Muscoskeletal Flashcards
What are the side effects of the following drugs?
a) methotrexate
b) gold
c) penicillamine
d) biologics (e.g. infliximab)
a) myelosuppression, liver damage, pneumonitis (the latter presents with fever, dry cough, SOB - must spot to prevent irreversible fibrosis developing!)
b) proteinuria
c) proteinuria, exacerbation of myasthenia gravis
d) reactivation of TB (hence why CXR mandatory)
Which enzyme must be measured prior to starting azathioprine and why?
TMPT
if deficient, higher risk of severe myelosuppression from azathioprine
Treatment for PMR?
Oral prednisolone 15mg/day long term
What do you give for bone protection in steroid use 3 months and longer?
ALWAYS give bisphosphonates
Which haematological disease makes you more suspectible to osteomyelitis? Why?
Sickle cell
RBC breakdown and increased iron assist siderophilic bacteria
Organism(s) responsible for osteomyelitis most commonly?
S.aureus
Except in Sickle cell patients, where it is salmonella
In hypocalcaemia secondary to CKD, what would levels of Ca, Ph, ALP and PTH be?
Ca - low
Ph - high
PTH - high
ALP - high
For achilles tendon rupture, what clinical examination would you do?
What is 1st line imaging?
Thompson test (patient prone, feet hanging off bed, squeeze calf muscle, if positive would see absence of foot plantar flexion)
USS
Which forearm/wrist movements are painful in tennis elbow (lateral epicondylitis)?
wrist extension
forearm supination
What are the 4 spondylarthropathies?
PEAR
Ank Spon
Reactive arthritis
Psoriatic arthritis
Enteropathic arthritis
What demographic does Ankylosing spondylitis affect?
Tends to be young males 20-30 yrs
Which diseases cause the following?
a) Bouchard nodes
b) Herbeden nodes
c) Gottron’s papules
d) Janeway lesions
e) Osler nodes
a) OA (painless)
b) OA (painless)
c) Dermatomyositis (painful red plaques on dorsal hand)
d) IE (Jane is painless)
e) IE (Osler - bad bloke - painful)
Blood test findings in antiphospholid syndrome? (antibodies, FBC, Clotting)
Anti-cardiolipin antibodies
Thrombocytopenia
Paradoxically raised APTT
Features of anti phospholipid syndrome?
Arterial and venous thrombosis
Recurrent miscarriages
Low platelets
High APTT
How do you manage Achilles tendonitis/rupture?
Rest + simple analgesia (NSAIDs)
If symptoms persist beyond 7 days, refer physio
Management of hip fracture?
Intracapsular (i.e. femoral neck/NOF):
displaced - hip replacement
undisplayed - internal fixation
Extracapsular (i.e. below femoral neck/trochanter and below)
intertrochanteric - DHS
subtrochanteric - intermedullary nail
Most common reason for hip replacement revision?
Aseptic loosening of hip prosthesis
Symptoms of dermatomysitis? Which antibody? What might underlying cause be?
Muscle weakness + skin changes
Gottron’s papules
Anti-Jo antibody
Malignancy
(also can be idiopathic or associated with CTD)
How to diagnose Chronic Fatigue Syndrome?
Tiredness screen first
Symptoms must persist 3 months and affect patient more than 50% of time
Incomplete fracture which involves bulging of cortex?
Buckle fracture
Treatment for Ankylosing Spondylitis?
NSAIDs
(it is inflammatory duh!)
Which bones does Paget’s affect?
Skull, spine, pelvis, femur, tibia
Levels of Ca, Ph, ALP, PTH in Paget’s?
High ALP, rest normal
Levels of Ca, Ph, ALP, PTH in osteomalacia?
Ca - low
PTH - high
ALP - high
Ph - low
How does osteomalacia affect muscles?
The lack of Vit D reduces muscle synthesis, causing proximal myopathy and therefore a ‘waddling gait’
Should all gout patients receive allopurinol? What must you ensure you also give them when commencing it, and for how long?
All patients should start allopurinol (urate lowering therapy) after their first attack, starting 100mg/day. And uptitrate later to aim for serum rate <360
YOU MUST ALSO GIVE COLCHICINE, otherwise risk precipitating gout (lowering serum urate mobilised rate crystals from joints which precipitates an inflammatory reaction)
Most common cause of septic arthritis in young adults?
Gonorrhoea!
What is carpal tunnel syndrome caused by? What are the 2 tests
Median nerve compression
Tinels (tap) test
Phalens (flexion) test
What are the main causes of dactylitis?
1) Sickle cell disease
2) Spondyloarthropathies (PEAR)
Which medications precipitate gout?
Loop diuretics
Alcohol
Cytotoxic drugs
Aspirin
When should you start bisphosphonates without DEXA?
1) over 75 and had fragility fracture
2) over 50 or postmenopausal and had osteoporotic vertebral fracture or commencing steroids >3 months
If achilles tendonitis symptoms persist >7 days despite rest and analgesia, what should you do?
Refer physio
How should you take bisphosphonates?
upright
with plenty of water
empty stomach
stay upright for 30mins after
Which foods can trigger gout?
Who should start urate lowering therapy?
Should you alter urate lowering therapy during an attack?
Foods high in purine
i.e yeast products, oily fish , liver, kidney
Anyone who has acute attack
No, do not change allopurinol during attack.
NB// colchicine can still be used in renal impairment, unlike NSAIDs
Medial epicondylitis vs cubital tunnel syndrome difference in symptoms?
Medial epicondylitis (golf elbow)
- pain localised to medial epicondyle.
worse on pronation
Cubital tunnel syndrome
- ulnar nerve compression in cubital tunnel, paraesthesia/pain in ulnar distribution, affecting 4th and 5th digits.
Symptoms of Baker’s cyst?
Non-tender lump just below popliteal fossa
Worse on extension of knee
What is the management of Rheumatoid Arthritis?
DMARD - Methotrexate
Bridge with prednisolone
If not working, try another DMARD
(e.g. sulfsalazine)
If failed 2 DMARDS - monoclonal antibody (inflximab)
Prednisolone is used for acute attacks
What is the X-ray feature specific to Rheumatoid Arthritis?
Juxta-articular osteopenia
Side effects of monoclonal antibodies (-ab) and etanercept?
Reactivation of TB
Side effect of Gold and penicillamine?
proteinuria
Which ligament is most commonly sprained in ankle inversion?
Anterior talofibular ligament
What are the Ottawa ankle criteria (they suggest if fracture needs excluding with XR)
Malleolar pain plus
tenderness on medial/lateral malleoli
unable to weight bear 4 steps
What are Dupuytren’s contracture?
What is test?
Which drug can cause it?
Abnormal thickening of palmar skin
Unable to place hand flat on table
Phenytoin
What is the neurology when following nerve roots affected in spinal pathology (e.g prolapsed disc)?
L3
L4
L5
S1
L3 - anterior thigh sensation lost
reduced knee extension (weak quads)
L4 - sensory loss over knee
reduced knee extension
L5 - sensory loss over dorsal foot
reduced foot dorsiflexion and toe dorsiflexion
S1 - sensory loss lateral aspect foot and posterolateral leg. reduced plantar flexion
Side effects of bisphosphonates?
Oesophageal irritation (heartburn)
rare - osteonecrosis of jaw (jaw pain, difficulty chewing)
What is a side effect of sulfsalazine?
Oligospermia
What are red flag symptoms of back pain?
thoracic back pain, especially if >50 yrs
cancer symptoms
spinal tenderness
foreign travel
CES
Symptoms of meniscal tear?
injury occurs on twisting motion
knee locking and giving way
gradual swelling as effusion forms
tenderness along joint line depending on medial/lateral meniscus torn
(fever and back pain - think disci tis) Most common organism in discitis?
S.aureus
Complications of discitis?
Epidural abscess (would see changing neurology as nerves compressed)
Sepsis
Also check for infective endocarditis (source of discitis likely seeding from bacteraemia
Symptoms of ankylosing spondylitis?
Clinical exam for it?
Extra articular features?
Morning stiffness (i.e. after rest) - improves with activity
Reduced lateral flexion lumbar spine
Schober’s test
(schirmer’s test is for Sjogren’s)
5A’s
anterior uveitis
apical fibrosis
Av node blocking
amyloidosis
achilles tendonitis
Osteoarthritis analgesia if co-codamol doesn’t work?
Oral ibuprofen + PPI cover
(rather than topical)
What are the risk factors for osteoporosis?
LOW BMI (not high BMI)
CKD (due to Vit D deficiency)
Smoking
Alcohol
Steroids
Gut absorption issues (e.g coeliac)
NB// In dermatomyotis, skin changes occur before muscle weakness
Which DMARD can cause a linked allergic reaction if someone has aspiirin allergy?
Sulfsalazie
Features of anti phospholipid syndrome?
arterial and venous thrombi
recurrent miscarriages
lived reticular
Treatment of PMR?
Same as temporal arteritis
Daily oral prednisolone (+ bone protection)
Pain on radial side of wrist over styloid process elicited by Finkelstein’s test?
De Quervain’s tenosynovitis
Tender swelling on elbow caused by pressure? Known as student elbow
Olecranon bursitis
NB// if fever, need to exclude septic bursitis
Pain on bending back?
Disc prolapse
Facet joint pain
What actually is Dupuytren’s contractures?
What causes them?
Thickening of the palmar fascia (not the tendon)
Alcohol
Liver disease
Manual labour
Phenytoin
Family history
How do you treat acute flares of Rheumatoid arthritis?
Oral and IM steroids!
(the DMARDs are for maintenance)
When do you use TNF-alpha in rheumatoid arthritis?
For maintenance, only once 2 other DMARDs haven’t worked
Why is obesity actually reduce the risk of osteoporosis?
Increased weight forces bones to be stronger
Also more fat means more peripheral conversion of oestrogen
What to do if alendronate causes GI effects?
Switch to risendronate
If patient can’t have bisphosphonates class of medication for bone protection/osteoporosis, what to give?
Denosumab (2nd line after bisphosphonates)
Which particular bisphosphonate should be given after hip fracture?
IV ZOLENDRONATE (once a year)
What’s the review policy for patients on bisphosphonates?
Redo FRAX and DEXA after 5 years. If low risk and not osteoporotic, can stop and review after 2 years
Pain over lateral thigh on palpation?
Cause?
Trochanteric bursitis
Caused by ITB rubbing over it repetitively
What are the features of Marfan’s?
Tall, high arched palate
Pectus excavatum
Arachnodactyly (2 tests, ulnar prominence over thumb and able to overlap thumb and pinky around wrist)
Repeated pneumothoraces
Aortic dissection
Is azathioprine safe in pregnancy?
Yes
Pain on middle third of shoulder abduction (roughly between 60 and 120 degrees) - cause?
Subacromial impingement (AKA painful arc syndrome)
Which nerve roots do femoral stretch and sciatic stretch test, test for?
Femoral stretch test - L3,L4
Sciatic stretch test - L5, S1
Management of nerve root compression?
Same as MSK back pain
4-6 weeks conservative Mx initially with NSAIDS + physio (rather than neuropathic analgesia)
If symptoms persist, then MRI
Which specific X-ray finding is present in pseudo gout?
Chondrocalcinosis
What is found in joint aspirate of pseudo gout?
positively birefringent rhomboid crystals
Risk factors for pseudogout
(Cause is calcium pyrophosphate deposition, usually in knee, shoulder, ?hand)
Risk factors: haemochromatosis, Wilson’s, hyperparathyroidism
Triad in reactive arthritis? Do all 3 need to be present?
Time between initial infection and reactive arthritis?
Dysuria + arthritis +/- conjunctivitis
No
approx 4 weeks
Skin finding associated with reactive arthritis?
Keratoderma blenorrhagicum
Most common organism in septic arthritis overall vs in young people?
Overall = S.Aureus
Young people = Gonorrhoea
Difference in symptoms between trigger finger and dupuytren’s contractures?
Trigger finger is sudden, locking pain whereas Dupuytren’s is painless inability to extend fingers and flatten hand - no locking, no pain, may have developed gradually
Dupuytren’s cannot be forced straight
What are Swan Neck deformity vs Boutonniere’s nodes?
Both seen in osteoarthritis
Swan neck - hyperextension PIP, hyeprflexion DIP
Boutonniere’s is opposite of that
Difference between myxoid cyst and ganglion cyst?
Myxoid cyst occurs on distal fingers just proximal to nail bed - occurs in OA joints. Filled with mucin
Ganglion cysts are dorsal aspect hand and wrist - filled with synovial fluid.
Risk factors for adhesive capsulitis?
Female
Diabetes
Non-dominant side
Which interaction with methotrexate should you be careful of?
Co-trimoxazole and trimehtoprim
(Co-trimoxazole contains trimethoprim)
Methotrexate and the above meds are DHF reductase inhibitors - so when given together, increase risk of myelosuppresion.
What is the examination for meniscal tear? What is the best imaging modality?
McMurray’s test
MRI for Meniscal tear
What are the symptoms of carpal tunnel?
Parathesia/weakness of thumb, index, middle fingers, can be worse at night. Patients sometimes reports shaking their hand helps.
NB// Avoid NSAIDs in elderly patients taking warfarin
