Musculoskeletal Flashcards
Define giant cell arteritis
A form of vaculitis of large arteries. Granulomatous inflammation of external carotid artery and its branches, usually the temporal artery.
Summarise the aetiology of giant cell arteritis
Cause is unknown
Genetic and environmental factors contribute
Age and infectious agents may also have causative role
Associated with HLA-DR4 and HLA-DRB1
Summarise the epidemiology of giant cell arteritis
More common in those over 50
More common in females
25% of patients also have polymyalgia rheumatica
Most common systemic vasculitis in adults
Peak age of onset = 65-70 years old
What are risk factors for giant cell arteritis?
Age > 50 Female Genetic Factors Smoking Atherosclerosis Environmental Factors
What are the presenting symptoms of giant cell arteritis?
Temporal headache with sensitivity on touching temporal region or brushing hair
Jaw claudication when eating
Visual symptoms - blurred vision, sudden blindness in one eye
Subacute onset
Systemic Symptoms: Malaise Low-grade fever Lethargy Weight loss Depression
Symptoms of polymyalgia rheumatica:
Tenderness and stiffness of muscles of the shoulder and pelvic girdle
Early morning pain
What are the signs on physical examination of giant cell arteritis?
Palpable, thickened, non-pulsatile temporal artery
Absent temporal artery pulse
Abnormal fundoscopy
Swelling and erythema overlying the temporal artery
Temporal tenderness
Reduced visual acuity
Asymmetric blood pressure measurements
What are the appropriate investigations for giant cell arteritis?
Bloods:
CRP/ESR - raised
Hb and platelets are low
LFTs - transaminases and ALP slightly raised
Temporal artery biopsy - segmental giant cells (granulomas) in elastic - GRANULOMATOUS INFLAMMATION
Temporal artery ultrasound - thickening, stenosis or occlusion
What is the management of giant cell arteritis?
Immediately start high dose corticosteroids:
40-60mg PREDNISOLONE to prevent visual loss
After 5-7 days reduce steroid dose based off symptoms and ESR
Analgesia if needed
Osteoporosis prophylaxis - bisphosphonates, calcium, vit D
Low dose aspirin (+ PPIs and gastroprotection): reduces risk of visual loss, TIAs and stroke
Annual CXR for up to 10 years to look for thoracic aortic aneurysm
What are the possible complications of giant cell arteritis?
Aortic aneurysm
Irreversible visual loss due to optic nerve ischaemia
Large-vessel stenoses
Carotid artery aneurysm
Glucocorticoid related adverse effects i.e. DM and osteoporotic fractures
Summarise the prognosis of giant cell arteritis
Complete remission expected within 2 years
Patients respond quickly to treatment
Visual loss in treated patients is very rare
1-2 year treatment with glucocorticoids often needed
Define tension headache
The normal headache. A type of primary headache characterised by dull, pressing/tightening headache which can be chronic or episodic.
Chronic tension headaches = more than 15 headaches per month
Summarise the aetiology of tension headaches
Cause is unknown
Risk factors: Mental Stress/Anxiety Squinting/eye strain Poor Posture Fatigue Dehydration Missing Meals
Summarise the epidemiology of tension headaches
Most common type of headache Prevalence of 42% in adults Most patients do not need treatment or are able to self-treat Slightly more common in females More common in young adults
What are the presenting symptoms of tension headache?
Dull, bilateral, tightening/pressing band-like headache
Non-pulsatile
Not worsened by daily activities
No nausea or autonomic symptoms
Photo/phonophobia present
Mild-moderate pain
Tenderness of muscles in the neck (i.e. trapezius muscles, SCM)
Gradual onset and variable duration
Usually responsive to over-the-counter medication
What are the signs on physical examination of tension headache?
No signs
What are the appropriate investigations for tension headaches?
Mainly clinical diagnosis therefore no investigations needed
Can consider:
CT Sinus: to exclude sphenoid sinusitis
MRI Brain: to exclude brain tumour
Lumbar Puncture: to exclude infective causes i.e. brain abscesses, meningitis
What is the management of a tension headache?
Analgesia:
Paracetamol
NSAIDs eg aspirin
Acetaminophen
Physical therapy if neck stiffness
Reassurance
Address triggers (e.g. stress, anxiety)
Advice on avoiding medications that can cause medication-induced headaches (e.g. opioids)
Chronic tension headache:
TCAs eg amitriptyline
Accupuncture
What are the possible complications of tension headaches?
NONE
What is the prognosis of tension headaches?
Self-treatment with simple analgesics is effective
Recurs but not severe or disabling
Define polymyalgia rheumatica
An immune-mediated inflammatory condition of unknown cause, which is characterised by severe bilateral pain and morning stiffness of the shoulder, neck and pelvic girdle.
Summarise the aetiology of polymyalgia rheumatica
Not well understood
Genetic and environmental factors
HLA-DR4 more likely
More likely following adenovirus or parvovirus B19 infection
Associated with temporal arteritis
- 40-50% of people with temporal arteritis have polymyalgia rheumatica
- 15% of people with polymyalgia rheumatica will develop temporal arteritis
Summarise the epidemiology of polymyalgia rheumatica
More common in women More common in those above 50 years old Associated with giant cell arteritis Incidence increases with age Peak age of onset = 73 years old
What are the presenting symptoms of polymyalgia rheumatica?
Bilateral hip, shoulder and pelvic-girdle pain/aching/stiffness Pain worse at morning on night Pain improves with exercise Difficulty standing up from chair or getting out of bed Pain on lifting arms above shoulders Fever Fatigue Loss of appetite Weight loss Symptoms >2 weeks
NO MUSCLE WEAKNESS
What are the signs on physical examination of polymyalgia rheumatica?
Bilateral arm tenderness
Bilateral shoulder and/or pelvic girdle pain
Bilateral shoulder and/or pelvic girdle stiffness
What are the appropriate investigations for polymyalgia rheumatica?
Bloods:
ESR/CRP - raised
Muscle enzymes eg creatine kinase are normal
Serum Protein electrophoresis: normal in polymyalgia rheumatica
TFTs: TSH may be raised if hypothyroidism is the cause of symptoms
Ultrasound - bursitis, joint effusions
What is the treatment of polymyalgia rheumatica?
Low dose corticosteroids - PREDNISOLONE - response within 24-72 hours
Healthy diet
Steroid-sparing agents (e.g. methotrexate) are sometimes used
Calcium, vitamin D and bisphosphonates (Steroids can lead to osteoporosis)
Assistance from physiotherapy and occupational therapy
Monitor for adverse effects of steroids i.e. osteoporosis
What are the possible complications of polymyalgia rheumatica?
Giant cell arteritis
Relapse
Complications of corticosteroids:
Osteoporosis - bone fractures
Infection risk
New onset T2DM
Summarise the prognosis of polymyalgia rheumatica
15% risk of getting temporal arteritis
Variable course and prognosis
Usually responds rapidly to steroid treatment
Relapse is common
Define rheumatoid arthritis
An autoimmune mediated chronic, progressive inflammatory disorder of the joints, mainly those of the hands and feet. It is characterised by symmetrical deforming polyarthritis and extra-articular manifestations
Summarise the aetiology of rheumatoid arthritis
Unknown
Genetic factors - HLA-DR1 and DR4 make it more likely
Environmental factors - cigarette smoke, pathogen exposure
Associated with other autoimmune conditions
Summarise the epidemiology of rheumatoid arthritis
1-2% of population
Peak diagnosis in 50s
Females more likely
What are the presenting symptoms of rheumatoid arthritis?
GRADUAL onset Joint pain (painful to touch and with range of motion exercises) Joint swelling Joint stiffness worse in the morning and worse with inactivity Impaired joint function Symmetrical joint involvement
Systemic Symptoms: Fever, Fatigue, Weight Loss, loss of appetite, muscle weakness
In severe RA:
Pleuritic chest pain due to pleural effusion
Scleritis/uveitis
Vasculitic Lesions (skin rashes)
What are the signs of rheumatoid arthritis on physical examination?
Most commonly in the HANDS and FEET
Can affect shoulders, elbows, knees, ankles, wrists
Affects more than 5 joints
Spindling of fingers
Swelling of MCP, PIP and MTP Joints
Tender joints
Reduction in range of movement
Late Signs Ulnar deviation of fingers Radial deviation of the wrist Swan neck deformity Boutonniere deformity Z deformity of the thumb
Rheumatoid nodules (firm subcutaneous nodules) on elbows, palms, over extensor tendons
Baker’s cyst development
What are the appropriate investigations for rheumatoid arthritis?
Clincal diagnosis
Bloods: FBC - anaemia, leukocytosis, thrombocytosis ESR/CRP - raised Rheumatoid factor positive Anti-CCP antibody positive
X-ray: Decreased bone density around joint Soft tissue swelling Decreased joint space Bony erosions
Joint aspiration - rule out septic arthritis
Define osteoarthritis
Age-related degenerative synovial joint disease when cartilage destruction exceeds repair, causing pain and disability.
Summarise the aetiology of osteoarthritis
Exact aetiology is unknown
Secondary Osteoarthritis - Other diseases lead to altered joint architecture and stability
Commonly associated diseases include:
Developmental abnormalities (e.g. hip dysplasia)
Trauma (e.g. previous fractures)
Inflammatory (e.g. rheumatoid arthritis, gout, septic arthritis)
Metabolic (e.g. haemochromatosis, acromegaly)
Risk factors: Age Inflammation Joint injury Obesity Mechanical stress Neurologic disorders Female Post-menopause Genetics Medications High bone mineral density
Summarise the epidemiology of osteoarthritis
Common in those over 50 years old
Very common
Common in women and more common as age increases
More common in Asians and Caucasians
What are the presenting symptoms of osteroarthritis?
Joint stiffness in the morning for less than an hour and in the evening
Joint pain worse with activity
Sharp, aching, burning joint pain
NO JOINT SWELLING
Limited range of movement
Functional difficulties
Stiffness and gelling after inactivity for a few minutes
What are the signs on physical examination of osteoarthritis?
Local joint tenderness Crepitus and pain during joint movement Joint effusion Restriction of range of joint movement Antalgic gait (gait to avoid pain)
Bony swellings along joint margins:
Heberden’s Nodes: DIP joint
Bouchard’s Nodes: PIP joint
