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Y3 > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

1
Q

What is ankylosing spondylitis?

A

Chronic progressive seronegative inflammatory arthropathy affecting preferentially the axial skeleton and large proximal joints

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2
Q

Summarise the epidemiology of ankylosing spondylitis

A

Common
2.5:1 M:W
2nd decade of life

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3
Q

Explain the aetiology of ankylosing spondylitis

A

Unknown
Strong association with HLA-B27 gene (>90% of cases HLA-B27 positive)
Hypothesised infective triggers and antigen cross-reactivity with self-peptides

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4
Q

What are the risk factors for ankylosing spondylitis?

A

HLA-B27
Endoplasmic reticulum aminopeptidase 1 (ERAP1) and interleukin 23 receptor (IL23R) genes
FHx

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5
Q

What are the presenting symptoms of ankylosing spondylitis?

A

Lower back and sacroiliac pain: worse in morning/rest, better w activity
Disturbed sleep
Progressive loss of spinal movement
Asymmetrical peripheral arthritis
Pleuritic chest pain (costovertebral joint involvement)
Heel pain (plantar fasciitis)
Non-specific: malaise, fatigue

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6
Q

What are the signs of ankylosing spondylitis O/E?

A

Reduced range of spinal movement (esp hip rotation)
Reduced lateral spinal flexion
Schober’s test: reduced increase in space between fingers <5cm
Tenderness over sacroiliac joints

Later stages:
Thoracic kyphosis
Spinal fusion
Question mark posture

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7
Q

What are the signs of extra-articular disease in ankylosing spondylitis?

A 
5 As:
Anterior uveitis
Apical lung fibrosis
Achilles tendonitis
Amyloidosis
Aortic regurgitation
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8
Q

How can ankylosing spondylitis be investigated?

A

Bloods:
FBC - anaemia of chronic disease
Rheumatoid factor -ve
ESR/CRP - high

Radiographs:
Anteroposterior and lateral of spine - bamboo spine
Anteroposterior of sacroiliac joints - symmetrical blurring of joint margins
Later stages - erosions, sclerosis, sacroiliac joint fusion
CXR - apical lung fibrosis

Lung function tests:
assess mechanical ventilatory impairment due to kyphosis

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9
Q

What is carpal tunnel syndrome?

A

The symptom complex brought on by compression of the median nerve in the carpal tunnel

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10
Q

Explain the aetiology of carpal tunnel syndrome

A

Symptoms caused by median nerve compression as it runs through the carpal tunnel
Usually idiopathic
May be secondary to:
- Tenosynovitis (eg in rheumatoid arthritis)
- Infiltrative disease of canal/increased soft tissue (eg amyloidosis, acromegaly)
- Bone involvement in wrist (eg OA, fracture)
- Fluid retention states (eg pregnancy, nephrotic syndrome)
- Obesity, menopause, DM

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11
Q

What are the risk factors for carpal tunnel syndrome?

A 
> 30
High BMI
Female
Fractured wrist/carpal bones
Rheumatoid arthritis
DM
Dialysis
Pregnancy
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12
Q

What are the presenting symptoms of carpal tunnel syndrome?

A

Tingling pain in hand and fingers
Numbness
Weakness and clumsiness of hand
Worse at night

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13
Q

What are the signs of carpal tunnel syndrome O/E?

A

Sensory impairment in median nerve distribution (thumb, finger 1, finger 2 and half of finger 3)
Weakness and wasting of thenar eminence
Tinel’s sign - tapping carpal tunnel causes symptoms
Phalen’s test - flexion of wrist for 1 min may cause symptoms

Signs of underlying cause - acromegaly, hypothyroidism

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14
Q

How can carpal tunnel syndrome be investigated?

A
  1. EMG - focal slowing of conduction velocity; prolongation of median distal motor latency; possible decreased amplitude of median sensory and/or motor nerves
  2. US/MRI wrist if SOL suspected, e.g. ganglion cyst
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15
Q

What is fibromyalgia?

A

A condition characterised by chronic widespread pain and a heightened pain response to pressure

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16
Q

Summarise the epidemiology of fibromyalgia

A

F:M = 6:1

Undiagnosed in 75% of affected people

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17
Q

Explain the aetiology of fibromyalgia

A
  • Cause unknown
  • Genetic + environmental factors
  • Runs in families, many genes involved
  • Environmental factors: psychological stress, trauma, certain infections
  • Pain appears to result from processes in CNS
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18
Q

What are the risk factors for fibromyalgia?

A

FHx
Rheumatological conditions
20-60yo
Female

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19
Q

What are the presenting symptoms of fibromyalgia?

A 
Chronic pain >3/12
Widespread (L+R, above+below waist + axial skeleton)
Profound fatigue
Unrefreshing sleep
Significant fatigue and pain w/small increases in physical exertion
Headaches
Numbness/tingling
Stiffness
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20
Q

What are the signs of fibromyalgia O/E?

A

Diffuse tenderness on examination

Sensitivity to sensory stimuli - bright lights, odours, noises

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21
Q

How is fibromyalgia investigated?

A

Clinical diagnosis:
Presence of chronic (>3 months), widespread body pain in muscles and joints, plus at least 11 of 18 tender points

ESR/CRP - normal (?inflamm)
TFT - normal (?hypo)
FBC - normal (?anaemia, iron deficiency)
RF - normal (?RA)
Anti-cyclic citrullinated protein antibody - normal (?RA)
ANA - normal (?SLE)
Vitamin D - normal
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22
Q

What is giant cell arteritis?

A

A granulomatous vasculitis of large and medium-sized arteries
Primarily affects branches of the external carotid artery

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23
Q

Summarise the epidemiology of giant cell arteritis

A 
> 50s
Incidence rises steadily after age 50
Highest between 70-80
Women 2-4x more than men
Northern Europe > Southern Europe
Whites > Blacks
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24
Q

Explain the aetiology of giant cell arteritis

A

Exact cause unknown

Genetic + environmental factors

Genetic polymorphisms in HLA-DRB104 and DRB101 alleles predispose

Infectious agents - Mycoplasma pneumoniae, parvovirus B19, parainfluenza virus, Chlamydia pneumoniae, VZV

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25
Q

What are the risk factors for giant cell arteritis?

A

> 50
Female
Live in N Europe/N European ancestry
Women: smoking, atherosclerosis

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26
Q

What are the presenting symptoms of giant cell arteritis?

A 
Subacute onset (few weeks)
Headache in temporal/occipital areas
Scalp tenderness
Jaw claudication
Blurred vision
Sudden blindness in one eye
Systemic: malaise, low-grade fever, lethargy, weight loss, depression
Symptoms of polymyalgia rheumatica: early morning pain and stiffness of muscles of shoulder + pelvic girdle
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27
Q

What are the signs of giant cell arteritis O/E?

A

Swelling and erythema overlying temporal artery
Scalp and temporal tenderness
Thickened non-pulsatile temporal artery
Reduced visual acuity
Stiff neck, shoulders, hips, and proximal extremities
Swelling of distal joints

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28
Q

How is giant cell arteritis investigated?

A

Bloods:

  • High ESR > 50
  • High CRP
  • FBC - normochromic, normocytic anaemia of chronic disease - normal WCC, elevated platelets, mild leukocytosis
  • LFTs: elevated transaminases, ALP

Temporal artery biopsy IMMEDIATELY:

  • within 48h of starting corticosteroids
  • -ve biopsy doesn’t exclude GCA
  • granulomatous inflammation
  • multinucleated giant cells
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29
Q

How is giant cell arteritis managed?

A

Prednisolone IMMEDIATELY to prevent vision loss
Aspirin
Osteoporosis prevention: calcium carbonate + ergocalciferol + alendronic acid
Tocilixumab/methotrexate

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30
Q

What are the possible complications of giant cell arteritis?

A

Carotid artery aneurysm
Aortic aneurysm
Thrombosis
Embolism to ophthalmic artery –> visual disturbance and loss of vision

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31
Q

What is the prognosis of giant cell arteritis?

A

Lasts around 2 years before complete remission

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32
Q

What is gout?

A

A disorder of uric acid metabolism causing recurrent bouts of acute arthritis caused by deposition of monosodium urate crystals in joints, and also soft tissues and kidneys

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33
Q

Summarise the epidemiology of gout

A

10x more common in males
V rare pre-puberty
Rare in pre-menopausal women
More common in higher social classes

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34
Q

What can precipitate an acute attack of gout?

A 
Trauma
Infection
Alcohol - red wine
Starvation
Seafood
Introduction/withdrawal of hypouricaemic agents
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35
Q

What are the risk factors for gout?

A

M 40-60
F 50-70
Male
Post-menopausal women
Meat, seafood alcohol
Thiazide + loop diuretics
Ciclosporin + tacrolimus (increased tubular reabsorption of urate, decreased glomerular filtration + interstitial nephropathy)
Pyarzinamide (increased urate re-abs)
Aspirin (increase urate)
HPRT/PRPP/G6PD deficiency (over produce urate)
High cell turnover state - haem malignancy, myeloproliferative disorders, psoriasis, chemo

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36
Q

Explain the aetiology of gout

A

Hyperuricaemia due to renal under-excretion of urate (90%) or over-production (10%) or both

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37
Q

What are the presenting symptoms of gout?

A 
Sudden excruciating monoarticular pain
Usually affects metatarsophalangeal joint of great toe (podagra)
Symptoms peak at 24h
Resolve over 7-10 days
Attacks often recurrent
Symptom-free between attacks
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38
Q

How is gout investigated?

A

Synovial fluid aspirate:

  • monosodium urate crystals present- needle-shaped, -ve birefringence under polarised light microscopy
  • WCC > 2 x10^9

Bloods:
FBC - raised WCC
Uric acid high > 416 micromol/L M/360 W

XR/US of joint:
Periarticular erosions
Tophi
Double contour line

AXR/KUB film
Uric acid renal stones

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39
Q

What is osteoarthritis?

A

Age-related degenerative joint disease when cartilage destruction exceeds repair, causing pain and disability

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40
Q

Summarise the epidemiology of osteoarthritis

A

Common
25% of those over 60
More common in females, caucasians and asians

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41
Q

Explain the aetiology of osteoarthritis

A

Synovial joint cartilage destruction
Eventually, loss of joint volume due to altered chondrocyte activity
Patchy chronic synovial inflammation
Fibrotic thickening of joint capsules

Primary - unknown aetiology, multifactorial

Secondary - other disease lead to altered joint architecture and stability

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42
Q

What are the risk factors for osteoarthritis?

A 
> 50
Female
Obesity
FHx
Manual occupation
Knee malalignment
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43
Q

What are the presenting symptoms of osteoarthritis?

A 
Joint pain and discomfort, use-related
Stiffness or gelling after inactivity
Difficulty with certain movements
Feel unstable
Restriction walking, climbing stairs and doing manual tasks
No systemic features
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44
Q

What are the signs of osteoarthritis O/E?

A 
Local joint tenderness
Bony swellings along joint margins:
Heberden's nodes: distal IPJ
Bouchard's nodes - proximal IPJ
Crepitus and pain during joint mvmt
Joint effusion
Restriction of range of joint mvmt
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45
Q

How is osteoarthritis investigated?

A

Joint XR:

  1. Loss of joint space (narrowing)
  2. Osteophytes
  3. Subchondral cysts
  4. Subchondral sclerosis
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46
Q

What are the secondary causes of osteoarthritis?

A
  • developmental abnormalities, eg hip dysplasia
  • trauma, eg previous fractures
  • inflamm eg rheumatoid arthritis, gout, septic arthritis
  • metabolic - haemochromatosis, acromegaly
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47
Q

What is osteomyelitis?

A

Infection of the bone leading to inflammation, necrosis and new bone formation
Can be acute, subacute or chronic

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48
Q

Summarise the epidemiology of osteomyelitis

A

Mostly in young children

<20% cases in adults

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49
Q

Explain the aetiology of osteomyelitis

A

Causative organisms:
Staphylococcus aureus
Group A Streptococcus

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50
Q

What are the risk factors for osteomyelitis?

A 
Penetrating injuries - open fracture
Surgical contamination
IV drug misuse
DM
Immunosuppression
Prosthesis
SCA
Peridontitis
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51
Q

What are the presenting symptoms of osteomyelitis?

A 
Pain in affected area
Fever
Malaise
Rigors
Hx of preceding skin lesion, sore throat, trauma or operation
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52
Q

What are the signs of osteomyelitis O/E?

A 
Localised erythema
Tenderness
Swelling
Warmth
Painful/limited mvmt of affected limb
Seropurulent discharge from associated wound/ulcer
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53
Q

How is osteomyelitis investigated?

A

Bloods:
FBC - raised WCC
ESR - raised
CRP - raised

XR of affected area:
Osteopenia
Bone destruction
Cortical breaches
Periosteal reaction
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54
Q

What is polymyalgia rheumatica?

A

An inflammatory condition of unknown cause, which is characterised by severe bilateral pain and morning stiffness of the shoulder, neck and pelvic girdle

Does NOT cause weakness

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55
Q

Summarise the epidemiology of polymyalgia rheumatica

A

Relatively common
> 50s
Peak age of onset = 73
3x more common in females

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56
Q

Explain the aetiology of polymyalgia rheumatica

A

Unknown
Genetic + env factors
Associated w temporal arteritis

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57
Q

What are the risk factors for polymyalgia rheumatica?

A

> 50
Giant cell arteritis
Female

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58
Q

What are the usual inclusion criteria for polymyalgia rheumatica?

A 
Non-specific
Usual inclusion criteria:
>50
Symptoms > 2 weeks
Bilateral shoulder or pelvic girdle aching, or both
Morning stiffness > 45 minutes
High ESR/CRP

No weakness
Symptoms worst when walking
Difficulty getting out of bed/raising arms to brush hair

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59
Q

How is polymyalgia rheumatica investigated?

A

High ESR
High CRP
FBC
US - bursitis, joint effusions

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60
Q

How is polymyalgia rheumatica managed?

A

Initial:
Corticosteroid - prednisolone
Ca + vit D + bisphosphonate - alendronic acid + cholecalciferol + calcium carbonate
NSAID - naproxen/ibuprofen

61
Q

What are the possible complications of polymyalgia rheumatica?

A

Chronic relapsing PMR

Secondary to corticosteroids:

  • increased risk of infection
  • osteoporosis
  • DMII
  • HTN
  • muscle weakness
  • cataracts, glaucoma
  • skin changes

GCA

62
Q

What is the prognosis of polymyalgia rheumatica?

A

Overall prognosis is good
Relapses are common
Tx for 2-3 years

Increased risk of relapse: female, high ESR > 40, peripheral arthritis

63
Q

What are polymyositis and dermatomyositis?

A

Connective tissue diseases characterised by inflammation of muscles

64
Q

Summarise the epidemiology of polymyositis and dermatomyositis

A

Polymyositis 30-60yo
Dermatomyositis any age: peak 5-10 and 50

Both 2x more common in females

65
Q

Explain the aetiology of polymyositis and dermatomyositis

A

Autoimmune basis

Viral infection

66
Q

What are the presenting symptoms of polymyositis?

A

Inflammatory myopathy with onset over weeks or months
Steady progression
Diffuse weakness in proximal muscles:
- difficulty rising from low chair, stairs, lifting objects, brushing hair
- fatigue, myalgia, muscle cramps

67
Q

What are the presenting symptoms of dermatomyositis?

A

Inflammatory myopathy
Onset over weeks or months
RASH
Systemic upset w fever, arthralgia, malaise, weight loss
Possible cardiac disease - conduction blocks, tachyarrhythmia
GI ulcers and infections
Interstitial lung disease

Kids have more non-muscular features

68
Q

What are the signs of polymyositis O/E?

A 
Muscle weakness
Not painful
Proximal myopathy
Extra-ocular muscles and distal muscles spared
Weak forced flexion of neck
Muscular atrophy
Muscles may be tender on palpation
69
Q

What are the signs of dermatomyositis O/E?

A

RASH characteristics:

  • blue-purple discolouration of the upper eyelids with periorbital oedema
  • flat red rash involving the face and upper trunk
  • raised purple-red scaly patches over extensor surfaces of joints and fingers
  • rash may affect knees, shoulders, back and upper arms
  • rash may be exacerbated by sunlight
  • proximal myopathy
  • muscle pain and tenderness in early disease
70
Q

How is polymyositis investigated?

A 
CK - 50x higher
Electromyography
Muscle biopsy - definitive test
Autoantibodies - eg myositis specific antibody, anti-Jo-1 antibody
Enzymes - eg SGOT, SGPT, LDH
71
Q

How is dermatomyositis investigated?

A 
CK
Enzymes - SGOT, SGPT, LDH raised
Autoantibodies - ANA, anti-mi-2, anti-jo-1
EMG - may be normal though
Muscle biopsy
72
Q

What is reactive arthritis?

A

Characterise by a sterile arthritis occurring after an extra-articular infection (commonly GI or urogenital)

73
Q

Summarise the epidemiology of reactive arthritis

A

20x more common in males

20-40 years

74
Q

Explain the aetiology of reactive arthritis

A

Associated with infections:
GI - salmonella, shigella, yersinia, campylobacter
Urogenital - chlamydia trachomatis

Initial activation of immune system by microbial antigen followed by autoimmune reaction that involves skin, eyes, and joints

HLA-B27 allele in 70-80% of patients

75
Q

What are the risk factors for reactive arthritis?

A

Male
HLA-B27
Preceding chlamydial or GI infection

76
Q

What are the presenting symptoms of reactive arthritis?

A

3-3 days after infection
Constitutional: fever, fatigue, weight loss
Enthesitis: heel pain
Mouth ulcers
Rash on soles or palms (keratoderma blenorrhagica)
Burning or stinging when passing urine (urethritis)
Arthritis
Low back pain (sacroiliitis)
Conjunctivitis

77
Q

What are the signs of reactive arthritis O/E?

A 
Asymmetrical oligoarthritis
Lower extremities
Sausage-shaped digits
Anterior uveitis
Oral ulceration
Circinate balanitis
Keratoderma blenorrhagica
78
Q

Identify the appropriate investigations for reactive arthritis

A 
ESR: raised
CRP: raised
ANA: -ve
RF: -ve
Urogenital and stool cultures: -ve
XR: sacroiliitis or enthesopathy
Arthrocentesis w synovial fluid analysis: -ve
79
Q

What is rheumatoid arthritis?

A

Chronic inflammatory systemic disease characterised by symmetrical deforming polyarthritis and extra-articular manifestations

80
Q

Summarise the epidemiology of rheumatoid arthritis

A

Common
1% of general population
3x more common in females
Peak incidence = 30-50yo

81
Q

Explain the aetiology of rheumatoid arthritis

A 
Autoimmune
Unknown cause
Associated w other AI diseases, eg Sjogren's
HLA-DR1
HLA-DR4
82
Q

What are the presenting symptoms of rheumatoid arthritis?

A 
Gradual onset
Joint pain
Swelling
Morning stiffness
Impaired function
Usually affects peripheral joints symmetrically
Systemic: fever, fatigue, weight loss
83
Q

What are the signs of rheumatoid arthritis O/E?

A

Arthritis - most common in hands

Early signs:

  • spindling of fingers
  • swelling of MCP and PIP joints
  • warm, tender joints
  • reduction in ROM

Late signs:

  • symmetrical deforming arthropathy
  • ulnar deviation of fingers due to subluxation of MCP joints
  • radial deviation of wrist
  • swan neck deformity
  • Boutonniere deformity
  • Z deformity of thumb
  • trigger finger
  • tendon rupture
  • wasting of small muscles of hand
  • palmar erythema
  • rheumatoid nodules
84
Q

What are the appropriate investigations for rheumatoid arthritis?

A

RF: +ve

Anti-cyclic citrullinated peptide antibody: +ve

Radiographs: erosions

85
Q

What are the risk factors for rheumatoid arthritis?

A

Genetic predisposition

86
Q

What is sarcoidosis?

A

Multisystem chronic granulomatous inflammatory disorder

87
Q

Summarise the epidemiology of sarcoidosis

A

Most common in Africans and Scandinavians

>50

88
Q

Explain the aetiology of sarcoidosis

A 
Unknown
Transmissible agents (eg viruses), environmental triggers and genetic factors

Unknown antigen presented on MHCII complexes on macrophages to CD4+ T-cells
These accumulate and release cytokines
Leads to formation of non-caseating granulomas in organs

89
Q

What are the risk factors for sarcoidosis?

A

20-40yo
FHx
Scandinavian
Female

90
Q

What are the presenting symptoms and signs of sarcoidosis?

A

General: fever, malaise, weight loss, bilateral parotid swelling, lymphadenopathy, hepatosplenomegaly

Pulmonary: breathlessness, dry cough, chest discomfort, minimal clinical signs

Musculoskeletal: bone cysts (eg dactylitis), polyarthralgia, myopathy

Eye: keratoconjunctivitis sicca, uveitis, papilloedema

Skin: lupus pernio, erythema nodosum, maculopapular eruptions

Neuro: lymphocytic meningitis, SOLs, pituitary infiltration, cerebellar ataxia, CN palsies, peripheral neuropathy

Cardiac: arrhythmia, BBB, pericarditis, cardiomyopathy, congestive HF

91
Q

What are the appropriate investigations for sarcoidosis?

A

Lung involvement
CXR - hilar and/or paratracheal adenopathy w upper lobe predominant, bilateral infiltrates; pleural effusions (rare), egg shell calcifications (very rare)
Lung function tests - restrictive/obstructive/mixed pattern

Splenic/BM involvement:
FBC - anaemia, leukopenia

Renal involvement:
Urea - elevated
Creatinine - elevated

Hepatic involvement:
LFTs - AST and ALT elevated

Cardiac involvement:
ECG - conduction defects

Serum Ca - elevated

Purified protein derivative of tuberculin (PPD) - -ve

92
Q

What is septic arthritis?

A

The infection of 1 or more joints caused by pathogenic inoculation of microbes

93
Q

Summarise the epidemiology of septic arthritis

A

Developed countries incidence = 6/100,000/yr

Underlying joint disease x10 = 70/100,000/yr

94
Q

Explain the aetiology of septic arthritis

A

Caused by pathogenic inoculation of micro-organisms into the joint, either directly or by the haematogenous route

Predominant causative organisms = staphylococci, streptococci

95
Q

What are the risk factors for septic arthritis?

A 
Underlying joint disease - RA, osteoarthritis, crystal arthritides
Joint prostheses
IVD abuse
DM
Cutaneous ulcers
96
Q

What are the presenting symptoms and signs of septic arthritis?

A

Hot, swollen, tender, restricted joint

Prosthetic joint

Short Hx of symptoms <2 weeks

Fever

97
Q

What are the appropriate investigations for septic arthritis?

A

Synovial fluid Gram stain and culture: MO present, culture reveals organism

Synovial fluid WCC: >100,000 sepsis

Blood culture: MO present, culture

WCC: elevated
ESR: elevated
CRP: elevated

Radiograph: degenerative changes, chondrocalcinosis
US: effusion, to guide aspiration

98
Q

What is Sjögren syndrome?

A

Chronic inflammatory and auto-immune disorder characterised by diminished lacrimal and salivary gland secretion (sicca complex)

99
Q

Summarise the epidemiology of Sjögren syndrome

A

Most common systemic AI rheumatic disease

F:M = 9:1

Population prevalence = 0.5-1.5%

60% have disease secondary to RA, SLE, or scleroderma

2 age peaks: 20s-30s and after menopause (mid 50s)

100
Q

Explain the aetiology of Sjögren syndrome

A

Lymphocytic infiltration into lacrimal and salivary glands

Genetic associations: HLA-B8, HLA-DR3

Associated AI diseases:
RA
Scleroderma
SLE
Polymyositis
Organ-specific AI disease - PBC, AI hepatitis, myasthenia gravis
101
Q

What are the risk factors for Sjögren syndrome?

A 
Female
SLE
Rheumatoid arthritis
Systemic sclerosis - scleroderma
HLA class II markers (A1, B8, DR3/DQ2)
20s-30s + after menopause
102
Q

What are the presenting symptoms of Sjögren syndrome?

A 
Fatigue
Dry eyes
Dry mouth
Fever
Weight loss
Depression
Dry cough, recurrent sinusitis
Dry skin or hair
Dry vagina --> dyspareunia
103
Q

What are the signs of Sjögren syndrome O/E?

A

Keratoconjunctivitis sicca
Xerostomia
Parotid or salivary gland enlargement

104
Q

What are the appropriate investigations for Sjögren syndrome?

A

Schirmer’s test - quantitively measures tears: +ve (<5mm wet after 5 minutes)

anti-60 kD (SS-A) Ro and anti-La (SS-B): +ve

105
Q

What is radiculopathy?

A

AKA pinched nerve

Set of conditions in which one or more nerves are a

106
Q

Summarise the epidemiology of radiculopathy

A

F > M

Cervical > lumbar

107
Q

Explain the aetiology of radiculopathy

A

Mechanical compression of a nerve root usually at the exit foramen or lateral recess

May be secondary to degenerative disc disease, OA, facet joint degeneration/hypertrophy, ligamentous hypertrophy, spondylolisthesis

108
Q

What are the risk factors for radiculopathy?

A 
Degenerative disc disease
Osteoarthritis
Facet joint degeneration/hypertrophy
Ligamentous hypertrophy
Spondylolisthesis
Radiation
DM
Neoplastic disease
Lyme meningitis
Aseptic meningitis
109
Q

What are the presenting symptoms of radiculopathy?

A

Sharp pain in back, arms, legs or shoulders
May worsen with certain activities - coughing, sneezing
Weakness or loss of reflexes in arms or legs
Numbness of skin “pins and needles” or other abnormal sensations in arms or legs

110
Q

What are the appropriate investigations for radiculopathy?

A

Neuro exam to identify affected nerve root

XR/CT/MRI

Nerve conduction studies

111
Q

What is spondylosis?

A

The degeneration of the spinal column from any cause

112
Q

Summarise the epidemiology of spondylosis

A

Elderly people

113
Q

Explain the aetiology of spondylosis

A

Caused by years of constant abnormal pressure, caused by joint subluxation, stress induced by sports, acute and/or repetitive trauma, or poor posture, being placed on the vertebrae and discs between them

Abnormal stress causes new bone formation to compensate for new weight distribution

114
Q

What are the presenting symptoms of spondylosis?

A

Lhermitte sign: feeling of electric shock w neck flexion

115
Q

What are the signs of spondylosis O/E?

A

Reduced ROM in neck

Lhermitte sign: feeling of electric shock w neck flexion

116
Q

What are the appropriate investigations for spondylosis?

A

Cervical compression test: laterally flex patient’s head and place downward pressure on it
- neck or shoulder pain on ipsilateral side = +ve result
MRI, CT

117
Q

Summarise the epidemiology of systemic sclerosis

A

Age of onset = 30-60
Peak incidence in 5th decade
5x more common in females
88/million in England

118
Q

Explain the aetiology of systemic sclerosis

A

Unknown
Genetic and environmental factors
Pathogenesis unclear
Activated monocytes, macrophages and lymphocytes may interact with:
- endothelial cells –> endothelial cell damage, platelet activation, BV narrowing
- fibroblasts –> lay down collagen in dermis

119
Q

What are the risk factors for systemic sclerosis?

A

FHx

Immune dysregulation - eg positive ANA

120
Q

What are the presenting symptoms of systemic sclerosis?

A 
Cold hands
Finger ulcers
Hand/foot swelling
Skin thickening
Can't grip objects
Heartburn, reflex, dysphagia
Bloating
Faecal incontinence
Arthralgia, myalgia
Difficulty breathing
Fatigue
Dry cough
Decreased exercise tolerance
121
Q

What are the signs of systemic sclerosis O/E?

A 
Secondary Raynaud's phenomenon
Digital pits or ulcers
Skin thickening:
diffuse cutaneous - proximal to elbows + anterior chest + abdo
limited cutaneous - distal to elbows + knees
both - face
Loss of function of hands
Sclerodactyly
Abnormal nail-fold capillaroscopy
Telangiectasia - fingers, palms, face, mucous membranes
Subcutaneous calcinosis
Dry crackles at lung bases
122
Q

What are the appropriate investigations for systemic sclerosis?

A

Serum auto-antibodies: +ve ANA
FBC: normal/microcytic anaemia w chronic GI bleed/micro-angiopathic haemolytic anaemia w scleroderma renal crisis
Ur, Cr: normal/elevated w scleroderma renal crisis
ESR: normal/elevated
CRP: elevated in severe disease
Urine microscopy: normal/mild proteinuria w few cells or casts in renal crisis
Lung function tests: interstitial lung disease - decreased FVC and DLCO + restrictive pattern/pulmonary HTN - disproportionate drop in DLCO vs FVC
ECG: normal/arrhythmias
Echocardiogram: pulmonary HTN - rise in RVSP/pericardial effusion or RV/LV diastolic dysfunction
CXR: normal/bi-basilar interstitial infiltrates/cardiomegaly/RHF
Barium swallow: diminished oesophageal peristalsis and gastroparesis/diminished muscle tone in lower oesophagus/reflux of barium/strictures

123
Q

What is pre-scleroderma?

A

Raynaud’s phenomenon
Nail-fold capillary changes
Antinuclear antibodies

124
Q

What is diffuse cutaneous systemic sclerosis?

A 
Raynaud's phenomenon
Followed by skin changes w truncal involvement
Tendon friction
Joint contracture
Early lung disease
Heart, GI and renal disease
Nail-fold capillary dilatation
125
Q

What is limited cutaneous systemic sclerosis?

A 
Previously known as CREST syndrome:
Calcinosis
Raynaud's phenomenon
(o)Esophageal dysmotility
Sclerodactyly
Telangiectasia
126
Q

What is scleroderma sine scleroderma?

A

Internal organ disease with no skin changes

127
Q

What is scleroderma sine scleroderma?

A

Internal organ disease with no skin changes

128
Q

What is vasculitis?

A

Inflammation and necrosis of blood vessels

129
Q

How are primary vasculitides classified?

A

Based on main vessel size affected

Large:

  1. Giant cell arteritis
  2. Takayasu’s arteritis

Medium:

  1. Polyarteritis nodosa
  2. Kawasaki’s disease

Small:

  1. Eosinophilic granulomatosis w polyangiitis (Churg-Strauss syndrome)
  2. Microscopic polyangiitis
  3. Wegner’s granulomatosis
  4. Henoch-Schonlein purpura
  5. Mixed essential cryoglobulinaemia (MEC)
  6. Relapsing polychondritis
130
Q

Explain the aetiology of vasculitides

A

Unknown
Suggested autoimmune origin
Immune complex deposition in BV walls –> inflammation

131
Q

What are the risk factors for eosinophilic granulomatosis with polyangiitis?

A

Hx of asthma, allergic rhinitis, or sinusitis

132
Q

What are the risk factors for microscopic polyangitis?

A

pANCA

133
Q

What are the risk factors for polyarteritis nodosa?

A

HBV infection

40-60 yos

134
Q

What are the risk factors for Takayasu arteritis?

A

Genetic predisposition - Japan, SE Asia, India, Mexico
Female (8x)
<40
Asian ethnicity

135
Q

What are the presenting symptoms and signs of all vasculitides?

A

General: fever, malaise, night sweats, weight loss

Skin: rash

Joint: arthralgia, arthritis

GI: abdo pain, haemorrhage, diarrhoea

Kidneys: glomerulonephritis, renal failure

Lungs: dyspnoea, cough, chest pain, haemoptysis, haemorrhage

CVS: pericarditis, coronary arteritis, myocarditis

CNS: mononeuritis multiplex, infarctions

Eyes: retinal haemorrhage, cotton wool spots

136
Q

What are the specific characteristics of polyarteritis nodosa?

A 
Microaneurysms
Thrombosis
Infarctions
HTN
Testicular pain
137
Q

What are the specific characteristics of Takayasu’s arteritis?

A 
Limb claudication
Absent pulses
Unequal blood pressures
Vascular bruits
Low-grade fever
TIA
138
Q

What are the specific characteristics of eosinophilic granulomatosis with polyangiitis?

A 
Focal numbness or weakness
Nasal discharge or stuffiness
Facial pain
Palpable purpura and petechiae on legs
Wheeze
139
Q

What are the appropriate investigations for eosinophilic granulomatosis with polyangiitis?

A

FBC: increased eosinophils
ANCA: +ve
ESR and CRP: raised
Ur and Cr: normal or raised
Urinanalysis: assess for glomerulonephritis - haem, prot, RBC casts
Lung function tests: reversible airway obstruction
CXR: interstitial infiltrates or nodules
ECG: LV regional wall motion abnormalities, intracardiac thrombus, pericardial effusion

140
Q

What are the appropriate investigations for granulomatosis with polyangiitis?

A 
Urinanalysis and microscopy: haematuria, proteinuria, dysmorphic RBCs, RBC casts
CT chest: lung nodules, infiltrates
ANCA: +ve
FBC: anaemia
Cr: raised
ESR: raised
141
Q

What are the appropriate investigations for Takayasu’s arteritis?

A

ESR: >50mm/hour in active disease
CRP: raised in active disease
CT/MRI angiography: segmental narrowing or occlusion, occasionally dilation, of affected vessels/aortic aneurysms/thickening of vessel walls

142
Q

What are the appropriate investigations for polyarteritis nodosa?

A

ESR, CRP: raised
FBC: normocytic anaemia, mildly elevated WCC, raised platelets
Complement: reduced
Cr: raised or normal
MSU: mild proteinuria or normal
LFTs: raised
HBV serology: +ve
HCV serology: +ve anti-hepatitis C antibodies
CK: normal or mildly raised
Cryoglobulins, blood culture, ANCA, ANA, anti-dsDNA, RF, anti-CCP, Lupus anticoag, IgG antiphospholipid abs, B2 glycoprotein: -ve
Fibrinogen: normal or raised
Convential digital subtraction angiography: microaneurysms, vessel ectasia, focal occlusive lesions in medium-sized vessels
Echocardiogram: normal

143
Q

What is pseudogout?

A

Arthritis associated with deposition of calcium pyrophosphate dihydrate (CPPD) crystals in the joint cartilage

144
Q

Summarise the epidemiology of pseudogout

A

Dramatic increase with age

145
Q

Explain the aetiology of pseudogout

A

Unknown

CPP crystals in mid-zone of articular hyaline and fibro-cartilage

146
Q

What are the risk factors for pseudogout?

A 
<60
Injury
HyperPT (chronic hyperCa)
Haemochromatosis
FHx
HypoMg
Hypophosphatasia (deficiency of ALP)
147
Q

What are the presenting symptoms of pseudogout?

A

Painful and tender joints
Wrist and shoulder involvement in OA
Sudden worsening of OA
Red and swollen joints

148
Q

What are the signs of pseudogout O/E?

A

Red, swollen, tender joints
Wrist and shoulder involvement
Joint effusion and fluctuance

149
Q

What are the appropriate investigations for pseudogout?

A

Arthrocentesis w synovial fluid analysis: positively birefringent rhomboidal crystals under polarised light confirms CPPD; fluids often bloody

XR: linear, stippled radio-opaque deposits in fibro-cartilage or hyaline articular cartilage of joints/calcified tendons/subchondral cysts/progressive rapid joint degeneration or bony collapse/patellofemoral knee involvement

Serum Ca: normal or raised
Serum PTH: normal or raised
Iron studies: normal or elevated
Serum Mg: normal or decreased
Serum ALP: normal or decreased

Y3 (20 decks)

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