MSK + Rheumatology Flashcards
What are the risk factors for developing mechanical back pain?
Heavy manual handling Female Older age Fibromyalgia Stress Smoking
What are the clinical features of mechanical back pain?
Pain that starts suddenly
Pain relieved by rest
Precipitated by injury
Stiff back
What are the red flags of back pain?
Acute onset in elderly Nocturnal pain Worse pain on being supine Fever Night sweats Weight loss Abdominal mass History of malignancy Neurological disturbance
How would you manage mechanical back pain?
Avoid prolonged inactivity
Analgesia
Physiotherapy
Name the three key signs of cauda equina compression.
- Alternating or bilateral root pain in legs
- Bladder + bowel incontinence
- Saddle anaesthesia
Fibromyalgia is a chronic condition that causes pain, fatigue and muscle ache. What are the psychosocial risk factors for this?
Divorced Female sex Sickness behaviours Social withdrawal Stress Lack of social support Low household income Low educational status
Which medical conditions are associated with fibromyalgia?
IBS
Depression
What are the symptoms of fibromyalgia?
Sleep disturbance Chronic widespread pain with no inflammation Severe fatigue Low mood Headache
How would you manage fibromyalgia?
Amitriptyline
CBT
Exercise programmes
What are the crystals in gout made out of?
Monosodium urate
What are the risk factors for developing gout?
Obesity High dietary purines Alcohol excess Diuretics Hypertension DM Chronic renal failure - kidneys fail to excrete uric acid
What are the signs of gout?
Monoarthritis - tends to be one joint
Swollen joint
Red shiny joint
Tophi - onion like aggregates of urate crystal
What investigations can you do to diagnose gout?
Serum urate
Polarized light microscopy - negatively birefringent urate needle shaped crystals
X-ray
What are the features of gout on an X-ray?
Soft tissue swelling
Erosions in juxta-articular bone
How would you manage gout?
NSAIDs
Colchicine - can cause diarrhoea
Steroids
Outline prophylaxis for gout.
Allopurinol
Lose weight
Cut down alcohol and purine reach foods
What type of crystals manifest in pseudo-gout?
Calcium pyrophosphate
What are the risk factors for developing pseudo-gout?
Old age
Hyperparathyroidism
Haemachromatosis
How would pseudo-gout appear on light microscopy?
Positive birefringent rhomboid shaped crystals
Which gene is rheumatoid arthritis associated with?
HLA-DR4/DR1
In RA, there is chronic inflammation of the joints, leading to joint space narrowing. What are the symptoms of RA?
Swollen painful joints - worse in morning Morning stiffness >30 mins Pain improves with activity Fatigue Fever Weight loss
What are the signs of RA?
Rubor = redness Calor = Heat Tumour = swelling Dolor = pain
Symmetrical polyarthritis
Ulnar deviation of fingers
Boutonniere and swan-neck deformities
What are the extra-articular signs of RA?
Sicca = dry eyes Nodules on elbows Lymphadenopathy Vasculitis Carpal tunnel syndrome Peripheral neuropathy Scleritis
What investigations would you do to diagnose RA?
FBC: anaemia of chronic disease
ESR/CRP
Rheumatoid factor
anti-CCP antibodies
How would RA appear on an x-ray?
Soft tissue swelling
Loss of joint space
Juxta-articular osteopenia
Bony erosions
How would you manage RA?
Methotrexate Sulfasalazine Hydroxychloroquine Gold injections TNF-a inhibitors Intra-articular steroid injections Rituximab (anti-CD20) Physiotherapy Surgery in severe cases
A DMARD is a disease-modifying anti-rheumatic drug. What is the major side effect of these drugs?
Immunosuppression
Which drug needs to be prescribed with methotrexate?
Folic acid 5mg
What are the adverse effects of methotrexate?
Mouth ulcers
Pulmonary fibrosis
Leukopenia
Teratogenic
What are the adverse effects of sulfasalazine?
Male infertility
What are the adverse effects of rituximab?
Night sweats
Thrombocytopenia
Polymyalgia rheumatica is an inflammatory condition that causes pain and stiffness in the shoulders, pelvic girdle and neck. Which condition is this associated with?
Giant cell arteritis
What are the symptoms of polymyalgia rheumatica?
Bilateral shoulder pain that may radiate to elbow Bilateral pelvic girdle pain Pain worse on movement Pain interferes with sleep Morning stiffness >45 mins Weight loss Fever Pitting oedema Carpel tunnel
Polymyalgia rheumatica is usually diagnosed after excluding other conditions. Along with routine bloods and x-ray, how would you confirm polymyalgia rheumatica?
Assess response to steroids
Outline the Don’t STOP plan for patients on long term steroids.
Don’t: - Patients should not stop taking steroids due to risk of adrenal crisis
S - sick day - increase steroids if patient becomes sick
T - treatment card
O - osteoporosis prophylaxis with bisphosphonates, calcium and Vitamin D
P - proton pump inhibitor
What are the risk factors for osteoarthritis?
Obesity Age Occupation Trauma Female FH
Why is obesity a risk factor for osteoarthritis?
Obesity is a low grade inflammatory state, with the release of IL-1 and TNF. Both of these cytokines mediate OA
What are the symptoms of osteoarthritis?
Joint pain on movement
Stiffness
Functional impairment n ADLs
Pain worse at end of day
What are the signs of osteoarthritis?
Asymmetrical joint Gait alteration Crepitus Tenderness Morning stiffness <15 mins Herderden's nodes at DIP joints Bouchard's nodes at PIP joints Cyst formation Reduced range of movement
What are the signs of osteoarthritis on x-ray?
LOSS: L - loss of joint space O - osteophytes S - subchondral sclerosis S - subchondral cysts
What is the non-medical management of osteoarthritis?
Exercise
Weight loss
Physio
Walking aids
What is the pharmacological management of osteoarthritis?
NSAIDs
Opiates
Intra-articular steroid injections
What is the surgical management of osteoarthritis?
Joint replacement
What is osteoporosis?
Decreased bone density
What are the risk factors for osteoporosis?
SHATTERED S - steroid use H - hyperthyroidism, hyperparathyroidism A - alcohol + tobacco T - thin, BMI <22 T - testosterone low (female) E - early menopause R - renal or liver failure E - erosive bone disease - RA D - dietary low calcium
Which hormone protects against osteoporosis?
Oestrogen
What does the FRAX tool predict?
Risk of fragility fracture over next 10 years
Which scan is used to measure bone mineral density?
DEXA scan
What T scores would you expect for someone with normal BDM, osteopenia and osteoporosis?
Normal = > -1 Osteopenia = -1 to -2.5 Osteoporosis = < -2.5
Which medical conditions are asked about in the FRAX score?
RA Kidney failure Cushing's Coeliac disease MS Hyperthyroidism Hyperparathyroidism Diabetes Previous fracture
Which medications are asked about in the FRAX score?
Glucocorticoids
Lithium
Barbiturates
Which FH is asked about in the FRAX score?
Parental fractured hip
What social history is asked about in the FRAX score?
Smoking status
Alcohol units
Which personal information is asked about in the FRAX score?
Age Sex Weight Height Femoral neck BMD
Which lifestyle changes would you advise for someone with osteoporosis?
Exercise Quit smoking Reduce alcohol Maintain healthy weight Adequate calcium and vitamin D
What is the first line medical treatment for osteoporosis and how does this work?
Bisphosphonates - reduce osteoclast activity, preventing reabsorption of bone
What are the side effects of bisphosphonates?
Reflux
Oesophageal erosions
What second line medications can be given for osteoporosis?
Denosumab - monoclonal antibody to RANK ligand
Strontium ranelate
Teriparatide
HRT
