Musculoskeletal

Question 1

What is Osteomyelitis

Answer 1

Inflammatory condition of the bone caused by an infective organism, most commonlyStaphylococcus aureus (except in SCA patients → salmonella species more common

Usually involves a single bone, may occur in the peripheral or axial skeleton

Question 2

What is Haematogenous Osteomyelitis

Answer 2

Results from bactaraemia and is usually monomicrobial
- Most common form in children
- Vertebral osteomyelitis → most common form of haematogenous osteomyelitis in adults

- Risk Factors: sickle cell anaemia, IV drug use, immunosuppression, infective endocarditis

Question 3

What is Non-Haematogenous Osteomyelitis

Answer 3

Results from contagious spread of infection from adjacent soft tissues to the bone or from direct injury/trauma to bone

- Poly microbial, most common form in adults
- Risk Factors → diabetic foot ulcers/pressure sores, diabetes mellitus, peripheral arterial disease

Question 4

What are the Risk Factors of Osteomyelitis

Answer 4

previous osteomyelitis, penetrating injury, IV drug misuse, diabetes, HIV infection, recent surgery, distant or local infections, sickle cell anaemia

Question 5

What are clinical features of Osteomyelitis

Answer 5

Limp or Reluctance to weight-bear→ common presentation fo acute osteomyelitis in children

• Non-specific Pain at site of infection
• Malaise, Fatigue, Fever, Chills
• Local inflammation, tenderness, erythema, or swelling
• Local Back Pain with systemic symptoms → native vertebral osteomyelitis

Question 6

What Investigations are needed for Osteomyelitis

Answer 6

Bone MRI→ most definitive imaging modality

Bone Biopsy→ Gold Standard before administering antibiotics. Identification of infection and the causative microorganism, so appropriate treatment

Blood Culture → may be positive, indicating the infective organism

WCC, ESR & CRP → raised

Question 7

What treatments are needed for Osteomyelitis (name antibiotic)

Answer 7

Antibiotic Therapy →flucloxacillin (IV)
- Abx treatment for 2-4 wks
- If Penicillin Allergic → clindamycin

Question 8

Example causes of Primary Osteoporosis

Answer 8

postmenopausal osteoporosis (decreased oestrogen leads to increased bone resorption due to increased osteoclast activity)

senile osteoporosis (gradual loss of bone mass as patients age)

rheumatoid arthritis

Question 9

Example causes of Secondary Osteoporosis

Answer 9

drug induced (long term corticosteroid therapy, or anticonvulsants, anticoagulants, PPIs), hypogonadism, hyperthyroidism, Cushings syndrome, immobilisation, hyperparathyroidism

Question 10

Osteoporosis vs Osteomalacia

Answer 10

Loss of bone density vs Loss of Bone mineral

DEXA scan vs Blood Vit D and serum calcium

Question 11

DEXA scan value for Osteoporosis?

Answer 11

DEXA → T-score ≤-2.5 indicates osteoporosis. (Osteopenia = -1 to -2.5)

Question 12

What is the management plan for Osteoporosis?

Answer 12

Bisphosphonates (Alendronate) → inhibit osteoclasts leading to reduced bone resorption. If patients can’t tolerate alendronate (due to upper GI side effects), give risedronate.

Denosumab→ 2nd line treatment for postmenopausal women with osteoporosis

Calcium and Vitamin D supplementation (Ergocalciferol)
Teriparatide→ PTH analogue

Avoid or minimise use of glucocorticoids

Question 13

What are the main side effects of Bisphosphonates and what else can they be used for?

Answer 13

Have side effect of dyspepsia and reflux due to oesophageal reactions (oesophagitis).

Can also cause osteonecrosis of the jaw

Can also be used for hypercalcaemia, Pagets disease and pain from bone metastases

Question 14

What are the main clinical features of temporal arteritis?

Answer 14

unilateral vision loss, headache, jaw claudication (pain when chewing), scalp tenderness

Tender, palpable temporal artery

Question 15

What is the main aetiology for Polymyalgia Rheumatica?

Answer 15

Aetiology → genetic predisposition + association with giant cell arteritis

Question 16

What is the main differentiating factor regarding Polymyalgia Rheumatica (steroid related)?

Answer 16

Rapid response to Steroids

Question 17

What is the management plan for Polymyalgia Rheumatica?

Answer 17

• 1st Line →Corticosteroids (Prednisolone)
  If patients don’t respond to steroids, alterative diagnosis should be considered. Increase dose if treatment-resistance or relapse.

Question 18

What is the investigation and management plan for Temporal Arteritis?

Answer 18

• Ix ⇒ raised ESR (first investigation). Temporal artery biopsy should be done (may show skip lesions).
• Tx ⇒ high dose steroids (prednisolone - given before biopsy done) and urgent Opthalmology review (same day)

No visual loss = high dose oral prednisolone. Vision loss = IV methylprednisolone.

Question 19

What 2 types of infection tend to cause Reactive Arthritis

Answer 19

gastrointestinal or urinary tract infection

Question 20

What are the main clinical features of Reactive Arthritis?

Answer 20

Arthritis → clinical symptoms develop 1-4 weeks after onset of infection. Usually larger joints in lower extremity.

Inflammation leads to painful, swollen, warm, red and stiff joints (normal ROM unlike septic), especially in morning.

Swelling of digits. May also get lower back pain.

Conjunctivitis or Uveitis

Symptoms from preceding infection → diarrhoea, dysuria, urethritis

Question 21

What constitutes as a Seronegative Spondyloarthropathy?

Answer 21

negative for rheumatoid factor and has a strong genetic association with HLA-B27

Question 22

What is the management plan for Reactive Arthritis?

Answer 22

• First Line → NSAIDs (Naproxen, Ibruprofen, Diclofenac)
  
  • If NSAIDs don’t work → Corticosteroids (Prednisolone)
  💡 Don’t use antibiotics for reactive arthritis
• Chronic Cases (refractory to both NSAIDs and corticosteroids) → DMARDs (Sulfasalazine)

Question 23

Key differences Septic Vs Reactive Arthritis

Answer 23

Reactive is Sterile
Reactive the ROM is preserved

Question 24

What is the management plan for Septic Arthritis?

Answer 24

Joint Drainage→ therapeutic arthrocentesis

IV Antibiotics which cover gram-positive cocci → flucloxacillin (or clindamycin if penicillin allergic)
- Course should be taken for at least 4-6 weeks

Question 25

What is SLE?

Answer 25

Multisystem autoimmune disease that predominantly affects women of childbearing age

• Type 3 hypersensitivity reaction
• F>M (9:1), onset usually at 20-40 yrs old, more common in Afro-Caribbeans
• Aetiology → genetic predisposition (HLA-DR2 and HLA-DR3), hormonal factors (hyperoestrogenic states), environmental factors (cigarette smoking)

Question 26

What syndrome is SLE associated with?

Answer 26

Associated with Anti-Phospholipid Syndrome →

increased risk of thrombus formation (recurrent PEs and DVTs) and recurrent miscarriages.

Prolonged APTT (paradoxical) and low platelets (thrombocytopenia).

Associated with anti-cardiolipin antibodies.

Question 27

How is Anti-Phospholipid Syndrome managed?

Answer 27

1st Line Managed with warfarin (after inital thromboembolic event - avoid warfarin in pregnant women).

if contraindicated- LMWH or aspirin

Question 28

What are the main clinical features of SLE?

Answer 28

• Malar (Butterfly) Rash
• Photosensitive Rash → rash occurs after sun exposure. Can be painful and pruritic and usually lasts a few days, healing without scarring
• Joints → arthritis and arthralgia. Distal symmetrical polyarthritis.
• Oral Ulcers
• Constitutional Symptoms → fatigue, fever, weight loss
• Raynaud’s Phenomenon → colour changes of the digits induced by cold (white → blue → red)
• CVS → pericarditis (and pleural effusion) or myocarditis

Question 29

What are the investigations for SLE?

Answer 29

• Antinuclear Antibody (ANA) → very sensitive, however may be positive in many other conditions so low specificity (hence useful as a ruleout test)
  
  • ANA is very unspecific antibody
• Anti-dsDNA → highly specific for SLE, less sensitive
• ESR → elevated (CRP often normal, may be high if patient has infection)
• Decreased Complement Levels (C3/C4)
• Urinalysis (urine dipstick) → check for proteinuria and renal involvement

Question 30

What is the management plan for SLE?

Answer 30

• 1st Line → Hydroxychloroquine
  • Requires visual acuity testing as can lead to severe and permanent visual loss. Baseline ophthalmological examinationand annual screening is generally recommened. Safe for use in pregnancy.
• General → NSAIDs, avoid smoking and UV light
• Topical Steroids for skin manifestations