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Phase 2a - conditions > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

1
Q

What is osteoarthritis?

A

A degenerative joint condition

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2
Q

What is the pathogenesis of osteoarthritis?

A

Metabolically active response to repeated injury or insult. Resulting in damage to articular cartilage and oedematous change.

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3
Q

What are the risk factors for osteoarthritis?

A 
Old age 
Female (post menopause)
Obesity
Previous joint trauma 
Occupation
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4
Q

Why does obesity increase the risk of osteoarthritis?

A

It is a pro-inflammatory state.

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5
Q

What are the symptoms of osteoarthritis?

A

Joint pain with movement
Morning stiffness <30 minutes
Is worse at the end of the day
Is functionally limiting

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6
Q

What are the signs of osteoarthritis?

A

Minimal swelling
Crepitus
Bouchard’s nodes - PIP
Herderden’s nodes - DIP (only this or psoriatic affects the DIP joints)

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7
Q

What are the X-Ray findings in osteoarthritis?

A

Loss of joint space
Osteophyte formation
Subchondrial sclerosis
Subchondrial cyst

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8
Q

What are the results of blood tests for osteoarthritis?

A

Normal

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9
Q

What is the conservative management for osteoarthritis?

A

Weight loss
Exercise
Physiotherapy

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10
Q

What is the medical management for osteoarthritis?

A

Analgesic ladder

Paracetamol - NSAIDs - weak opioids

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11
Q

What is the surgical management for osteoarthritis?

A

Osteophyte removal

Arthroplasty

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12
Q

What is inflammatory osteoarthritis?

A

A rare subset of OA with an inflammatory component. Can be treated with a mixture of OA and RA therapies.

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13
Q

What is rheumatoid arthritis?

A

Chronic systemic inflammatory disease causing symmetrical deforming polyarthritis.

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14
Q

What is the serological typing of rheumatoid arthritis?

A

Seropostive

Seronegative

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15
Q

What immune factors are measure to determine the serotyping of someone with rheumatoid arthritis?

A

Rheumatoid factor

Anti-cyclic citrullinated peptide (anti-CCP)

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16
Q

What is the most common serotype of RA?

A

Seropositive (70%)

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17
Q

Why a person be rheumatoid factor positive?

A

Cancer
Chronic infections
Rheumatoid arthritis
It is NOT SPECIFIC

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18
Q

What are the risk factors for RA?

A 
Female 
Smoking 
Stress
Premenopausal 
Infection
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19
Q

What are the symptoms of RA?

A

Painful and stiff small joints of the hand
Episode of >1hour of morning stiffness
Symptoms ease with use

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20
Q

What are the signs of RA?

A 
Inflamed MCP, PIP, MTP joints 
Ulnar deviation of fingers 
Swan neck deformity 
Z-thumb 
Muscle wasting
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21
Q

What are possible extra-articular involvements of RA?

A 
Soft tissue - tensynovitis
Lungs - pulmonary fibrosis 
Vasculitis 
Eyes - sicca
Amyloidosis
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22
Q

What are the clinical features that indicate RA?

A

Morning stiffness
Hands
Symmetrical
Inflamed joints

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23
Q

What investigations should be carried out in RA?

A

Serology for RA and anti-CCP - remember not specific
Blood tests - raised CRP and ESR
X-Ray

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24
Q

What are the X-ray findings in RA?

A

Loss of joint space
Erosions
Soft tissue swelling
Soft bones - osteopenia

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25
What pain relief is typically offered in RA?
NSAIDs
26
What are DMARDs?
Disease modifying anti-rheumatic drugs
27
What is the first line DMARD to use in RA?
Methotrexate
28
What are the side effects of methotrexate?
``` Nausea Diarrhoea Renal problems Headaches Mouth ulcers ```
29
What must be offered in concordance with methotrexate and why?
Folic acid. Methotrexate interferes with absorption of B vitamins. Must not be taken on the same day.
30
What biologic drugs can be offered in RA?
Rituximab - monoclonal antibody that targets CD-20 on B-cells. Anti-TNF alpha
31
What can help induce remission and resolve flareups in RA?
Steroids.
32
What lifestyle advice can be offered in RA?
Exercise Weight loss Quit smoking Physiotherapy
33
What are the differences between inflammatory and degenerative joint conditions?
Inflam. eases with use v get worse Morning stiffness >60 minutes v <60 Swelling due to effusions v bony swellings Joints hot and red v not clinically inflamed affects younger v older Hands and feet v knees and hips NSAIDs response v less NSAID response.
34
What is osteoporosis?
Disease of low bone mass, deterioration of bone tissue leading to bone fragility and fracture risk.
35
What is the pathophysiology of osteoporosis?
Increases resorption by osteoclasts and decreased formation by osteoblasts.
36
What is the link between osteoporosis and oestrogen?
Oestrogen is bone protective, so post menopause there is increased bone remodelling and a higher risk of osteoporosis.
37
What are the risk factors for osteoporosis?
``` Steroids Hyperthyroidism Alcohol Thin Testosterone low Early menopause Renal failure ```
38
How may osteoporosis be secondary?
Secondary to disease or drugs.
39
What are the symptoms of osteoporosis?
Asymptomatic. Until fracture.
40
What is a tool for measuring a person's risk of fracture?
FRAX | Uses age, sex, previous fractures, steroid use.
41
What are common fracture site in osteoporosis?
Hip Wrist Vertebrae
42
What is the diagnostic tool for osteoporosis?
DEXA scan - dual energy X-ray absorptiometry.
43
What measures does a DEXA scan provide?
Area Mineral content T-score
44
What is the T-score in osteoporosis?
The number of standard deviations that the bone density is from the average.
45
What does a T score of >0 mean?
Better bone density than the average
46
What does a t score of >-1 mean?
Normal
47
What does a t score of -1 --> -2.5 mean?
Osteopenia
48
What does a t score of
Osteoporosis
49
What lifestyle changes can be recommended in osteoporosis?
``` Quit smoking Reduce alcohol consumption Regular weight bearing exercise Calcium and vit D rich diet Fall prevention ```
50
What pharmacological options are available in osteoporosis?
Bisphosphonates - causes osteoclast apoptosis HRT - oestrogen protective Demosumab - interrupts signalling Teriparatide - for non responding osteoporosis
51
What are the pathological causes of bone fractures?
Osteoporosis Cancer Infection
52
What are the features of inflammation?
``` Redness Swelling Heat Pain Loss of function ```
53
What are four examples of autoimmune rheumatological disorders?
Systemic lupus erythematosus Sjogren's syndrome Systemic sclerosis Polymyositis
54
What are the immune associations of SLE?
Antinuclear antibodies | Anti-double stranded DNA antibodies
55
Are the immune associations of SLE sensitive or specific?
ANA - sensitive (>95% +ve) | anti-dsDNA - specific but only 60% are +ve
56
What are the risk factors for SLE?
Female (90%) Afro-Caribbean Family history
57
What are triggers for SLE flare ups?
UV light EBV Drugs
58
What are the general features of SLE?
Malaise Fatigue Myalgia Weight loss
59
What are the system specific presentations of SLE?
``` Arthralgia Rashes Reynaud's Renal disorder - ie. nephritis CNS - epilepsy, migraine, meningitis Anti phospholipid syndrome (occurs in 20%) MANY OTHERS. ```
60
What are the investigations in SLE?
Serological tests for the auto antibodies | Bloods - raised inflammatory markers
61
What is the management for a flare of SLE?
IV immunosuppression and steroids
62
What drugs can be used for maintenance of SLE?
Low dose steroids Biologics- rituxumab (CD20 B cell target) Symptomatic treatment
63
What are the main clinical features of Sjogren's syndrome?
Dry eyes Dry mouth Fatigue Parotid swelling
64
What is the treatment for Sjogren's syndrome?
Tear replacement | Hydration
65
What is the serological grouping of spondyloarthropathies?
All seronegative (no RF factor).
66
What is the genetic association of the spondyloarthropathies?
HLA B27
67
What are the conditions that make up the spondyloarthropathy group?
``` Ankylosing spondylitis Psoriatic arthritis Reactive arthritis Enteropathic arthritis Idiopathic juvenile arthritis ```
68
Which spondyloarthritis has the strongest HLA B27 link?
Ankylosing spondylitis
69
What is the mechanism of damage in ankylosing spondylitis?
Inflammation of the spine and rib cage - bone forms - eventually fuses - leading to spinal deformity.
70
What are the symptoms of ankylosing spondylitis?
Inflammatory back pain Radiates to buttocks Extra-articular involvement - dactylitis, psoriasis, enthsitis, arthritis, crohn's, uveitis.
71
What are the features of inflammatory back pain?
<40 years old Wakes at night Improves with activity
72
What is the first radiological sign of ankylosing spondylitis?
Sacroilitis
73
What investigations should be carried out in ankylosing spondylitis?
X Ray MRI - can detect changes earlier Bloods - raised CRP and ESR Genetic testing - HLA B27 in 90%
74
Why is it important to treat early in ankylosing spondylitis?
Any changes that can be seen on imaging are non-reversible so important to treat before changes occur.
75
What are the lifestyle recommendations is ankylosing spondylitis?
Exercise | Physiotherapy
76
What are the pharmacological options in ankylosing spondylitis?
NSAIDs | Biologics - anti-TNF alpha
77
What is the HLA B27 association in psoriatic arthritis?
60-70%
78
What is the presentation of psoriatic arthritis?
Symmetrical polyarthritis DIP joints can be affected Extra-articular - dactylitis, psoriatic changes.
79
What is the management of ankylosing spondylitis?
NSAIDs DMARDs - methotrexate anti-TNF alpha
80
What is reactive arthritis?
Arthritis triggered by a distant infection
81
What is the presentation of reactive arthritis?
Conjunctivitis Urethritis Arthritis Cant see, cant pee, cant climb a tree.
82
What is the treatment of reactive arthritis?
Treat cause with antibiotics Rest joint NSAIDs
83
What is enteropathic arthritis?
Arthritis associated with inflammatory bowel disease, coeliac disease etc.
84
What is vasculitis?
Inflammation and necrosis of blood vessel walls with subsequent impaired blood flow or rupture.
85
What is the immune association of vasculitis?
Anti-neutrophil cytoplasmic antibodies (ANCA)
86
Which vasculitis conditions are typically ANCA positive?
Small vessel and some medium.
87
What are the two types of ANCA?
cytoplasmic-ANCA | perinuclear-ANCA
88
How are types of vasculitis divided?
According to size - small, medium and large.
89
What are the general systemic features of vasculitis?
Fatigue Fever Weight loss
90
What are more organ specific feature of vasculitis?
``` Skin - purpura, ulcers Eyes - scleritis, visual probelms Cardiac - MI/IHD Neuro - stroke/fits ANYTHING depending on where the vasculitis has occurred. ```
91
What investigations should be carried out in vasculitis?
Blood - raised ESR ad CRP ANCA serology Symptomatic investigations Angiography - with biopsy for diagnosis
92
What is the mainstay of management for vasculitis?
Steroids
93
What are the large vessel vasculitides?
Giant cell arteritis | Takayasu's arteritis
94
What age groups does giant cell arteritis typically affect?
Elderly
95
What are the symptoms of giant cell arteritis?
Headache Scalp tenderness (and in the temporal artery region) Jaw claudication Amaurosis fugax or sudden blindness in one eye.
96
When investigations should be carried out in giant cell arteritis?
Bloods - raised ESR | Temporal artery biopsy
97
Why should treatment be started promptly in GCA?
Visual loss is irreversible in GCA.
98
What is the treatment for GCA?
``` Prompt corticosteroids (prednisolone) (these can usually be stopped after 2 years when the GCS is in complete remission) ```
99
Why may symptoms not resolve with steroid use in GCA?
Wrong diagnosis!
100
What are examples of medium vessel vasculitis?
Polyarteritis nodosa | Kowasak's disease
101
Which of the medium vessel vasculitis can be ANCA +ve?
Polyarteritis nodosa
102
What are examples of small vessel vasculitis?
Granulomatous with polyangitis (c-ANCA) Churg-Strauss (p-ANCA) Microscopic polyangitis (c-ANCA)
103
What systems do small vessel vasculitis typically affect?
Respiratory | Renal
104
What is polymyalgia rheumatica?
Auto-inflammatory condition of joints and muscles. Often occurs in combination with GCA.
105
What is the presentation of polymyalgia rheumatica?
Symmetrical aching and tenderness | Morning stiffness
106
What is gout?
Deposition of sodium urate crystals in joints
107
What is epidemiology of gout?
Men >40 years Linked to a western diet
108
What is the pathophysiology of sodium urate crystal formation?
Purine metabolism produces uric acid by use of the enzyme xanthine oxidase. Normally they are excreted but in excess they can crystallise.
109
What is the normal concentration of uric acid in the blood?
0.3mmol/l
110
What are the causes of under excretion of uric acid?
``` Alcohol Renal impairment Hypertension Obesity Diuretics ```
111
What are the causes of over production of uric acid?
Metabolic syndrome | Increase intake - meat, shellfish, alcohol, fructose drinks.
112
What is the presentation of gout?
Sever inflammation of one joint | Most common - metatarsophalangeal joint (big toes)
113
What are the precipitating factors for a gout attack?
Alcohol binge Sepsis Trauma
114
What are the effects of recurrent gout attacks?
Tophi can form and cause deformation
115
What investigations should be carrie out in gout?
Joint aspiration microscopy | Serum urate
116
What does microscopy show in gout?
Negatively befringent needles.
117
What is the treatment for acute gout?
NSAIDs Colchicine Steroids
118
What is the treatment for chronic gout?
Aim to lower urate to 0.3mmol/l | Xanthine oxidase inhibitor - allopurinol
119
What lifestyle advice can be recommended in gout?
Modify diet - less high purine foods Weight loss Alcohol reduction Eat dairy
120
What is pseudogout?
Deposition of calcium pyrophosphate crystals in joints.
121
What are the risk factors pseudogout?
Old age Hyperparathryoidism Diabetes
122
What is the clinical presentation of psuedogout?
Acute monoarthritis Most common in the knee Severe pain, stiffness and swelling
123
What are the investigations needed in pseudogout?
Aspiration and microscopy | X-Ray
124
What are the results of pseudogout microscopy?
Weakly positive birefringent rhomboids.
125
What is the management of acute pseudogout?
NSAIDs Colchicine Rest, ice pack, physiotherapy
126
What is the management of chronic pseudogout?
Methotrexate
127
What is the most common bone tumour?
Secondary bone tumours
128
What are three examples of primary bone tumours?
Osteosarcoma Ewing sarcoma Chondrosarcoma
129
What are the symptoms of primary bone tumours?
Pain - unremitting and nocturnal Local redness Systemic - fatigue, weight loss, anaemia, unexplained bone fractures.
130
What investigations are needed for a primary bone tumour?
X-Ray MRI Biopsy
131
What features of a bone lesion can indicate that it is malignant?
Poorly defined zone of transition Larger periosteal reaction Cortical destruction
132
What are the treatment options for primary bone tumours?
Chemotherapy Radiotherapy Surgery Bisphosphonates
133
What 5 primary tumours are likely to spread to bone?
``` Breast Prostate Kidney Lung Thyroid ```
134
What is myeloma?
A malignant proliferation of plasma cells.
135
What is fibromyalgia?
Non-specific muscular disorder with unknown cause, no sign of inflammation.
136
What are the risk factors for fibromyalgia?
``` Female Middle age Low household income Divorce Chronic disease - IBS, headache, depression, fatigue. ```
137
What is the presentation of fibromyalgia?
Chronic symptoms >3 months Widespread pain Absence of inflammation
138
What are the symptoms of fibromyalgia?
Pain worse with stress, cold and activity Morning stiffness Non-restorative sleep
139
What are the results of investigations for fibromyalgia?
Usually all normal
140
What is the general management for fibromyalgia?
Reassurance Education CBT Exercise
141
What are the pharmacological options for fibromyalgia?
Analgesia
142
What are the risk factors for mechanical back pain?
Manual work - stooping and twisting, lifting, vibrations Smoking Poor working conditions Increasing age
143
What is the general advice for mechanical back pain?
``` Continue normal activities - NOT REST Correct sitting and working posture Lifting technique Heat pads Analgesia ```
144
What is septic arthritis?
Infection of a joint
145
What is the most common causative agent of septic arthritis in a normal joint?
Staphylococcus aureus
146
What are other causes of septic arthritis of the normal joint?
Neisseria gonorrhoea E.coli H. Influenzae
147
What are the risk factors for septic arthritis?
Joint disease Recent surgery Immunosuppression Penetrating trauma
148
What is the presentation of a septic joint?
Painful, red, hot, swollen Fever Monoarthritis usually Knee>hip>shoulder
149
What investigations should be carried out in septic arthritis?
Urgent joint aspirate (off antibiotics)
150
What is the appearance of infected joint fluid?
Turgid fluid | Cloudy
151
What is the management of a septic joint?
``` Aspiration (repeat as needed) Antibiotics (flucloxacillin if S aureus) Rest Analgesia Stop any immunosuppression if possible ```
152
What is the most common causative agent of infection of a prosthetic joint?
Staphylococcus epidermidis
153
What is the presentation of infection of a prosthetic joint?
Recent joint operation or infection Painful, hot, swollen Skin breakdown and discharge
154
What investigation should be carried out in infection of a prosthetic joint?
Joint aspirate and microscopy X-Ray Bloods
155
What is the management of infection of a prosthetic joint?
``` Antibiotics - will not cure but will suppress infection. Surgical debridement Excision arthroplasty Exchange arthroplasty Amputation ```
156
What is osteomyelitis?
Infection localised to bone.
157
How may infection spread to the bone?
Direct inoculation - ie. broken bone or surgery Contiguous spread - ie. from surrounding tissue Haematogenous spread - spontaneous infection.
158
Where does haematogenous spread often affect bones?
Children - long bones | Adult - vertebrae
159
What are the risk factors for osteomyelitis?
``` Trauma Reduced vascular supply Bone/joint condition Immune deficiency IVDU ```
160
What is the most common causative agent for osteomyelitis?
Staphylococcus aureus
161
What is the presentation of osteomyelitis?
``` Fever Malaise Pain - worse on movement Local tenderness Swelling ```
162
What are the investigations for osteomyelitis?
Bloods - raised ESR and CRP Imaging - X-Ray then MRI Bone biopsy
163
Why may a bone biopsy be positive if the bone is not actually infected?
Skin commensal picked up in biopsy.
164
What are the differential diagnoses for osteomyelitis?
``` Soft tissue infection Avascular necrosis Gout Fracture Bursitis ```
165
What is the management of osteomyelitis?
Surgical debridement | Antibiotics

Phase 2a - conditions (11 decks)

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