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
What are the appropriate investigations for osteoarthritis?
X-ray of affected joints: Loss of joint space Subchondral sclerosis Osteophytes Subcondral cysts
Bloods:
Serum ESR/CRP - normal
Rheumatoid factor - distinguish between osteoarthritis and rheumatoid - NEGATIVE
Anti-CCP antibody - distinguish between osteoarthritis and rheumatoid - NEGATIVE
Define septic arthritis
The infection of 1 or more joints by pathogenic inoculation of microbes by either direct inoculation or haematogenous spread.
Summarise the aetiology of septic arthritis
In most cases there is systemic infection allowing for haematogenous spread
Gonnococcal arthritis caused by neisseria gonorrhoaea is a minority and expected in sexually active adolescents
Most common is STAPHYLOCOCCUS AUREUS
Gram negative bacteria more common in old and immunocompromised
Common causative organisms:
Bacteria
All ages: Staphylococcus aureus, TB
< 4 years: Streptococcus pneumoniae, Streptococcus pyogenes, Neisseria meningitidis
16-40 years: Neisseria gonorrhoeae
Viruses: Rubella, Mumps, Hepatitis B, Parvovirus B19
Fungi: Candida
Summarise the epidemiology of septic arthritis
6 cases per 100,000 per year
Incidence increases in those with underlying joint disease or prosthetic joints
Most common in children and elderly
What are the risk factors for septic arthritis?
Recent orthopaedic procedures Osteomyelitis Diabetes Immunosuppression Alcoholism Underlying joint disease Joint prostheses IV drug use
What are the presenting symptoms of septic arthritis?
Red, swollen, warm joint
Painful joint - EXCRUCIATING
Restricted range of movement
Fever
Usually a monoarthropathy (usually affecting one large joint)
May cause a polyarthropathy in the immunosuppressed
Tuberculous arthritis develops more slowly and is more chronic
What are the signs on physical examination of septic arthritis?
Painful, hot, swollen and immobile joint
Erythema
Severe pain prevents passive movement
Pyrexia
What are the appropriate investigations for septic arthritis?
JOINT ASPIRATION AND ANALYSIS OF OBTAINED SYNOVIAL FLUID - MC&S: Purulent aspirate High white cell count Positive gram stain or culture PCR of aspirate if expect viral cause
Bloods: FBC: high WCC, high neutrophils CRP/ESR: High Blood cultures - MC&S Viral serology may be useful
Plain Joint Radiographs: Affected joint can show signs of damage following the infection
Joint USS - may show presence of joint effusion
MRI Scan: Useful for detecting osteomyelitis
Define carpal tunnel syndrome
A nerve entrapment disorder causing signs and symptoms due to compression of the median nerve, often resulting in tingling, pain and parasthesia of the lateral 3 and a half fingers.
Explain the aetiology of carpal tunnel syndrome
It is caused by compression of the median nerve. This can occur from any inflammation of nearby tendons and tissues, leading to oedema.
Overuse/repetitive stress injury can cause
Usually idiopathic
Can be secondary to:
Tenosynovitis - rheumatoid arthritis
Infiltrative diseases of the canal/soft tissue - amyloidosis, acromegaly
Bone involvement in the wrist - osteoarthritis, fracture
Fluid retention states - pregnancy, nephrotic syndrome
Obesity
Menopause
Diabetes
What are the risk factors of carpal tunnel syndrome?
Obesity Pregnancy Diabetes mellitus Hypothyroidism Rheumatoid arthritis Fractured wrist Female Increased age
Summarise the epidemiology of carpal tunnel syndrome
3 times more common in females
Most common in 40-60 year olds
1 in 25 people
Most common entrapment neuropathy
What are the presenting symptoms of carpal tunnel syndrome?
Numbness (parasthesia) in lateral 3 and a half digits
Pain in lateral 3 and a half digits
Dull ache over lateral 3 and a half digits
Tingling/burning over lateral 3 and a half digits
Muscle weakness
Clumsiness - difficulty with fine motor tasks eg doing buttons, turning keys, holding small objects
Symptoms worse at night
Aching and pain in forearm
Gradual onset in symptoms
Cold sensitivity
What are the signs on physical examination of carpal tunnel syndrome?
Sensory impairment in the median nerve distribution
Thenar muscle wasting and weakening
Phalen’s maneuvre - flexing the wrist as far as possible and holding for a minute causing reproduction of symptoms
Tinel’s sign - tapping over the flexor retinaculum causes symptoms
What are the appropriate investigations for carpal tunnel syndrome?
EMG - slowing of conduction velocity in median sensory nerves across the carpal tunnel
USS/MRI wrist - may show space occupying lesion
Define reactive arthritis
A type of seronegative spondlyarthropathy. Inflammation of joints following a genitourinary or gastrointestinal infection
What is the triad of Reiter’s syndrome?
Reactive arthritis
Urethritis
Conjunctivitis
Summarise the aetiology of reactive arthritis
Associated with HLA-B27
Often following genitourinary infection eg chlamydia (most common) or gastroenteritis eg salmonella, shigella, yersinia, campylobacter, e. coli
GRAM NEGATIVE CAUSATIVE ORGANISMS
Summarise the epidemiology of reactive arthritis
Much more common in males
Affects adults
Age of onset: 20-40 years
Seen in 2% of patients with non-specific urethritis
What are the presenting symptoms of reactive arthritis
Preceding urogenital or gastroenteritis 2-4 weeks previously
Pain and swelling of single large joint
Painful, stinging on urination if urethritis
Red, painful eye if conjunctivitis
Dyspareuria if cervicitis
Chest pain and fever if pericarditis
Low back pain (due to sacroiliitis)
Painful heels (due to enthesitis and plantar fasciitis)
Skin Rash
Penile Ulcer
Constitutional symptoms: Fever, Fatigue and Weight Loss
What are the signs on physical examination of reactive arthritis?
Asymmetrical oligoarthritis
Affects the larger joints in lower extremities
Tender, swollen, warm, red and stiff joints
Dactylitis: Sausage-shaped digits
Conjunctivitis and Anterior uveitis
Circinate balanitis: Scaling red patches on the glans penis
Keratoderma Blennorrhagica: Brownish-red macules Vesicopustules Yellowish-brown scales Found on the SOLES and PALMS
Aortitis: This can cause aortic regurgitation which can precipitate heart failure Oral Ulceration (usually painless) Nail dystrophy Hyperkeratosis Onycholysis
What are the appropriate investigations of reactive arthritis?
FBC - anaemia suggests severe systemic illness
ESR/CRP - high
HLA-B27 testing - positive
ANA and Rheumatoid factor - NEGATIVE (to rule out differentials)
Stool or Urethral Swabs and Cultures - may be negative by the time the arthritis develops
Urine Screen for Chlamydia trachomatis
Plain X-Rays:
Chronic cases
Erosions seen at the entheses (insertion of tendons into bone)
Sacroiliitis
Arthrocentesis with synovial fluid analysis - exclude crystal induced arthritis such as gout
Define gout
An syndrome characterised by hyperuricaemia and deposition of urate crystals into soft tissue and joint, resulting in recurrent bouts of acute inflammatory monoarthropathy, often affecting the big toe.
Summarise the aetiology of gout
Caused by hyperuricaemia and deposition of monosodium urate crystals in the joint
Decreased excretion of uric acid - 90%
- Idiopathic
- Renal failure
- Medication eg thiazide diuretics
Overproduction of purines
- Consumption of purine-rich food (shellfish, red meat)
- Increased nucleic acid turnover (e.g. lymphoma, leukaemia, psoriasis)
- Increased synthesis of urate
Genetic predisposition
Chemotherapy/radiotherapy causing tumour lysis syndrome
Drugs causing gout = CAN'T LEAP Ciclosporin Alcohol Nicotinic acid Thiazides Loop diuretics Ethambutol Aspirin Pyrizinamide
What are the risk factors of gout?
Male Alcohol Diabetes/insulin resistance Hypertension Obesity Dyslipidaemia Increasing age Renal insufficiency Consumption of Meat Seafood and alcohol ‘CANT LEAP’ Drugs Genetic Susceptibility High cell turnover rate
Summarise the epidemiology of gout
Incidence increases with age
More common in men - male to female ratio 7:1
Prevalence of 1%
Very rare pre-puberty and in pre-menopausal women
More common in HIGHER social classes
What are the presenting symptoms of gout?
Precipitating factors: Alcohol Red meat intake Increased thiazide diuretic dose Trauma Infection Introduction or withdrawal of hypouricemic agents
Sudden onset severe pain Swollen, red, erythematous, warm joint Often metatarsolphalangeal joint of big toe Joint stiffness Monoarticular - few joints affected Tender Pain wakes them up from sleep Joint feels like it is on fire
Symptoms peak at 24 hours and resolve over 7-10 days
Asymptomatic by monoarticular arthritis pain
What are the signs on physical exmamination of gout?
Erythematous, oedematous warm joint which is tender to light palpation
Limited joint movement
Tophi in external ear, olecranon, achilles tendon, toe
Fever
What are the appropriate investigations in gout?
Serum uric acid - hyperuricaemia
Urine uric acid
CRP/ESR - elevated
WCC - elevated
Synovial joint aspiration:
Increased WBCs with neutrophil predominance
Monosodium urate crystals
Synovial fluid polarised light microscopy:
Negative bifringence
Sharp needle shaped deposits - yellow under parallel light, blue under perpendicular light
X-Ray:
Crystal deposits, Periarticular erosions
USS (erosions, tophi, double contour line)
AXR/KUB Film: Uric acid renal stones may be seen - increased risk of nephrolithiasis
Define psuedogout
Arthritis associated with calcium pyrophosphate dihydrate crystal deposition in joint cartilage.
Summarise the aetiology of pseudogout
Caused be deposition of calcium pyrophosphate crystals in joint cartilage
Often idiopathic
It is associated with: Hyperparathyroidism Hypothyroidism Haemochromatosis Trauma Hypomagnesemia Hypophosphataemia
Precipitating factors: Intercurrent illness, Surgery, Local trauma
Summarise the epidemiology of pseudogout
Increasing incidence with age
More common >60
More common in females
What are the presenting symptoms of pseudogout?
Painful, swollen, red, warm joint Affects >1 joint Often large joint such as knee Reduced joint mobility Fever and malaise Sudden worsening of osteoarthritis
What are the signs on physical examination of pseudogout?
Acute Arthritis:
Red, hot, tender, swollen joints
Restricted range of movement (esp. shoulders, wrists, MCP Joints)
Chronic Arthropathy: Similar to osteoarthritis Bony swelling Crepitus Deformity Restriction of movement
What are the appropriate investigations of pseudogout?
WCC and ESR - elevated
Synovial fluid analysis:
See rhomboid or rod-shaped calcium pyrophosphate crystals
Crystals show positive bifringence
X-Ray: chondrocalcinosis, signs of osteoarthritis (Loss of Joint space, Osteophytes, Subchondral cysts, Sclerosis)
Exclude other causes:
Serum calcium - exclude hyperparathyroidism
Serum PTH - exclude hyperparathyroidism
Iron studies - exclude haemochromatosis
Serum magnesium - exclude hypomagnesaemia
Serum ALP - exclude hypophosphatasia
Define fibromyalgia
Chronic pain disorder in mainly middle aged females characterised by widespread muscle pain, increased tenderness, decreased pain threshold and mood and sleep disturbances.
Summarise the aetiology of fibromyalgia
Aetiology is unknown
Thought to be due to problem with pain perception in brain
Genetic impact as often runs in families
Environmental impact - common in those who experienced child abuse
Risk factors: Female Family history of fibromyalgia Age 20-60 Rheumatological condition
Summarise the epidemiology of fibromyalgia
Most common in middle aged women
Average age of presentation is 35 years old
What are the presenting symptoms of fibromyalgia?
Widespread musculoskeletal pain with associated stiffness Morning stiffness Increased tenderness Headaches Fatigue which is unrelieved by sleep Sleep disturbance Mood disturbance Cognitive disturbance - concentration, memory Hypersensitivity to light, noise, smell Parasthesia Tingling and numbness Fluid retention
Symptoms occuring for >3 months
What are the signs on physical examination of fibromyalgia?
Normal physical examination with increased tenderness
What are the appropriate investigations for fibromyalgia?
Mainly a clinical diagnosis
Tenderness in 11 out of out of 18 points
Widespread pain on both sides of body, above and below waist for at least 3 months
Pain location >7 areas with symptom severity >5/12
Investigations to exclude other cause: FBC - exclude anaemia, iron deficiency TFT - exclude hypothyroid RF and anti-CCP - exclude rhuematoid arthritis ESR/CRP ANA - exclude SLE
Define ankylosing spondylitis
A seronegative spondyloarthropathy, characterised by axial spine involvement, inflammatory back pain, sacroiliitis and vertebral fusion.
Summarise the aetiology of ankylosing spondylitis
Aetiology unknown
Autoimmune condition however no associated auto-antibodies
Associated with HLA-B27
Infective triggers and antigen cross-reactivity with self-peptides have been hypothesised
Associated with family history
Pathophysiology:
Inflammation starts at the entheses (where ligaments attach to vertebral bodies)
Persistent inflammation leads to reactive new bone formation
Changes begin in the lumbar vertebrae and progress superiorly
Summarise the epidemiology of ankylosing spondylitis
Most common in young men
Usually presents in 20s
Men present earlier
What are the presenting symptoms of ankylosing spondylitis?
Lower back pain - worse in morning or when resting, relieved by exercise, insidious onset, wakes up from sleep
Limited range of movement of back
Inflammed and painful tendons
Buttock pain due to sacroiliitis
Symptoms of Iritis/Uveitis: redness, discomfort, photophobia
Pleuritic Chest Pain, Dyspnoea (due to costovertebral joint involvement)
Heel Pain (due to plantar fasciitis)
Malaise, Fatigue
What are the signs on physical examination of ankylosing spondylitis?
Reduced range of spinal movement: hip rotation and lateral spinal flexion
Tenderness over sacroiliac joints
Loss of lumbar lordosis - QUESTION MARK POSTURE
Schober’s Test:
Two fingers placed on back 10cm apart
Patient bends over
Normal = distance between fingers increases by >5cm
Reduced movement would suggest ankylosing spondylitis
Thoracic kyphosis
Spinal fusion
Signs of Extra-Articular Disease: 5 As Anterior Uveitis Apical lung fibrosis Achilles Tendonitis Amyloidosis Aortic Regurgitation
Signs and symptoms of IBD
What are the appropriate investigations of ankylosing spondylitis?
MRI spine - early = joint space narrowing and erosion, later = spine fusion
Pelvic X-ray - scaroiliitis
X-Ray spine - bamboo spine (fusion of vertebrae)
CRP/ESR - elevated
Genetic testing - HLA-B27 positive
CXR: Check for apical lung fibrosis
Lung Function Tests: assess mechanical ventilatory impairment due to kyphosis
Define osteomyelitis
Inflammed bone or bone marrow, usually due to infection most commonly by staphylococcus aureus. It leads to inflammation and necrosis of bone and formation of new bone and can be acute or chronic.
Summarise the aetiology of osteomyelitis
Can be caused by haematogenous spread from bacteraemia, direct innoculation due to trauma or surgery, contiguous spread from an adjacent area
Most common causative agent is staphylococcus aureus
In IVDU - psuedomonas can affect
In sickle cell - salmonella can affect
In neonates - group B strep and E.coli can affect
Risk Factors: Diabetes Immunosuppression IV drug use Prostheses Sickle-cell anaemia
Summarise the epidemiology of osteomyelitis
More common in children 2-12 years old
3 times more common in boys
What are the presenting symptoms of osteomyelitis?
Pain at site of infection Fever/rigors Fatigue Swelling of area Redness at area Reduced movement of affected area Malaise History of preceding skin lesion, sore throat, trauma or operation
What are the signs on physical examination of osteomyelitis?
Erythema Tenderness Warm Swollen joint Reduced range of movement Sero-purulent discharge from an associated wound or ulcer
What are the appropriate investigations for osteomyelitis?
FBC - elevated WBC ESR/CRP - elevated Blood culture Bone biopsy and culture X-ray - radiolucency, soft tissue swelling, osteopenia Swabs of wound or discharge
Define cervical spondylosis
Progressive degenerative process affecting the cervical vertebral bodies and intervertebral discs and causing compression of the spinal cord and/or nerve roots.
Summarise the aetiology of cervical spondylosis
Osteoarthritic degeneration of the vertebral bodies leads to the formation of osteophytes
These osteophytes protrude on to the foramina and spinal canal
This leads to compression of:
Nerve roots: radiculopathy
Anterior spinal cord: myelopathy
Risk Factors: Older Age > 40, Obesity, Previous Trauma, Poor Posture, Inactivity
Summarise the epidemiology of cervical spondylosis
Mean age at diagnosis = 48 years old
More common in males
What are the presenting symptoms of cervical spondylosis?
Neck pain/stiffness Arm pain (stabbing or dull ache) Atypical chest pain Breast pain Pain in the face Pins and needles and/or paraesthesia
Spinal stenosis (severe disease): Lack of coordination/clumsiness of hands i.e. buttoning a shirt Heaviness or weakness in arms or legs Problems walking (gait disturbance) Problems controlling bladder and bowel
What are the signs on physical examination of cervical spondylosis?
ARMS:
Atrophy of the forearm and hand muscles
Segmental muscle weakness in a nerve root distribution
Hyporeflexia
Sensory loss (mainly pain and temperature)
Pseudo athetosis (writhing finger movements when hands are outstretched, fingers spread, and eyes closed)
LEGS – if cervical cord compression: Increased tone Weakness Hyperreflexia Extensor plantar response Reduced vibration and joint position sense
Lhermitte’s Sign: neck flexion causes crepitus (grating sound) and/or paraesthesia down the spine
What are the appropriate investigations for cervical spondylosis?
Spinal X-ray (lateral) - Can detect osteoarthritis change
MRI - Allows exclusion of root and cord compression, exclude spinal cord tumour and nerve root infiltration
