Musculoskeletal Flashcards
Define amyloidosis.
Heterogenous group of diseases characterised by extracellular deposition of amyloid fibrils.
- Type AA = serum amyloid A protein*
- -Type AL = Monoclonal immunoglobulin light chains*
- Type ATTR (familial amyloid polyneuropathy) = Genetic-variant transthyretin*
What are the presenting signs and symptoms of amyloidosis?
o Renal = proteinuria, nephrotic syndrome, renal failure
o Cardiac = restrictive cardiomyopathy, heart failure, arrhythmia, angina
o GI = macroglossia (characteristic of AL), hepatosplenomegaly, gut dysmotility, malabsorption, bleeding
o Neurological = sensory and motor neuropathy, autonomic neuropathy, carpal tunnel syndrome
o Skin = waxy skin and easy bruising, purpura around the eyes (characteristic of AL), plaques and nodules
o Joints = painful asymmetrical large joints, enlargement of anterior shoulder
o Haematological = bleeding tendency
What are the appropriate investigations for amyloidosis?
o Tissue Biopsy
o Urine = proteinuria, free immunoglobulin light chains (in AL)
o Bloods = CRP/ESR, Rheumatoid factor, Immunoglobulin levels, Serum protein electrophoresis, LFTs, U&Es
o SAP Scan = radiolabelled SAP will localise the deposits of amyloid
Define ankylosing spondylitis.
Seronegative inflammatory arthropathy affecting preferentially the axial skeletal and large proximal joints.
What are the risk factors/causes of ankylosing spondylitis?
o Unknown cause
- Linked to HLA-B27 (over 90% of cases)
- Possible infective triggers and antigen cross-reactivity
What are the presenting symptoms of ankylosing spondylitis?
o Lower back and sacroiliac pain
o Disturbed sleep
o Pain pattern -> worse in the morning or with rest but better with activity
o Progressive loss of spinal movement
o Symptoms of asymmetrical peripheral arthritis
o Pleuritic chest pain (due to costovertebral joint involvement)
o Heel pain (due to plantar fasciitis)
o Non-specific symptoms (e.g. malaise, fatigue)
What are the clinical signs of ankylosing spondylitis on examination?
o Reduced range of spinal movement (particularly hip rotation)
o Reduced lateral spinal flexion
o Schober’s Test = 2 fingers are placed on the patients back about 10 cm apart -> patient is asked to bend over -> distance between the two fingers should increase by > 5 cm on forward flexion -> reduced movement would suggest ankylosing spondylitis
o Tenderness over the sacroiliac joints
o Later stages = Thoracic kyphosis, Spinal fusion, Question mark posture
o Signs of Extra-Articular Disease = 5 As = Anterior uveitis, Apical lung fibrosis, Achilles tendinitis, Amyloidosis, Aortic regurgitation
What are the appropriate investigations for ankylosing spondylitis?
o Bloods = FBC (anaemia of chronic disease, Rheumatoid factor (negative), ESR/CRP (high)
o Radiographs
- Anteroposterior and lateral radiographs of the spine = Bamboo spine
- Anteroposterior radiograph of sacroiliac joints = Symmetrical blurring of joint margins
- Later stages = erosions, sclerosis, sacroiliac joint fusion
- CXR = check for apical lung fibrosis
o Lung Function Tests = assess mechanical ventilatory impairment due to kyphosis
Define spondylosis.
Progressive degenerative process affecting the vertebral bodies and intervertebral discs, and causing compression of the spinal cord and/or nerve roots.
What are the presenting symptoms of spondylosis?
o Neck/Back pain/stiffness
o Arm pain (stabbing or dull ache)
o Paraesthesia
o Weakness
o Clumsiness in the hands
o Weak and stiff legs
o Gait disturbance
o Atypical chest pain
o Breast pain
o Pain in the face
What are the clinical signs of spondylosis on examination?
o Arms = atrophy of the forearm and hand muscles, segmental muscle weakness in a nerve root distribution, hyporeflexia, sensory loss (mainly pain and temperature), pseudoathetosis (writhing finger movements when hands are outstretched, fingers spread and eyes closed)
o Legs = increased tone, weakness, hyper-reflexia, extensor plantar response, reduced vibration and joint position sense
o Lhermitte’s Sign = neck flexion causes crepitus (grating sound) and/or paraesthesia down the spine
What are the appropriate investigations for spondylitis?
o Spinal X-ray - lateral
Define gout.
A disorder of uric acid metabolism causing recurrent bouts of acute arthritis caused by deposition of monosodium urate crystals in joints, soft tissues and kidneys.
What are the causes of gout?
o Hyperuricaemia
- Increased urate intake or production = increased dietary intake, increased nucleic acid turnover (e.g. lymphoma, leukaemia, psoriasis), increased synthesis of urate (e.g. Lesch-Nyhan syndrome)
- Decreased Renal Excretion = idiopathic, drugs (e.g. ciclosporin, alcohol, loop diuretics), renal dysfunction
What are the presenting signs and symptoms of an acute attack of gout?
o Precipitating factors = trauma, infection, alcohol, starvation, introduction or withdrawal of hypouricaemic agents
o Sudden excruciating monoarticular pain - usually affects the metatarsophalangeal joint of the great toe with symptoms peaking at 24 hrs
They resolve over 7-10 days
o Can present with cellulitis, polyarticular or periarticular involvement
What are the presenting signs and symptoms of intercritical gout?
o None
- Intercritical gout = asymptomatic period between acute attacks
What are the presenting signs and symptoms of chronic tophaceous gout?
o Follow repeated acute attacks
o Persistent low-grade fever
o Polyarticular pain with painful tophi (urate deposits)
o Best seen on tendons and the pinna of the ear
What are the presenting signs and symptoms of urate urolithiasis?
o Renal calculi symptoms
- Severe pain in the groin and/or side
- Blood in urine
- Vomiting and nausea
- WBCs or pus in the urine
- Reduced amount of urine excreted
- Burning sensation during urination
- Persistent urge to urinate
- Fever and chills if there is an infection
What are the appropriate investigations for gout?
o Synovial Fluid Aspirate = monosodium urate crystals will be seen - needle-shaped, negative birefringence under polarised light microscopy
- Microscopy and culture will also be performed to exclude septic arthritis
o Bloods = FBC (raised WCC), U&Es, Raised urate, Raised ESR
o AXR/KUB Film = Uric acid renal stones may be seen
Define pseudogout.
Arthritis associated with deposition of calcium pyrophosphate dihydrate (CPPD) crystals in the joint cartilage.
What are the risk factors for pseudogout?
o Joint damage - osteoarthritis, trauma etc
o Precipitating factors = Intercurrent illness, Surgery, Local trauma
o Rarer conditions = Haemochromatosis, Hyperparathyroidism, Hypomagnesaemia, Hypophosphatasia
What are the presenting symptoms of pseudogout?
o Acute Arthritis = Painful, Swollen Joint
o Chronic Arthropathy = Pain, Stiffness, Functional impairment
o Uncommon Presentations = Tendonitis, Tenosynovitis, Bursitis
What are the clinical signs of pseudogout on examination?
o Acute Arthritis = Red, Hot, Tender, Restricted range of movement, Fever
o Chronic Arthropathy = Similar to osteoarthritis, Bony swelling, Crepitus, Deformity, Restriction of movement
What are the appropriate investigations for pseudogout?
o Bloods = High WCC in acute attacks, High ESR
o Blood culture = exclude septic arthritis
o Joint Aspiration = Rhomboid, brick-shaped crystals, positive birefringence, culture/gram-staining to exclude septic arthritis
o Plain Radiograph of the Joint = Chondrocalcinosis
- Signs of osteoarthritis = Loss of joint space, Osteophytes, Subchondral cysts, Sclerosis
Define giant cell arteritis.
Granulomatous inflammation of large arteries, particularly branches of the external carotid artery, most commonly the temporal artery.
What are the risk factors for giant cell arteritis?
o Age
o Some infections
o Associated with HLA-DR4 and HLA-DRB1
What are the presenting symptoms of giant cell arteritis?
o Subacute onset (usually over a few weeks)
o Headache
o Scalp tenderness
o Jaw claudication
o Blurred vision
o Sudden blindness in one eye
o Systemic = malaise, low-grade fever, lethargy, weight loss, depression
o Symptoms of polymyalgia rheumatica = early morning pain and stiffness of muscles of the shoulder and pelvic girdle
What are the clinical signs of giant cell arteritis on examination?
o Swelling and erythema overlying the temporal artery
o Scalp and temporal tenderness
o Thickened non-pulsatile temporal artery
o Reduced visual acuity
What are the appropriate investigations for giant cell arteritis?
o Bloods = High ESR, FBC (normocytic anaemia of chronic disease)
o Temporal Artery Biopsy = Performed within 48 hrs of starting corticosteroids - negative biopsy doesn’t necessarily rule out GCA
What is the management plan for giant cell arteritis?
o High dose oral prednisolone immediately to prevent visual loss - reduce the dose of prednisolone gradually over time
o Many patients need to be kept on a maintenance dose of prednisolone for 1-2 yrs
o Low dose aspirin (with PPIs and gastroprotection) - reduces risk of visual loss, TIAs and stroke
o Annual CXR for up to 10 yrs to look for thoracic aortic aneurysms
What are the possible complications of giant cell arteritis?
o Carotid artery aneurysms
o Aortic aneurysms
o Thrombosis
o Embolism to the ophthalmic artery leading to visual disturbance and loss of vision
Define osteoarthritis.
Age-related degenerative joint disease when cartilage destruction exceeds repair, causing pain and disability.
What are the risk factors for osteoarthritis?
o Obesity
o Developmental abnormalities (e.g. hip dysplasia)
o Trauma (e.g. previous fractures)
o Inflammatory (e.g. rheumatoid arthritis, gout, septic arthritis)
o Metabolic (e.g. haemochromatosis, acromegaly)
What are the presenting symptoms of osteoarthritis?
o Joint pain and discomfort
o Use-related
o Stiffness or gelling after inactivity
o Difficulty with certain movements
o Feelings of instability
o Restriction walking, climbing stairs and doing manual tasks
o Systemic features are usually absent
What are the clinical signs of osteoarthritis on examination?
oLocal joint tenderness
o Bony swellings along joint margins
- Heberden’s Nodes - dista interphalangeal joint
- Bouchard’s Nodes - proximal interphalangeal joint
o Crepitus and pain during joint movement
o Joint effusion
o Restriction of range of joint movement