MSK / Rheumatology Flashcards
What would make something a degenerative disease rather than an inflammatory disease?
Pain increases with use - clicks/clunks Stiffness is not prolonged (less than 30 minutes) - any time of day No swelling Not clinically inflammed Older Patients Less convincing response to NSAIDs
What would make something an inflammatory disease rather than degenerative disease?
Pain Eases With Use
Stiffness: Significant (more than 60 minutes), early morning or at rest
Swelling, synovial and/or bony joints
Hot and Red
Young Patients, Psoriasis or Family History
Responds well to NSAIDs
What kind of cartilage is most affected by osteoarthritis?
Articular Cartilage
What Is Ehlers-Danlos Syndrome?
Genetic condition in which symptoms may include hyperflexible joints, stretchy skin, and abnormal scar formation
What is the management procedure for a bone fracture?
Reduce, Immobilise, Rehabilitate - use analgesia and examine before and after manipulation
Name some of the common conditions associated with Rheumatoid Arthritis
Amyloidosis, Lung Involvement: Pleural Effusion, Fibrosing alveolitis, Anaemia (Normochromic normocytic, iron deficiency), Peripheral Neuropathy, Scleritis
What are some of the risk factors for osteoporosis?
Inflammatory Disease (cytokines increase bone resorption)
Endocrine diseases - Thyroid hormone and parathyroid hormone increase bone turnover so hyperthyroidism and hyperparathyroidism.
Cushing’s Syndrome - overproduction of cortisol.
Early Menopause
Anorexia, low body weight.
Medications: Glucocorticoids, Depo=provera (contraceptive pill), Oestrogen Blockers, GnRH analogues
What are the common symptoms of gout?
Typically presents in middle aged male with sudden onset of sever pain, swelling and redness of the metatarsophalangeal joint. Attack may be precipitated by dietary or alcoholic excess. dehydration or starting a diuretic.
What is the first marker to be raised in the inflammation process? - what does this do
Anti-inflammatory cytokines - IL-1, IL-6 and TNF (Tumour Necrosis Factor) - They release proteinases that lead to destruction of cartilage
What is a T Score?
A Standard deviation comparing your bone density with a gender matched young adult mean score. Above -1 is good, below -2.5 is osteoporosis. In the middle is osteopenia.
What are some of the clinical features of Carpal Tunnel syndrome?
Weakness and wasting of thenar muscles, and sensory loss of palm and palmar aspects of radial three and a half fingers. Tapping may induce pain.
What tool is used to diagnose osteoporosis - what is required for a diagnosis?
DXA Scan - T Score lower than -2.5
What are the four cardinal signs of an inflammation?
Rubour, Calor, Tumour, Dolor
How does Systemic Sclerosis (Scleroderma) present - limited cutaneous scleroderma?
Usually starts with Raynaud’s Phenomenon and followed by skin changes (thickening, bound to underlying structure and fingers taper) ‘Beaking’ of the nose - painful digital ulcers
How do Disease-modifying antirheumatic drugs (DMARDS) work? Give an example.
Mainly through inhibition of inflammatory cytokines - reduce inflammation and slow development of joint erosion. Methotrexate
Histologically, how are gout and pseudogout differentiated?
Calcium pyrophosohate crystals are positively befringent under polarised light, sodium urate crystals are negatively befringent under polarised light.
What is Bradford-Hill Criteria?
9 principles of causality:
- Strength of Association
- Consistency in association
- Exposure-response relationship
- Specificity
- Temporal Relationship
- Coherence of Evidence
- Biological Gradient
- Plausibility
- Analogy
What are the symptoms for osteoarthritis?
Pain
Functional Impairment of Activities of Daily Living
Alteration in Gait
Joint Swelling
Bony Enlargement
Tenderness
Crepitus (grating, crackling, popping under skin and joints)
What are some of the signs and symptoms of Marfan’s Syndrome?
Disproportionately long legs, arms, toes and fingers Extremely tall and slender build Long, narrow face High arched neck and crowded teeth Indented or protruding sternum Cystic changes in lungs Flat feet Curved Spine
How does Allopurinol work
Inhibits xanthine oxidase, an enzyme in the purine breakdown pathway
What are some of the characteristic symptoms of systemic lupus erythematosus?
Wolf rash on face, joint pain and stiffness, extreme tireness that won’t go away with rest, skin rashes over nose and cheeks. Raynaud’s, weight loss, swollen glands and sensitivity to light
How can repetitive strain disorder be treated?
Regular rest breaks, reduces force, ergonomically neutral working posture, ergonomic computer keyboards and mice
Describe Gout.
Inflammatory arthritis caused by hyperuricaemia and intra-articular sodium urate crystal deposition.
Which organism most commonly causes septic arthritis?
Staphylococcus Aureus
What blood markers would indicate inflammatory disease?
Raised ESR and Fibrinogen
Which conditions are highly associated with the HLA B27 gene? What does HLA stand for?
Spondyloarthritis:
Including psoriatic arthritis, ankylosing spondylitis, reactive arthritis and enteropathic arthritis - Human Leucocyte Antigen
Which radioisotope is used to image bones on MRI?
Technetium 99
How is gout treated in an acute attack?
Anti inflammatory drugs, NSAIDS such as diclofenac or Cox inhibitors such as lumiracoxib. If NSAIDS intolerated give colchicine. Corticosteroids can also be used such as methylprednisolone
What are the main clinical features of sjogrens syndrome?
Dry Eyes (Keratoconjunctivitis sicca) and dry mouth (xerostomia). Other features include arthritis, Raynauds phenomenon, renal tubular defects causing diabetes insipidus. Lymphocytic infiltration and fibrosis of exocrine glands, in particular the lacrimal and salivary glands.
Which immunoglobulin is rheumatoid factor predominantly encountered as?
IgM
Which serum autoantibodies are specific for diffuse cutaneous scleroderma?
Anti-topoisomerase,
anti-RNA polymerase I & III
How is SLE treated?
Anti-inflammatory medications such as ibuprofen, DMARDS such as hydroxychloroquine for fatigue and skin/joint problems, Steroid tablets, injections and creams.
What is the most common bone cancer?
Bony metastasis - from breast, lung, prostate, kindey, thyroid
What is the commonest pathological reason for gout?
Impaired renal excretion of uric acid.
What is Phalen’s test?
Test for Carpal Tunnel syndrome - symptoms are reproduced on passive maximal wrist flexion.
Give an example of a TNF-alpha inhibitor
Infliximab
Which tendon is usually affected in rotator cuff problems?
Supraspinatus tendon
What is the initial treatment for septic arthritis when S. Aureus is suspected and patient is not allergic to penicillin?
Flucloxacillin IV 6 hourly.
Adequate joint drainge
NSAIDs for pain relief
Immobilize joint in acute stages
Which nerve is affected in carpal tunnel syndrome?
Median Nerve
How does Systemic Sclerosis - Diffuse Cutaneous Scleroderma - present?
Skin changes are more rapid and widespread than in limited cutaneous scleroderma. GI involvement with dilation and atony in oeseophagus, this presents as heartburn and dysphagia . Renal involvement - acute & chronic kidney disease. Lung Disease - fibrosis and pulmonary vascular disease resulting in pulmonary hypertension.
What is Mirel’s Scoring system used for?
Used to help identify patients due palliative therapy but at risk of francture
What alternative medications can help with symptoms of joint disease?
Turmeric, Chinese Herbal Medicines
Where does Ewing’s Sarcoma arise from, what do these look like in histology?
Neural Crest Cells - dense blue cells.
How does pseudogout differentiate from gout?
Calcium pyroposphate instead of sodium urate.
More common in elderly women and usually affects knee or wrist.
In younger people it may be associated with haemochromatosis, hyperparathyroidism, Wilson’s Disease or Alkaptonuria.
How is osteoporosis treated?
Teriparatide (Synthetic PTH) - Increases bone formation
Bisphosphonates e.g. Alendronate orally - inhibit an enzyme in the cholesterol synthesis pathway.
Denosumab - Monoclonal antibody to RANK ligand - switches off bone resorption
Which genetic mutation is associated with osteosarcoma?
p53 mutation
What are the grading stages for MSK malignancies?
G0 - Histologically benign
G1 - Low Grade Malignant
G2 - High Grad eMalignant
Which biological markers can be present in somebody with Rheumatoid Arthritis? Which is more specific for diagnosis?
Anti-Cyclic Citrullinated Peptides (Anti-CCP antibodies) and Rheumatoid Factor - higher specificity with Anti-CCP. 10% healthy population have rheumatoid factor
What are the risk factors for osteoarthritis?
Age - due to cumulative effect of traumatic insult
Female gender preponderance
Link with Obesity - adipose tissue is pro inflammatory Occupational factors - playing football
What are the clinical features of spondyloarthritis?
SPINEACHE Pneumonic Sausage Digits (Dactylitis) Psoriasis and Positive Family History of SpA Inflammatory Back Pain NSAID good response Enthesitis (Heel) Arthritis Crohns Disease/ Colitis Elevated CRP (C Reactive Protein) HLA B27 Eye (Uveitis)
Need to Have HLA B27 + 2 Features
or Sacroillitis on imaging plus one feature
What are some of the risk factors for Septic Arthritis?
Prosthetic Joints, Pre existing join disease, recent intra-articular steroid injections, diabetes mellitus
What are the two crystals which account for the majority of crystal induced arthritis?
Sodium Urate & Calcium Pyrophosphate
What are some of the signs for Ewing’s Sarcoma or Osteosarcoma on X Ray?
Codman’s Triangle
Sunburst Appearance
Onion-skin appearance
Which MSK malignancy is more common in younger generation?
Osteosarcoma
Which enzyme is key in the pathway that causes gout?
Xanthine Oxidase
What are the 7 classifications of fractures?
Open/Closed Oblique Spiral Butterfly Segmental Transverse Comminuted
What is Tinel’s Sign?
Tapping on carpal tunnel reproduces sign
What non-medical methods can aid osteoarthritis?
Patient Education, activity and exercise, weight loss, physiotherapy, occupational therapy, footwear (insoles), walking aids
How are further attacks of gout prevented?
Allopurinol, obese patients should lose weight.
Reduce alcohol consumption. Thiazides should be withdrawn.
Purine rich foods such as offal, some fish/shellfish, spinach should be avoided.
How are normal, inflammatory and septic fluids differentiated from joint aspiration.
Normal Fluid - Straw Coloured - contains less than 3000 WCC/mm3
Inflammatory fluid - Cloudy coloured, contains more than 3000 WCC/mm3
Septic Fluid - Opaque, contains up to 75,000 WCC/mm3 - most of these are neutrophils
Which test is used to test for Sjogrens ?
Schirmer test - standard strip of filter paper on inside of lower eyelid; wetting of less than 10mm in 5 minutes is positive - confirms defective tear production
Define Osteoporosis.
A systemic skeletal disease, low bone mass and microarchitectual deterioration of bone tissue with a consequent increase in bone fragility and susceptability to fracture.
Name some of the high risk work activitites that can cause MSK disorders?
Heavy Manual Lifting Lifting Above Shoulder Height Lifting From Below Knee Height Incorrect Manual Handling Technique Forceful Movements Fast Repetitive Work Poor Posture
How Is Spondyloarthritis treated?
Anti-Inflammatory medications (methotrexate), Physiotherapy & Exercise. Anti-TNF Medications (Tumour Necrosing Factor)
What is one of the major risks of hip operations?
Femoral Head Necrosis - fractures risk blood supply to femoral head.
Which two medications are commonly used for inflammatory arthritis and associated conditions?
NSAIDS - chemotherapy agents such as Methotrexate - Chloroquine for Arthralgia
What is the pathophysiology of Systemic Lupus Erythematosus?
Body’s immune system produces antibodies against itself which particularly targets the cell nucleus. Believed to be a type III immune response with some type II involvement
What is CREST syndrome?
Calcinosis Raynaud's Phenomenon Esophageal Involvement Sclerodactyly - Tapering of fingers Telangiecstasia 'Spider Veins' - small dilated blood vessels
In which arthritic condition would you expect to see Ulnar Deviation, Swan Neck deformity & Boutonniere Deformity?
Rheumatoid Arthritis
What are the radiological features of osteoarthritis?
JOSSA Joint Space Narrowing Osteophyte Formation Subchondral Sclerosis Subchondral Cysts Abnormalities of Bone Contour
What are the clinical features of septic arthritis?
Hot, swollen, painful, red joint which has developed acutely. Fever - in 20% cases more than one joint affected
