Musculoskeletal Flashcards
1
Q
How does osteoarthritis look like on X-ray?
A
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
2
Q
How does synovial fluid from someone suffering from osteoarthritis look like?
A
Clear/straw coloured and viscous
3
Q
What may be seen on X ray of someone with rheumatoid arthritis?
A
Soft tissue swelling
Juxta-articular osteopenia
Loss of joint space
Later… bony erosions and subluxation
4
Q
What is DAS28?
A
A way of measuring disease activity in rheumatoid arthritis
5
Q
Where would you see the “pencil in cup” deformity?
A
Psoriatic arthritis
6
Q
Why might someone with AS experience anterior mechanical chest pain?
A
Costochondritis
7
Q
What is the pathophysiology behind bamboo spine?
A
Vertebral syndesmophytes (bony growths from ligaments) fuse with vertebral body above
8
Q
What are the causes of gout?
A
- Hereditary
- Increased dietary purines
- Alcohol XS
- Diuretics
- Leukaemia
- Cytotoxics
9
Q
What are the crystals of someone with gout like?
A
Negatively birefringent urate crystals
10
Q
What medications are available for someone experiencing an acute episode of gout?
A
NSAIDs, coxib, colchicine
11
Q
What drug is used as prophylaxis for gout?
A
Allopurinol
12
Q
What are allopurinol’s side effects?
A
Rash, fever, decreased WCC,
13
Q
What is the timing of a patient with gout taking allopurinol relative to their latest acute episode?
What medication should they take alongside it then and why?
A
Wait until 3 weeks after an acute episode to start allopurinol and cover with an NSAID or colchicine as allopurinol may trigger an acute attack
14
Q
What 3 things make up Reiter’s syndrome?
A
Urethritis, reactive arthritis. conjunctivitis
15
Q
What happens to the following in SLE:
- ESR
- CRP
- C3 + C4
- C3d + C4d
A
- increased ESR
- normal CRP
- decreased C3 + C4
- increased C3d + C4d
16
Q
Which antibodies are associated with SLE?
A
ANA positive, DNA Ab (v specific)
17
Q
What malignancy is a higher risk in patients with SLE?
A
Non-Hodgkin’s b-cell lymphoma
18
Q
What is a positive Schirmer’s test and what diagnosis does it suggest?
A
< 5mm in 5 mins
Suggest Sjogren’s
19
Q
What is another name for “Limited cutaneous systemic sclerosis”?
A
CREST syndrome
20
Q
What parts of the body are affected in Limited cutaneous systemic sclerosis AKA Crest syndrome?
A
Skin involvement limited to face, hands and feet.
21
Q
Which antibody is associated with Limited cutaneous systemic sclerosis AKA Crest syndrome?
A
Anti-centromere antibody
22
Q
Where does diffuse cutaneous systemic sclerosis affect?
A
Diffuse skin involvement and early organ fibrosis
23
Q
What 2 investigations must be annually done in a patient suffering from diffuse cutaneous systemic sclerosis?
A
ECHO and Spirometry
24
Q
Name 5 skin signs that may be seen in patients with dermatomyositis
A
- Macular rash (shawl sign)
- Heliotrope (lilac) rash on eyelids
- Nailfold erythema
- Gottron’s papules
- Subcutaneous calcifications
25
What is the pattern of muscle weakness seen in patients with polymyositis/ dermatomyositis?
Insiduous onset of progressive symmetrical proximal muscle weakness and myositis
26
What tests should be done on patients with polymyositis/ dermatomyositis?
- Increased muscle enzymes
- Electromyography: Fibrillation potentials
- Muscle biopsy
- Screen for malignancy
27
What are the treatment options for a patient with polymyositis/ dermatomyositis?
Prednisolone, immunosuppressives, cytotoxics Hydroxychloroquine of topical tacrolimus for skin disease
28
What antibodies are associated with Sjogren's syndrome?
RhF
Anti-Ro
Anti-La
29
Which is the most specific antibody for RA?
Anti-CCP
30
Which antibody is associated with antiphospholipid syndrome?
Anti-cardiolipin antibody
31
Name 2 antibodies associated with polymyositis/ dermatomyositis?
Anti Mi-2 and Anti Jo-1
32
Which antibody is associated with diffuse systemic sclerosis?
Anti-Scl 70
33
What is the 1st line treatment for rheumatoid arthritis?
DMARDs
34
How long may it take before symptomatic benefit is gained from DMARDs?
6 - 12 weeks
35
Which combo of DMARDs give the best results in rheumatoid arthritis?
Methotrexate + Sulfasalazine + Hydroxychloroquine
36
What must you monitor for someone on DMARDs and why?
Must do regular FBC monitoring as DMARDs are immunosuppressives that can cause pancytopenia
37
What are the side effects of methotrexate?
Pneumonitis. oral ulcers, hepatotoxicity
38
What are the side effects of Sulfasalazine?q
Rash, low sperm count, oral ulcers
39
What is a side effect of hydroxychloroquine?
Irreversible retinopathy
40
At what stage would you use biologics in someone with rheumatoid arthritis?
When they have active rheumatoid arthritis after failure to respond to 2 DMARDs and with a DAS 28 of >5.1
41
Give an example of a type of biologic
TNFa inhibitors e.g. infliximab, etanercept
42
If TNFa inhibitors do not work in a patient with RA what should you try next?
B cell depletion (e.g. Rituximab)
43
If B cell depletion (e.g. Rituximab) doesn't work in someone with RA what are your other options?
- IL-1 + IL-6 inhibition
| - Abatacept (disrupts T cell function)
44
List some common organisms involved in osteomyelitis
Staph aureus; pseudomonas; E coli; streptococci
45
What is the pathophysiology behind a sequestrum forming? When would you see them?
Infection of the bone --> cortex erosion, holes --> pus lifts up periosteum --> interrupts blood supply and necrotic fragments may form = sequestrum.
Seen in chronic osteomyelitis
46
What is involucrum?
New bone that may form as a result of pus in the bone lifting up the periosteum
47
How might a patient describe the pain and their movement if they have osteomyelitis?
The pain is of gradual onset and the patient would be unwilling to move over a few days.
48
What is the gold standard way to diagnose osteomyelitis?
Bone biopsy and culture
49
What and when would you see x-ray changes on someone with osteomyelitis?
X-ray changes would not become apparent or 10 -14 days.
| Hazziness +/- loss of density and subperiosteal reaction
50
How do you treat acute osteomyelitis?
6 weeks of antibiotics (Vancomycin and cefotaxime IVI), drain abscesses and remove sequestra.
51
What is one way you can diagnose chronic osteomyelitis and what is the treatment for it?
If bone can be felt on probing ulcer = chronic osteomyelitis
Antibiotics for at least 12 weeks
52
What is TB in the vertebral body called?
Pott's disease
53
What is the treatment for bone TB?
Drain abscesses, immobilise joint, start a 1 year course of: Rifampicin, Isoniazid, pyrazinamide.
Gentle exercise
54
How would a bone sarcoma present?
Non-mechanical bone joint pain, bone pain at night, bony swellings and pathological fractures
55
What is the most common type of primary malignant bone tumour? What lesions would it show on X-ray?
Multiple myeloma. Multiple punched-out osteolytic lesions
56
Who tends to develop primary sarcoma and it which bones does this tend to happen in?
Primary sarcoma commonly affects teens. Tends to occur in the metaphysis of long bones, especially around the knee)
57
Give 2 circumstances where secondary sarcoma is more likely?
Paget's disease and after irradiation
58
Other than MRI staging, what other imaging should you do in patients with sarcoma?
HRCT Chest to screen for pulmonary mets
59
What is Ewing's sarcoma? In whom does it tend to occur? What is the genetic cause?
Malignant round-cell tumour of long bones (typically diaphysis) and limb girdles. Teens. T11:22 chromosomal translocation
60
In whom does Chondrosarcoma occur in and in what part of the skeleton. What is the treatment and why are the treatment options limited?
Axial skeleton of middle-aged. Treatment is excision. NO response to chemo or radiotherapy.
61
In which bone cancer would you find Sunray spiculation on imaging? What causes it?
Osteosarcoma. Sunray speculation is caused by bone destruction and new bone formation
62
In which bone cancer would you expect to find periosteal elevation/ Codman's triangle?
Osteosarcoma
63
What sign would you see on imaging Ewing's sarcoma? What causes it?
'Onion ring' sign. Caused by new bone formation in concentric layers.
64
What would you see on imaging chondrosarcoma?
Popcorn calcification
65
What is the commonest bone tumour? Whereabouts is it typically found?
Osteochondroma - typically found around knee/ proximal femur/ humerus
66
How does osteochrondroma present? What is it associated to?
Presents as a painful mass. Linked with trauma.
67
How would osteochondroma present on X-ray?
A bone spur arising from the cortex. usually pointing away from the joint
68
What rheumatological condition is 50% of giant cell arteritis associated with?
Polymyalgia rheumatica
69
If trabecular bone is affected in osteoporosis, what type of fracture is likely occur?
Crush fractures
70
If cortical bone is affected in osteoporosis, what type of fracture is likely occur?
Long bone fractures
71
What are risk factors for osteoporosis?
```
Steroids
Hyperthyroidism
Alcohol
Thin
Testosterone
Early menopause
Renal liver failure
Erosive bone disease (e.g. myeloma, RA)
Dietary (decreased Ca2+, malabsorption, T1DM)
```
Parental history, prolonged immobility, increase tobacco use.
72
What happen to calcium, phosphate and alk phos in osteoporosis?
Relatively normal!
73
What does FRAX do?
It estimates 10 year risk of osteoporotic fracture.
74
What lifestyle advice should you suggest to someone with osteoporosis?
Stop smoking and alcohol, weight-bearing exercise.
75
What advice should you give to patients who take bisphosphonates?
Swallow pills with plenty of water and remain upright for 30 mins and wait 30 mins before eating or taking any other drugs.
76
What are the side effects of bisphosphonates?
Photosensitivity; GI upset; oesophageal ulcers.
77
What may Denosumab be used to treat? How does it work?
Denosumab may be used in the treatment of osteoporosis. It is a monoclonal antibody to the RANL ligand --> inhibits activation of osteoclasts
78
How does a bone scan/ radionuclide scan work?
Tracer is injected, 4 hours later the scan is done - tracer collects more where bone is breaking down and repairing.
79
What imaging modality is used for babies with suspected Developmental dysplasia their hips?
Ultrasound scan
80
List 5 risk factors for fibromyalgia
Female, middle aged, poor, divorced, low education
81
What does 'yellow flags' mean?
= psychosocial RFs for developing persisting chronic pain and long-term disability.
82
Give some examples of yellow flags
Belief that pain and activity are harmful
Sickness behaviours
Social withdrawal
83
How may fibromyalgia present?
```
Chronic pain (>3 months) and widespread
Unrefreshing sleep, pain with small increases in physical exertion, widespread + severe tender points.
```
84
What treatment options are available for fibromyalgia?
- Encourage patient to remain as active as they can and to continue work
- Graded exercise programmes
- CBT
- Low-dose amitriptyline/pregabalin
NB: Do NOT give steroids/NSAIDs as there is NO inflammation
85
Define CFS
Persistent disabling fatigue lasting >6 months, affecting mental and physical function, present >50% of the time + 4 or more of the following:
- Myalgia
- Polyarthralgia
- Poor memory
- Unrefreshing sleep
- Fatigue after exertion >24 hours ago
- Persistent sore throat
- Tender cervical/axillary lymph nodes
86
What are the 2 treatment options available for CFS?
Graded exercise and CBT (no meds!)
87
If fluid were to be aspirated from the hip of a child with transient synovitis, what would you find in it?
No pathogens as it is sterile!
88
What is the Kocher criteria used for?
To diagnose septic arthritis in children
89
What must be done ASAP in a child with septic arthritis and why?
Joint must be drained ASAP as pus destroys articular cartilage
90
What are the 4 aspects of Kocher criteria?
1) WBC >12,000
2) Non-weight bearing
3) ESR >40
4) Fever > 38.5
91
What is the most common organism to cause infection of a hip replacement?
Staph epidermis
92
List the 4 Kanavel signs associated with infective tenosynovitis of the hand?
1) "Sausage digit"
2) Held in passive flexion
3) Pain to percussion/palpation of flexor tendon sheath
4) Pain with passive extension
93
What are the 5 P's of compartment syndrome
```
Pain
Pallor
Perishingly cold
Paralysis
Pulselessness
```
94
What are the 4 Waddell's signs and what do they suggest?
Waddell's signs suggest that there is a psychological component to chronic lower back pain.
1) Superficial and widespread/ non-anatomic rotation
2) Stimulation tests (axial loading and pain on stimulated movement)
3) Distracted straight leg raise
4) Non-anatomic sensory changes
5) Overreaction
95
Which nerve root is affected in a L5/S1 prolapse?
S1 root compression
96
How would an S1 root compression present?
Calf pain, weak foot plantar flexion, decreased sensation over sole of foot and back of calf. decreased ankle jerk
97
Which nerve root is affected in a L4/L5 prolapse?
L5 root compression
98
How would an L5 root compression present?
Hallux extension is weak and sensation is reduced on outer dorsum of foot
99
How lumbar spinal stenosis present? I.e. when is the pain worse?
What would be the result of the straight leg raising test?
- Pain is worse on walking with aching and heaviness in one or both legs --> patient stops walking
- Pain on extension
- Negative straight leg raise
- Few CNS signs
100
Define kyphosis. Which part of the spine does it typically occur and what appearance does this create?
XS curvation of spine in sagittal plane. Typically affects thoraco-cervical spine. Patient is leaning forward.
101
What is another term for painful arc syndrome? What is the pathophysiology behind it?
AKA Subacromial impingement
Occurs when there is inflammation of the subacromial bursa that is between the acromion of the scapula and rotator cuff tendons --> irritated and inflamed muscle tendons
102
What is another name for the scarf test? What does it test for?
AKA cross arm adduction test.
| Tests for acromioclavicular joint injury
103
What is another term for frozen shoulder?
Adhesive capsulitis
104
List some risk factors for frozen shoulder
- Over 40 years old
- Women
- Decreased mobility
- DM
- Hyper/hypo- thyroidism
105
How should you treat a patient whose frozen shoulder has not improved for 2 years?
Manipulate under general anaesthetic/ arthroscopic capsular release
106
What does TUBS stand for?
Traumatic Unilateral dislocations w/ a Bankart Lesion requiring Surgery
107
What is the mechanism of action for a TUBS to occur?
Anteriorly directed force on arm when shoulder is abducted and externally rotated.
108
Name the carpal bones from laterally to medially and from bottom row to top row
- Scaphoid
- Lunate
- Triquetrum
- Pisiform
- Trapezium
- Trapezoid
- Capitate
- Hamate
109
Which 2 of the annular ligaments of the fingers prevent bowstringing?
A2 and A4
110
Which annular ligament is most commonly involved in trigger finger?
A1
111
What do cruciate ligaments of the hand do?
Prevent sheath collapse during digital motion.
112
What is De Quervain's disease?
It is a stenosing tenosynovitis (thickening and tightening) of 1st extensor compartment, abductor pollicis longus and extensor pollicis brevis tendons as they cross the distal radial styloid.
113
What is Finkelstein's sign? If positive, what diagnosis does it support?
Pain elicited by gripping thumb into palm of same hand with passive ulnar deviation.
de Quervain's tenosynovitis
114
What are the treatment options for someone with De Quervain's disease?
- Thumb splint
- Ice
- NSAIDs
- Corticosteroid injection
- Splitting tendon sheaths
115
What is 'trigger finger'? Which fingers are most commonly affected? What is the pathophysiology?
Tendon nodules. It is caused by swelling of flexor tendon or tightening of the sheath. Ring and middle fingers most commonly affected with nodule proximal to A1 pulley preventing tendon gliding smoothly - 'catches' finger.
116
What are the features of a 'trigger finger'?
Finger is locked in flexion and jams when extended - has to be flicked straight.
117
What is a big risk factor for trigger finger?
Diabetes Mellitus
118
What are the treatment options for someone with trigger finger?
- Splinting
- Steroid infection
- Surgery
119
What is Dupuytren's contracture? Which fingers are most commonly affected?
Progressive, painless fibrotic thickening of palmar fascia with skin puckering and tethering.
Ring and middle fingers most commonly affected.
Bilateral
120
Name 2 treatment options for Dupuytren's contracture?
Injectable Clostridium Histolyticum, percutaneous needle fasciotomy
121
Describe how Boutonniere's deformity arises
Rupture of extensor tendon at base of middle pharynx allows lateral bands of extensor mechanism to slip towards to palm - turns them into flexors of PIP joint.
122
How does a Boutonniere's finger present?
Flexion at PIP joints and hyperextension at DIP joints.
123
What does a wrist ganglion contain and how does this arise? What is the treatment?
Contains gelatinous fluid due to mucoid degeneration of the synovium. Aspiration
124
What is the mechanism of injury resulting in a mallet finger? What is the treatment?
Sudden blow to extended finger which ruptures the extensor tendon at the distal phalanx. Splint for 6 weeks.
125
What deformity would arise if a mallet finger is not treated? How does this deformity look like?
It can turn into a swan-neck deformity = DIP flexion and PIP hyperextension
126
What is another term for tennis elbow?
Lateral epicondylitis
127
What is the pathophysiology behind tennis elbow?
There is inflammation where the common extensor tendon arises from the lateral epicondyle of the humerus.
128
How can you elicit pain in someone with tennis elbow?
Ask patient to extend their wrist and then resist extension of middle finger
129
How would you manage someone with tennis elbow?
Most cases will naturally resolve by restricting activities.
Refer to physio if needed.
130
Name a condition that causes ulnar neuritis
Cubital tunnel syndrome
131
What is the pathophysiology behind cubital tunnel syndrome?
Osteoarthritic of rheumatoid narrowing at ulnar groove and constriction of ulnar nerve as it passes behind the medial epicondyle, or friction of the ulnar nerve due to cubitus valgus.
132
Name 4 risk factors for avascular necrosis
- XS alcohol
- Corticosteroids
- Sickle cell anaemia
- Chemotherapy
133
How does slipped upper femoral epiphysis present?
| In what position is the foot held in?
Knee pain in teens. Affects males more. The patient lies with their foot externally rotated. Usually presents after minor injury with pain in groin/ anterior thigh/ knee.
134
What happens in slipped upper femoral epiphysis?
There is displacement through the growth plate w/ epiphysis slipping down and back.
135
Which movements are restricted in slipped upper femoral epiphysis?
Flexion, abduction and medial rotation
136
Name 3 complications of slipped upper femoral epiphysis
- Early OA
- Stable joints becoming unstable
- Avascular necrosis of the femoral head
137
What is the treatment for slipped upper femoral epiphysis?
Surgery: early internal fixation
138
What is an attractive alternative to a total knee replacement for early osteoarthritis in young, active patients?
Osteotomy as prosthesis only lasts for around 15 years.
139
Name 5 causes for anterior knee pain. Include their alternative names.
- Patello-femoral OA
- Patellar tendonitis (jumper's knee)
- Prepatellar bursitis (Housemaid's knee)
- Infrapatellar bursitis (Clergyman's knee)
- Referred hip pain
140
What % of people with slipped upper femoral epiphysis are able to weight bear?
90% can weightbear (are stable)
141
What is another name for Housemaid's knee?
Prepatellar bursitis
142
What is another name for infrapatellar bursitis?
Clergyman's knee
143
What is jumper's knee?
Patellar tendonitis
