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MSK/Rheumatology Flashcards

1
Q

Gene associated with seronegative spondyloarthritis

A

HLA-B27

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2
Q

Felty’s Syndrome features

A
  1. Rheumatoid arthritis
  2. Splenomegaly
  3. Neutropenia
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3
Q

Sjogren’s Syndrome: What does it affect/ Symptoms ?

A

Autoimmune condition affecting EXOCRINE GLANDS
—> dry mucous membranes (Dry mouth, dry eyes, dry vagina)

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4
Q

What is Primary Sjogren’s Syndrome?

A

Disease occurs in isolation

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5
Q

What is secondary Sjogren’s Syndrome?

A

Disease occurs related to SLE or Rheumatoid arthritis

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6
Q

What is Schirmer Test?

A

Test for Sjogren’s Syndrome

Insert filter paper under lower eyelid with strip hanging down
Leave for 5 mins
Distance along strip that becomes moist measured
Normal = > 15 mm
Significant for Sjogren’s < 10 mm

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7
Q

Management of Sjogren’s Syndrome

A

Artificial tears, saliva, vaginal lubricants

Hydroxychloroquine - to halt progression of disease

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8
Q

What is dermatomyositis ?

A

Rare disease that causes muscle weakness and skin rash
Connective tissue disorder —> chronic inflammation of the skin and muscles

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9
Q

Skin features of dermatomyositis

A

Scaly erythematous patches (Gottron lesions) on knuckles, elbows, knees
Photosensitive erythematous rash on back, shoulders, neck
Purple rash on face and eyelids
Perioribital swelling
Subcutaneous calcinosis (calcium deposits in subcutaneous tissue)

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10
Q

Auto-antibodies associated with dermatomyositis

A

Anti-Jo-1
Anti-Mi-2
Anti-nuclear

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11
Q

Dermatomyositis cause

A

Idiopathic
But associated with underlying malignancy in 1/4 of patients

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12
Q

Treatment of GCA (temporal arteritis)

A

High dose prednisolone (40-60mg/d) PO

Or IV methylprednisolone if rapidly progressing visual impairment

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13
Q

What are antiphospholipid antibodies?

A

E.g. anticardiolipin antibodies, Anti-beta-2-glycoprotein-I antibodies, Lupus anticoagulants

These antibodies interfere with coagulation and create a hypercoagulable state where the blood is more prone to clotting.

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14
Q

What is antiphospholipid syndrome?

A

Antiphospholipid syndrome is a disorder associated with antiphospholipid antibodies where the blood becomes prone to clotting. The patient is in a hyper-coagulable state. The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage.

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15
Q

What condition is antiphospholipid syndrome often secondary to?

A

Systemic Lupus Erythematosus

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16
Q

Complications of antiphospholipid syndrome

A
  1. Venous thromboembolism (DVT, PE)
  2. Arterial thrombus (Stroke, MI, Renal thrombosis)
  3. Pregnancy complications (recurrent miscarriage, stillbirth, preeclampisa)
  4. Livedo reticularis (mottled, lace like rash on skin)
  5. Libmann-sacks Endocarditis (Non bacterial vegetations on valves)
  6. Thrombocytopenia (low platelets)
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17
Q

Management of antiphospholipid syndrome

A

Long term warfarin (INR 2-3)

Pregnant women - low molecular weight heparin (e.g. enoxaparin) plus aspirin

(warfarin CI in pregnancy)

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18
Q

Causes of ACUTE monoarthritis (one joint)

A

Septic arthritis until proven otherwise !!!
Gout
Pseudogout
Trauma
Haemarthrosis

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19
Q

Causes of CHRONIC monoarthritis

A

TB
Psoriatic arthritis
Reactive arthritis
Osteoarthritis
Traumatic e.g. meniscus tear
Osteonecrosis
Neuropathic e.g. Charcot’s joint

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20
Q

What is charcot’s (neuropathic) Joint?

A

Most commonly seen as a complication of diabetes due to peripheral neuropathy
Damaged and deformed joint due to loss of sensation

Swelling, redness, pain, typically in the ankle
Can cause gross structural deformities, skin ulceration - osteoclast activation causes rapid bone destruction
Could lead to lower limb amputation!

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21
Q

Causes of ACUTE polyarthritis

A

Rheumatoid arthritis
Reactive arthritis
Psoriatic arthritis
SLE
Vasculitis
Uncontrolled gout

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22
Q

Causes of CHRONIC (> 3 months) polyarthritis

A

Rheumatoid arthritis
Reactive arthritis
Psoriatic arthritis
SLE
Vasculitis
Uncontrolled gout

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23
Q

Causes of arthritis affecting the DIPJs

A

Osteoarthritis- Heberden’s nodes
Psoriatic arthritis - + nail dystrophy on affected digit

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24
Q

What are Heberden’s nodes

A

Small, pea-sized boney growths that occur at DIPJ (closest to tip of finger)
Occur in osteoarthritis

Pick up “He(r)bs” with tips of fingers

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25
What are Bouchard’s nodes
Boney swelling affecting the proximal interphalangeal joint Occur in osteoarthritis Anatomically closer to “bouch” (mouth)
26
What is calcinosis?
Calcium salts deposited in the skin and subcutaneous tissue Hard yellowish lumps Associated with various disorders such as: - Systemic sclerosis - Dermatomyositis - Cutaneous lupus erythematosis - Connective tissue disorders
27
How to distinguish inflammatory from mechanial disease?
Inflammatory - morning stiffness > 1 hour - improvement with activity - rest makes it worse - fatigue - systemic symptoms Mechanical - morning stiffness < 30 mins - Activity makes it worse - Rest makes it better - no systemic symptoms
28
What is the GALS assessment
Quick screening assessment for MSK disorders Gait Arms (Hands, wrists, elbows, shoulders) Legs Spine Then proceed to detailed regional examination of a joint if any problem detected
29
What is an antalgic gait?
Pain causing a limp (reduced time on affected side)
30
What is a trendelenberg gait?
Due to poor hip abduction (weak gluteus medialis) Pelvis drops down when standing - opposite side to affected leg
31
What is a sensory ataxic gait?
Wide based, stamping Worse when eyes shut (Stamping = to compensate for lack of sensory input)
32
What is a cerebella ataxic gait?
Wide based, staggering gait Arms often flung out to try improve balance Looks like “drunk”
33
What is a Hemiplegic gait?
Narrow-based Legs swung forward Toes scrape the ground
34
What is a Parkinsonian gait?
Difficulty initiating walking Shuffling Reduced arm swing
35
What is a waddling gait ?
Duck-like Due to bilateral hip weakness
36
What is Tinel’s test?
Used to diagnose carpal tunnel syndrome Tap over carpal tunnel for 30-60 seconds If patient develops tingling in thumb and radial 2.5 fingers - suggests median nerve irritation
37
What is phalen’s test ?
To help diagnose carpel tunnel syndrome Patient holds wrist in complete forced flexion (pushing dorsal sides of both hands together for 60 seconds) If patient develops symptoms then test is positive
38
When to use ESR test and what does it reflect?
Done if signs of inflammation Reflects presence of fibrinogen, immunoglobulins
39
What does seropositive and seronegative mean?
Seropositive = RF+ Seronegative = RF-
40
What is “CREST” syndrome and what does it stand for?
A subtype of systemic sclerosis (scleroderma) = LIMITED scleroderma Calcinosis Raynaud’s Esophageal dysmotility (GORD) Sclerodactyly (thick, swollen fingers) Telangiectasia
41
Subtypes of systemic sclerosis (scleroderma)
Limited - peripheral skin involvement (distal to elbows and knees) Diffuse - widespread skin changes (may involve whole body)
42
Lung problems associated with methotrexate
Pneumonitis (similar presentation to hypersensitivity pneumonitis) - develops within 1 year of starting treatment - acute / sub acute - Cough, Fever, dyspnoea Pulmonary fibrosis - develops due to long-term exposure to methotrexate
43
What is Felty’s Syndrome
Rheumatoid arthritis + Splenomegaly + Low WCC
44
What medication has a severe interaction with azathioprine
Allopurinol - bone marrow suppression
45
Causes of Dactylitis
Spondyloarthritis e.g. psoriatic and reactive arthritis Sickle-cell disease More rare: TB, Sarcoidosis, syphilis
46
Important pre-operative imaging in patient with rheumatoid arthritis
Anteroposterior and lateral cervical spine radiographs Because atlantoaxial subluxation is a rare complication of RA Can lead to cervical cord compression Screen for this pre-op Pt would need to go to surgery in C-Spine collar so the neck is not hyperextended on intubation
47
Osteoporosis bone profile blood test results
Commonly all normal !
48
Diagnostic test for osteoporosis and normal/osteoporosis/osteopenia values
Dual energy X-ray absorptiometry (DEXA) Scan of lumbar spine T-score < - 2.5 = Osteoporosis T-Score between -2.5 to -1 = Osteopenia T-Score >= -1 = normal (T-Score is the number of SDs from the mean bone density for same gender at age of peak density (25 yrs))
49
Osteoporosis vs osteopenia
Osteopenia is a less severe reduction in done density than osteoporosis
50
Non-modifiable risk factors for osteoporosis
Advanced age Female gender Caucasian or south Asian FHx of osteoporosis-gene
51
Modifiable risk factors for osteoporosis
Low BMI Premature menopause (<45) Calcium/VitD deficiency Alcohol/smoking Reduced activity Iatrogenic - Long term steroids - SSRis, PPIs, anti-epileptics and anti-oestrogens
52
Tool used to give prediction of fragility fracture over next 10 years
FRAX
53
Components of FRAX scoring tool
Age BMI Co-morbidities Smoking/alcohol FHx +/- DEXA scan score
54
Management of osteoporosis
1. Lifestyle changes - activity - healthy weight - calcium/vitD intake - avoid falls - stop smoking/drinking 2. Vitamin D & Calcium - e.g. calcichew-D3 3. Bisphosphonates (reduced osteoclast activity) - Alendronate (weekly) - Risedronate (weekly) - Zoledronic acid (yearly IV) Other options - Denosumab (monoclonal Ab that blocks osteoclast activity) - Raloxifene (selective oestrogen receptor modulator - stimulates on bone but blocks in breasts and uterus) - HRT (in early menopause)
55
Important side effects of bisphosphonates
Reflux/oesophageal erosisons - sit upright for 30 mins after taking them Atypical fractures Osteonecrosis of Jaw Osteonecrosis of external auditory canal
56
Follow up for osteoporosis patients on bisphosphonates
Repeat FRAX and DEXA scan after 3-5 years Consider a "treatment holiday" if BMD has improved and they have not had any fragility fractures (break from Tx for 18months - 3 yrs)
57
What are gout trophi
Subcutaneous deposits of uric acid Typically affecting small joints and connective issues of the hands, elbows and ears DIP joints are the most affected in the hands
58
Joints commonly affected in gout
Metatarsophalangeal joint (base of big toe) Wrists Carpometacarpal joints (base of thumb)
59
What does aspirate fluid show in gout?
No bacterial growth - important to rule out septic arthritis Needle shaped crystals Negatively birefringent of polarised light Monosodium urate crystals
60
What does joint X-ray show in gout?
Early signs = soft tissue swelling Late signs = "punched out erosions" in juxa-articular bone with sclerotic borders and overhanging edges Joint space maintained
61
Management during acute gout flare
NSAIDs Colchicine Steroids (3rd line) If patient already taking allopurinol then it should be continued
62
Prophylactic mangement of gout
Allopurinol (xanthine oxidase inhibitor) Lifestyle changes - weight loss, stay hydrated, minimise alcohol and purine-based food consumption (Meat, seafood)
63
NICE guidlines for starting Allopurinol for gout
urate-lowering therapy (ULT) for gout patients who suffer from ≥2 attacks per year When commencing ULT (allopurinol) colchicine cover should be co-prescribed for up to 6 months from initiation. If colchicine is unsuitable, NICE recommends considering NSAID cover as an alternative.
64
Crystals that cause gout vs pseudogout
Gout --> URIC ACID (monosodium urate monohydrate crystals) Pseudogout --> CALCIUM PYROPHOSPHATE (calcium pyrophosphate crystals)
65
Risk factors for pseudogout
Associated with trauma and osteoarthritis Hyperparathyroidism Hemochromatosis Look diuretics causing hypomagnesemia Wilsons disease
66
What needs to be corrected before starting bisphosphonates and why?
Vitamin D and calcium because bisphosphonates may worsen hypocalcaemia due to reduced calcium efflux from bones, potentially resulting in arrhythmias/seizures
67
What is Osteomalacia
a condition where bones become soft and weak Often caused by not having enough VitD Similar to rickets seen in children
68
Causes of osteomalacia
Vit D deficiency (malabsorption, lack of sunlight, diet) CKD Drug induced (e.g. anticonvulsants) Liver disease Coeliac disease
69
Signs of osteomalacia on X-ray
Translucent bands (Looser's zones or pseudofractures)
70
Management of osteomalacia
VitD supplements Calcium supplements if dietary Ca is inadequate
71
Raynauds disease vs Raynauds phenomenon
Disease = genetic component (young females) Phenomenon = secondary to another condition
72
Management of mild/moderate Raynaud's
Lifestyle: stop smoking, warm clothes, avoid triggers / meds (COCP, BBs) Vasodilators: CCBs (nifedipine)
73
Management of severe Raynaud's
IV prostaglandins (Iloprost) +/- surgery (last resort) - e.g. embolectomy
74
Triad associated with reactive arthritis
Arthritis Urethritis Conjunctivitis "Cant see, cant wee, can't bend a knee" (formally called REITER'S SYNDROME)
75
Causes of reactive arthritis
1. Post-STI (men mostly) - Chlamydia trachomatis = sexually acquired reactive arthrtits 2. Post-dysenteric - shigella, salmonella, campylobacter etc.
76
Management of reactive arthritis
Symptomatic: Analgesia, NSAIDs, Intra-articulation steroids Persistent disease - sulfalazine and methotrexate may be used **Sx rarely last > 12 months
77
When to test for Anti-cyclic citrullinated peptide antibody (Anti-CCP) ?
Suspected rheumatoid arthritis but the patient is rheumatoid factor negative Test for anti CCP next (much higher specificity)
78
Red flags for lower back pain
age < 20 years or > 50 years history of previous malignancy night pain history of trauma systemically unwell e.g. weight loss, fever

FINALS (19 decks)

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