MSK + Rheumatology Flashcards
What is osteoarthritis?
Degenerative joint disorder involving the entire joint and characterised by joint pain, stiffness and functional limitation.
What is the aetiology of osteoarthritis?
result of mechanical and biological events which destabilise the normal process of degradation and synthesis of articular cartilage chondrocytes, extracellular matrix, and subchondral bone
What are the risk fators osteoarthritis?
obesity
age
occupation
trauma
being female
family history
What is the pathophysiology of osteoarthritis?
Imbalanced cartilage breakdown > repair; ↑chondrocyte metalloproteinase secretion
Bone attempts to overcome this w/ T1 collagen; abnormal bony growths (osteophytes)
What are the key presentations of osteoarthritis?
Joint pain
Stiffness
Deformity, instability and reduced joint function
Heberden nodes (affects DIP joints)
What are the investigations for osteoarthritis?
NICE suggests that diagnosis can be made without any investigations if the patient is >45yrs, has typical activity related pain and no morning stiffness or stiffness lasting less than 30 minutes
What are the XR signs for osteoarthritis?
Loss of joint space
Osteophytes
Subchondral sclerosis
Subchondral cysts
What are some differentials for osteoarthritis?
Bursitis
Gout
Pseudogout
What is the management for osteoarthritis?
Pt education and lifestyle advice
Physiotherapy and occupational therapy +/- orthotics
Analgesia for symptomatic relief:
Oral paracetamol and topical NSAIDs
Add oral NSAIDs and consider also prescribing a PPI
Consider opiates such as codeine and morphine
Intra articular steroid injections provide temporary inflammation and pain reduction
Joint replacement in severe cases
What are the most commonly affected joints in osteoarthritis?
hips, knees, sacro-iliac joints, distal-interphalangeal joints in the hands (DIPs), carpo-metacarpal joint at the base of the thumb, wrist, cervical spine
What is rheumatoid arthritis?
autoimmune condition causing chronic inflammation of the synovial lining of the joints, tendon sheaths and bursa
What is the epidemiology of RA?
3 times more common in women than men
Affects around 1% of the population
Most common inflammatory arthritis seen by physicians
What are the risk factors for RA?
Age 30-50 yrs
Female
FHx
Smoking
What is the pathophysiology of RA?
arginine –> citrulline mutation in T2 collagen => anti-CCP formation
IFN-a causes further pro-inflammatory recruitment to synovium
- synovial lining expands and tumour -like mass (pannus) grows past joint margins
- pannus destroys subchondral bone + articular cartilage
What are the key presentations of RA?
symmetrical distal polyarthopathy
key symptoms: pain, swelling, stiffness of the joint (often worse in the morning and eases as day goes on)
What are some signs of RA?
Swan neck deformity
Boutonniere’s deformity (flexion at PIP joint)
Ulnar deviation
Rheumatoid nodules
Vasculitic lesion
What are some associated symptoms of RA?
fatigue, weight loss, flu-like illness, muscle aches and weakness
What are the investigations for RA?
Usually clinically diagnosed
Bloods = ↑ESR/CRP, normocytic normochromic anaemia (mc as can also cause microcytic and macrocytic)
Serology = +ve anti-CCP (80% specific), +ve RF (70% non-specific)
Radiographs
ultrasonography
What are the XR signs of RA?
LESS
Loss of joint space
Eroded bone
Soft tissue swelling
Soft bones (osteoporosis)
What are some differentials for RA?
Psoriatic arthritis
infectious arthritis
Gout
SLE
Osteoarthritis
What is the management of RA?
Short course of steroids at first presentation and during flare-ups to settle disease
DMARD (disease modifying antirheumatic drugs)- methotrexate
NSAID analgesia
Intra-articular steroid injection if very painful
Biologics 1st line- TNF-a inhibitor (infliximab
2nd line - B cell inhibitor - Rituximab
What are the commonly affected joints in RA?
the small joints of the hands and feet, the wrist, ankle, MCP and PIP
What are the extra-articular effects of RA?
lungs (PE, pulmonary fibrosis), heart (↑IHD risk), eyes (episcleritis, keratoconjunctivitis sicca), spinal cord compression, kidney (CKD), rheumatoid skin nodules
What is gout
Type of crystal arthropathy associated with chronically high blood uric acid levels
What is the aetiology of gout?
Urate crystals are deposited in the joint causing it to become hot, swollen and painful
What are the risk factors for gout?
Male
Obesity
High purine diet (meat and seafood)
Alcohol diuretics
Existing cardiovascular or kidney disease
Family history
What is the pathophysiology of gout?
↑uric acid/CKD –> impaired excretion of uric acid –> monosodium urate
What are the 4 clinical phases of gout when left untreated?
asymptomatic
hyperuricaemia - uric acid is building up in the blood and starting to form crystals around joints
acute/recurrent gout - symptoms start to occur, causing a painful gout attack
inter-critical gout - periods of remission between gout attacks
chronic tophaceous gout - frequent gout pain and tophi form in jointsf
What are the key presentations of gout?
Monoarticular and typically big toe
Sudden onset, severe swollen big toe - can’t put weight on it!
What are the investigations for gout?
can be diagnosed clinically or using joint fluid aspirate (no bacteria + needle shape crystals, negatively birefringent of polarised light, monosodium urate crystals)
What is the management for gout
Diet changes - ↓purines, ↑dairy
NSAIDs then consider colchicine, then steroid injection
prevention : allopurinol (xanthine oxidase inhibitor)
Which joints are most commonly affected by gout?
Most commonly seen in the metatarsophalangeal joints (base of big toe), wrists and carpometacarpal joints (base of thumb)
What is pseudogout?
calcium pyrophosphate crystals deposit along joint capsule
Also known as chondrocalcinosis
What are the risk factors for pseudogout?
Elderly females (70+)
Diabetes
Metabolic diseases
osteoarthritis
What are the key presentations for pseudogout?
Often polyarticular with knee commonly involved
Swollen hot red joint
What are the investigations for pseudogout?
Joint aspiration + polarised light → +vely birefringent, rhomboid shaped crystals
What are the XR signs for pseudogout?
chondrocalcinosis (thin white line in the middle of joint space caused by calcium deposition)
+ LOSS
What is the management for pseudogout?
Only acute management - NSAIDS, then colchicine, then steroid injection (no prevention drug here)
What is osteoporosis?
reduced bone density
What is osteopenia
reduction in bone density like osteoporosis but less severe
What are the risk factors for osteoporosis?
Steroids
Hypothyroid/hyperparathyroid
Alcohol + smoking
Thin (↓BMI)
Testosterone↓
Early menopause (↓oestrogen)
Renal /liver failure
Erosive + inflammatory disease
DMT1 or malabsorption
What are the key presentations of osteoporosis?
Fractures (proximal femur (falls), Colles’ forked wrist; fall on outstretched wrist), compression vertebral crush (may cause kyphosis))
What are the investigations for osteoporosis?
DEXA scan (produces T score 1<T≤2.5)
FRAX score
What is the management for osteoporosis?
Bisphosphonates (alendronate, risedronate, inhibit RANK-L signalling —> osteoclast inhibition)
mAB denosumab (inhibit RANK-L)
HRT - oestrogen, testosterone
Oestrogen receptor modulator -raloxifene
Recombinant PTH - teraparatide
What does direct inoculation mean in osteomyelitis?
When trauma or surgery results in direct access for polymicrobial or monomicrobial infection
What is contiguous spread in osteopmyelitis?
When infection spreads from adjacent soft tissues and joints
- can be poly or monomicrobial
- most common in older adults with DM, chronic ulcers, vascular disease, arthroplasties
What is haematogenous seeding in osteomyelitis?
Infection caused by bacterial seeding from the blood
- Most common in long bones in children and vertebrae in adults
- monomicrobial
What is gonococcal arthritis?
joint inflammation which occurs with disseminated gonococcal infection
Sx: fever, arthritis, tenosynovitis, maculopapular rash
What is osteomalacia?
defective bone mineralisation resulting from insufficient vitamin D and causing “soft” bones
What is the prevalence of osteomalacia?
2%
What are the causes of osteomalacia?
Hypoparathyroidsim (↑Ca2+ release from bone –> less available for mineral formation)
Vitamin D deficiency (malabsorption/reduced intake/poor sunlight)
CKD/renal failure (↓active vit D production (25-dihydroxyvitamin D → 1,25-dihydroxyvitamin D))
Liver failure (↓reaction in vit D pathway (cholecalciferol → 25-hydroxyvitamin D)
Anticonvulsant drugs (↑CYP450 metabolism of vit D)
What are the risk factors for osteomalacia?
Decreased sunlight to skin exposure.
Diet.
Dark skin.
Obesity.
Elderly.
Medications that may precipitate vitamin D deficiency.
Renal or hepatic disease.
Malabsorptive syndromes.
What is the pathophysiology of osteomalacia?
inadequate vitamin D leads to a lack of calcium and phosphate in the blood which are required for the constriction of bone
low levels result in defective bone mineralisation
What are the key presentations of osteomalacia?
Fatigue
Bone pain
Muscle weakness
Muscle aches
Pathological or abnormal fractures
Difficulty weight bearing
Can be asymptomatic
What are the investigations for osteomalacia?
Bloods (hypocalcemia, ↑PTH, ↓serum Ca2+, ↓25(OH) vitamin D
BM biopsy - incomplete mineralisation (GS)
XR = looser zones (defective mineralisation)
What is the management for osteomalacia?
Vitamin D replacement (colecalciferol) + ↑dietary intake (D3 tablets, eggs)
What percentage of women over 50 yrs old will have a fracture due to osteoporosis?
50%
What percentage of men over the age of 50 will have fractures due to osteoporosis?
1/5
What is Paget’s disease?
Excessive bone turnover due to uncoordinated excessive activity of both osteoblasts and osteoclasts leading to patchy areas of high and low density bone.
What are the key presentations of Paget’s?
Pain in bone
Arthralgia
Nerve compression/neural deafness
Increased bone density
Cardiac failure
Skull or vertebral sclerosis
What are the x-ray findings of Paget’s?
Bone enlargement and deformity
Osteoporosis circumscripta (well defined less-dense lesions of bone)
Cotton wool appearance of the skull (poorly denied patchy areas of sclerosis and lysis)
V-shaped defects in the long bones (osteolytic v-shaped lesions
What are the investigations for Paget’s disease?
Bloods (↑ALP, normal Ca2+ and phosphate)
X-ray
What is the management for Paget’s disease?
Bisphosphonates
NSAIDs for bone pain
VItamin D + Calcium supplements
What are the key complications of Paget’s disease?
Osteogenic sarcoma (severe bone cancer)
Spinal stenosis and spinal cord compression (spinal canal narrowing which can compress spinal nerves)
What is fibromyalgia?
Chronic widespread musculoskeletal pain for 3+ months with all other causes ruled out
What is the prevalence of fibromyalgia?
Prevalence = 0.5-5%
What are the risk factors for fibromyalgia?
Females
Depression
Stress
20-60 yrs
FHx
What is the pathophysiology of fibromyalgia?
The primary pathology in fibromyalgia is in the CNS and involves pain and/or sensory amplification
A hallmark of these conditions is diffuse hyperalgesia (increased pain in response to normally painful stimuli) and/or allodynia (pain in response to normally non-painful stimuli)
What are the key presentations of fibromyalgia?
Chronic pain
Diffuse tenderness on exam
Fatigue unrelieved by rest
Sleep disturbance
Mood disturbance
Cognitive dysfunction
Headaches
Numbness /tingling sensations
Stiffness
Sensitivity to sensory stimuli such as bright lights, odours, noises
What are the investigations for fibromyalgia?
Clinical diagnosis - all other possible causes ruled out
What are the differentials for fibromyalgia?
Polymyalgia Rheumatica = large cell vasculitis presenting as chronic pain syndrome (↑ESR+CRP is diagnostic and treatment is prednisolone)
Myofascial pain syndrome
Chronic fatigue syndrome
Rheumatoid arthritis
Vitamin D deficiency
What is the management for fibromyalgia
Education + physiotherapy
Antidepressant for severe neuropathic pain (e.g. TCAs; amitriptyline) + CBT
What is Sjogren’s syndrome?
Chronic inflammatory and autoimmune exocrine disorder characterised by diminished lacrimal and salivary gland secretion
What are the risk factors for Sjogren’s?
Females
40-50 yrs
FHx
HLA B8/DR3
SLE
Rheumatoid arthritis
Systemic sclerosis
What are the key presentations for Sjogren’s?
Dry eyes (keratoconjunctivitis sicca)
Mouth (xerostoma)
Vagina
Fatigue
What are the investigations for Sjogren’s?
serology (anti-RO, anti LA, ANA +ve)
schirmer test +ve (induce tears and place filter under eyes, tears travel <10mm)
What is the management for Sjogren’s?
artificial tears, saliva + lubricant for sexual activity
*sometimes hydroxychloroquine given
What is SLE?
Systemic Lupus Erythematosus is autoimmune systemic inflammation due to hypersensitivity type 3 reaction
What is the epidemiology of SLE?
25 in 100,000
most commonly seen in females age 20-40 yrs
what are the risk factors for SLE?
Female
HLA B8/DR2/DR3
C4 A null allele
Drugs (e.g. isoniazid, procainamide)
Afro-caribbean descent
Sun exposure
Smoking
FHx
What is the pathophysiology of SLE?
Impaired apoptotic debris presented to TH2 → B cell activation → antigen-antibody complexes
Antinuclear antibodies cause the immune system to target proteins within the person’s cell nuclei resulting in an inflammatory response and tissue damage
What are the key presentations of SLE?
Butterfly rash + photosensitivity
Glomerulonephritis
Seizures + psychosis
Mouth ulcers
Fatigue
Weight loss
What are some other symptoms of SLE?
Serositis
Anaemia
Hair loss
Lymphadenopathy and splenomegaly
Joint pain, myalgia, Raynaud’s, pyrexia
What are the investigations for SLE?
FBC
C3 + C4 levels (decreased)
Raised CRP/ESR
Immunoglobulins
Urinalysis - hematuria +++, proteinuria ++
Renal biopsy
(GS) Autoantibodies - anti-dsDNA (specific to SLE, 70% of pts have), ANA (less specific but 85% pts have) + anti-RO, anti-SM, anti-LA
What is the management for SLE?
Lifestyle (↓sunlight + stop triggering drugs)
Corticosteroids (main) - prednisolone
Hydroxychloroquine
NSAIDs
Azathioprine if severe
What are the complications for SLE?
CVD, infection, anaemia of chronic disease, pericarditis, pleuritis, interstitial lung disease
What is antiphospholipid syndrome?
Persistent antiphospholipid antibodies resulting in a variety of clinical features characterised by thromboses and pregnancy-related morbidity.
What are the risk factors for antiphospholipid syndrome?
Systemic lupus erythematosus
Autoimmune rheumatological disorders (Sjogren syndrome, rheumatoid arthritis, systemic sclerosis)
Other autoimmune disease (e.g. hypo-/hyperthyroidism, pernicious anaemia, coeliac disease)
What are the key presentations of antiphospholipid syndrome?
CLOTS
Coagulopathy
Livedo reticularis
Obstetric issues - miscarriages, stillbirth, preeclampsia
Thrombocytopenia
↑risk of arteria (stroke, MI)l + venous thrombosis (DVT, PE)
What is the diagnostic history for antiphospholipid syndrome
Hx of thrombosis or pregnancy complication plus persistent antibodies as above
What is the management for antiphospholipid syndrome?
Long term warfarin
Low molecular weight heparin plus aspirin for pregnant women