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Medicine Y6 > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

1
Q

Lower Back Pain: red flags

A
  • Signs of malignancy
    • age < 20 years or > 50 years
    • history of previous malignancy
    • night pain
    • systemically unwell e.g. weight loss, fever
  • Signs of cauda equina
    • faecal / urinary incontinence
    • loss of anoperoneal sensation / tone
  • History of trauma

(Dr Joshi)

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2
Q

Ankle Injury: indications for x-ray

A

The Ottawa Rules: An ankle x-ray is required only if there is any pain in the malleolar zone and any one of the following findings:

  • bony tenderness at the lateral malleolar zone (from the tip of the lateral malleolus to include the lower 6 cm of posterior border of the fibular)
  • bony tenderness at the medial malleolar zone (from the tip of the medial malleolus to the lower 6 cm of the posterior border of the tibia)
  • inability to walk four weight bearing steps immediately after the injury and in the emergency department
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3
Q

A pt presents with frontal balding, cataracts, a pacemaker and a slow-releasing handshake. What is the diagnosis?

A

Myotonic dystrophy

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4
Q

What are the clinical features of myotonic dystrophy?

A

Slow-releasing handshake Myopathic facies Cataracts Frontal balding Cardiomyopathies + heart blocks (cause of death) Learning difficulties

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5
Q

After examining hands in RA, what else should you examine / ask about?

A
  • eyes (episcleritis or scleritis in ~5%))
  • voice changes (inflamm at cricoarytenoid joint –> hoarseness)
  • neck pain
  • auscultate chest (pleuritis, pulmonary fibrosis in severe cases)
  • auscultate heart (pericarditis, myocarditis, CAD in severe cases)
  • examine abdo for splenomegaly (Felty’s Syndrome = RA, splenomegaly, low WBC)
  • examine limbs for peripheral neuropathy

(Mirza)

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6
Q

Define rheumatoid arthritis

A

A chronic systemic inflammatory condition causing joint destruction and deformity, primarily affecting the small joints of the hand and feet and progressing proximally.

(UpToDate)

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7
Q

Summarise the epidemiology of rheumatoid arthritis

A

Prevalence: ~1% population

Usually presents in 50s, F:M 2:1 in younger pts

(BMJ)

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8
Q

Explain the aetiology / risk factors of rheumatoid arthritis

A

Unknown aetiology

RFs:

gentic: HLA DR4, PTPN22
smoking: weak
* (BMJ)*

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9
Q

Rheumatoid arthritis: hand signs

A
  • Swan neck deformity (PIP hyperextended, DIP flexed)
  • Boutonniere’s deformity (PIP flexed, DIP hyperextended)
  • Ulnar deviation
  • Z-shaped thumb
  • Rheumatoid nodules (over extensor tendons)
  • Morning stiffness >1h

(BMJ)

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10
Q

Rheumatoid arthritis: diagnostic criteria

A

ACR-EULAR criteria: >6/10 needed

A- Joint Involvement

0: Large Joint
1: 2-10 large joints
2: 1-3 small joints (with or without involvement of large joints)
3: 4-10 small joints (with or without involvement of large joints)
5: >10 joints (atleast 1 small joint)

B- Serology

0: Negative RF and negative ACPA
2: Low-positive RF or low-positive ACPA
3: High-positive RF or high-positive ACPA

C- Acute Phase Reactants

0: Normal CRP and Normal ESR
1: Abnormal CRP and Abnormal ESR

D- Duration of Symptoms

0: <6 weeks
1: >6 weeks
* (Radiopaedia, BMJ)*

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11
Q

Identify appropriate investigations for rheumatoid arthritis

A
  • Bloods:
    • diagnosis: rheumatoid factor, anti-CCP Ab, CRP, ESR
    • DMARD-prep: FBC, HepB/C screen, LFTs
  • Imaging: radiographs

(BMJ)

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12
Q

Outline a management plan for rheumatoid arthritis

A
  • Conservative - pt education
  • Medical
    • 1st line: methotrexate + 1 other DMARD (sulfasalazine, leflunomide, ~hydroxycholorquine))
      • corticosteroid (eg prednisolone PO)
    • +/- NSAID
    • 2nd line: a biological (+ DMARD)
      • Anti-TNF (infliximab, etanercept) or
      • Tocilizumab (anti-B/T cell) or abatacept (anti-T cell)
    • 3rd line: Rituximab (anti-B cell) + DMARD
  • Surgical (eg prosthetic joints)
    • Indicated if tx-refractory +

progressive or risk of tendon rupture / nerve compression / stress fracture.

(BMJ, NICE)

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13
Q

Identify the possible complications of rheumatoid arthritis

A
  • Common
    • Work disability
    • Coronary artery disease
  • Less common
    • Felty Syndrome (RA + splenomegaly + low WCC)
  • Eye (scleritis or episcleritis in 5%)
  • Voice (hoarse)
  • Lung (pleuritis, pulmonary fibrosis)
  • Heart (pericarditis, myocarditis)
  • Peripheral neuropathy

(BMJ)

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14
Q

Describe the following types of fracture

Oblique:

Comminuted:

Transverse:

Spiral:

Segmental:

A

Oblique: fracture lies oblique to the long axis of the bone

Comminuted: >2 fragments

Transverse: fracture lies perpendicular to the long axis of bone

Spiral: fracture lies severely oblique with rotation along the long axis of the bone

Segmental: more than one fracture along a bone

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15
Q

Outline the grading system for open fractures

A

Gustilo and Anderson classification system

Grade: Injury

1: Low energy wound <1cm
2: Greater than 1cm wound with moderate soft tissue damage
3: High energy wound > 1cm with extensive soft tissue damage

3 A: Adequate soft tissue coverage

3 B: Inadequate soft tissue coverage

3 C: Associated arterial injury

(Passmedicine)

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16
Q

Explain the risk factors of osteoarthritis

A

RFs:

mechanical - osteoperosis, trauma, mechanical stress, periarticular muscle weakness, joint abnormality, obesity

hormonal - low oestrogen levels (post-menopausal)

congenital - articular congenital deformities

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17
Q

Generate a management plan for osteoarthritis

A
  • Conservative
    • wt loss, local muscle strengthening, supports, braces
  • Medical
    • 1st line: paracetamol + topical NSAID (if knee / hand)
    • 2nd line: PO NSAID (+PPI) or opiods or intra-articular steroids
  • Surgical
    • Joint replacement

(PassMedicine, NICE)

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18
Q

Identify the possible complications of osteoarthritis

A

Short term: effusion

Long term: Functional decline, spinal stenosis in cervical / lumbar OA

Tx-related: NSAID-related GI bleed or AKI, surgical complications

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19
Q

Generate a management plan for ankylosing spondylitis

A
  • Conservative
    • Regular exercise, physiotherapy
  • Medical
    • 1st line: NSAIDs
    • 2nd line: DMARD (only if peripheral joint invovlement)
    • 3rd line: Anti-TNF (severe refractory disease)
  • Surgical: if thoracic kyphosis

(Passmedicine, BMJ)

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20
Q

Explain the aetiology / risk factors of ankylosing spondylitis

A

HLA B27 (90% ank spond pts have it, 10% total pop)

Male

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21
Q

Summarise the epidemiology of ankylosing spondylitis

A

M:F 10:1

20% present in juveniles

Usually presents 20-30y

(BMJ, Passmedicine)

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22
Q

What are the characteristic signs of ankylosing spondylitis on a plain radiograph?

A

Characteristics of ankylosing spondylitis on plain radiograph:

Sacroilitis: subchondral sclerosis, subchondral erosions

Squaring of lumbar vertebrae

Bamboo spine (late)

Syndesmophytes: ossification of outer fibres of annulus fibrosus

CXR: apical fibrosis

(Passmedicine)

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23
Q

Summarise the prognosis for patients with ankylosing spondylitis

A

Variable progression

  • pts with regular exercise regimes do best.
  • 20% progress to bamboo spine

No increase in mortality

(BMJ)

24
Q

Identify the possible complications of ankylosing spondylitis

A

Long: achilles tendonitis, apical fibrosis, anterior uveitis, arthritis (peripheral) aortic regurgitation, AV node block, amyloidosis, cauda equina syndrome, osteoperosis

(Passmedicine, BMJ)

25
# Define fibromyalgia
Syndrome of unknown aetiology characterised with widespread pain throughout the body, with tenderness located at specific anatomical sites *(Passmedicine)*
26
Summarise the epidemiology of fibromyalgia
F:M 10:1 Peak incidence at 30-50 *(passmedicine)*
27
Generate a management plan for fibromyalgia
* Conservative: education, regular exercise, CBT * Medical: * Induce remission * 1st line: TCA (eg amytryptyline, try for 6w) * 2nd line: SNRI (eg duloxetine, 1st line if comorbid depression or fatigue) or pregabalin / gabapetin (if sleep distrubance) * 3rd line: TCA +/- SNRI +/- gabapentoid * Analgesia: naproxen or tramadol *(BMJ)*
28
What are the criteria for normal, osteopenia and osteoperosis on a DEXA scan?
Basics ## Footnote T score: based on bone mass of young reference population T score of -1.0 means bone mass of one standard deviation below that of young reference population Z score is adjusted for age, gender and ethnic factors T score \> -1.0 = normal -1.0 to -2.5 = osteopaenia \< -2.5 = osteoporosis *(Passmedicine)*
29
List signs of a fracture
Pain Unable to wt bare Skin changes Deformity Adjacent structural injury (neurovascular) Oedema Crepitus *(lecture)*
30
Outline how to describe a fracture from a plain radiograph
1. Describe the film: who, what, when and where 2. Type of fracture: * complete (all the way through bone): transverse, oblique, spiral, comminuted * incomplete: bowing, buckle, greenstick * Salter-Harris 3. Location: diaphysis, metaphysis, epiphysis 4. Displacement: translation, anglulation/rotation 5. If joint: intra-articular vs extra-articular * (lecture, radiopaedia)*
31
What are the features of osteoarthritis on a plane radiograph?
* Loss of joint space * Osteophytes * Subchondral cysts * Subchondral sclerosis
32
What are the special tests of the knee examination?
**CCC** Collaterals - MCL, LCL Cruciates - anterior draw and posterior draw test, Lachman's test Cartilages - McMurray test (medial: hip flexed, knee 90 degress, externally rotate tibia with valgus pressure at knee, slowy extend leg. +ve sign is pain so just offer)
33
What are the special tests of the hip examination?
**T T** * Trendelenberg test (put hands on pts ASISs, get them to lift one leg, if non-weightbearing side droops, there is pathology in hip abductors of other side) * Thomas' test (for fixed flexion deformity: pt supine, flex one hip, +ve if other leg lifts off the bed)
34
What are the special tests of the shoulder examination?
**I SITS** * Impingement: * Arc: internally rotate, abduct, pain from 60-120 degrees suggests impigment * Kennedy-Hawkins test: abduct shoulder 90, elbow 90, internally rotate * Supraspinatus: Job's test (empty beer can: internally rotated, push up) * Infraspinatus + Teres Minor: shoulder abducted, elbow 90, push my hands apart * Subscapularis: arm behind your back, push against my hand *(lecture)*
35
What is the definition of frozen shoulder
Pain in all ranges of movement, with a normal shoulder X-ray
36
Generate a management plan for reactive arthritis
* Medical * Symptom relief * 1st line: NSAIDs * 2nd line: steroids * If chronic arthritis, consider DMARDs * 1st line: sulfasalazine *(BMJ)*
37
Summarise the prognosis for patients with reactive arthritis
25% have recurrent episodes, 10% have chronic disease ## Footnote *(passmedicine)*
38
Identify appropriate investigations for reactive arthritis
* Bloods: CRP, ESP, FBC, RF + ANA (rule out DDx) * Cultures: urine, stool, genital * Arthrocentesis: synovial fluid -ve for WBCs and crystals *(BMJ)*
39
Recognise the presenting symptoms of reactive arthritis
Features * usually w/i 4w of initial infection - sx generally last ~4-6m * asymmetrical oligoarthritis of lower limbs * dactylitis * symptoms of urethritis * eye: conjunctivitis (seen in 50%), anterior uveitis * skin: circinate balanitis (painless vesicles on the coronal margin of the prepuce), keratoderma blenorrhagica (waxy yellow/brown papules on palms and soles) *(passmedicine)*
40
Explain the risk factors of reactive arthritis
* Infection: STI (chlamydia, gonorrhoea), gastroenteritis * Genetic: HLA B27 *(passmedicine)*
41
# Define reactive arthritis
Reactive arthritis is defined as an arthritis that develops following an infection where the organism cannot be recovered from the joint. *(passmedicine)*
42
What is Reiter's Syndrome?
Reiter's Syndrome = reactive arthritis + urethritis + conjunctivitis
43
Generate a management plan for gout and pseudogout
* Acute * Conservative: raise limb, avoid trauma, keep joint cool (ice-pack) but not covered, diet change (reduce red meat/ETOH/fat/sugar, keep hydrated), stop smoking * Medical: * 1st line: NSAID (indomethacin, to 48h after attack) + PPI * 2nd line: colchicine PO (SE: diarrhoea) * 3rd line: steroid PO * Paracetamol +/- codeine if all above are CI * Keep taking allopurinol at same dose, come back in 3d if no improvement * Prophylaxis * Allopurinol PO (start 2w after attack with NSAID/colchicine cover, titrate dose to serum urate) * +/- probenecid (increases urate excretion) * R/v serum uric acid, UEs, lipids, glucose at 6w ## Footnote *(Passmedicine, NICE)*
44
# Define antiphospholipid syndrome
Antiphospholipid syndrome is an acquired disorder characterised by a predisposition to both venous and arterial thromboses, recurrent fetal loss and thrombocytopenia. It may occur as a primary disorder or secondary to other conditions, most commonly systemic lupus erythematosus (SLE) *(passmedicine)*
45
Generate a management plan for antiphospholipid syndrome
* Conservative: * Risk factor modification: manage hyperlipidaemia, HTN, T2DM, obesity. Smoking cessation. Improve mobility. * Medical - based on BCSH guidelines * Immediate: LMWH or unfractionated heparin * Ongoing: Warfarin (target INR and course varies). Start after delivery if pregnant * initial venous thromboembolic events: target INR 2-3 for 6 months * recurrent venous thromboembolic events: lifelong warfarin, if occurred whilst taking warfarin then increase target INR to 3-4 * arterial thrombosis: lifelong warfarin with target INR 2-3 *(passmedicine, BMJ)*
46
Identify appropriate investigations for antiphospholipid syndrome
Confirm diagnosis * Bloods: lupus anticoagulant, anticardiolipin antibodies, anti-beta2-glycoprotein I antibodies, FBC, UEs Assess DDx * Bloods: ANA, double-stranded DNA, and extractable nuclear antigen antibodies * (BMJ)*
47
Identify the possible complications of antiphospholipid syndrome
Obstetric: pregnancy loss, pre-eclampsia, IUGR, placental abruption Thromboembolic: PE, CVA, DVT *(BMJ)*
48
What conditions are associated with anti-phospholipid syndrome?
Associations: * pregnancy * SLE (40%) and other autoimmune disorders (RA 6%) * lymphoproliferative disorders * phenothiazines (rare) *(passmedicine)*
49
Summarise the epidemiology of antiphospholipid syndrome
F\>M, onset in reproductive years 20% of recurrent pregnancy loss 1-5% prevalence in general population *(BMJ)*
50
What are the characteristics of rheumatoid arthritis on a plane radiography
* Subluxation * Juxta-articular osteoperosis * Peri-articular erosions * Loss of joint space ## Footnote *(passmedicine)*
51
Identify appropriate investigatons in gout / psuedogout
* X-ray joint * Aspirate joint + examine under polarised light: * needle-shaped negatively birefringent crystals = gout * weakly birefringent rhomboid shaped crystals = psuedogout *(Meeran)*
52
What are the possible complications of gout?
* Tophus - uric acid crystals in joints/cartilage/bone. Pathognomonic for gout. If untreated can --\> severe arthritis. * Nephrolithiasis (urate stones) * Chronic uric acid nephropathy (--\> CKD, usually in combination with RFs eg T2DM, HTN etc) *(UpToDate)*
53
Summarise the prognosis for patients with gout
Episodes are self-limiting Recurrence is common Complications are rare
54
Explain the aetiology / risk factors of gout
Hyperuricaemia Diet (purine-rich): alcohol , red meat, seafood High cell turnover: malignancy, chemotherapy RFs: obesity, HTN, T2DM, diuretics *(BMJ)*
55
What are seronegative spondyloarthropathies?
Inflammatory arthridies affecting the spine and peripheral joints w/o production of rheumatoid factor * HLA-B27 associated * (AS)*
56
What are the 4 seronegative spondyloarthropathies?
PARE * Psoriatic arthritis * Ankylosing spondylitis * Reactive arthritis * Enteric arthropathy (associated with IBD, coeliac, Whipple's disease) *(Adam, OHCM)*

Medicine Y6 (14 decks)

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