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Clinical sciences > MSK/Rheumatology > Flashcards

MSK/Rheumatology Flashcards

1
Q

What is rheumatology?

A

Medical management of MSK disease. Prevalence increases with age. Mainly inflammatory joint pain.

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2
Q

What is inflammation?

A

Reaction of the microcirculation. Movement of fluid and white blood cells into extravascular tissues due to pro inflammatory cytokines.

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3
Q

What are the 4 pillars of inflammation?

A

Rubor (redness)
Calor (heat)
Dolor (painful)
Tumour (swollen)

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4
Q

How can an inflamed joint present?

A
  1. Hot, painful, red, swollen joint
  2. Deformity
  3. Stiffness
  4. Poor mobility/function
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5
Q

Give the main differences between inflammatory and degenerative joint pain.

A
  1. Pain - in inflammatory, pain eases with use whereas degenerative pain gets worse with use
  2. Stiffness - inflammatory stiffness is significant (>60mins) whereas degenerative generally less than 30 mins. Degenerative stiffness is generally morning and evening and inflammatory stiffness generally morning and at rest.
  3. Hot and red - only inflammatory
  4. Joint distrubution - inflammatory generally hands and feet whereas degenerative - carpometacarpel joint, distal interpharangeal joints, and knees.
  5. Swelling - inflammatory = synovial+/- bony. Degenerative = bony
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6
Q

Which type of joint pain generally responds to NSAIDs?

A

Inflammatory joint pain

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7
Q

Typically patient that presents with inflammatory joint pain vs one that presents with degenerative joint pain?

A

Inflammatory - often younger, with family history of inflammatory joint pain. May have psoriasis

Degenerative - older, prior occupation/sport

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8
Q

What is the relationship between work and mortality?

A

Higher mortality if don’t work

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9
Q

What are the Bradford Hill criteria?

A

Guidelines useful for providing evidence of a causal relationship between an apparent cause and effect.

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10
Q

Name 6 of the Bradford-Hill criteria?

A
  1. Strength of association (high and significant odds ratio)
  2. Consistency in association
  3. Exposure-response relationship
  4. Temporal relationship (effect after cause)
  5. Specificity
  6. Coherence
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11
Q

Name some high risk activities for MSK issues.

A
  1. Heavy manual handling
  2. Lifting above shoulders
  3. Lifting below knees
  4. Incorrect manual handling technique
  5. Forceful repetitive work
  6. Poor postures
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12
Q

What type of disease is carpal tunnel syndrome?

A

Entrapment neuropathy

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13
Q

Carpal tunnel syndrome is a result of pressure on what nerve?

A

Median nerve

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14
Q

What factors are associated with carpal tunnel syndrome?

A

Diabetes, obesity, pregnancy, OCP, hypothyroidism, RA, acromegaly

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15
Q

What is Tinel’s sign and what does it test for?

A

Tapping over carpel tunnel in attempt to elicit paraesthesia in median nerve distrubution

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16
Q

What is Phalen’s test and what does it test for?

A

Maximal wrist flexion for one min. May elicit symptoms of carpal tunnel syndrome, equally can be unreliable.

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17
Q

Typical clinical features of carpal tunnel syndrome?

A
  1. Aching pain in hand and arm - especially at night

2. Paraesthesia in thumb index and middle finger - relieved by hanging over end of bed and shaking ‘wake and shake’

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18
Q

What muscles does the median nerve supply?

A

LOAF

Lumbricals, opponens pollicis, abductor pollicis brevis, flexor pollicis brevis

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19
Q

What is the difference between Raynaud’s phenomenon and Raynaud’s disease?

A

Raynaud’s disease, the cause of the Raynaud’s is unknown and arises spontaneously. Whereas Raynaud’s phenomenon there is an underlying cause..

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20
Q

What is Raynaud’s?

A

Peripheral digital ischaemia due to paraoxysmal vasospasm, precipitated by cold or emotion.

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21
Q

What precipitates Raynaud’s?

A

Cold or emotion

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22
Q

What are some of the underlying causes of Raynaud’s phenomenon?

A
  1. Connective tissue disorders
  2. Occupational (vibrating tools)
  3. Obstructive e.g. atheroma
  4. Blood condition (cold agglutinin disease, monoclonal gammopathy)
  5. Drugs (B-blocker)
  6. Hypothyroidism
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23
Q

What drugs can cause Raynaud’s phenomenon?

A

Beta blockers

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24
Q

What is the colour change in Raynaud’s?

A

Yellow –> Blue –> Red

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25
Q

What are the symptoms of Raynaud’s?

A
  1. Fingers and toes ache
  2. Fingers and toes change colour
  3. Tingling, numbness and loss of dexterity
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26
Q

What is the management of Raynaud’s?

A
  1. Keep warm
  2. Stop smoking
  3. Nifedipine (CCB)
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27
Q

Why is Nifedipine used to treat Raynaud’s?

A

Is a CCB and so relaxes blood vessels

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28
Q

Differential of Raynaud’s?

A

Hypothenar hammer syndrome (occlusion of ulnar artery)

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29
Q

Age range normally affected by Raynaud’s disease?

A

Young women

30
Q

Common workplace injuries that classify for industrial injuries disablement benefit (IIDB)?

A
  • Carpal tunnel syndrome
  • Tenosynovitis
  • Writer’s cramp (RSD)
  • Osteoarthritis of hip for farmers (10 years plus in job)
  • Osteoarthritis of knee for floor layers, miners (10 years plus in job)
31
Q

What is tenosynovitis?

A

Inflammation of tendon or sheath around tendon causing pain, swelling and dysfunction.

32
Q

What causes tenosynovitis?

A

Forceful and repetitive hand movements, or previous injury or strain

33
Q

How is tenosynovitis managed?

A
  1. NSAIDs
  2. Steroid injection
  3. Rest
  4. Change job
  5. IIDB
34
Q

What are the symptoms of tenosynovitis?

A

Pain and swelling in the wrist and forearm.

O/E crepitus

35
Q

What test is used to detect tenosynovitis?

A

Finkelstein test

36
Q

What crystal causes gout?

A

Monosodium urate

37
Q

What crystal causes pseudogout?

A

Calcium pyrophosphate

38
Q

Is gout more common in men or women?

A

10 x more common in men

39
Q

What is the main cause of gout?

A

Impaired renal excretion of uric acid

40
Q

What are the four clinical syndromes caused by deposition of sodium urate crystals and hyperuricaemia?

A
  1. Acute sodium urate synovitis
  2. Chronic polyarticular gout
  3. Chronic tophaceous gout
  4. Urate renal stone formation
41
Q

Where does acute monoarthropathy usually occur in gout?

A

MTP joint of big toe

42
Q

Differential diagnosis of acute monoarthropathy that must always first be ruled out?

A

Septic arthritis

43
Q

What are the main causes of gout?

A

Increased production of uric acid - Diet (increased intake of purines), cell death (chemotherapy), errors of metabolism (Lesch Nyan syndrome), cell damage (surgery)

Failure of uric acid to be excreted- Drugs (low dose aspirin and diuretics), fructose, high insulin levels.

Assosciations with: hypertensive patients, diabetic patients and patients with chronic renal failure

44
Q

What is the most common inflammatory arthritis in the UK?

A

Gout

45
Q

What is the saturation point of uric acid in the blood and what is the normal range? What does this show?

A

Sat point = 380 mmol/l

Normal range = 200-430 - indicating that some people will normally be above saturation point. However only 1 in 5 with hyperuricaemia will develop gout.

46
Q

If gout is left untreated what can happen to the bone?

A

Periarticular punched out erosion

47
Q

In terms of diet, what are the biggest risk factors for developing gout?

A
  1. High alcohol intake (beer>spirits>wine)
  2. High red meat intake
  3. High seafood intake
  4. High fructose intake (sugary drinks, sweets)
48
Q

What food products are protective against gout?

A

Dairy products, cherries, things with Vit C

49
Q

What advice is given to a patient with gout to attempt to improve management?

A
  1. Low calorie diet/lose weight
  2. Avoid alcohol excess, red meat, and low dose aspirin
  3. Rest and elevate affected joint
50
Q

Where is the most common site for tophi to form in gout?

A

Pinna

51
Q

What is the main investigation done in gout? What would you expect to see?

A

Aspirate joint and polarized light microscopy of synovial fluid

Would see negatively birefringent urate crystals

52
Q

What can trigger an attack of acute gout?

A

Dietary or alcoholic excess, dehydration, starting a diuretic, cold, trauma or sepsis

53
Q

What are the main renal causes for gout?

A

Genetics, insulin levels, diuretics, fructose

54
Q

What is the treatment of acute gout?

A

Colchicine
NSAIDS
Steroids
Ice

Cherries and Vit C help shorten attacks

55
Q

What is the treatment of chronic gout?

A
  1. Uricosuric drugs (Losartan, fenofibrate) - increase excretion of urate
  2. Allopurinol start at 100mg / 24 and titrate upwards every 3 weeks until urate <300μm/L (gout prophylaxis)
  3. Colchicine for up to 6 months
  4. NSAIDs for up to 6 weeks
56
Q

How is allopurinol dosage decided for gout?

A

Start at 100mg/24 hours and titrate upwards every 3 weeks until urate <300μm/L

57
Q

What is a normal eGFR?

A

90-120 ml/min/1.73m2

58
Q

If an individuals eGFR is less than 50, how is the dosage of allopurinol decided in gout?

A

Start 1.5mg/unit eGFR/ day and titrate upwards by 1.5mg/ unit eGFR/ day every 3 weeks until serum urate is less than 300.

59
Q

What drug is used in gout if allopurinol is CI or there are side effects?

A

Febuxostat

60
Q

If patient’s eGFR is between 20 and 30, what drug is used instead of allopurinol?

A

Benzbromarone

61
Q

What are tophi and how do they cause bone erosion?

A

Smooth white onion like aggregates of urate crystals with inflammatory cells. They release local proteolytic enzymes

62
Q

What can gout increase the risk of ?

A

Hypertension, renal disease, CVS disease, Type 2 diabetes and OA damage to joints

63
Q

What is another term for pseudogout?

A

Pyrophosphate arthropathy

64
Q

What crystals are deposited on joint surface in pseudogout?

A

Calcium pyrophosphate

65
Q

What is the typically clinical presentation of a patient with pseudogout?

A

Hot, red, swollen joints (in particular larger joints such as wrist, ankle, knee or MCP joint)

Generally elderly patients

Generally monoarthropathy

66
Q

What are the risk factors for pseudogout?

A

Older age, hyperparathyroidism, haemachromatosis, hypophosphataemia, diabetes

67
Q

On xray, how does pseudogout present?

A

Chondrocalcinosis

68
Q

How is pseudogout diagnosed?

A

Aspirate joint
Culture (can be infected) and polarised light microscopy
On polarised light microscopy will see weakly positive birefringent crystals

69
Q

Management of pseudogout?

A

Intrarticular steroids +- colchicine

Methotextrate in chronic

Ice pack in acute attacks

70
Q

Typical joints that are involved in degenerative joint pain?

A

CMCJ, DIPJ, knees

Clinical sciences (10 decks)

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