Musculoskeletal Flashcards
What does ESR stand for?
Erythrocyte sedimentation rate
Give 2 circumstances where there are false positives of ESR
- ) Age
- ) Female
- ) Obesity
- ) Ethnicity
- ) Hypercholesterolaemia
- ) Anaemia
What does CRP stand for?
C-reactive protein
Where is CRP released, and in response to what?
Liver, IL-6
What type of joint disease is osteoarthritis?
Degenerative
Give 2 things osteoarthritis can be secondary to
- ) Obesity
- ) Occupational factors
- ) Haemochromatosis
What is the process of osteoarthritis mediated by?
Cytokines
What are the main pathological features of osteoarthritis? (2)
- ) Loss of cartilage
- ) Disordered bone repair
Give 4 risk factors for osteoarthritis
- ) Age
- ) Gender (F more after menopause)
- ) Genetic predisposition
- ) Obesity (low grade inflammatory state)
- ) Occupation (manual labour)
- ) Local trauma, inflammatory arthritis, abnormal biomechanics
Give 3 main symptoms that differentiate osteoarthritis from rheumatoid arthritis
- ) Stiffness after rest for <30 minutes
- ) Pain worse on exertion
- ) Worse pain at end of day
Give 3 commonly affected joints in osteoarthritis
- ) DIP
- ) Thumb CMP
- ) Knees
- ) Hip
Give 3 symptoms of osteoarthritis
- ) Pain and crepitus on movement
- ) Background ache at rest
- ) Worse with activity
- ) Joint tenderness, derangement, bony swelling
- ) Reduced range of movement
What are the 2 types of nodes in osteoarthritis?
Heberden’s - DIP
Bouchard’s - PIP
What do plain radiographs show in OA?
LOSS Loss of joint space Osteophytes Subarticular sclerosis Subchondral cysts
Give 4 treatment options for OA
- ) Exercise
- ) Analgesia
- ) Intra-articular steroid injections
- ) Heat/cold packs
- ) Walking aids
- ) Joint replacement
Where do the majority of septic arthritis cases occur?
Knee
Give 3 risk factors for septic arthritis
- ) Pre-existing joint disease (esp. RA)
- ) DM
- ) Immunosuppression
- ) Chronic renal failure
- ) Recent joint surgery
- ) Prosthetic joints
- ) IVDU
- ) Age >80
What is the main differential diagnosis for septic arthritis?
Crystal arthropathies
What is the main investigation for septic arthritis?
Urgent joint aspiration for synovial fluid microscopy and culture
What must we do prior to giving antibiotics in septic arthritis?
Blood cultures
Give 3 causative organisms for septic arthritis
- ) Staph aureus
- ) Streptococci
- ) Neisseria gonococcus
- ) Gram negative bacilli
What is the treatment for septic arthritis?
- ) Empirical IV antibiotics (flucloxacillin)
- ) Vancomycin if MRSA risk
- ) Cefotaxine if gram negative, gonococcus
- ) Possible washout and debridement
What do we give instead of flucloxacillin if the patient is penicillin allergic?
Clindamycin
What is osteomyelitis?
Infection and inflammation of the bone and bone marrow
What are the 2 classifications of osteomyelitis?
- ) Acute/chronic suppurative osteomyelitis
- ) Diffuse/focal sclerosing
Give 3 of the most common causative organisms for osteomyelitis
- ) Staph aureus
- ) Enterobacter species
- ) Streptococcal species
- ) H. influenzae
Which infection in osteomyelitis is more common in sickle cell disease?
Salmonella
Give 3 risk factors for osteomyelitis
- ) Behavioural factors (risk of trauma)
- ) Vascular supply
- ) Pre-existing bone/joint problem
- ) Immune deficiency
- ) IVDU
- ) TB
- ) Injury
- ) Surgery
What bones are usually affected in osteomyelitis? (2)
Adult - vertebrae and pelvis
Children - long bones
What type of osteomyelitis usually occurs in children?
Acute haematogenous osteomyelitis (blood to bone)
What is the pathogenesis of osteomyelitis in children?
1) Blood flow slower in metaphysis (shaft)
2) Endothelial basement membranes absent
3) Capillaries lack/have inactive phagocytic cells
4) High blood flow in developing bones (to carry infection)
What type of osteomyelitis usually occurs in adults?
Contiguous osteomyelitis (infection to bone)
What is the pathogenesis of osteomyelitis in adults?
1) Vertebrae become more vascular with age
2) Bacterial seeding of vertebral endplate more likely
3) Lumbar > thoracic > cervical
Give 2 key histopathological changes that occur in osteomyelitis
- ) Necrotic bone - sequestra
- ) New bone formation - involucrum
Why do sequestra and involucrum occur in osteomyelitis?
Interruption of periosteal blood supply due to inflammatory exudate extending through periosteum
Give 2 symptoms of osteomyelitis
- ) Several day onset
- ) Dull pain at site of OM
- ) May be aggravated by movement
Give 3 signs of osteomyelitis
- ) Fevers, riggers, sweats, malaise
- ) Tenderness, warmth, erythema, swelling
- ) Draining sinus tract
- ) Deep/large ulcers failing to heal despite several weeks treatment
- ) Non-healing fractures
What can osteomyelitis also present as?
Septic arthritis
Give 3 tests we do to diagnose osteomyelitis
- ) Radiographs and CT
- ) MRI
- ) Bloods
What do radiographs and CTs show in osteomyelitis?
- ) Cortical destruction in advanced disease
- ) Soft tissue swelling
- ) Sclerosis
- ) Sequestra
- ) Periosteal reaction
- ) Takes 1-2 weeks to show changes
What does an MRI show in osteomyelitis?
- ) Marrow oedema
- ) Delineates cortical, bone marrow and soft tissue inflammation
- ) Takes 3-5 days to show cahnges
What is the treatment for osteomyelitis?
Prolonged specific antibiotic therapy
What are crystals?
Homogenous solids that act to remove excess ions by surface binding
What is a crystal arthropathy?
Arthritis caused by crystal deposition in the joint lining
What type of crystals occur in gout?
Monosodium urate crystals
What type of crystals occur in pseudogout?
Calcium pyrophosphate crystals
Where does the majority of gout present?
Metatarsophalangeal joint of big toe
Give 3 things gout attacks may be precipitated by
- ) Trauma
- ) Surgery
- ) Starvation
- ) Infection
- ) Diuretics
What are long term urate deposits known as?
Tophi
What does severe joint inflammation present as?
Hot, red, swollen joints
What is uric acid produced from, and what is a key enzyme in this pathway?
Purine metabolism, xanthine oxidase
Give 3 causes of under excretion of uric acid
- ) Drugs (aspirin), alcohol
- ) Renal impairment
- ) HTN/ anti-HTNs
- ) Metabolic syndrome
- ) Diuretics
- ) Age
- ) Male
- ) Post menopause
Give 3 causes of over production of uric acid
- ) Diet (alcohol, meat, fructose)
- ) Hyperlipidaemia
- ) Psoriasis
- ) Chemotherapy
What is the amplification loop hypothesis?
The more crystals you have, there more likely you are to get more
Give 2 locations of tophi
- ) Pinna ear cartilage
- ) Joints
- ) Tendons
Give 3 associations of diseases with gout
- ) DM
- ) CVD
- ) HTN
- ) Chronic renal failure
What is tophaceous gout?
Long term deposition without treatment
What is the main test for gout?
Polarised light microscopy of synovial fluid
What does a polarised light microscopy of synovial fluid show in gout?
Negatively birefringent urate crystals, needle shaped
What do radiographs show in gout?
- ) Soft tissue swelling early
- ) Well defined punched out erosions in juxta-articular bone later
What is the treatment of gout? (3)
- ) High dose NSAID or colchicine
- ) Steroids
- ) Rest and elevate joint
Give 3 lifestyle changes for the prevention of gout
- ) Lose weight
- ) Avoid prolonged fasts
- ) Avoid alcohol excess
- ) Avoid purine-rich meats
- ) Avoid low dose aspirin
When should we start prophylaxis for gout and what is it?
- ) >1 attack a year, tophi, renal stones
- ) Allopurinol
- ) Titrate and increase until plasma urate <0.3mmol/L
- ) Wait until 3 weeks after acute episode
- ) Cover with NSAID/colchicine
What is allopurinol?
Xanthine oxidase inhibitor
Give 3 risk factors for pseudogout
- ) Hyperparathyroidism
- ) Haemochromatosis
- ) Hypophosphataemia
Which joints are affected in pseudogout?
Knee > wrist > shoulder > ankle > elbow
What does a polarised light microscopy of synovial fluid show in pseudogout?
Weakly positive birefringent crystals, rhomboid shaped
What is pseudogout associated with on an XR?
Soft tissue calcium deposition
What is the management of pseudogout?
- ) Cool packs, rest
- ) Aspiration
- ) Intra-articular steroids
- ) NSAIDs (+PPI) +/- colchicine may prevent acute attacks
- ) Methotrexate and hydroxychloroquine for chronic
What should we check for if the pseudogout is early onset (<55), polyarticular, or frequent?
Metabolic disease
What is osteoporosis?
Reduced bone mass and micro-architectural deterioration in bone tissue
What can occur if trabecular bone is affected in osteoporosis?
Crushing fractures of vertebrae
What can occur if cortical bone is affected in osteoporosis?
Long bone fractures more likely (femoral neck)
Does osteoporosis occur more in men or women >50, and why?
Women, lose trabecular with age
Give 3 risk factors for primary osteoporosis
- ) Parental history
- ) Alcohol
- ) RA
- ) Low BMI
- ) Prolonged immobility
- ) Untreated menopause
Give 9 other risk factors for osteoporosis (acronym)
SHATTERED Steroid use Hyperthyroidism, hyperparathyroidism, hypercalciuria Alcohol and tobacco Thin (low BMI <18.5) Testosterone decreased Early menopause Renal/liver failure Erosive/inflammatory bone disease (RA) Dietary calcium low, DM
What % of women will have a fracture due to osteoporosis in their lifetime?
50%
What is the Eular buckling theory? (osteoporosis)
Connections between horizontal trabeculae decrease, therefore decrease in overall strength
What are the 2 tests for osteoporosis?
XR, DEXA
What does DEXA stand for?
Dual energy XR absorptiometry
Where do we scan with DEXA?
Hip
What is the T-score in a DEXA scan?
The number of standard deviations the bone mineral density is from the young healthy adult average (25)
What does each decrease of 1SD in bone mineral density give?
2.6 times increased risk of hip fracture
What do the T-scores mean in osteoporosis? (5)
- ) >0, better than normal
- ) 0 to -1, normal
- ) -1 to -2.5, osteopenia
- ) >-2.5, osteoporosis
- ) >-2.5 plus fracture, severe osteoporosis
What is a risk assessment tool for estimating 10 year risk of osteoporotic fracture in untreated patients?
FRAX
Give 3 lifestyle changes to make in osteoporosis
- ) Quit smoking
- ) Reduce alcohol
- ) Weight bearing exercise
- ) Balance exercises
- ) Cacium and vitamin D diet
- ) Home based fall prevention
How should a patient take bisphosphonates?
Plenty of water, upright for >30 minutes, wait 30 mins before eating/other drugs
What is denosumab and when should it be given?
Monoclonal antibody to RANK ligand, given SC twice yearly, has fast offset
What does RANK stand for?
Receptor Activator of Nuclear factor-Kappa B
What does anti-resorptive treatment do in osteoporosis?
Decreases osteoclast activity and bone turnover (allows osteoblasts to catch up)
What does anabolic treatment do in osteoporosis?
Increases osteoblast activity and bone formation
Give 3 examples of anti-resorptive treatment in osteoporosis (5)
- ) Bisphosphonates - alendronic acid
- ) Strontium ranelate - only in severe intolerance and without CVD
- ) HRT
- ) Raloxifene - selective osterogen receptor modulator
- ) Denosumab
Give an example of anabolic treatment in osteoporosis
Teriparatide - recombinant PTH
Give 3 differences between osteomalacia and osteoporosis
- ) OM serum calcium low, OP no biochemical changes
- ) OM has decreased mineralisation of bone, OP no defect in mineralisation
- ) OM ache and weakness, OP no symptoms
What is Raynaud’s syndrome?
Peripheral digital ischaemia due to paroxysmal vasospasm
What is Raynaud’s syndrome precipitated by?
Cold, emotion
What occurs to the fingers or toes in Raynaud’s syndrome? (4)
- ) Ache and change colour
- ) Pale (ischamia)
- ) Blue (deoxygenation)
- ) Red (reactive hyperaemia)
What is idiopathic Raynaud’s syndrome?
Raynaud’s disease
What is Raynaud’s syndrome with an underlying cause?
Raynaud’s phenomenon
Give 3 conditions in which Raynaud’s phenomenon may be exhibited
- ) Systemic sclerosis
- ) SLE
- ) RA
- ) Occupational, vibrating tools
- ) Obstructive conditions
- ) Thrombocytosis
- ) Beta-blockers
- ) Hypothyroidism
What is the treatment for Raynaud’s?
- ) Keep warm
- ) Stop smoking
- ) Nifedipine
- ) Possible sympathectomy (sympathetic nerve trunk resection)
What is fibromyalgia?
Syndrome with symptoms of fatigue and widespread pain
Give 4 risk factors for fibromyalgia
- ) Female
- ) Middle age
- ) Low income
- ) Divorced
- ) Low educational status
- ) Problems at work/family
- ) Anxiety
Give 4 psychosocial risk factor yellow flags for developing persisting chronic pain and long term disability
- ) Belief that pain and activity are harmful
- ) Sickness behaviours such as extended rest
- ) Social withdrawal
- ) Emotional problems such as low mood, anxiety, stress
- ) Problems/dissatisfaction at work
- ) Problems with claims for compensation/time off work
- ) Overprotective family/lack of support
- ) Inappropriate expectations of treatment
Give 3 conditions fibromyalgia is associated with
- ) Chronic fatigue syndrome
- ) IBS
- ) Chronic headaches
- ) RA
- ) AS
- ) SLE
Give 3 diagnostic features of fibromyalgia
- ) Chronic pain >3 months
- ) Widespread pain (L, R, above, below was it, axial skeleton)
- ) Profound fatigue
Give 3 additional features of fibromyalgia
- ) Morning stiffness
- ) Paraesthesiae
- ) Headaches
- ) Poor concentration
- ) Low mood
- ) Sleep disturbance
- ) Widespread and severe tender points
What is the treatment of fibromyalgia?
- ) Remain active
- ) Keep working
- ) Exclude alternative diagnosis
- ) Exercise
- ) Pacing of activity
- ) Relaxation
- ) Rehabilitation
- ) Physiotherapy
- ) CBT for coping strategies and achievable goals
What medications can we give in fibromyalgia?
- ) Low dose amitriptyline - pain and sleep
- ) Duloxetine or SSRI - anxiety and depression
What is vasculitis?
Inflammatory disorder of blood vessel walls
Give 3 things vasculitis can be secondary to
- ) SLE
- ) RA
- ) Hepatitis B, C
- ) HIV
How is vasculitis categorised?
By the size of the vessel affected
What does vasculitis cause?
Destruction (aneurysm/rupture) or stenosis
Give 2 examples of each of large and medium vasculitis
Large - giant cell arteritis, Takayasu’s arteritis
Medium - polyarteritis nodosa, Kawasaki disease
Give 4 examples of small vessel vasculitis
ANCA associated: -) Microscopic polyangiitis -) Granulomatosis with polyangiitis ANCA negative: -) Goodpasture's disease -) IgA vasculitis
What is the main symptom of vasculitis?
Overwhelming fatigue with increased ESR/CRP
Give 10 symptoms of vasculitis (think systems)
-) Systemic - fever, malaise, weight loss, etc
-) Skin - purpura, ulcers etc
-) Eyes - episcleritis
-) ENT - epistaxis, stridor
-) Pulmonary - haemoptysis and dyspnoea
-) Cardiac - angina, MI, HF
-) GI - pain, perforation
-) Renal - HTN, renal failure
-) Neuro - stroke, fits, confusion
-) GU - testicular pain
NOT EXHAUSTIVE LIST
What does ANCA stand for?
Anti-neutrophil cytoplasmic antibodies
What is c-ANCA?
Cytoplasmic ANCA
What is p-ANCA?
Perinuclear ANCA
What test do we do to diagnose vasculitis?
Angiography +/- biopsy
How do we treat vasculitis?
Large - steroids
Medium/small - immunosuppression with steroids +/- cyclophosphamide or methotrexate/azathioprine
What is giant cell arteritis also known as?
Temportal arteritis
What is giant cell arteritis associated with in 50%?
Polymyalgia rheumatic
What type of arteritis is giant cell?
Granulomatous
Give 4 symptoms for giant cell arteritis
- ) Headache
- ) Temporal artery and scalp tenderness
- ) Tongue/jaw claudication
- ) Amaurosis fungax/sudden unilateral blindness
- ) Dyspnoea, weight loss, morning stiffness, unequal/weak pulses
What do blood tests show in giant cell arteritis?
- ) Very increased ESR and CRP
- ) Increased platelets
- ) Increased ALP
- ) Decreased Hb
Is giant cell arteritis ANCA positive or negative?
Negative
What is the gold standard of diagnosis in giant cell arteritis?
Temporal artery, be aware of skip lesions
What is the treatment of giant cell arteritis? (4)
- ) Immediate prednisolone/IV methylprednisolone
- ) Reduce when symptoms resolve and ESR down
- ) Balance risks of long term steroid treatment
- ) PPI, bisphosphonate, calcium with colecalciferol
What is polyarteritis nodosa? (PAN)
Necrotising vasculitis that causes aneurysms and thrombosis in medium sized arteries
What does PAN lead to?
Infarction in the affected organs with severe systemic symptoms
What gender is giant cell arteritis more common in?
Females
What gender is PAN more common in?
Males
Give 3 symptoms of PAN
- ) Systemic features
- ) Skin, renal, cardiac, GI, GU, neuro problems
Is PAN ANCA positive or negative?
Negative
What tests are diagnostic for PAN?
- ) Renal/mesenteric angiography
- ) Renal biopsy
What is the treatment for PAN?
- ) Control BP
- ) Steroids for mild
- ) Steroid sparing agent for severe
What is PAN associated with?
Hep B
What is polymyalgia rheumatic?
Not a true vasculitis, frequently occurs with GCA
How does polymyalgia rheumatic present?
Subacute onset of bilateral aching, tenderness, morning stiffness in shoulders and proximal limb muscles
What are other symptoms of polymyalgia rheumatic?
- ) Mild polyarthritis
- ) Tenosynovitis
- ) Carpal tunnel syndrome
- ) Systemic features
What is the treatment for polymyalgia rheumatic?
Prednisolone with gastric and bone protection
What is granulomatosis with polyangiitis also known as?
Wegener’s granulomatosis
What is granulomatosis with polyangiitis?
Necrotising granulomatous vasculitis of arterioles, capillaries and post capillary venues
What is granulomatosis with polyangiitis associated with?
Anti-neutophil cytoplasmic antibodies (c-ANCA)
What is the classic triad that granulomatosis with polyangiitis affects?
Upper respiratory tract, lungs, kidney
What are the skin signs of granulomatosis with polyangiitis?
Red spots on legs and feet
What is the treatment for granulomatosis with polyangiitis?
- ) Corticosteroids and cyclophosphamide (or rituximab) for remission
- ) Azathioprine and methotrexate for maintenance
- ) Possible plasma exchange
- ) Co-trimoxazole as prophylaxis
Give 5 red flags for back pain
- ) Aged <20 or >55
- ) Acute onset in elderly
- ) Constant/progressive/nocturnal pain
- ) Worse pain when supine
- ) Fever, night sweats, weight loss
- ) History of malignancy, abdominal mass
- ) Thoracic back pain
- ) Morning stiffness
- ) Bilateral/alternating leg pain, leg claudication, exercise related leg pain
- ) Neuro, sphincter disturbance
- ) Current/recent infection
- ) Immunosuppression
If someone was lifting something heavy, and they describe a ‘popping’ sensation in their back, this is what?
A slipped disc
What are the most likely causes of back pain according to age? (15-30)
- ) Prolapsed disc
- ) Trauma
- ) Fractures
- ) Ankylosing spondylitis
- ) Pregnancy
What are the most likely causes of back pain according to age? (30-50)
- ) Degenerative spinal disease
- ) Prolapsed disc
- ) Malignancy
What are the most likely causes of back pain according to age? (>50)
- ) Degererative
- ) Osteoporotic vertebral colapse
- ) Paget’s disease
- ) Malignancy
- ) Myeloma
- ) Spinal stenosis
Give 2 rarer causes of back pain
- ) Cauda equina tumours
- ) Psoas abscess
- ) Spinal infection
What is the best imaging tool for back pain, and what can it detect?
MRI, can detect disc prolapse, cord compression, cancer, infection, inflammation
What is the treatment for back pain?
- ) Stay active
- ) Paracetamol +/- NSAIDs +/- codeine
- ) Consider low dose amitriptyline if these fail
- ) Physiotherapy, acupuncture, exercise programme
- ) Psychosocial issues
What are the spondyloarthropathies? (SpA)
Group of related chronic inflammatory conditions
Give the 7 shared clinical features of SpA
1) Seronegativity (RF -ve)
2) HLA B27 association
3) Axial arthritis - pathology in spine and sacroiliacs
4) Asymmetrical arge joint oligo/monoarthritis
5) Enthesitis - inflammation of site of insertion of tendon/ligament into bone
6) Dactylitis - inflammation of entire digit
7) Extra-articular - iritis, psoriaform past, oral ulcers, IBD, aortic valve incompetence
What are the features of SpA? (acronym)
SPINEACHE Sausage digit (dactylitis) Psoriasis Inflammatory back pain NSAID good response Enthesitis (heel) Arthritis Crohn's/colitis/elevated CRP HLA B27 Eye (uveitis)
What is ankylosing spondylitis? (AS)
Chronic inflammatory disease of spine and sacroiliac joints
In which gender is AS more common?
Men
What is the typical patient in AS?
<30 man with gradual onset of low back pain that is worse at night with spinal morning stiffness relieved by exercise
Where does the pain radiate from/to in AS?
Pain radiates from sacroiliac joints to hips/buttocks, usually improves towards end of day
What is AS associated with? (3)
Osteoporosis, aortic valve incompetence, pulmonary apical fibrosis
Give 3 other symptoms of AS
- ) Progressive loss of spinal movement
- ) Enthesitis in achilles tendonitis, plantar fasciitis
- ) Anterior mechanical chest pain
- ) Fatigue
What are the pathological steps of bamboo spine in AS?
1) Bony proliferations due to enthesitis between ligaments and vertebra (vertebral syndesmophytes)
2) These fuse with vertebral body above, causing ankylosis
3) Calcification of ligaments with ankylosis leads to bamboo spine
What is the delayed damage theory in AS?
The sequence of structural damage is
1) Inflammation
2) Erosive damage repair
3) New bone formation
What does an MRI show in AS?
- ) Detection of active inflammation (bone marrow oedema)
- ) Erosions
- ) Sclerosis
- ) Ankylosis
What does an XR show in AS?
- ) SI joint space narrowing/widening
- ) Sclerosis
- ) Erosions
- ) Ankylosis/fusion
What is the treatment for AS?
- ) Exercise
- ) NSAIDs
- ) TNF alpha blockers
- ) Local steroid injections for pain
- ) Surgery - replacement
- ) Bisphosphonates
Give an example of a TNF alpha blocer
Etanercept, adalimumab
What is psoriatic arthritis?
Can occur with psoriasis and present before skin changes
What are the 5 patterns psoriatic arthritis can present with?
1) Symmetrical polyarthritis (like RA)
2) DIP joints only
3) Asymmetrical oligoarthritis
4) Spinal (similar to AS)
- ) Psoriatic arthritis mutilans (rare, severe)
What radiological changes are seen in psoriatic arthritis?
Erosive changes, ‘pencil in cup’ deformity
Give 3 features of psoriatic arthritis
- ) Nail changes
- ) Synovitis (dactylitis)
- ) Acneiform rashes
- ) Palmo-plantar pustulosis
What is the management of psoriatic arthritis?
- ) NSAIDs
- ) Suldasalazine
- ) Methotrexate
- ) Anti TNF agents
- ) Possible IL 12/23 blockers
What does DMARD stand for?
Disease modifying anti rheumatic drugs
What is reactive arthritis?
A condition in which arthritis and other clinical manifestations occur as an autoimmune response to infection elsewhere in the body (may have resolved)
What infections does reactive arthritis occur after?
- ) Urethritis (chlamydia/ureaplasma)
- ) Dysentery (campylobacter/salmonella)
Give 3 symptoms of reactive arthritis
- ) Iritis
- ) Keratoderma blenorrhagica (brown raised plaques on soles and palms)
- ) Mouth ulcers
- ) Circinate balanitis (penile ulceration)
- ) Enthesitis
What is Reiter’s syndrome?
Triad of urethritis, arthritis, conjunctivitis
What does an XR in reactive arthritis show?
Enthesitis with periosteal reaction
What is the management of reactive arthritis?
- ) Splnit affected joints
- ) NSAIDs/local steroid injections
- ) Sulfasalazine or methotrexate if >6 months
What is enteropathic/enteric arthritis associated with?
IBC, GI bypass, coeliac and Whipple’s disease
How do we treat enteropathic arthritis?
Treatment of bowel symptoms, DMARDs
What is rheumatoid arthritis?
A chronic systemic inflammatory disease characterised by a symmetrical, deforming, peripheral polyarthris
What does RA increase the risk of?
CVD
What is the typical presentation of RA?
Symmetrical, swollen, painful and stiff small joints of hands and feet
What are the 3 types of bone loss in RA?
- ) Focal erosion
- ) Periarticular osteoporosis
- ) Generalised osteoporosis in skeleton
Is the prevalence of RA increased or decreased in smokers?
Increased
What is RA linked to? (genetically)
HLA DR4/DR1
How long does stiffness last in RA?
> 60 minutes
Is RA better or worse with use?
Better
Give 3 less common presentations of RA
- ) Sudden onset, widespread arthritis
- ) Recurrent mono/polyarthritis of joints
- ) Persistant monoarthritis
- ) Systemic illness with extra articular symptoms
- ) Polymyalgic onset
- ) Recurrent soft tissue problems
Give 2 signs of early RA
- ) Inflammation
- ) Swollen MCP, PIP, wrist, MTP (often symmetrical)
- ) Tenosynovitis/bursitis
Give 2 signs of late RA
- ) Joint damage, deformities
- ) Ulnar deviation
- ) Subluxation of wrist and fingers
- ) Boutonniere and swan neck of fingers
- ) Z-deformity of thumbs
- ) Hand extensor tendon rupture
Give 4 extra-articular manifestations of RA
-) Nodules (elbows, lungs, etc)
-) Lungs (pleural disease, interstitial fibrosis etc)
-) Cardiac (IHD, pericarditis, pericardial effusion etc)
-) Eye (episcleritis, scleritis etc)
-) Osteoporosis
NOT COMPREHENSIVE
What is Felty’s syndrome?
RA and splenomegaly and neutropenia
What 2 things are usually positive in RA?
RF and anti CCP (very specific)
What does anti CCP stand for?
Anticyclic citrullinated peptide antibodies
What does an XR show in RA?
Soft tissue swelling, juxta-articular osteopenia, decreased joint space
What are better at identifying synovitis and bone erosions than XRs in RA?
MRI and US
What 4 things can be found with a blood test in RA?
- ) Anaemia of chronic disease
- ) Increased platelets
- ) Increased ESR
- ) Increased CRP
What is the management of RA?
- ) Treat to target
- ) DMARDs and biological agents
- ) Steroids
- ) NSAIDs
- ) Physio and occupational therapy
- ) Surgery
- ) Manage risk factors (CVD and cerebrovascular disease)
Give 2 examples of a biological DMARD used for RA
- ) TNF alpha blocker
- ) IL-1 receptor blocker (anakinra)
- ) Rituximab (lysis of B cells)
- ) Tocilizumab (IL-6 receptor antibody)
- ) Abatacept (T cell function disruption)
Give 2 examples of a non-biological DMARD used for RA
- ) Sulfasalazine
- ) Methotrexate (CI pregnancy)
- ) Leflunomide
Give 4 autoimmune connective tissue disorders
- ) SLE
- ) Systemic sclerosis
- ) Sjogren’s syndrome
- ) Polymyositis
- ) Dermatomyositis
What is Sjogren’s syndrome?
A chronic inflammatory autoimmune disorder
What is the pathology in Sjogren’s?
Lymphocytic infiltration and fibrosis of exocrine glands (especially lacrimal/salivary)
Give 3 clinical features of Sjogren’s
- ) Decreased tear production
- ) Decreased salivation
- ) Parotid swelling
Give 3 other features of Sjogren’s
-) Vaginal dryness
-) Dyspareunia (painful sex)
-) Dry cough
-) Dysphagia
-) Polyarthritis
-) Raynaud’s
-) Lymphadenopathy
-) Vasculitis
-) Fatigue
-) Peripheral neuropathy
ETC
Give 2 things decreased tear production in Sjogren’s causes
- ) Dry eyes
- ) Keratoconjunctivitis sicca
How do we measure conjunctival dryness in Sjogren’s?
Schirmer’s test - <5mm in 5mins is positive
What 4 things may be present in blood tests in Sjogren’s?
- ) Anti Ro antibody
- ) Anti La antibody
- ) RF
- ) ANA
What does a biopsy show in Sjogren’s?
Focal lymphocytic aggregation
What does Rose Bengal staining show in Sjogren’s?
Keratitis
How do we treat Sjogren’s?
- ) Treat sicca (artificial tears, frequent drinks)
- ) NSAIDs and hydroxycholoroquine for arthralgia
- ) Immunosuppressants for severe
What 3 things does systemic sclerosis feature?
- ) Scleroderma (skin fibrosis)
- ) Internal organ fibrosis
- ) Microvascular abnormalities
What was limited systemic sclerosis formally known as?
CREST syndrome
What is limited systemic sclerosis associated with?
Anticentromere antibodies (75%)
What parts of the body does limited systemic sclerosis involve?
Face, hands, feet
Give 5 features of limited systemic sclerosis
- ) Calcinosis of subcutaneous tissues
- ) Raynaud’s syndrome
- ) Oesophageal and gut dysmotility
- ) Sclerodactyly (digit inflammation)
- ) Telangiectasia (spider veins)
What do we treat pulmonary HTN with in limited systemic sclerosis? (2)
Sildenafil, bosentan
What parts of the body does diffuse systemic sclerosis involve?
Whole body
What are 2 antibodies found in diffuse systemic sclerosis?
- ) Antitopoisomerase-1 (SCL-70, 40%)
- ) Anti-RNA polymerase (20%)
What 4 systems are potentially fibrosed in systemic sclerosis?
Lung, cardiac, GI, renal
What is the treatment for systemic sclerosis?
- ) Immunosuppression (cyclophosphamide)
- ) Monitor BP and renal function
- ) ACEI/ARBs (+PPIs)
- ) Treat Raynaud’s
- ) Annual echocardiograms and spirometry
What can antiphospholipid syndrome cause? (4)
CLOTs Coagulation defect Livedo reticularis Obstetric problems Thrombocytopaenia
How do we treat antiphospholipid syndrome?
Aspirin/warfarin if recurrent
What are polymyositis and dermatomyositis?
Rare conditions characterised by the insidious onset of progressive symmetrical proximal muscle weakness and autoimmune mediate striated muscle inflammation (myositis)
What are poly/dermatomyositis associated with?
Myalgia +/- arthralgia
What may muscle weakness cause in poly/dermatomyositis?
- ) Dysphagia
- ) Dysphonia
- ) Respiratory weakness
Dermatomyositis features myositis plus what 3 skin signs
- ) Macular rash
- ) Lilac-purple (heliotrope) rash on eyelids
- ) Mailfold erythema
- ) Gottron’s papules (red papules over knickers)
What do we need to screen for in poly/dermatomyositis?
Cancers
Give 3 extra-muscular signs of poly/dermatomyositis
- ) Fever
- ) Arthralgia
- ) Raynaud’s
- ) Interstitial lung fibrosis
- ) Myocardial involvement
Give 2 antibodies associated with poly/dermatomyositis
Anti-Mi2, anti-Jo1
What do we test for in poly/dermatomyositis? (4)
- ) Increased muscle enzymes
- ) EMG shows characteristic fibrillation potentials
- ) Muscle biopsy
- ) MRI shows muscle oedema in acute myositis
Give 4 muscle enzymes
- ) ALT (alanine transaminase)
- ) AST (aspartate transaminase)
- ) LDH (lactate dehydrogenase)
- ) CK (creatinine kinase)
- ) Aldolase
What is the treatment for poly/dermatomyositis?
- ) Prednisolone
- ) Immunosuppressives and cytotoxic if resistance
- ) Hydroxychloroquine/topical tacrolimus for skin disease
What is systemic lupus erythematous? (SLE)
Mutisystemic autoimmnue disease
What are the pathogenic steps of SLE? (4)
- ) Autoantibodies made against variety of autoantigens
- ) Form immune complexes
- ) Inadequate clearance of immune complexes
- ) Host of immune responses which cause tissue inflammation and damage
Which gender is SLE more common in?
Women
Which ethnicities is SLE more common in?
Afro-Caribbean, Asia
What 3 genetic associations are there in SLE?
HLA B8
HLA DR2
HLA DR3
Give 3 non-specific symptoms of SLE
- ) Malaise
- ) Fatigue
- ) Myalgia
- ) Fever
What type of presentation does SLE have?
Remitting and relapsing illness of variable presentation and course
Give 5 clinical criteria of SLE
- ) Acute cutaneous lupus (malaria rash/butterfly, photosensitive rash)
- ) Chronic cutaneous lupus (discoid rash)
- ) Non scarring alopecia
- ) Oral/nasal ulcers
- ) Synovitis (2 or more joints)
- ) Serositis (lung/pericardial pain)
- ) Urinanalysis (proteinuria)
- ) Neuro features (seizures, psychosis)
- ) Haemolytic anaemia
- ) Leucopenia
- ) Thrombocytopenia
Give 3 other features of SLE
- ) Lymphadenopathy
- ) Weight loss
- ) Alopecia
- ) Nail fold infarcts
- ) Raynaud’s
- ) Non infective endocarditis
- ) Stroke
- ) Retinate exudates
Give 3 laboratory criteria for SLE
- ) +ve ANA
- ) Anti-dsDNA
- ) Anti-Smith antibodies
- ) Antiphospholipid Abs
- ) Low complement (C3, C4)
- ) +ve Direct Coombs
What are ESR and CRP like in SLE?
High ESR, normal CRP
Give 3 causes of drug induced lupus
- ) Isoniazid
- ) Hydralazine
- ) Quinidine
- ) Anti-TNF agents
What is the general treatment for SLE?
- ) Sunblock
- ) Hydroxychloroquine
- ) Screen for co-morbidities
- ) Topical steroids for skin flares
How do we maintain SLE? (3)
- ) NSAIDs and hydroxychloroquine for joint and skin
- ) Azathioprine, methotrexate, mycophendlate as steroid-sparing agents
- ) Belimumab for autoantibody positive disease
What do we give for moderate flares in SLE?
DMARDs or mycophenolate
What do we give for severe flares in SLE? (4)
- ) Urgent high dose steroids
- ) Mycophenolate
- ) Rituximab
- ) Cyclophosphamide
What do we give for lupus nephritis?
- ) Intensive immunosuppression with steroids and cyclophosphamide
- ) BP control vital
- ) Possible renal replacement therapy
What is the most common causative organism of infections?
Coagulase negative staph, then staph aureus
Give 3 mechanisms of infection
- ) Transient bacteraemia (e.g. from gut)
- ) Pets and wounds
- ) Dental work, already coloniser
- ) Index surgery infection
What is propionibacteria?
A skin commensal involvement in upper limb (real) and lower limb (contaminant) infections
Give 3 risk factors for a joint prosthesis infection
- ) Male sex
- ) Hybrid fixation
- ) Cement without antibiotics
- ) Inflammatory disease
- ) Hip fracture
- ) Femoral head necrosis
What infection is extra bone formation associated with?
Staph infection
Give 3 treatment options for infection of a joint prosthesis
- ) Antibiotic suppression
- ) Debridement and retention of prosthesis
- ) Excision/exchange arthroplasty
- ) One/two stage exchange
- ) Amputation
What can we do to make the likelihood of detecting an infection when using CRP and ESR?
Multiple sasmples
What is the gold standard for the diagnosis of a joint infection?
Aspiration
What is the limitation to aspiration when detecting an infection?
Cannot do if patient has had antibiotics in last 2 weeks
What inflammatory marker has a sensitivity/specificity of 95% for a joint infection?
Alpha defensin
What does gonococcal arthritis occur with?
Disseminated gonococcal infection
Give 3 features of gonococcal arthritis presentation
- ) Fever
- ) Arthritis
- ) Tenosynovitis
- ) Polyarticular
- ) Maculopapular pustular rash common in peripheries (palms, sole, painful before visible)
How do we detect the organism in gonococcal arthritis?
Mucosal swabs and blood cultures
What is a sunburst appearance on an XR indicative of? (2)
Osteosarcoma, Ewing’s
What is a onion skin appearance on an XR indicative of?
Ewing’s
What is the appearance of Codman’s triangle on an XR indicative of? (5)
Osteosarcoma, Ewing’s, OM, GCT, metastasis
What 3 things can a bone scan tell us?
- ) How fast blood is flowing to lesion
- ) Inflammation
- ) Uptake within bone (turnover rate)
What 4 imaging tools can we use to detect a bone tumour?
US, CT, MRI, XR
What system do we use to stage malignant and benign bone tumours?
Enneking
What are the 3 grades for a malignant tumour?
G0 - histologically benign, well differentiated, low mitotic count
G1 - low grade malignant, moderate diff, local spread only, few mitoses
G2 - high grade malignant, poorly diff, frequent mitoses, high risk of mets
What are the 3 grades for a benign tumour?
Grade 1 - latent, well defined, stops growing, may heal
Grade 2 - active, growth limited by natural barriers, may expand
Grade 3 - aggressive, not limited by natural barriers, mets present in 5%, high recurrence
What does the prefix ‘osteo’ relate to?
Bone
What does the prefix ‘chondro’ relate to?
Cartilage
What does the prefix ‘rhabdomyo’ relate to?
Skeletal muslce
What does the prefix ‘lipo’ relate to?
Fat
What does the suffix ‘oma’ relate to?
Benign tumour
What does the suffix ‘sarcoma’ relate to?
Malignant connective tissue tumour
What does the suffix ‘carcinoma’ relate to?
Malignant epithelial/endothelial tumour
What does the suffix ‘blastoma’ relate to?
Malignant tumour of embryonic cells
What does a pleomorphic soft tissue sarcoma mean?
It doesn’t have a clear tissue of origin
Give 4 things we describe when looking at an XR with a suspected tumour
- ) Radiographic view, anatomical location
- ) Epi/meta/diaphysis
- ) Bone/cartilage forming
- ) Bone destruction/reaction
- ) Zone of transition
- ) Benign/malignant
What mutation is osteosarcoma associated with?
p53
What do XRs show in osteosarcoma?
Bone formation with bone destruction
What is the most common type of osteosarcoma?
High grade intramedullary osteosarcoma
What is the treatment for osteosarcoma?
Multi-agent chemo pre-op
Give 3 different types of osteosarcoma
- ) Intramedullary
- ) Parosteal
- ) Periosteal
- ) Telangiectatic
What does Ewing’s sarcoma arise from?
Neural crest cells (neuroectodermal origin)
What is the genetic element of Ewing’s sarcoma?
Balanced translocation t(11,22)
What type of lesion occurs in Ewing’s sarcoma?
Diaphyseal, destructive lytic lesion
How do we diagnose Ewing’s sarcoma?
Bone marrow biopsy (carefully!)
How do we treat Ewing’s sarcoma?
Chemo, radio, excision/reconstruction
How does multiple myeloma present? (3)
- ) Bone pain
- ) Pathological fractures
- ) Fatigue (anaemia)
What proteins are seen in the urine in multiple myeloma?
Bence-Jones proteins
What does an XR show in multiple myeloma?
Punched out lytic lesions (pepper pot skull)
What does blood serum electrophoresis show in multiple myeloma?
Monoclonal bands
What is the treatment for multiple myeloma?
Surgical stabilisation and radiotherapy
What does histology show in multiple myeloma?
Plasma cells and perinuclear halo
What is a soft tissue sarcoma?
Malignant tumour of connective tissue
Give 4 factors where we would consider masses to be malignant in soft tissue sarcoma
- ) >5cm
- ) Deep to fascia
- ) Enlarging in size
- ) Painful
What 5 tumours most commonly metastasise to bone?
- ) Breast
- ) Lung
- ) Prostate
- ) Kidney
- ) Thyoid
How is RANK-L involved in bone resorption?
Activation of osteoclasts by tumour cells, RANK-L binds to RANK receptor on osteoclasts
Give 3 presentations of bony mets
- ) Bone pain
- ) General malaise
- ) Pathological fractures
Give 3 management principles for bony mets
- ) Correct metabolic abnormalities (CALCIUM)
- ) XRs
- ) Mirel’s score
- ) Possible primary disease
- ) Treat met as primary
- ) If widespread, lease with oncology
What is Mirel’s scoring system used for?
Diagnosing impending pathological fractures
What are the 4 parameters for Mirel’s score?
-) Site of lesion
-) Pain
-) Nature of lesion
-) Width of cortical destruction
3 points a parameter
What score gives a 33% chance of fracture?
9, give prophylactic stabilisation
Give 3 local complications of surgery
- ) Haematoma
- ) LOF
- ) Infection (silver coating of implant reduces risk)
- ) Local recurrence
Where does the blood supply of the hip come from?
Medial and lateral femoral arteries
What is a significant trauma defined as?
> 20mph or >20ft fall
Give 4 things a fracture can be
- ) Intra/extra articular
- ) Associated with dislocation
- ) Transverse/oblique/spiral/butterfly/comminution/segmental
- ) Broken skin
What is the management of a fracture?
Analgesia, reduce, immboilise, rehabilitate
What is Paget’s disease of bone?
Focal disorder of bone remodelling
What are the pathogenic steps of Paget’s disease? (6)
1) Increase in osteoclastic bone reabsorption
2) Compensatory increase in bone formation
3) Increased local bone blood flow
4) Increased fibrous tissue deposition in adjacent bone marrow
5) Bone formation exceeds bone resorption
6) New bone is weaker and more likely to fracture
What is a genetic mutation that can cause Paget’s?
Mutation of the gene that codes for the osteoclast mediator protein p62
How is Paget’s often found?
Incidental finding of elevated serum alkaline phosphatase
Give 3 of the most commonly affected sites of Paget’s disease
Pelvis, femur, lumbar spine, skull, fibia
Give 3 symptoms of Paget’s disease
- ) Bone and joint pain
- ) Deformities (e.g. bowed tibia)
- ) Neurological complications
- ) High output HF
- ) Hypercalcaemia
- ) Pathological fractures
- ) Osteoarthritis, osteosarcoma
What is the treatment for Paget’s?
Bisphosphonates, analgesia/alendronic acid
What is osteomalacia?
Defective mineralisation of newly formed bone matrix (osteoid)
What is the difference between osteomalacia and osteoporosis?
OM - normal amount of bone, low mineral content
OP - Mineralisation unchanged, overall bone loss
What is the difference between rickets and OM?
Rickets - during period of bone growth
OM - after fusion of epiphyses
Give 3 symptoms of rickets
- ) Growth retardation
- ) Hypotonia
- ) Apathy in infants
- ) Knock-kneed
- ) Bow-legged
- ) Deformities of metaphyseal-epiphyseal junction
- ) Ill
Give 3 symptoms of OM
- ) Bone pain and tenderness
- ) Fractures (esp. femoral neck)
- ) Proximal myopathy (waddling gait)
What does an XR show in Paget’s disease? (4)
- ) Localised enlargement of bone
- ) Patchy cortical thickening
- ) Sclerosis, osteolysis, deformity
- ) Hot spots
Give 5 causes of osteomalacia
- ) Vitamin D deficiency
- ) Renal osteodystrophy (renal failure)
- ) Drug induced (anticonvulsants)
- ) Vitamin D resistance
- ) Liver disease
- ) Tumour induced osteomalacia (oncogenic hypophosphataemia)
Give 2 causes of vitamin D deficiency
- ) Malabsorption
- ) Poor diet
- ) Lack of sunlight
Give 4 findings in the plasma in OM
- ) Decreased Ca
- ) Decreased PO4
- ) Increased ALP
- ) Increased PTH
- ) Decreased 25(OH)-vitamin D (except in resistance)
What does an XR show in OM?
- ) Loss of cortical bone
- ) Partical fractures, especially at Looser’s zones (scapula, inferior femoral neck, medial femoral shaft)
What does an XR show in rickets?
Cupped, ragged metaphyseal surfaces
What is the treatment for OM?
- ) Diet - vitamin D
- ) Malabsoprtion/hepatic disease - Vitamin D2 (ergocalciferol)
- ) Renal/resistance - Alfacalcidol/calcitriol
What risk is there with aldacalcidol and calcitriol?
Hypercalcaemia! - monitor
What are the steps of the conversion of vitamin D into its active form? (4)
1) 7-dehydrocholestrol (from sun)
2) Cholecalciferol (vitamin D3, or from diet)
3) 25-hydroxyvitamin D3 (in liver)
4) 1,25-dihydroxyvitamin D3 (in kidneys)
Give 4 symptoms of granulomatosis with polyangiitis
-) Nasal obstruction, ulcers, epistaxis, destruction of nasal septum
-) Sinusitis
-) Glomeruloneprhtis, proteinuria, haematuria
-) Cough, haemopysis, pleuritis
-) Skin purpura, nodules, peripheral neuropathy, arthritis/arthralgia
-) Keratitis, conjunctivitis, scleritis, episcleritis, uveitis
ETC
What is a specific test for granulomatosis with polyangiitis?
cANCA directed against PR3
What does a CXR show in granulomatosis with polyangiitis?
Nodules +/- fluffy infiltrates of pulmonary haemorrhage
What may a CT show in granulomatosis with polyangiitis?
Diffuse alveolar haemorrhage
