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1MSRA - Learning Points > Muscoskeletal > Flashcards

Muscoskeletal Flashcards

1
Q

What are the side effects of the following drugs?

a) methotrexate
b) gold
c) penicillamine
d) biologics (e.g. infliximab)

A

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)

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2
Q

Which enzyme must be measured prior to starting azathioprine and why?

A

TMPT

if deficient, higher risk of severe myelosuppression from azathioprine

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3
Q

Treatment for PMR?

A

Oral prednisolone 15mg/day long term

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4
Q

What do you give for bone protection in steroid use 3 months and longer?

A

ALWAYS give bisphosphonates

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5
Q

Which haematological disease makes you more suspectible to osteomyelitis? Why?

A

Sickle cell

RBC breakdown and increased iron assist siderophilic bacteria

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6
Q

Organism(s) responsible for osteomyelitis most commonly?

A

S.aureus

Except in Sickle cell patients, where it is salmonella

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7
Q

In hypocalcaemia secondary to CKD, what would levels of Ca, Ph, ALP and PTH be?

A

Ca - low
Ph - high
PTH - high
ALP - high

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8
Q

For achilles tendon rupture, what clinical examination would you do?

What is 1st line imaging?

A

Thompson test (patient prone, feet hanging off bed, squeeze calf muscle, if positive would see absence of foot plantar flexion)

USS

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9
Q

Which forearm/wrist movements are painful in tennis elbow (lateral epicondylitis)?

A

wrist extension
forearm supination

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10
Q

What are the 4 spondylarthropathies?

A

PEAR

Ank Spon
Reactive arthritis

Psoriatic arthritis
Enteropathic arthritis

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11
Q

What demographic does Ankylosing spondylitis affect?

A

Tends to be young males 20-30 yrs

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12
Q

Which diseases cause the following?

a) Bouchard nodes
b) Herbeden nodes
c) Gottron’s papules
d) Janeway lesions
e) Osler nodes

A

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)

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13
Q

Blood test findings in antiphospholid syndrome? (antibodies, FBC, Clotting)

A

Anti-cardiolipin antibodies

Thrombocytopenia

Paradoxically raised APTT

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14
Q

Features of anti phospholipid syndrome?

A

Arterial and venous thrombosis
Recurrent miscarriages
Low platelets
High APTT

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15
Q

How do you manage Achilles tendonitis/rupture?

A

Rest + simple analgesia (NSAIDs)

If symptoms persist beyond 7 days, refer physio

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16
Q

Management of hip fracture?

A

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

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17
Q

Most common reason for hip replacement revision?

A

Aseptic loosening of hip prosthesis

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18
Q

Symptoms of dermatomysitis? Which antibody? What might underlying cause be?

A

Muscle weakness + skin changes
Gottron’s papules
Anti-Jo antibody

Malignancy
(also can be idiopathic or associated with CTD)

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19
Q

How to diagnose Chronic Fatigue Syndrome?

A

Tiredness screen first

Symptoms must persist 3 months and affect patient more than 50% of time

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20
Q

Incomplete fracture which involves bulging of cortex?

A

Buckle fracture

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21
Q

Treatment for Ankylosing Spondylitis?

A

NSAIDs

(it is inflammatory duh!)

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22
Q

Which bones does Paget’s affect?

A

Skull, spine, pelvis, femur, tibia

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23
Q

Levels of Ca, Ph, ALP, PTH in Paget’s?

A

High ALP, rest normal

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24
Q

Levels of Ca, Ph, ALP, PTH in osteomalacia?

A

Ca - low
PTH - high
ALP - high
Ph - low

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25
Q

How does osteomalacia affect muscles?

A

The lack of Vit D reduces muscle synthesis, causing proximal myopathy and therefore a ‘waddling gait’

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26
Q

Should all gout patients receive allopurinol? What must you ensure you also give them when commencing it, and for how long?

A

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)

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27
Q

Most common cause of septic arthritis in young adults?

A

Gonorrhoea!

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28
Q

What is carpal tunnel syndrome caused by? What are the 2 tests

A

Median nerve compression

Tinels (tap) test
Phalens (flexion) test

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29
Q

What are the main causes of dactylitis?

A

1) Sickle cell disease
2) Spondyloarthropathies (PEAR)

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30
Q

Which medications precipitate gout?

A

Loop diuretics
Alcohol
Cytotoxic drugs
Aspirin

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31
Q

When should you start bisphosphonates without DEXA?

A

1) over 75 and had fragility fracture
2) over 50 or postmenopausal and had osteoporotic vertebral fracture or commencing steroids >3 months

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32
Q

If achilles tendonitis symptoms persist >7 days despite rest and analgesia, what should you do?

A

Refer physio

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33
Q

How should you take bisphosphonates?

A

upright
with plenty of water
empty stomach
stay upright for 30mins after

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34
Q

Which foods can trigger gout?
Who should start urate lowering therapy?
Should you alter urate lowering therapy during an attack?

A

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

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35
Q

Medial epicondylitis vs cubital tunnel syndrome difference in symptoms?

A

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.

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36
Q

Symptoms of Baker’s cyst?

A

Non-tender lump just below popliteal fossa
Worse on extension of knee

37
Q

What is the management of Rheumatoid Arthritis?

A

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

38
Q

What is the X-ray feature specific to Rheumatoid Arthritis?

A

Juxta-articular osteopenia

39
Q

Side effects of monoclonal antibodies (-ab) and etanercept?

A

Reactivation of TB

40
Q

Side effect of Gold and penicillamine?

A

proteinuria

41
Q

Which ligament is most commonly sprained in ankle inversion?

A

Anterior talofibular ligament

42
Q

What are the Ottawa ankle criteria (they suggest if fracture needs excluding with XR)

A

Malleolar pain plus
tenderness on medial/lateral malleoli
unable to weight bear 4 steps

43
Q

What are Dupuytren’s contracture?
What is test?
Which drug can cause it?

A

Abnormal thickening of palmar skin
Unable to place hand flat on table
Phenytoin

44
Q

What is the neurology when following nerve roots affected in spinal pathology (e.g prolapsed disc)?

L3
L4
L5
S1

A

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

45
Q

Side effects of bisphosphonates?

A

Oesophageal irritation (heartburn)

rare - osteonecrosis of jaw (jaw pain, difficulty chewing)

46
Q

What is a side effect of sulfsalazine?

A

Oligospermia

47
Q

What are red flag symptoms of back pain?

A

thoracic back pain, especially if >50 yrs
cancer symptoms
spinal tenderness
foreign travel
CES

48
Q

Symptoms of meniscal tear?

A

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

49
Q

(fever and back pain - think disci tis) Most common organism in discitis?

A

S.aureus

50
Q

Complications of discitis?

A

Epidural abscess (would see changing neurology as nerves compressed)

Sepsis

Also check for infective endocarditis (source of discitis likely seeding from bacteraemia

51
Q

Symptoms of ankylosing spondylitis?
Clinical exam for it?
Extra articular features?

A

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

52
Q

Osteoarthritis analgesia if co-codamol doesn’t work?

A

Oral ibuprofen + PPI cover
(rather than topical)

53
Q

What are the risk factors for osteoporosis?

A

LOW BMI (not high BMI)
CKD (due to Vit D deficiency)
Smoking
Alcohol
Steroids
Gut absorption issues (e.g coeliac)

54
Q

NB// In dermatomyotis, skin changes occur before muscle weakness

A
55
Q

Which DMARD can cause a linked allergic reaction if someone has aspiirin allergy?

A

Sulfsalazie

56
Q

Features of anti phospholipid syndrome?

A

arterial and venous thrombi
recurrent miscarriages
lived reticular

57
Q

Treatment of PMR?

A

Same as temporal arteritis
Daily oral prednisolone (+ bone protection)

58
Q

Pain on radial side of wrist over styloid process elicited by Finkelstein’s test?

A

De Quervain’s tenosynovitis

59
Q

Tender swelling on elbow caused by pressure? Known as student elbow

A

Olecranon bursitis

NB// if fever, need to exclude septic bursitis

60
Q

Pain on bending back?

A

Disc prolapse
Facet joint pain

61
Q

What actually is Dupuytren’s contractures?

What causes them?

A

Thickening of the palmar fascia (not the tendon)

Alcohol
Liver disease
Manual labour
Phenytoin
Family history

62
Q

How do you treat acute flares of Rheumatoid arthritis?

A

Oral and IM steroids!

(the DMARDs are for maintenance)

63
Q

When do you use TNF-alpha in rheumatoid arthritis?

A

For maintenance, only once 2 other DMARDs haven’t worked

64
Q

Why is obesity actually reduce the risk of osteoporosis?

A

Increased weight forces bones to be stronger

Also more fat means more peripheral conversion of oestrogen

65
Q

What to do if alendronate causes GI effects?

A

Switch to risendronate

66
Q

If patient can’t have bisphosphonates class of medication for bone protection/osteoporosis, what to give?

A

Denosumab (2nd line after bisphosphonates)

67
Q

Which particular bisphosphonate should be given after hip fracture?

A

IV ZOLENDRONATE (once a year)

68
Q

What’s the review policy for patients on bisphosphonates?

A

Redo FRAX and DEXA after 5 years. If low risk and not osteoporotic, can stop and review after 2 years

69
Q

Pain over lateral thigh on palpation?
Cause?

A

Trochanteric bursitis
Caused by ITB rubbing over it repetitively

70
Q

What are the features of Marfan’s?

A

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

71
Q

Is azathioprine safe in pregnancy?

A

Yes

72
Q

Pain on middle third of shoulder abduction (roughly between 60 and 120 degrees) - cause?

A

Subacromial impingement (AKA painful arc syndrome)

73
Q

Which nerve roots do femoral stretch and sciatic stretch test, test for?

A

Femoral stretch test - L3,L4

Sciatic stretch test - L5, S1

74
Q

Management of nerve root compression?

A

Same as MSK back pain

4-6 weeks conservative Mx initially with NSAIDS + physio (rather than neuropathic analgesia)

If symptoms persist, then MRI

75
Q

Which specific X-ray finding is present in pseudo gout?

A

Chondrocalcinosis

76
Q

What is found in joint aspirate of pseudo gout?

A

positively birefringent rhomboid crystals

77
Q

Risk factors for pseudogout

A

(Cause is calcium pyrophosphate deposition, usually in knee, shoulder, ?hand)

Risk factors: haemochromatosis, Wilson’s, hyperparathyroidism

78
Q

Triad in reactive arthritis? Do all 3 need to be present?

Time between initial infection and reactive arthritis?

A

Dysuria + arthritis +/- conjunctivitis

No

approx 4 weeks

79
Q

Skin finding associated with reactive arthritis?

A

Keratoderma blenorrhagicum

80
Q

Most common organism in septic arthritis overall vs in young people?

A

Overall = S.Aureus

Young people = Gonorrhoea

81
Q

Difference in symptoms between trigger finger and dupuytren’s contractures?

A

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

82
Q

What are Swan Neck deformity vs Boutonniere’s nodes?

A

Both seen in osteoarthritis
Swan neck - hyperextension PIP, hyeprflexion DIP

Boutonniere’s is opposite of that

83
Q

Difference between myxoid cyst and ganglion cyst?

A

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.

84
Q

Risk factors for adhesive capsulitis?

A

Female
Diabetes
Non-dominant side

85
Q

Which interaction with methotrexate should you be careful of?

A

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.

86
Q

What is the examination for meniscal tear? What is the best imaging modality?

A

McMurray’s test

MRI for Meniscal tear

87
Q

What are the symptoms of carpal tunnel?

A

Parathesia/weakness of thumb, index, middle fingers, can be worse at night. Patients sometimes reports shaking their hand helps.

88
Q

NB// Avoid NSAIDs in elderly patients taking warfarin

A

1MSRA - Learning Points (20 decks)

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