Musculoskeletal Flashcards

Question

What are the appropriate investigations for polymyalgia rheumatica?

Answer 1

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

Answer 2

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

Answer 3

Giant cell arteritis Relapse Complications of corticosteroids: Osteoporosis - bone fractures Infection risk New onset T2DM

Answer 4

15% risk of getting temporal arteritis Variable course and prognosis Usually responds rapidly to steroid treatment Relapse is common

Answer 5

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

Answer 6

Unknown Genetic factors - HLA-DR1 and DR4 make it more likely Environmental factors - cigarette smoke, pathogen exposure Associated with other autoimmune conditions

Answer 7

1-2% of population Peak diagnosis in 50s Females more likely

Answer 8

``` 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)

Answer 9

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

Answer 10

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

Answer 11

Age-related degenerative synovial joint disease when cartilage destruction exceeds repair, causing pain and disability.

Answer 12

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 ```

Answer 13

Common in those over 50 years old Very common Common in women and more common as age increases More common in Asians and Caucasians

Answer 14

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

Answer 15

``` 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

Answer 16

``` 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

Answer 17

The infection of 1 or more joints by pathogenic inoculation of microbes by either direct inoculation or haematogenous spread.

Answer 18

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

Answer 19

6 cases per 100,000 per year Incidence increases in those with underlying joint disease or prosthetic joints Most common in children and elderly

Answer 20

``` Recent orthopaedic procedures Osteomyelitis Diabetes Immunosuppression Alcoholism Underlying joint disease Joint prostheses IV drug use ```

Answer 21

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

Answer 22

Painful, hot, swollen and immobile joint Erythema Severe pain prevents passive movement Pyrexia

Answer 23

``` 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

Answer 24

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.

Answer 25

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

Answer 26

``` Obesity Pregnancy Diabetes mellitus Hypothyroidism Rheumatoid arthritis Fractured wrist Female Increased age ```

Answer 27

3 times more common in females Most common in 40-60 year olds 1 in 25 people Most common entrapment neuropathy

Answer 28

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

Answer 29

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

Answer 30

EMG - slowing of conduction velocity in median sensory nerves across the carpal tunnel USS/MRI wrist - may show space occupying lesion

Answer 31

A type of seronegative spondlyarthropathy. Inflammation of joints following a genitourinary or gastrointestinal infection

Answer 32

Reactive arthritis Urethritis Conjunctivitis

Answer 33

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

Answer 34

Much more common in males Affects adults Age of onset: 20-40 years Seen in 2% of patients with non-specific urethritis

Answer 35

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

Answer 36

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 ```

Answer 37

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

Answer 38

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.

Answer 39

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 ```

Answer 40

``` 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 ```

Answer 41

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

Answer 42

``` 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

Answer 43

Erythematous, oedematous warm joint which is tender to light palpation Limited joint movement Tophi in external ear, olecranon, achilles tendon, toe Fever

Answer 44

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

Answer 45

Arthritis associated with calcium pyrophosphate dihydrate crystal deposition in joint cartilage.

Answer 46

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

Answer 47

Increasing incidence with age More common >60 More common in females

Answer 48

``` Painful, swollen, red, warm joint Affects >1 joint Often large joint such as knee Reduced joint mobility Fever and malaise Sudden worsening of osteoarthritis ```

Answer 49

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 ```

Answer 50

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

Answer 51

Chronic pain disorder in mainly middle aged females characterised by widespread muscle pain, increased tenderness, decreased pain threshold and mood and sleep disturbances.

Answer 52

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 ```

Answer 53

Most common in middle aged women | Average age of presentation is 35 years old

Answer 54

``` 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

Answer 55

Normal physical examination with increased tenderness

Answer 56

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 ```

Answer 57

A seronegative spondyloarthropathy, characterised by axial spine involvement, inflammatory back pain, sacroiliitis and vertebral fusion.

Answer 58

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

Answer 59

Most common in young men Usually presents in 20s Men present earlier

Answer 60

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

Answer 61

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

Answer 62

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

Answer 63

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.

Answer 64

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 ```

Answer 65

More common in children 2-12 years old | 3 times more common in boys

Answer 66

``` 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 ```

Answer 67

``` Erythema Tenderness Warm Swollen joint Reduced range of movement Sero-purulent discharge from an associated wound or ulcer ```

Answer 68

``` FBC - elevated WBC ESR/CRP - elevated Blood culture Bone biopsy and culture X-ray - radiolucency, soft tissue swelling, osteopenia Swabs of wound or discharge ```

Answer 69

Progressive degenerative process affecting the cervical vertebral bodies and intervertebral discs and causing compression of the spinal cord and/or nerve roots.

Answer 70

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

Answer 71

Mean age at diagnosis = 48 years old | More common in males

Answer 72

``` 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 ```

Answer 73

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

Answer 74

Spinal X-ray (lateral) - Can detect osteoarthritis change | MRI - Allows exclusion of root and cord compression, exclude spinal cord tumour and nerve root infiltration