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Year 3 diagnosis and management > Musculoskeletal > Flashcards

Musculoskeletal Flashcards

1
Q

What is ankylosing spondylitis and what does it mainly affect?

A

Seronegative inflammatory arthropathy preferentially affecting the axial skeleton and large proximal joints

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2
Q

Which gene is ankylosing spondylitis associated with?

A

HLA-B27

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3
Q

Describe the pattern of pain in ankylosing spondylitis?

A
  • Worse in the morning
  • Better with activity
  • Worse when resting
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4
Q

Apart from back pain, where else can you get pain in ankylosing spondylitis?

A
  • Pleuritic chest pain - costovertebral joints

* Heel pain - plantar fasciitis

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5
Q

Describe the test used for ankylosing spondylitis on examination?

A

Schober’s test
• 2 fingers placed on back 10cm apart
• Distance should increase by >5cm on forward flexion

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6
Q

What are the signs of extra-articular disease in ankylosing spondylitis?

A 
5 As
• Anterior uveitis
• Apical lung fibrosis
• Achilles tendinitis
• Amyloidosis
• Aortic regurgitation
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7
Q

Investigations (imaging) for ankylosing spondylitis?

A
  • X-ray - bamboo spine, sclerosis, erosions

* MRI - bone marrow oedema

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8
Q

Difference between gout and pseudogout cause?

A

Gout
• disorder of uric acid metabolism
• monosodium urate crystal deposition

Pseudogout
• calcium pyrophosphate dihydrate (CPPD) crystal deposition

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9
Q

Presentation of gout and pseudogout?

A 
Gout (more common in males)
• Sudden excruciating monoarticular pain
• Usually metatarsophalangeal joint of great toe
• Can present with cellulitis
• Renal calculi symptoms

Pseudogout (more common in females)
• acute arthritis
• chronic arthropathy, similar to osteoarthritis

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10
Q

What is intercritical and chronic tophaceous gout?

A
  • Intercritical - asymptomatic between acute attacks

* Chronic tophaceous - persistent low-grade fever, painful tophi, repeated acute attacks

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11
Q

Investigations for gout and pseudogout?

A

Synovial fluid aspirate
• Gout - needle-shaped crystals, negative birefringence
• Pseudogout - rhomboid, brick-shaped crystals, positive birefringence

(polarised light microscopy)

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12
Q

What is fibromyalgia?

A

Chronic pain disorder with unknown cause

mainly women

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13
Q

Diagnosis of fibromyalgia?

A

Clinical

  • Widespread pain involving both sides of the body, above and below the waist for AT LEAST 3 MONTHS
  • Presence of 11 tender points among the 9 pairs of specific sites
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14
Q

The symptoms of which inflammatory disorder can present with giant cell arteritis?

A

Polymyalgia rheumatica - early morning pain and stiffness of muscles of shoulder and pelvic girdle

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15
Q

Presentation of polymyositis and dermatomyositis

A 
Polymyositis
• proximal muscle weakness
• distal muscles spared
• dysphagia
• no rash
Dermatomyositis
- Rash
• photosensitive
• heliotrope rash in periorbital region
• macular rash over back and shoulders
• Gottron's papules over extensor surfaces
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16
Q

Investigations for polymyositis and dermatomyositis?

A
  • High CK (better for P)
  • EMG (better for P)
  • Autoantibodies
  • Diagnostic - muscle biopsy
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17
Q

Signs of osteoarthritis and rheumatoid arthritis?

A

Osteoarthritis
• Heberden’s nodes - DIP joint
• Bouchard’s nodes - PIP joint
• Pain in large weight bearing joints and carpometacarpal joints

Rheumatoid arthritis
• Swan neck deformity
• Boutonniere deformity
• Swelling of MCP and PIP joints
• Ulnar deviation of fingers
• Radial deviation of wrist
• Rheumatoid nodules
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18
Q

History of osteoarthritis and rheumatoid arthritis?

A 
Osteoarthritis
• Unilateral
• (Morning stiffness <30mins)
• Pain with use
• Better with rest

Rheumatoid arthritis
• Bilateral
• Morning stiffness >45 mins
• Better with use

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19
Q

X-ray findings in osteoarthritis and rheumatoid arthritis?

A 
Osteoarthritis (LOSS)
• Loss of joint space
• Osteophytes forming at joint margins
• Subchondral sclerosis
• Subchondral cysts
Rheumatoid arthritis
• Loss of joint space
• Juxta-articular osteoporosis
• Periarticular erosions/osteopaenia
• Subluxation (partial dislocation)
• Soft tissue swelling
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20
Q

Rheumatoid arthritis HLA associations?

A

HLA-DR1

HLA-DR4

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21
Q

Best diagnostic marker for rheumatoid arthritis?

A

Anti-cyclic citrullinated peptide antibody

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22
Q

What is reactive and septic arthritis?

A

Reactive
• Sterile arthritis
• After extra-articular infection (GI or urogenital)

Septic
• Inta-articular infection (spreading systemic infection in most cases)
• Staphylococcus aureus (G+)
• Neisseria gonorrhoeae (G-) in sexually active young adults

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23
Q

Presentation of reactive and septic arthritis?

A

Reactive
• Reiter’s syndrome - conjunctivitis, urethritis, arthritis (can’t see, can’t pee, can’t climb a tree)
• Oral ulceration
• Circinate balanitis
• Keratoderma blenorrhagica on soles and palms

Septic
• Usually monoarthropathy
• Excruciating joint pain, hot and swollen
• Most common in knee

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24
Q

Most important investigation for septic arthritis?

A

Joint aspiration
• Grossly purulent
•Gram staining
• MC&S (or PCR if viral)

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25
Q

Reactive arthritis HLA association?

A

HLA-B27

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26
Q

What is osteomyelitis?

A

Infection of bone
• Inflammation
• Necrosis
• New bone formation

27
Q

Who mostly gets osteomyelitis?

A

Young children

28
Q

Presentation of osteomyelitis?

A
  • Pain
  • Fever, rigors
  • History of skin lesion, sore throat, trauma
  • Inflamed area
  • Seropurulent discharge from associated wound
29
Q

Investigation for osteomyelitis?

A
  • MRI - best

* Radionuclide scan - increased uptake in infected sites

30
Q

What is polymyalgia rheumatica?

A

Inflammatory condition characterised by severe bilateral pain and morning stiffness of:
• shoulder
• neck
• pelvic girlde

NOT weakness

31
Q

History of polymylagia rheumatica?

A
  • Flu-like symptoms at onset
  • Difficulty getting out of bed or raising arms due to morning stiffness (> 45 mins)
  • Worse when walking
32
Q

Investigations for polymylagia rheumatica?

A

Bloods - raised ESR (and CRP)
USS - trochanteric bursitis

Not required, but histology would show:
• Vasculitis with giant cells
• Certain sections of artery skipped
• Mainly arteries of muscle bed

33
Q

Treatment of polymyalgia rheumatica?

A

Oral prednisolone

34
Q

What is Sjogren’s syndrome?

A

Inflammation and destruction of exocrine glands (usually salivary and lacrimal)

Lymphocitic infiltration and fibrosis

35
Q

Presentation of Sjogren’s?

A
  • Fatigue, fever, weight loss
  • Dry eyes
  • Dry mouth - secondary dysphagia
  • Dry skin
  • Raynaud’s
36
Q

What is secondary Sjogren’s due to?

A

Rheumatoid arthritis or other connective tissue disorders

37
Q

Investigations for Sjogren’s?

A

Diagnostic - Schirmer’s test (strip of filter paper under eyelid, positive if < 10mm wet after 5 mins)

Antibodies: rheumatoid factor, ANA, anti-Ro, anti-LA

38
Q

What is spondylosis?

A

Degeneration of vertebral bodies and intervertebral discs - compression of spinal cord / nerve roots by osteophytes

39
Q

Signs of spondylosis?

A

If roots - LMN sign (arm in cervical)
If cord - UMN signs (legs in cervical)

  • Sensory loss
  • Pseudoathetosis - writhing finger movements when hands outstretched (cervical roots)
  • Lhermitte’s sign (crepitus / paraesthesia)
40
Q

Investigations for spondylosis?

A

Spinal X-ray

41
Q

Diagnosis of SLE?

A

4/11 of the following:

SOAP BRAIN MD
• Serositis
• Oral ulcers
• Arthritis
• Photosensitivity
• Bloods (haemolytic anaemia/leukopaenia/thrombocytopaenia)
• Renal disease
• ANA
• Immunological disorder (anti-dsDNA)
• Neurological disease
• Malar rash
• Discoid rash
42
Q

Most common cardiac manifestation of SLE?

A

Pericarditis

43
Q

HLA in SLE?

A

HLA-DR2

HLA-DR3

44
Q

Best diagnostic test for SLE?

A

Anti-dsDNA

45
Q

Inflammatory markers in SLE?

A

Normal CRP

Raised ESR

46
Q

What is systemic sclerosis?

A

Connective tissue disease characterised by widespread small blood vessel damage and fibrosis in skin and internal organs

aka scleroderma

47
Q

What is seen diffuse cutaneous systemic sclerosis (40%)?

A

Scleroderma mainly in trunk and proximal limbs

  • Raynaud’s
  • Nail-fold capillary changes
  • Tendon friction
  • Joint contracture
  • Lung, heart, GI and renal disease
  • Interstitial lung disease and pulmonary arterial hypertension is main cause of death
48
Q

What is seen in limited cutaneous systemic sclerosis (60%)?

A 
CREST
• Calcinosis
• Raynaud's
• Esophageal dysmotility
• Sclerodactyly
• Telangiectasia

Scleroderma mainly in face and distal limbs

49
Q

What is scleroderma sine scleroderma?

A

Internal organ disease with no skin changes

50
Q

Signs of systemic sclerosis?
• Skin
• Hands
• Face

A
  • Skin - Raynaud’s
  • Hands - swollen, thickened, tight, shiny, ulcers
  • Face - microstomia, telangiectasia
51
Q

Which antibodies are associated with limited cutaneous ss and diffuse cutaneous ss?

A

Limited cutaneous - anti-centromere

Diffuse cutaneous - anti-topoisomerase II (anti-Scl-70)

52
Q

Which vessel size does eosinophilic granulomatosis with polyangiitis (Churg-Strauss) affect?

A

Small (may also affect medium)

53
Q

Which vessel size does granulomatosis with polyangiitis (Wegner’s) affect?

A

Small (may also affect medium)

54
Q

Which vessel size does microscopic polyangiitis affect?

A

Small

55
Q

Which vessel size does Polyarteritis nodosa affect?

A

Medium

56
Q

Which vessel size does Takayasu’s arteritis affect?

A

Large

57
Q

Features of eosinophilic granulomatosis with polyangiitis (Churg-Strauss) and granulomatosis with polyangiitis (Wegner’s)?

A

EGPA
• asthma
• paranasal sinusitis
• mononeuritis multiplex

GPA
• Epistaxis/haemoptysis
• Sinusitis
• Nasal crusting
• Saddle-shaped nose
• Renal failure
58
Q

Features of microscopic polyangiitis?

A
  • Renal impairment
  • Palpable purpura
  • Mononeuritis multiplex
59
Q

Antibodies in EGPA, GPA and microscopic polyangiitis?

A
  • pANCA - EGPA and microscopic polyangiitis

* cANCA - GPA

60
Q

Features of polyarteritis nodosa?

A
  • Testicular pain
  • Livedo reticularis - mottled, lace-like purplish skin discolouration
  • Renal failure
  • Haematuria
61
Q

Risk factor for polyarteritis nodosa? (seen in serology)

A

Hepatitis B

62
Q

In whom is Takayasu’s arteritis most common?

A

Japanese females

63
Q

Presentation of Takayasu’s arteritis?

A
  • Absent limb pulses
  • Unequal blood pressure in upper limbs
  • Carotid bruit
  • Intermittent claudication
  • Aortic regurgitation
64
Q

Signs of Carpal Tunnel syndrome?

A
  • Weakness and wasting of thenar eminence
  • Tinel’s signs - tapping the carpal tunnel causes symptoms
  • Phalen’s test - flexion of the wrist for 1 min may cause symptoms

Year 3 diagnosis and management (9 decks)

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