Musculoskeletal Flashcards
1
Q
Which cancers are most likely to metastasise to bone?
A
- prostate
- breast
- lung
- kidney
- thyroid
- myeloma
2
Q
What are some side effects of bisphosphonates?
A
- fever / flu-like symptoms
- hypocalcaemia
- bone & joint pain
- constipation / diarrhoea
- oesophagitis / oesophageal irritation
- osteonecrosis of the jaw
3
Q
Examples of bisphosphonates?
A
- alendronic acid
- zoledronic acid
(-dronic acid / -dronate)
4
Q
Bisphosphonates mechanism of action?
A
- pyrophosphate analogues
- bind to hydroxyapatite crystals
- promote osteoclast apoptosis and disrupt cholesterol synthesis pathway (to decrease osteoclast function)
- decreased bone resorption
5
Q
X ray features of osteoarthritis?
A
- joint space narrowing
- osteophyte formation
- subchondral cysts
- subchondral sclerosis
6
Q
Investigation to diagnose Sjögren’s syndrome?
A
Schirmer’s test - strip of paper in eye to measure tear production.
Tear production is decreased in Sjögren’s syndrome.
7
Q
What does a pencil-in-cup X ray deformity signify?
A
- arthritis mutilans
- may indicate psoriatic arthritis
8
Q
What does a bamboo spine deformity signify?
A
Advanced ankylosing spondylitis
9
Q
First-line management of ankylosing spondylitis?
A
Ibuprofen
10
Q
Preventative gout medication?
A
Allopurinol
11
Q
Allopurinol mechanism of action?
A
Reduces production of uric acid by inhibiting xanthine oxidase.
12
Q
T score for osteoporosis?
A
< -2.5
13
Q
T score for osteopenia?
A
-1 to -2.5
14
Q
What autoantibodies are found in granulomatosis with polyangiitis?
A
cANCA (antis neutrophil cytoplasmic antibodies)
15
Q
What was granulomatosis with polyangiitis formerly known as?
A
Wegener’s granulomatosis
16
Q
What are some clinical manifestations of granulomatosis with polyangiitis?
A
- sinusitis
- nose bleeds
- saddle shaped nose (perforated septum)
- cough, wheeze, haemoptysis
- glomerulonephritis
17
Q
Investigations for Sjögren’s syndrome?
A
Blood tests - ANA, anti-Ro, anti-La, rheumatoid factor
Schirmer test
18
Q
What type of arthritis does Sjögren’s syndrome cause?
A
- chronic (there may be acute flares)
- systemic
- inflammatory
- symmetric
- autoimmune
- non-erosive
19
Q
Management of Sjögren’s syndrome?
A
- artificial saliva / tears
- vaginal lubricants
- pilocarpine (muscarinic agonist)
- corticosteroids
- methotrexate / azathioprine / cyclophosphamide
20
Q
What is Sjögren’s syndrome?
A
Lymphocyte-mediated autoimmune disease characterised by destruction of the minor salivary glands, lacrimal glands and joints.
21
Q
Clinical triad found in Sjögren’s syndrome?
A
- xerostomia (dry mouth)
- xerophthalmia (dry eyes)
- inflammatory arthritis
22
Q
What diseases might Sjögren’s syndrome occur secondary to?
A
- rheumatoid arthritis
- SLE
- other autoimmune conditions
23
Q
What autoantibodies are found in patients with SLE?
A
- ANA
- anti-dsDNA
24
Q
What gene is associated with ankylosing spondylitis?
A
HLA B27
25
X ray findings in ankylosing spondylitis?
- bamboo spine
- vertebral body squaring
- subchondral sclerosis and erosions
- syndesmophytes
- ossification of ligaments, discs and joints
- fusion of costovertebral & sacroiliac joints
26
Anti-TNF drug examples?
- infliximab
- adalimumab
- etanercept
27
Pathophysiology of osteoarthritis?
Imbalance between cartilage being worn down and chondrocytes repairing it.
28
What is Paget’s disease of bone?
Excessive uncoordinated bone turnover, with increased activity of both osteoblasts and osteoclasts.
Particularly affects the axial skeleton.
29
How does the skull appear in Paget’s disease of bone?
Cotton wool appearance due to patches of increased and decreased density.
30
Which antibody is most specific for rheumatoid arthritis?
anti-cyclic citrullinated peptide antibody
31
Management of rheumatoid arthritis?
1. DMARD monotherapy (methotrexate / leflunomide / sulfasalazine)
2. DMARDs x 2
3. methotrexate + anti-TNF
4. methotrexate + rituximab
32
What is Felty’s syndrome?
Complication of rheumatoid arthritis.
- rheumatoid arthritis
- neutropenia
- splenomegaly
33
What is polymyalgia rheumatica?
Immune-mediated inflammatory disorder causing pain, stiffness and inflammation in the shoulders, neck, and hip muscles.
34
What is dermatomyositis?
Chronic inflammation of the skin and muscles.
35
What is polymyositis?
Chronic inflammation of the muscles.
36
What are some blood markers for dermato- / polymyositis?
- raised creatinine kinase
- anti-Jo-1
- anti-Mi-2 (dermatomyositis only)
- ANA (dermatomyositis only)
37
What are the muscle symptoms of dermato- / polymyositis?
- muscle pain, fatigue, and weakness
- bilateral
- typically proximal muscles affected
- shoulder and pelvic girdle
- develops over weeks
38
What are the skin symptoms of dermatomyositis?
- Gottron lesions (erythematous plaques)
- photosensitive erythematous rash on back, shoulders, and neck
- purple rash on face & eyelids
- periorbital oedema
- subcutaneous calcinosis
39
What is the function of 1-alpha-hydroxylase?
Hormone secreted by the proximal convoluted tubule, activates vitamin D to form calcitriol.
40
What condition causes brittle bones in adults due to a lack of vitamin D?
osteomalacia
41
What condition occurs in children due to a lack of vitamin D?
Ricketts
42
Why does Ricketts not occur in adulthood?
Ricketts occurs due to impaired bone mineralisation PRIOR to epiphyseal closure.
43
How is giant cell arteritis diagnosed?
Multinucleated giant cells seen on temporal artery biopsy.
44
Management of giant cell arteritis?
Steroids
45
Gout microscopy appearance?
- negatively birefringent on polarised light microscopy
| - needle-shaped monosodium urate crystals
46
Pseudogout microscopy appearance?
- positively birefringent on polarised light microscopy
| - rhomboid crystals of calcium pyrophosphate
47
Classic X ray change in pseudogout?
chondrocalcinosis - thin white line in joint space due to calcium deposition
48
Most common joint affected in pseudogout?
knee
49
What is fibromyalgia?
Disorder characterised by widespread musculoskeletal pain accompanied by fatigue, sleep, memory and mood issues.
50
What are some risk factors for developing fibromyalgia?
- depression, anxiety, stress
- dissatisfaction at work
- middle age
- low income
- divorced
- low educational status
51
What empirical antibiotics are first line for septic arthritis?
Flucloxacillin + rifampicin for the first two weeks.
52
OA vs RA pattern of joint involvement?
OA - asymmetrical
| RA - symmetrical
53
OA vs RA most common joints affected?
OA - DIPJs, knees, hips
| RA - PIPJs (rarely DIPJs), wrists, feet
54
OA vs RA joint stiffness?
OA - less than 30 minutes morning stiffness
| RA - more than 30 minutes morning stiffness
55
OA vs RA effect of movement?
OA - pain worsens with movement
| RA - pain improves with movement
56
Osteoarthritis hand signs?
Bouchard's nodes (PIPJ)
Heberden's nodes (DIPJ)
B comes before H
57
Genetic associations of RA?
HLA DR4 / HLA DR2
58
RA X ray signs?
LESS
- loss of joint space
- erosions
- soft tissue swelling
- soft bones
59
RA hand signs?
- Boutonniere deformity
- swan neck deformity
- ulnar deviation
- Z shaped thumb deformity
60
Side effects of methotrexate?
- pulmonary fibrosis
| - teratogenic
61
What is taken with methotrexate?
Folic acid (on a DIFFERENT day)
62
What is Caplan's syndrome?
Rheumatoid pneumoconiosis - occurs in people with RA who have inhaled coal dust / silica.
Pulmonary fibrosis with pulmonary nodules.
63
What is osteoporosis?
Skeletal disease characterised by low bone density and micro-architectural defects in bone tissue, resulting in increased bone fragility and susceptibility to fracture.
64
Risk factors for osteoporosis?
- steroid use
- hyperthyroidism / hyperparathyroidism
- low BMI
- early menopause
- malabsorption
65
Protective factor for oestoporosis?
Oestrogen
66
Investigations for osteoporosis?
- x-ray shows fragility fractures
- DEXA scan
- FRAX score
67
What is the FRAX score?
Risk of a fragility fracture over the next 10 years.
68
Classic triad of symptoms of reactive arthritis?
Can't see, can't pee, can't climb a tree.
| conjunctivitis, urethritis, arthritis
69
Most common cause of native joint septic arthritis?
Staph aureus
70
Cause of septic arthritis in young & sexually active patients?
Neisseria gonorrhoea
71
Cause of septic arthritis in joint replacement patients?
Staph epidermidis
72
Cause of septic arthritis in IVDU / immunocompromised?
- E. coli
| - pseudomonas aeruginosa
73
Antibodies associated with SLE?
- ANA (non-specific)
| - anti-dsDNA (highly specific)
74
Syndromes associated with SLE?
- antiphospholipid syndrome
| - Raynaud's
75
First line for mild SLE?
Hydroxychloroquine
76
Bone tumour symptoms?
- persistent bone pain
- nocturnal bone pain
- rest pain
- unexplained fractures
- fatigue / weight loss / fever
- swelling / lump
77
What group of patients does osteosarcoma most commonly affect?
More common in males than females.
| Peak incidence 13-16 years.
78
Distinguishing features of osteosarcoma?
- childhood and adolescence
- overlying skin ulceration
- affects the distal femur, proximal tibia (bones around the knee)
79
Distinguishing features of Ewing's sarcoma?
- childhood and adolescence
- may affect pelvis, femur, humerus, ribs
- onion skin x ray appearance
80
Distinguishing features of chondrosarcoma?
- affects adults over 40
- femur, pelvis, arm, knee
- ring and arcs calcification
81
What is pANCA?
perinuclear ANCA (targets MPO inside neutrophils)
82
What is cANCA?
cytoplasmic ANCA
83
What type of hypersensitivity reaction is SLE?
Type III
84
Rheumatological condition associated with miscarriage?
SLE
85
What is Raynaud's associated with?
- SLE
- systemic sclerosis
- RA
- dermatomyositis
86
Medication for Raynaud's?
CCB
87
What is systemic sclerosis?
Multisystem autoimmune disease in which there is increased fibroblast activity, and therefore increased collagen deposition. This results in abnormal growth of connective tissue.
88
Signs and symptoms of systemic sclerosis?
- beak-like nose and small mouth
- calcinosis (deposition in subcutaneous tissues)
- raynauds
- oesophageal dysmotility or strictures
- sclerodactyly (thickening of skin on fingers / toes)
- telangiectasia
(CREST)
89
Organ involvement in systemic sclerosis?
- GI
- renal
- lung
90
Management of systemic sclerosis?
Manage symptoms:
- GI - PPIs
- renal - ACEi
- pulmonary fibrosis - cyclophosphamide
- Raynaud's - handwarmers
91
Investigations for Paget's disease?
- ALP elevated
- calcium and phosphate normal
- X rays show osteoarthritis, cotton wool skull appearance
92
Management of Paget's disease?
- bisphosphonates
| - NSAIDs
93
What is osteomalacia?
Defective bone mineralisation due to inadequate phosphate / calcium or due to increased bone resorption (hyperparathyroidism).
94
What is osteomyelitis?
Infection of bone marrow.
95
Routes of infection in osteomyelitis?
- haematogenous
- open wound
- contiguous from skin
96
Gold standard for osteomyelitis diagnosis?
Bone biopsy
97
What is osteoarthritis?
Degenerative synovial joint disorder, characterised by progressive loss of articular cartilage and remodelling of the underlying bone.
98
Risk factors for OA?
- older age
- female
- obesity
- previous trauma
- manual occupation
99
What is an osteophytes?
Boney spur growing around a joint.
100
What is a subchondral cyst?
Sac of fluid formed inside a joint.
101
Investigations for OA?
Diagnosis can be made clinically if patient is over 45 with typical OA presentation.
- x-rays
- CRP / ESR (normal)
102
Management of OA?
- exercise (muscle strengthening and aerobic fitness)
- physiotherapy
- weight loss
- step-wise approach to pain management
- arthroplasty
103
Risk factors for RA?
- family Hx
- smoking
- female
104
How does RF cause disease?
- targets Fc portion of the IgG antibody
| - results in recruitment of inflammatory cells and complement activation
105
Investigations for RA?
- RF, anti-CCP
- CRP / ESR
- FBC (anaemia)
- x-ray
- MRI
106
Summary of RA management?
- DMARDs
- corticosteroids & NSAIDs (adjuncts)
- biological therapies
- arthroplasty / arthroscopy
- analgesia
- physiotherapy
107
Drug for mild RA?
Hydroxychloroquine
108
Pharmacological management of RA?
1. Methotrexate / leflunomide / sulfasalazine monotherapy.
2. Combination of DMARDs.
3. Methotrexate + anti-TNF (infliximab).
4. Methotrexate + rituximab.
109
Mechanism of action of methotrexate?
Disrupts folate metabolism and suppresses components of the immune system.
110
Side effects of anti-TNF drugs?
Reactivation of TB and hep B.
111
Side effects of rituximab?
- night sweats
| - thrombocytopenia
112
Complications of RA?
- Felty syndrome
- pericarditis
- pleural effusions
113
What are tophi?
Subcutaneous deposits of uric acid. Typically affect the small joints and connective tissues of the hands (DIPJs), elbows and ears.
114
Risk factors for gout?
- male
- obesity
- high purine diet (meat and seafood)
- excessive alcohol
- diuretics
- renal impairment
- older age
115
Pathophysiology of gout?
- hyperuricaemia results in super-saturation and crystal formation (monosodium urate)
- urate crystals trigger an acute inflammatory response, activating cytokines and signalling pathways
- influx of neutrophils into the joint
116
How does gout resolve (spontaneously)?
Clearance of urate crystals by macrophages.
117
Gold standard investigation for gout?
Joint fluid aspiration with synovial fluid analysis.
118
Differentials for gout?
- pseudogout
| - septic arthritis
119
Treatment of acute gout?
1. NSAIDs
2. colchicine
3. corticosteroids
120
Long term gout prevention?
- allopurinol (xanthine oxidase inhibitor)
| - dietary modifications and weight loss
121
Pathophysiology of pseudogout?
- chondrocytes deposit calcium pyrophosphate
- local CPP supersaturation (due to excess production) leads to crystal formation
- crystals stimulate a pro-inflammatory response with activation of phagocytes and neutrophils
122
Gold standard investigation for pseudogout?
Joint aspiration and synovial fluid analysis.
123
Management of pseudogout?
```
Conservative: ice packs, rest joint.
Pharmacological: NSAIDs, colchicine, corticosteroids.
Joint injection (corticosteroid + lidocaine).
```
124
What gene are spondyloarthropathies associated with?
HLA-B27
125
What is ankylosing spondylitis?
Seronegative inflammatory arthritis characterised by inflammation of the sacroiliac joints and the axial skeleton.
126
Risk factors for AS?
- male
- family Hx
- HLA-B27
127
Pathophysiology of AS?
- inflammation between vertebrae and intervertebral discs results in ossification and syndesmophyte formation
- syndesmophyte bridging across multiple vertebrae leads to 'bamboo spine'
128
What are syndesmophytes?
Ossified spinal ligaments
129
Typical presentation of AS?
Young male with chronic lower back pain and morning stiffness.
May have achilles tendon enthesitis and anterior uveitis.
130
7 As of AS?
- aortitis
- anterior uveitis
- AV block
- atlanto-axial instability
- apical lung fibrosis
- amyloidosis
- IgA nephropathy
131
Schober test?
Test of spinal movement limitation in AS.
| Increase of less than 5cm during flexion is a positive result.
132
X ray signs in AS?
- dagger sign (central radiodense line due to ligament ossification)
- bamboo spine
- squaring of vertebral bodies
- syndesmophytes
- vertebral body fusion
133
Investigations for AS?
- x-rays
- genetic testing (HLA-B27)
- CRP / ESR elevated
134
Management of AS?
1. Non-pharmacological (physiotherapy).
2. NSAIDs (+ PPIs).
3. Methoxtrexate
4. Anti-TNF agents.
135
Complications of AS?
- limited mobility (due to spinal fusion)
- osteoporosis
- spinal cord injury
- restrictive lung disease (fibrosis)
136
What is psoriatic arthritis?
Seronegative inflammatory spondyloarthritis associated with psoriasis.
137
Pattern of joint involvement in psoriatic arthritis?
- symmetrical polyarthritis (similar to RA)
| - spondylitic pattern (similar to AS)
138
Signs and symptoms of psoriatic arthritis?
- psoriatic plaques
- nail pitting and onycholysis
- dactylitis
- enthesitis
- inflammatory eye disease
- arthritis mutilans
139
What is onycholysis?
Separation of the nail from the nail bed.
140
X ray findings in psoriatic arthritis?
- pencil-in-cup deformities (erosions)
- soft tissue swelling
- osteolysis
- syndesmophytes (advanced spinal involvement)
141
Management of psoriatic arthritis?
1. NSAIDs
2. Methotrexate
3. Anti-TNF agents
142
What is reactive arthritis?
Seronegative inflammatory arthritis causing sterile joint inflammation post-infection.
143
What infections commonly precede reactive arthritis?
Urogenital (chlamydia, neisseria gonorrhoeae).
| GI (campylobacter, shigella, salmonella).
144
What is Poncet's disease?
Reactive arthritis caused by mycobacterial infection.
145
Pathophysiology of reactive arthritis?
Molecular mimicry - cross reaction of pathogen antigens with self antigens.
146
Investigations for reactive arthritis?
- joint aspiration and synovial fluid analysis
- blood cultures
- x-rays
- mid-stream urine MC&S
147
Management of reactive arthritis?
- treat precipitating infection
- NSAIDs
- corticosteroids
- steroid joint injection
148
What is SLE?
Inflammatory autoimmune connective tissue disease, affecting multiple organs and systems.
149
Risk factors for SLE?
- female
- Black ethnicity
- family history
150
Signs and symptoms of SLE?
- fatigue, weight loss
- arthralgia and myalgia (non-erosive arthritis)
- photosensitive malar rash / discoid rash
- dyspnoea & pleuritic chest pain
- mouth ulcers
- hair loss
- Raynaud's
- thrombosis
151
Investigations for SLE?
- ANA and anti-dsDNA antibodies
- prothrombin time & anti-phospholipid antibodies
- CXR
- chest CT
- X-rays of joints
- renal biopsy (for lupus nephritis)
152
Management of SLE?
- hydroxychloroquine
- corticosteroids
- methotrexate
- rituximab
- sun protection
153
Complications of SLE?
- anaemia
- pericarditis
- pleural effusion
- lupus nephritis
- thrombosis
- susceptible to infection
- corticosteroid-related complications
154
Most common cause of back pain?
Mechanical
155
Differentials for back pain?
- mechanical
- spondyloarthritis
- osteomyelitis
- malignancy
- fracture
- osteoarthritis
- pyelonephritis
156
Treatment of fibromyalgia?
Neuropathic pain relief - tricyclic antidepressants (amitriptyline), gabapentin, pregabalin.
Opiates
157
What is fibromyalgia?
Chronic pain syndrome characterised by the presence of widespread body pain (neuropathic). Often co-morbid symptoms - fatigue, memory and mood problems, sleep disturbance.
158
Criteria for fibromyalgia diagnosis?
11 out of 18 tender point sites.
| Pain history of at least 3 months.
159
Inheritance of Marfan syndrome?
Autosomal dominant
160
What is Marfan syndrome?
Autosomal dominant connective tissue disorder characterised by loss of elastic tissue.
161
Complications of Marfan syndrome?
- aortic dissection
| - heart failure
162
Signs and symptoms of Marfan syndrome?
- tall stature
- wide arm span
- arachnodactyly
- pectus excavatum
- joint hypermobility
163
Treatment of antiphospholipid syndrome?
LMWH
164
Most common cause of osteomyelitis in sickle cell anaemia patients?
salmonella
165
Does alcohol cause osteoporosis or osteomalacia?
Osteoporosis
166
Antibodies in anti-phospholipid syndrome?
- lupus anticoagulant
- anti-cardiolipin
- anti-beta2 GP1
167
Risk factors for osteomalacia?
- reduced sun exposure
| - low dietary vitamin D
168
Age range in fibromyalgia?
30-60
