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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
Q

What pain relief is typically offered in RA?

A

NSAIDs

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26
Q

What are DMARDs?

A

Disease modifying anti-rheumatic drugs

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27
Q

What is the first line DMARD to use in RA?

A

Methotrexate

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28
Q

What are the side effects of methotrexate?

A 
Nausea
Diarrhoea 
Renal problems 
Headaches 
Mouth ulcers
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29
Q

What must be offered in concordance with methotrexate and why?

A

Folic acid. Methotrexate interferes with absorption of B vitamins. Must not be taken on the same day.

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30
Q

What biologic drugs can be offered in RA?

A

Rituximab - monoclonal antibody that targets CD-20 on B-cells.
Anti-TNF alpha

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31
Q

What can help induce remission and resolve flareups in RA?

A

Steroids.

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32
Q

What lifestyle advice can be offered in RA?

A

Exercise
Weight loss
Quit smoking
Physiotherapy

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33
Q

What are the differences between inflammatory and degenerative joint conditions?

A

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.

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34
Q

What is osteoporosis?

A

Disease of low bone mass, deterioration of bone tissue leading to bone fragility and fracture risk.

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35
Q

What is the pathophysiology of osteoporosis?

A

Increases resorption by osteoclasts and decreased formation by osteoblasts.

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36
Q

What is the link between osteoporosis and oestrogen?

A

Oestrogen is bone protective, so post menopause there is increased bone remodelling and a higher risk of osteoporosis.

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37
Q

What are the risk factors for osteoporosis?

A 
Steroids 
Hyperthyroidism 
Alcohol 
Thin 
Testosterone low
Early menopause 
Renal failure
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38
Q

How may osteoporosis be secondary?

A

Secondary to disease or drugs.

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39
Q

What are the symptoms of osteoporosis?

A

Asymptomatic. Until fracture.

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40
Q

What is a tool for measuring a person’s risk of fracture?

A

FRAX

Uses age, sex, previous fractures, steroid use.

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41
Q

What are common fracture site in osteoporosis?

A

Hip
Wrist
Vertebrae

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42
Q

What is the diagnostic tool for osteoporosis?

A

DEXA scan - dual energy X-ray absorptiometry.

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43
Q

What measures does a DEXA scan provide?

A

Area
Mineral content
T-score

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44
Q

What is the T-score in osteoporosis?

A

The number of standard deviations that the bone density is from the average.

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45
Q

What does a T score of >0 mean?

A

Better bone density than the average

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46
Q

What does a t score of >-1 mean?

A

Normal

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47
Q

What does a t score of -1 –> -2.5 mean?

A

Osteopenia

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48
Q

What does a t score of

A

Osteoporosis

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49
Q

What lifestyle changes can be recommended in osteoporosis?

A 
Quit smoking 
Reduce alcohol consumption 
Regular weight bearing exercise
Calcium and vit D rich diet 
Fall prevention
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50
Q

What pharmacological options are available in osteoporosis?

A

Bisphosphonates - causes osteoclast apoptosis
HRT - oestrogen protective
Demosumab - interrupts signalling
Teriparatide - for non responding osteoporosis

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51
Q

What are the pathological causes of bone fractures?

A

Osteoporosis
Cancer
Infection

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52
Q

What are the features of inflammation?

A 
Redness 
Swelling 
Heat 
Pain 
Loss of function
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53
Q

What are four examples of autoimmune rheumatological disorders?

A

Systemic lupus erythematosus
Sjogren’s syndrome
Systemic sclerosis
Polymyositis

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54
Q

What are the immune associations of SLE?

A

Antinuclear antibodies

Anti-double stranded DNA antibodies

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55
Q

Are the immune associations of SLE sensitive or specific?

A

ANA - sensitive (>95% +ve)

anti-dsDNA - specific but only 60% are +ve

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56
Q

What are the risk factors for SLE?

A

Female (90%)
Afro-Caribbean
Family history

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57
Q

What are triggers for SLE flare ups?

A

UV light
EBV
Drugs

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58
Q

What are the general features of SLE?

A

Malaise
Fatigue
Myalgia
Weight loss

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59
Q

What are the system specific presentations of SLE?

A 
Arthralgia 
Rashes 
Reynaud's 
Renal disorder - ie. nephritis 
CNS - epilepsy, migraine, meningitis 
Anti phospholipid syndrome (occurs in 20%)
MANY OTHERS.
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60
Q

What are the investigations in SLE?

A

Serological tests for the auto antibodies

Bloods - raised inflammatory markers

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61
Q

What is the management for a flare of SLE?

A

IV immunosuppression and steroids

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62
Q

What drugs can be used for maintenance of SLE?

A

Low dose steroids
Biologics- rituxumab (CD20 B cell target)
Symptomatic treatment

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63
Q

What are the main clinical features of Sjogren’s syndrome?

A

Dry eyes
Dry mouth
Fatigue
Parotid swelling

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64
Q

What is the treatment for Sjogren’s syndrome?

A

Tear replacement

Hydration

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65
Q

What is the serological grouping of spondyloarthropathies?

A

All seronegative (no RF factor).

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66
Q

What is the genetic association of the spondyloarthropathies?

A

HLA B27

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67
Q

What are the conditions that make up the spondyloarthropathy group?

A 
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis
Enteropathic arthritis
Idiopathic juvenile arthritis
68
Q

Which spondyloarthritis has the strongest HLA B27 link?

A

Ankylosing spondylitis

69
Q

What is the mechanism of damage in ankylosing spondylitis?

A

Inflammation of the spine and rib cage - bone forms - eventually fuses - leading to spinal deformity.

70
Q

What are the symptoms of ankylosing spondylitis?

A

Inflammatory back pain
Radiates to buttocks
Extra-articular involvement - dactylitis, psoriasis, enthsitis, arthritis, crohn’s, uveitis.

71
Q

What are the features of inflammatory back pain?

A

<40 years old
Wakes at night
Improves with activity

72
Q

What is the first radiological sign of ankylosing spondylitis?

A

Sacroilitis

73
Q

What investigations should be carried out in ankylosing spondylitis?

A

X Ray
MRI - can detect changes earlier
Bloods - raised CRP and ESR
Genetic testing - HLA B27 in 90%

74
Q

Why is it important to treat early in ankylosing spondylitis?

A

Any changes that can be seen on imaging are non-reversible so important to treat before changes occur.

75
Q

What are the lifestyle recommendations is ankylosing spondylitis?

A

Exercise

Physiotherapy

76
Q

What are the pharmacological options in ankylosing spondylitis?

A

NSAIDs

Biologics - anti-TNF alpha

77
Q

What is the HLA B27 association in psoriatic arthritis?

A

60-70%

78
Q

What is the presentation of psoriatic arthritis?

A

Symmetrical polyarthritis
DIP joints can be affected
Extra-articular - dactylitis, psoriatic changes.

79
Q

What is the management of ankylosing spondylitis?

A

NSAIDs
DMARDs - methotrexate
anti-TNF alpha

80
Q

What is reactive arthritis?

A

Arthritis triggered by a distant infection

81
Q

What is the presentation of reactive arthritis?

A

Conjunctivitis
Urethritis
Arthritis
Cant see, cant pee, cant climb a tree.

82
Q

What is the treatment of reactive arthritis?

A

Treat cause with antibiotics
Rest joint
NSAIDs

83
Q

What is enteropathic arthritis?

A

Arthritis associated with inflammatory bowel disease, coeliac disease etc.

84
Q

What is vasculitis?

A

Inflammation and necrosis of blood vessel walls with subsequent impaired blood flow or rupture.

85
Q

What is the immune association of vasculitis?

A

Anti-neutrophil cytoplasmic antibodies (ANCA)

86
Q

Which vasculitis conditions are typically ANCA positive?

A

Small vessel and some medium.

87
Q

What are the two types of ANCA?

A

cytoplasmic-ANCA

perinuclear-ANCA

88
Q

How are types of vasculitis divided?

A

According to size - small, medium and large.

89
Q

What are the general systemic features of vasculitis?

A

Fatigue
Fever
Weight loss

90
Q

What are more organ specific feature of vasculitis?

A 
Skin - purpura, ulcers
Eyes - scleritis, visual probelms
Cardiac - MI/IHD
Neuro - stroke/fits
ANYTHING depending on where the vasculitis has occurred.
91
Q

What investigations should be carried out in vasculitis?

A

Blood - raised ESR ad CRP
ANCA serology
Symptomatic investigations
Angiography - with biopsy for diagnosis

92
Q

What is the mainstay of management for vasculitis?

A

Steroids

93
Q

What are the large vessel vasculitides?

A

Giant cell arteritis

Takayasu’s arteritis

94
Q

What age groups does giant cell arteritis typically affect?

A

Elderly

95
Q

What are the symptoms of giant cell arteritis?

A

Headache
Scalp tenderness (and in the temporal artery region)
Jaw claudication
Amaurosis fugax or sudden blindness in one eye.

96
Q

When investigations should be carried out in giant cell arteritis?

A

Bloods - raised ESR

Temporal artery biopsy

97
Q

Why should treatment be started promptly in GCA?

A

Visual loss is irreversible in GCA.

98
Q

What is the treatment for GCA?

A 
Prompt corticosteroids (prednisolone)
(these can usually be stopped after 2 years when the GCS is in complete remission)
99
Q

Why may symptoms not resolve with steroid use in GCA?

A

Wrong diagnosis!

100
Q

What are examples of medium vessel vasculitis?

A

Polyarteritis nodosa

Kowasak’s disease

101
Q

Which of the medium vessel vasculitis can be ANCA +ve?

A

Polyarteritis nodosa

102
Q

What are examples of small vessel vasculitis?

A

Granulomatous with polyangitis (c-ANCA)
Churg-Strauss (p-ANCA)
Microscopic polyangitis (c-ANCA)

103
Q

What systems do small vessel vasculitis typically affect?

A

Respiratory

Renal

104
Q

What is polymyalgia rheumatica?

A

Auto-inflammatory condition of joints and muscles. Often occurs in combination with GCA.

105
Q

What is the presentation of polymyalgia rheumatica?

A

Symmetrical aching and tenderness

Morning stiffness

106
Q

What is gout?

A

Deposition of sodium urate crystals in joints

107
Q

What is epidemiology of gout?

A

Men
>40 years
Linked to a western diet

108
Q

What is the pathophysiology of sodium urate crystal formation?

A

Purine metabolism produces uric acid by use of the enzyme xanthine oxidase. Normally they are excreted but in excess they can crystallise.

109
Q

What is the normal concentration of uric acid in the blood?

A

0.3mmol/l

110
Q

What are the causes of under excretion of uric acid?

A 
Alcohol 
Renal impairment 
Hypertension 
Obesity 
Diuretics
111
Q

What are the causes of over production of uric acid?

A

Metabolic syndrome

Increase intake - meat, shellfish, alcohol, fructose drinks.

112
Q

What is the presentation of gout?

A

Sever inflammation of one joint

Most common - metatarsophalangeal joint (big toes)

113
Q

What are the precipitating factors for a gout attack?

A

Alcohol binge
Sepsis
Trauma

114
Q

What are the effects of recurrent gout attacks?

A

Tophi can form and cause deformation

115
Q

What investigations should be carrie out in gout?

A

Joint aspiration microscopy

Serum urate

116
Q

What does microscopy show in gout?

A

Negatively befringent needles.

117
Q

What is the treatment for acute gout?

A

NSAIDs
Colchicine
Steroids

118
Q

What is the treatment for chronic gout?

A

Aim to lower urate to 0.3mmol/l

Xanthine oxidase inhibitor - allopurinol

119
Q

What lifestyle advice can be recommended in gout?

A

Modify diet - less high purine foods
Weight loss
Alcohol reduction
Eat dairy

120
Q

What is pseudogout?

A

Deposition of calcium pyrophosphate crystals in joints.

121
Q

What are the risk factors pseudogout?

A

Old age
Hyperparathryoidism
Diabetes

122
Q

What is the clinical presentation of psuedogout?

A

Acute monoarthritis
Most common in the knee
Severe pain, stiffness and swelling

123
Q

What are the investigations needed in pseudogout?

A

Aspiration and microscopy

X-Ray

124
Q

What are the results of pseudogout microscopy?

A

Weakly positive birefringent rhomboids.

125
Q

What is the management of acute pseudogout?

A

NSAIDs
Colchicine
Rest, ice pack, physiotherapy

126
Q

What is the management of chronic pseudogout?

A

Methotrexate

127
Q

What is the most common bone tumour?

A

Secondary bone tumours

128
Q

What are three examples of primary bone tumours?

A

Osteosarcoma
Ewing sarcoma
Chondrosarcoma

129
Q

What are the symptoms of primary bone tumours?

A

Pain - unremitting and nocturnal
Local redness
Systemic - fatigue, weight loss, anaemia, unexplained bone fractures.

130
Q

What investigations are needed for a primary bone tumour?

A

X-Ray
MRI
Biopsy

131
Q

What features of a bone lesion can indicate that it is malignant?

A

Poorly defined zone of transition
Larger periosteal reaction
Cortical destruction

132
Q

What are the treatment options for primary bone tumours?

A

Chemotherapy
Radiotherapy
Surgery
Bisphosphonates

133
Q

What 5 primary tumours are likely to spread to bone?

A 
Breast
Prostate 
Kidney 
Lung 
Thyroid
134
Q

What is myeloma?

A

A malignant proliferation of plasma cells.

135
Q

What is fibromyalgia?

A

Non-specific muscular disorder with unknown cause, no sign of inflammation.

136
Q

What are the risk factors for fibromyalgia?

A 
Female 
Middle age 
Low household income 
Divorce
Chronic disease - IBS, headache, depression, fatigue.
137
Q

What is the presentation of fibromyalgia?

A

Chronic symptoms >3 months
Widespread pain
Absence of inflammation

138
Q

What are the symptoms of fibromyalgia?

A

Pain worse with stress, cold and activity
Morning stiffness
Non-restorative sleep

139
Q

What are the results of investigations for fibromyalgia?

A

Usually all normal

140
Q

What is the general management for fibromyalgia?

A

Reassurance
Education
CBT
Exercise

141
Q

What are the pharmacological options for fibromyalgia?

A

Analgesia

142
Q

What are the risk factors for mechanical back pain?

A

Manual work - stooping and twisting, lifting, vibrations
Smoking
Poor working conditions
Increasing age

143
Q

What is the general advice for mechanical back pain?

A 
Continue normal activities - NOT REST
Correct sitting and working posture
Lifting technique 
Heat pads
Analgesia
144
Q

What is septic arthritis?

A

Infection of a joint

145
Q

What is the most common causative agent of septic arthritis in a normal joint?

A

Staphylococcus aureus

146
Q

What are other causes of septic arthritis of the normal joint?

A

Neisseria gonorrhoea
E.coli
H. Influenzae

147
Q

What are the risk factors for septic arthritis?

A

Joint disease
Recent surgery
Immunosuppression
Penetrating trauma

148
Q

What is the presentation of a septic joint?

A

Painful, red, hot, swollen
Fever
Monoarthritis usually
Knee>hip>shoulder

149
Q

What investigations should be carried out in septic arthritis?

A

Urgent joint aspirate (off antibiotics)

150
Q

What is the appearance of infected joint fluid?

A

Turgid fluid

Cloudy

151
Q

What is the management of a septic joint?

A 
Aspiration (repeat as needed)
Antibiotics (flucloxacillin if S aureus)
Rest 
Analgesia 
Stop any immunosuppression if possible
152
Q

What is the most common causative agent of infection of a prosthetic joint?

A

Staphylococcus epidermidis

153
Q

What is the presentation of infection of a prosthetic joint?

A

Recent joint operation or infection
Painful, hot, swollen
Skin breakdown and discharge

154
Q

What investigation should be carried out in infection of a prosthetic joint?

A

Joint aspirate and microscopy
X-Ray
Bloods

155
Q

What is the management of infection of a prosthetic joint?

A 
Antibiotics - will not cure but will suppress infection.
Surgical debridement 
Excision arthroplasty
Exchange arthroplasty 
Amputation
156
Q

What is osteomyelitis?

A

Infection localised to bone.

157
Q

How may infection spread to the bone?

A

Direct inoculation - ie. broken bone or surgery
Contiguous spread - ie. from surrounding tissue
Haematogenous spread - spontaneous infection.

158
Q

Where does haematogenous spread often affect bones?

A

Children - long bones

Adult - vertebrae

159
Q

What are the risk factors for osteomyelitis?

A 
Trauma 
Reduced vascular supply 
Bone/joint condition 
Immune deficiency 
IVDU
160
Q

What is the most common causative agent for osteomyelitis?

A

Staphylococcus aureus

161
Q

What is the presentation of osteomyelitis?

A 
Fever
Malaise 
Pain - worse on movement 
Local tenderness
Swelling
162
Q

What are the investigations for osteomyelitis?

A

Bloods - raised ESR and CRP
Imaging - X-Ray then MRI
Bone biopsy

163
Q

Why may a bone biopsy be positive if the bone is not actually infected?

A

Skin commensal picked up in biopsy.

164
Q

What are the differential diagnoses for osteomyelitis?

A 
Soft tissue infection 
Avascular necrosis 
Gout 
Fracture
Bursitis
165
Q

What is the management of osteomyelitis?

A

Surgical debridement

Antibiotics

Phase 2a - conditions (11 decks)

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