- Anti Ro and anti La
- artificial tears etc
main feature bechets
- recurrent oral and genital ulcers
- HLA B51
- pathergy test
- steroids
ehlers danlos
- joint pain and hypermobility
- beighton score
what is a colles fracture
- transverse fracture of distal radius
what is compartment syndrome
- pressure within fascial compartment is abnormally elevated = cut off blood flow
5 Ps of acute compartment syndrome
- Pain
- Paraesthesia
- Pale
- Pressure high
- Paralysis
Mx compartment syndrome
needle naometry
-remove dressings, elevate lef, maintain BP
- fasciotomy
most common bug in osteomyelitis
- staphylococcus aureus
S+S omyelitis
- fever
- pain
- red
- swelling
Ix and mx omyelitis
- XR = periosteal reaction, osteopenia, destruction
- MRI
- cultures
Mx - debridement
- 6w flucloxacillin
trochnteric bursitis
- inflammation of bursa over trochanter on outer hip
- gradual onset outer hip pain, aching or burning, worse activity, hard to lie
special tests fot troncharic bursitis
- trendelenburg
- resisted abduction
- resisted internal rotation
- resisted external rotation
mx trochanteric bursitis
- rest
- ice
- anaglesia
- physio
- steroid injections
olecranon bursitis
- bony lump at elbow
- repetitive movements
- swollen, warm, tender, fluid filled
- aspirate if think infection
- rest, ice, compression, analgesia
what is a compound fracture
skin is broken and bone exposed to the air
what is a stable fracture
sections of bone remain in alignment at the fracture
pathological fracture
bone breaks due to an abnormality within the bone
what is a colles fracture
transverse fracture of the distal radius near the wrist
- distal portion displaces upwards
which bones have vulnerable blood supplies (risk avascular necrosis)
- Scaphoid bone
- Femoral head
- Humeral head
- Talus
- Navicular
- 5th metatarsal foot
weber classification of fractures to lateral malleolus
- A = below ankle joint
- B = at level of ankle joint
- C = above the ankle joint = syndesmosis disrupted
gurds major criteria for fat embolism
- resp distress
- petechial rash
- cerebral involvement
Intracapsular hip fracture
- Break in femoral neck within capsule of hip joint
- 1 = incomplete and non-displaced
- 2 = complete fracture and non-displaced
- 3 = partial displacement
- 4 = full displacement
extracapsular
- leave head of femur intact
surgery for intertrochanteric fractures
- dynamic hip screw
subtrochanteric fractures surgery
- intramedullary nail
presentation hip fracture
- pain in groin or hip
- not able to weight bear
- shortened, abducted and externally rotated leg
F1 mx hip fracture
- analgesia
- X rays
- VTE proph
- pre-op assessment
- orthogeris
septic arthritis common bacteria
- staph aureus most
- n gonorrhoea
Mx septic arthritis
- joint aspiration
- empirical antibiotics IV
- 4-6w abx
- fluclox 1st line, clindamycin in pen allergy
GCA presentation
- unilateral headache
- scalp tenderness
- jaw claudication
- blurred/loss vision
dx GCA
- presenttion
- raised inflam markers
- temporal artery biopsy
- duplex USS = halo sign
GCA biopsy finds
multinucleated giant cells
Mx GCA
- 40-60mg pred if no vision or jaw claud
- 500-1000mg pred if visual or jaw
- aspirin
- PPI
- bisphosphonates
skin changes in dermatomyositis
- gottron papules
- heliotrope rash
presentation myositis
- muscle weakness, gradual onset and symmetrical
- pain
test in myositis
creatinine kinase = high due to inflammation = in thousands
polymyositosis antibody
anti-jo 1
antiphospholipid syndrome
- antip antibodies = cause inflammation and increase thrombosis
- VTE and pregnancy complications
specific signs antiphospholipid
- livedo reticularis = lace rash
- libmann sacks endocarditis
- thrombocytopenia
Mx antip
- warfarin long term
- LMWH and aspirin pregnancy
antip antibodies
- lupus anticoagulant
- anticardiolipin
- anti b2 glycoprotein
sjogrens
- dry eyes, mouth and vagina
- joint pain
- dry skin
anti ro and anti la
presentation polymyalgia rheumatica
- shoulder pain and stiffness
- pelvic girdle pain and stiffness
- neck pain and stiffness
- worse in morning and after rest, interferes sleep
tx PMR
- 15mg prednisolone daily
- follow up 1 week
limited cutaneous systemic sclerosis
- Calcinosis
- Raynauds
- Esophageal dysmotility
- Sclerodactyly
- Telangiectasia
diffuse cutaneous systemic sclerosis
- cardio problems = systemic and pul htn
- lung problems = fibrosis
- kidney problems
anti centromere bodies in
limited cutaneous ss
anti scl 70 antibodies in
diffuse cutaneous ss
ottawa rules ankle fracture
Ankle XR only needed if pain in malleolar zone and 1 of
- Bony tenderness at lateral malleolar zone
- Bony tenderness at medial malleolar zone
- inability to walk 4 weight bearing steps immediately after injury and in ED
Colles fracture
- transverse fracture of radius
- 1 inch proximal to radio-carpal joint
- dorsal displacement and angulation
- Complications = median nerve injury, compartment syndrome
anterior cruciate ligament
- lateral blow to the knee
- pop
- swollen
- instability
- anterior draw
- lachmans
medial epicondylitis
- pain worse with wrist flexion and pronation
- pain and tenderness localised to medial epicondyle
Garden classification hip fractures
1 = incomplete and non displaced
2 = complete and non-displaced
3 = partial displacement (angle)
4 = full displacement (parallel)
SE displaced intracapsular fractures
- disrupt blood supply = avascular necrosis
- no disruption in extra = heal well
how does a displaced hip fracture look
- short leg
- externally rotated
posterior dislocated femur with no fracture looks
short leg
internal rotation
Mx undisplaced IC fracture
- early mobilisation
- internal fixation
- cannulated screw
Mx displaced IC frcture
- hemiarthroplasty or tota hip replacement
Mx intertrochanteric extracapsular
- sliding or dynamic screw
mx subtrochanteric EC fracture
Intramedullary nail
all ankle fractures should be…
promptly reduced to remove pressure and necrosis
marfans genetics
autosomal dominant = affects gene responsible for creating fibrillin
features marfans
- tall
- long neck
- arachnodactyly
- high arch palate
- hypermobile
- pectus carinatum or exavatum
associated conditions marfans
- pneumothorax
- GORD
- mitral valve prolapse with regurgitation
- aortic valve prolapse with regurgitation
- aortic aneurysms
- scoliosis
marfans preventative meds
- bb
- angiotensin 2 receptor antagonists
most common type ehlers danlos
- hypermobile ED = joint hypermobility and stretchy soft skin
- AD
presentation ed
- joint pain
- hypermobile
- dislocations
- soft stretchy skin
- poor wound healing
score for hypermobility
beighton
