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WFH > MSK/Rheumatology 6/7/20 > Flashcards

MSK/Rheumatology 6/7/20 Flashcards

1
Q

contraindicated drugs for patients on methotrexate

A
  • trimethoprim
  • cotrimoxazole (septrin)
  • high dose aspirin

cause bone marrow toxicity

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2
Q

inflammatory vs degenerative

A
  • stiffness
    > over 30-60 mins/better with exercise/morning = inflammatory
    > under 30 mins/worse with exercise = degenerative
  • joint distribution
    > hands and feet = inflammatory
    > knees, fingers, thumb base = degenerative
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3
Q

MSK history red flags

A

BONE PAIN
- at rest/at night - possibly tumour/infection/fracture
NEURALGIC
- pain/paraesthesia in dermatomal distribution - possibly root or periph nerve compression
INFECTIVE
- warm, usually monoarthralgia

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4
Q

complications of rheumatoid arthritis

A
  • interstitial lung disease (pul fibrosis)
  • pleural effusion
  • pericardial effusion leading to cardiomegaly
  • nephrotic syndrome, check kidney function and oedema
  • vasculitis, small vessels of nose/digits more commonly
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5
Q

blood tests to monitor methotrexate

A

3 monthly when stable on drug, fortnightly before stable

  • FBC (pancytopenia risk)
  • U+Es (renally excreted)
  • LFTs (methotrexate binds to albumin)
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6
Q

ecg changes in pericarditis

A
  • ‘saddle-shaped’ ST elevation

- PR depression: most specific ECG marker for pericarditis

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7
Q

methotrexate in those trying for baby

A

remember methotrexate is teratogenic (men and women come off methotrexate for 3 months before trying for baby)

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8
Q

safe alternatives to methotrexate in pregnancy/breastfeeding

A
  • sulfasalazine

- hydroxychloroquine

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9
Q

co-prescribe methotrexate with…?

A

weekly folic acid (>24hrs after methotrexate dose)

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10
Q

biologic DMARDs key points

A
  • more potent immunosuppressants than regular DMARDs, at risk of atypical and typical infections
  • stop bDMARDs for duration of Abx and 2 weeks after
  • for elective surgery stop bDMARDs for half life + 1 wk
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11
Q

radiological changes of rheumatoid arthritis

A

LESS

Loss of joint space
Erosions
Soft tissue swelling
Soft bones (oteopenia)

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12
Q

examples of anti-TNF biologic DMARDs

A
  • infliximab

- etanercept

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13
Q

examples of lymphocyte suppressing biologic DMARDs

A

T cells = abatacept

B cells = rituximab

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14
Q

example of anti-IL6 biologic DMARDs

A

Tocilizumab

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15
Q

fractures that have highest risk of compartment syndrome as a complication

A
  • supracondylar fracture (humerus just above elbow)

- tibial shaft fracture

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16
Q

diagnosis of compartment syndrome

A

measurement of intracompartmental pressure:

  • pressure >20mmHg = abnormal
  • pressure >40mmHg is diagnostic

compartment syndrome does not typically show pathology on x-ray

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17
Q

features of compartment syndrome

A

6 Ps but not always all 6

  • severe Pain, especially on passive movement and not relieved even by morphine
  • Parasthesiae
  • Pallor/Poikilothermia may be present
  • Pulselessness (pulse may still be felt as the necrosis occurs as a result of microvascular compromise)
  • Paralysis of the muscle group may occur
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18
Q

complications of compartment syndrome

A
  • necrosis (can lead to muscle contractures eg. Volkmann’s contracture)
  • rhabdomyolysis/AKI
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19
Q

management of compartment syndrome

A
  • surgical (fasciotomy) to relieve pressure
  • give fluids to prevent AKI if rhabdomyolysis occurs
  • if due to an external factor (eg. misplaced cast) removal may provide spontaneous recovery

management must be prompt as muscle group death may occur within 4-6hrs

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20
Q

causes of compartment syndrome

A
  • trauma (fracture, crush, gunshot)
  • external (tight cast, burns)
  • internal (fluid overload, post-ischaemic swelling, bleeding disorders)
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21
Q

muscles and function of anterior compartment

A 
muscles:
- tibialis anterior
- extensor hallucis longus
- extensor digitorum longus
- peroneus tertius
function:
- dorsiflexion of ankle/foot
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22
Q

muscles and function of lateral compartment

A 
muscles:
- peroneus longus
- peroneus brevis
function:
- plantarflexion of foot
- eversion of foot
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23
Q

muscles and function of deep posterior compartment

A 
muscles:
- tibialis posterior
- flexor digitorum longus
- flexor hallucis longus
function:
- plantarflexion of foot
- inversion of foot
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24
Q

muscles and function of superficial posterior compartment

A 
muscles:
- gastrocnemius
- soleus
- plantaris
function:
- plantarflexion of foot
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25
Q

FRAX criteria

A
  • age
  • sex
  • height, weight, BMI (frailty)
  • previous fracture
  • parent fractured hip
  • glucocorticoids
  • rheumatoid arthritis
  • secondary osteoporosis (type 1 diabetes, hyperthyroid/parathyroidism, chronic liver disease, premature menopause, IBD/coeliac , etc.)
  • diet/alcohol/smoking
  • BMD scan result
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26
Q

osteoporosis/penia T score

A 
osteopenia = -1 to -2.5
osteoporosis = -2.5 or lower

confirm osteoporosis wit DEXA scan

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27
Q

side effects of bisphosphonates

A
  • oesophagitis (orally), dosing instructions reduce risk
  • IV bisphosphonates may cause flu-like symptoms
  • AF risk

RARE
> osteonecrosis of jaw
> atypical femoral fractures

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28
Q

bisphosphonate dosing instructions PO

A
  • take on empty stomach in morning
  • swallow with big glass of water
  • no food/drink/meds for at least 30 mins
  • stay sat/stood up after taking to reduce oesophagitis/reflux risk
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29
Q

denosumab

A
  • monoclonal antibody to RANK ligand
  • prevents osteoclast differentiation and reduces activity
  • 6 monthly subcut injection
  • suited to older/frailer patients
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30
Q

teriparatide

A
  • PTH analogue
  • stimulates osteoblast activity
  • daily subcut injection for 2 yrs
  • expensive so reserved for those with severe osteoporosis unresponsive to bisphosphonates
31
Q

Paget’s disease of bone pathophysiology

A

genetic and geographical factors

  • bone remodelling disorder
  • overactive osteoclasts
  • compensatory increased osteoblast activity
  • disorganised mosaic of woven (weak) and lamellar (strong) bone
32
Q

Paget’s disease of bone features

A 
triad of:
- pain
- deformity
- fracture
RARELY:
- deafness
- myelopathy (-> spinal cord compression)
33
Q

radiological signs of Paget’s disease of bone

A
  • expansion of bone
  • cortical thickening
  • abnormal texture
34
Q

biochemistry of Paget’s

A
  • high AlkPhos

- Ca/Phos usually normal

35
Q

management of Paget’s

A
  • bisphosphonate eg. alendronate (counter overactive osteoclasts)
  • surgery may be required for complications
36
Q

symptoms of hypercalcaemia

A
  • polydipsia
  • polyuria
  • constipation
  • nausea

later:
- confusion/coma
- renal stones
- short QT interval

37
Q

skin manifestations of systemic lupus erythematosus (SLE)

A
  • photosensitive ‘butterfly’ rash
  • discoid lupus
  • alopecia
  • livedo reticularis: net-like rash
  • Raynaud’s phenomenon
38
Q

cardiovascular manifestations of systemic lupus erythematosus (SLE)

A
  • pericarditis
  • myocarditis
  • cardiomyopathy
39
Q

renal manifestations of systemic lupus erythematosus (SLE)

A
  • proteinuria

- glomerulonephritis (diffuse proliferative glomerulonephritis is the most common type)

40
Q

respiratory manifestations of systemic lupus erythematosus (SLE)

A
  • pleurisy and pleural effusions

- fibrosing alveolitis

41
Q

neuropsychiatric manifestations of systemic lupus erythematosus (SLE)

A
  • anxiety and depression
  • psychosis
  • seizures
42
Q

general features of SLE

A
  • fatigue
  • fever
  • mouth ulcers
  • lymphadenopathy
  • ANA and anti-dsDNA autoantibodies
43
Q

adverse effects of methotrexate

A
  • mucositis
  • myelosuppression
  • pulmonary fibrosis
  • liver fibrosis
44
Q

treatment of methotrexate toxicity

A

folinic acid

45
Q

adverse effects of sulfasalazine

A
  • oligospermia
  • Stevens-Johnson syndrome
  • lung fibrosis
  • myelosuppression
  • may colour tears → stained contact lenses
46
Q

sulfasalazine cautions

A
  • G6PD deficiency

- allergy to aspirin or sulphonamides (trimethoprim)

47
Q

osteoarthritis radiological signs

A

JOSS

  • joint space narrowing
  • osteophytes
  • subchondral sclerosis
  • subchondral cysts
48
Q

features of cauda equina syndrome

A
  • lower back or sciatica pain
  • urinary incontinence/retention
  • saddle paraesthesia
  • decreased anal tone
49
Q

management of cauda equina syndrome

A

Urgent MRI

acute:
- surgery to decompress
- Abx if abscess is cause
degenerative:
- surgery if possible
- NSAIDs/corticosteroids
50
Q

management of a fracture

A

ALL FRACTURES
- Immobilise the fracture (including the proximal and distal joints)
- Monitor neurovascular status
OPEN FRACTURES
- IV broad spectrum antibiotics
- Lavage and debridement within 6 hours of injury

51
Q

GU complications of pelvic injury

A
  • haematuria
  • urinary retention
  • urethral injury
  • bladder injury
52
Q

causes of anaemia of chronic disease

A
  • malignancy
  • chronic infections eg. TB
  • connective tissues disease eg. rheumatoid arthritis
53
Q

RFs for adhesive capsulitis (frozen shoulder)

A
  • age 40-60
  • diabetes
  • cardiovascular disease
54
Q

management of adhesive capsulitis (frozen shoulder)

A

stiffness may persist for months/years

  • analgesia
  • physio and exercise
  • intracapsular steroid injection
55
Q

upper brachial plexus injury

A
  • Erb’s palsy

- associated C5, C6 dermatomal sensory loss

56
Q

lower brachial plexus injury

A
  • Klumpke’s palsy (claw hand due to myotomal loss)
  • associated C8, T1 dermatomal sensory loss
  • T1 can lead to ipsilateral Horner’s
57
Q

features of shoulder impingement

A
  • pain and stiffness
  • particularly when doing overhead movements
  • management is with analgesia, physio, rarely surgical decompression
58
Q

osteosarcoma

A

most common bone malignancy

  • adolescent males typically
  • warm, painful swelling
  • periosteal sunburst appearance
59
Q

Ewing’s sarcoma

A
  • adolescents
  • warm, painful, growing mass along long bone
  • systemic features (inc WCC, ESR, fever, anaemia)
  • onion skin periosteal reaction
60
Q

chondrosarcoma

A
  • older patients
  • pain with a mass in cartilage
  • ‘fluffy popcorn calcification’ lesion
61
Q

assessment for C-spine injury

A

ABCDE

  • full immobilisation until C-Spine ‘cleared’
  • detailed history and examination
  • imaging as required
62
Q

management of confirmed C-spine injury

A

ABCDE

  • airway management
  • secure patient with full in-line stabilisation
  • maintain ‘neutral’ neck position, use a jaw thrust if required rather than chin lift
  • semi-rigid collar
  • secure head with blocks and tape
63
Q

most common nerve lesion causing foot drop

A

common peroneal nerve injury

64
Q

management of OA

A
  • weight loss and aerobic exercise are effective at reducing pain and maintaining joint function
  • weight-bearing exercise should be avoided as it can accelerate the progression of the disease
  • physiotherapy and occupational therapy input
  • walking aids may be useful
  • NSAIDs particularly effective
  • surgery may be required
65
Q

management of osteomyelitis/septic arthritis

A

commonly due to staph aureus

  • flucloxacillin (clindamycin if pen allergy) for 4-6 wks (12+ in chronic OM)
  • surgical debridement useful in OM
  • may add fusidic acid/rifampicin in severe OA for first 2 weeks
66
Q

RFs for osteoporosis

A 
SHATTERED FAMILY
S – Steroid use
H – Hyperthyroidism, hyperparathyroidism
A – Alcohol and smoking
T – Thin (BMI<22)
T – Testosterone deficiency
E – Early menopause
R – Renal/liver failure
E – Erosive/inflammatory bone disease
D – Diabetes
FAMILY HISTORY
67
Q

autoantibodies in RA

A

anti-CCP (anti-cyclic citrullinated peptide)

rheumatoid factor

68
Q

management of RA

A
  • oral methotrexate and bridging steroid initially
  • treat flares with oral/IA prednisolone
  • second line = sulfasalazine then TNFa biologics eg. etanacept
69
Q

SPINEACHE mnemonic for seronegative spondyloarthropathies

A 
Sausage digits
Psoriasis
Inflammation
NSAIDs effective
Enthesitis
Arthritis
Crohn's/colitis
HLA-B27
Eyes (uveitis)
70
Q

management of SLE

A

start off with NSAIDs and hydroxychloroquine

71
Q

gout crystals + management

A

urate crystals
negatively birefringent needles
- colchicine acutely then allopurinol
- lifestyle changes

72
Q

pseudogout crystals

A

apatite crystals

positively birefringent rhomboids

73
Q

which cancers spread to bone?

A 
Prostate – blastic = growth-promoting
Breast – mixed pattern
Kidney – lytic = breakdown
Thyroid – lytic 
Lungs – lytic

WFH (18 decks)

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