Musculoskeletal Flashcards
Gout
Excessive uric acid leads to formation of monosodium urate crystals which become deposited in joints causing inflammation.
C: Infection, sepsis, trauma, dehydration, thiazide diuretics, alcohol, diet rich in meat and seafood, obesity, untreated hypertension, family history.
S: Single acute, hot, swollen and painful joint. Usually MTP joint in big toe, base of the thumb, wrist, DIP joints in hands.
D: Aspiration of fluid from the joint - Needle shaped monosodium urate crystals, no bacteria, negative birefringment of polarised light.
T: Acute - NSAIDs and Colchicine. Chronic - Titrate with Allopurinol prophylaxis initiated after acute attack. Aim to get urate levels <300umol/L.
Ankylosing Spondylitis
Chronic inflammation in the intervertebral discs and facet joints of the spine, that leads to destruction, replacement with fibrin and formation of syndesmophytes.
C: Unknown - autoimmune response. HLA-B27 gene link.
S: Weight loss, fever, fatigue, buttock pain (if sacroiliac joints), neck pain (if cervical joints), back pain (if thoracic joints), stiffness, dyspnoea, anterior uveitis, aortic regurg, enthesitis.
D: MRI - narrowing or erosion of the joint spaces (early) and joint fusion (later). X-ray or CT - ‘bamboo spine’. Genetic testing for HLA-B27.
T: NSAIDs, parcetamol/codeine, physiotherapy, DMARDs (sulfasalazine and methotrexate), anti-TNF therapy, Secukinumab, corticosteroid injections, surgery (usually hip or knee replacements).
Psoriatic arthritis
Type of joint inflammation that happens in patients with psoriasis. Following the formation of the psoriatic plaque, joint erosion and ossification occurs due to activation of osteoblasts and ostoclasts.
C: Unknown - autoimmune response. HLA-B27 gene link. May be linked with physical trauma or infection.
S: Pain, swelling, warmth and stiffness in affected joints. Red and scaley patches on skin.
D: Blood tests for Rheumatoid factor and anti-ccp antibodies (absent), HLA-B27 testing, X-ray.
T: NSAIDs, DMARDs (methotrexate and sulfasalazine), TNF-inhibitors, corticosteroid injections, surgery (hip and knee replacements).
Reactive arthritis
Inflammation of a joint that usually develops after an infection (2-3 weeks).
C: Sexually transmitted infection like Chlamydia. Gastroenteritis caused by bacteria like Shigella, Salmonella, Campylobacter, E.coli. HLA-B27 gene link.
S: Pain and swelling in knee, ankle, hip or small joints in the feet. Can also lead to uteritis (painful urination), conjunctivitis (redness of the eye), cervicitis (pain during intercourse), Pericarditis (chest pain and fevers), Keratoderma blenorrhagicum (skin rash on feet).
D: Clinical examination, previous infection, HLA-B27 testing.
T: Antibiotics to treat the infection, NSAIDs, DMARDs (methotrexate and sulfasalazine), steroids, rest, physiotherapy, ice packs, heat pads.
Osteoporosis
When the action of osteoclasts is greater than the action of osteoblasts, it leads to fewer trabeculae, thinning of the cortical bone, widening of the haversian canals, increasing the risk of fragility fractures.
C: Low oestrogen, low serum calcium, alcohol consumption, drugs like glucocorticoids, heparin, L-thyroxine, physical inactivity, DM, Cushing’s syndrome, Hyperprolactinemia, Turner’s syndrome.
S: Vertebral/compression fractures (back pain, height loss, hunched posture), femoral neck fractures, distal radius fractures.
D: Dual-energy X-ray absorptiometry (DEXA) scan giving a T score (treat if -2.5 or less)
T: Bisphosphonates (alendronate or risedronate), vit D and calcium supplements, exercise, reduce alcohol and smoking.
Septic Arthritis
Infection within a joint. Most common cause is Staphylococcus aureus. Medical emergency!
C: Trauma, complication of joint surgery, sepsis. Risk factors - RA, DM, immunocompromised, IV drug users, CKD, >80.
S: Single joint affected (usually knee), painful, red, swollen, stiffness, reduced ROM, fever, lethargy, sepsis.
D: Blood cultures, aspirate the joint (Gram staining, crystal microscopy, culture, antibiotic sensitivity).
T: Low threshold of suspicion - empirical IV antibiotics. Antibiotic course for 6 weeks - Vancomycin can be used for gram-positive cocci, ceftriaxone for gram-negative cocci, and ceftazidime for gram-negative rods.
Joint wash out and aspiration until there is no recurrent effusion.
Osteoarthritis
Chronic age-related, dynamic reaction pattern of a joint in response to insult or injury.
C: Age, trauma, obesity, decline in neuromuscular function, post-menopause, occupation links, inflammatory arthritis, joint hypermobility, DM, haemochromotosis.
S: Activity-related joint pain, reduced ROM, crepitus, warmth, boney swelling, synovitis, antalgic gait, Heberden’s and Bouchard’s nodes, muscle wasting and weakness.
D: X-ray (loss of joint space, osteophyte formation, subchondral cysts and sclerosis).
T: Exercise, weight loss, physiotherapy, walking aids, Topical and oral NSAIDs, capsaicin cream, paracetamol, transdermal patches (buprenorphine, lignocaine), intra-articular steroid injection, surgery.
SLE
Chronic autoimmune disease with relapsing-remitting periods that affects multiple organs.
C: Genetics, environmental triggers (UV light, smoking, viruses, bacteria, physical/emotional stress, trauma, medications).
S: Classically fever, rash and joint pain in a woman of child bearing age. Also - severe fatigue, joint swelling, headaches, malar rash, hair loss, anaemia, blood clotting problems, Raynauld’s disease, photosensitivity, ulcers, pleuritis or pericarditis.
D: Antibody tests - Anti-dsDNA, Anti-Smith, Anti-phospholipid antibody, CXR, FBC, urinalysis.
T: Ease symptoms with NSAIDs, steroid creams for rashes, corticosteroids, DMARDs, Chloroquine and hydroxychloroquine (antimalarials), rituximab and belimumab in severe SLE.
Scleroderma/Systemic sclerosis
A rare autoimmune disorder in which normal tissue is replaced by thick dense connective tissue, affecting the skin, blood vessels and internal organs.
C: Unknown. Genetic predispositon. Environmental triggers - viral infection: cytomegalovirus or parvovirus b19, exposure to silica dust, organic solvents or vinyl chloride, drugs - cocaine, bleomycin, pentazocine.
S: Sclerodactyly (ulceration, curling of the hand), microstomia (narrow mouth), Raynauld’s disease, telangiectasia, oesophageal dysfunction, PH, pulmonary fibrosis, hypertension, RHF, organ damage.
D: Antibodies - anti-SCL70, ARA, ACA, BP, FBC, endoscopy, pulmonary function tests.
T: Immunosuppressants, steroids, mosturisers
PPIs for gastro-oesophageal reflux
Calcium channel blockers for Raynaud’s phenomenon
NSAIDs for the pain
ACE inhibitors for hypertension
Surgery may be needed
Sjogren’s syndrome
Autoimmune disease where the immune system attacks the exocrine glands, most commonly the salivary glands and lacrimal glands.
C: Unknown. Genetic links with HLA-DRW52, HLA-DQA1, HLA-DQB1 genes. Environmental triggers: infection of the salivary and lacrimal glands.
S: Dryness of body surfaces, keratoconjunctivitis, blurred vision, itching, redness, burning of the eyes, dry mouth, difficulty tasting and swallowing, cracks and fissures in the mouth, ulceration of the nasal septum, difficulty speaking, swelling of glands.
D: Sialometry - can be used to measure the saliva flow
Blood tests - presence of anti-SSA and anti-SSB antibodies
Lip biopsy - increased numbers of CD4 T cells, plasma cells and macrophages, thickening of the inner duct wall
T: Artificial tears, corticosteroid eye drops, moisture chamber spectacles, punctal plugs, saliva substitues, Pilocarpine, Hydroxychloroquine, good dental hygiene, avoid drying environments.
Dermatomyositis
Autoimmune disorder whereby inflammation causes destruction of cells and blood vessels, causing tissue ischaemia in muscle or skin.
C: People with HLA-D3 or HLA-D5 genes may develop it after being exposed to Coxsackie virus or specific tumour antigens produced by ovarian, lung or breast cancer.
S: Muscle (bilateral weakness, atrophy, pain). Skin (purple rash on the upper eye lids, shoulder, back (heliotrope rash), malar rash, gottron’s sign (flat, red, scaly papules on the back of the fingers, elbows or knees, which is photosensitive, itchy, painful and can bleed).
D: ANA, anti-Mi-2, anti-Jo-1 in blood, increased CK levels, Electromyogram (abnormal), muscle biopsy.
T: Corticosteroids - prednisolone
Antimalarial medications - hydroxychloroquine and chloroquine, sometimes effective for skin rashes
Sun avoidance and protective clothing
Vitamin D deficiency
Body’s metabolic needs are not met as there is not enough 25-hydroxyvitamin D.
C: Insufficient dietary vitD, increased need in pregnancy, obesity, impaired absorption (small bowel disease, bariatric surgery, gastrectomy, pathology of hepatobiliary tree, pancreas, abetalipoproteinemia, decreased synthesis, impaired liver or kidney hydroxylation (renal failure, cirrhosis), medication.
S: Asymptomatic, fractures, dental enamel hypoplasia, bone tenderness, muscle weakness, cramping, numbness/tingling, bone malformations.
D: X-ray, DEXA scan, decreased serum 25-hydroxyvitamin D and serum calcium, increased alkaline phosphatase and PTH.
T: Vitamin D3 supplementation
- Dietary: fish, egg yolk, fortified foods
- Supplementation
- UV exposure
- Increased calcium intake
Osteomyelitis
Inflammation of the bone or bone marrow, typically resulting from infection.
C: Staph aureus, Salmonella, Pasteurella multocida.
Spread via trauma, infection from another site, IV drug use, surgery, severe vascular compromise, haemodialysis or dental extraction.
S: Pain at site of infection, fever, may affect use of limb (acute), prolonged fevers, weight loss (chronic).
D: FBC, ESR, CRP, X-ray (loss of bone mass), bone scan or MRI, bone biopsy.
T: Antibiotic treatment specific to pathogen. Surgery if there is an abscess, particularly a vertebral abscess causing neural compression or spinal instability
Surgery to remove any necrotic bone - removal of the sequestrum in chronic osteomyelitis.
Rheumatoid Arthritis
Chronic, systemic, inflammatory, auto-immune disease characterized by symmetrical deforming polyarthropathy.
C: Unknown. Risk factors include family history, being female, bacteria, viruses such as EBV, trauma or injury, smoking, obesity.
S: Joint pain, swelling, stiffness. Persistent synovitis, loss of function, deformities such as Boutonniere and swan neck finger and nodules, weight loss, fever, fatigue.
D: RF (in 60/70%), Anti-CCP (in 80%), X-ray, CRP, ESR, specialist assessment.
T: NSAIDs & PPI
Refer for to Rheumatologist
Conventional disease modifying anti-rheumatic drug (cDMARD)
Hydroxychloroquine for people with Palindromic Rheumatism
Glucocorticoids to manage short term flare ups
Compartment syndrome
Occurs when the pressure in the compartments that hold muscles, nerves, blood vessels surrounded by a layer of fascia becomes too high and tissue damage occurs due to hypoxia.
C: Bleeding inside the compartment (long bone fractures, penetrating wounds or surgical procedures), swelling (burns, drug injections, repetitive use of injured muscles, tetany and seizures), limb compression, reperfusion injury.
S: Pain (sharp and deep), Paraesthesia, Pulselessness, Pallor and poikilothermia, Paralysis.
D: Physical examination, intra-compartmental pressure monitors, CK and myoglobin (raised), Radiography, MRI, CT and ultrasound.
T: Fasciotomy - cutting the fascia, relieving the pressure, restoring the blood flow.
This can be left open for a few days before the cause of the pressure is treated.
Sprains and strains
A sprain is an injury to the ligament which connects two or more bones to a joint.
A strain refers to an overstretching and tearing of muscles or tendons.
C: Sprain (joint being forced suddenly outside its usual range of movement) Strain (the relevant part has been stretched beyond its limits, or it has been forced to contract too strongly).
S: Sprain (inflammation, swelling, and bruising), Strain (first degree - tender and painful, second - pain, tenderness, swelling, third - complete LOF).
D: Physical examination, X-ray
T: Rest 48-72 hours, ice for 15-20 minutes every two or three hours, compression with a bandage, elevation, physiotherapy, painkillers, surgery (rarely).
Dislocations
An injury in which the bones in a joint are forced apart and out of their usual positions.
C: An injury which produces an impact on the joint, such as falls, accidents involving moving vehicles and collisions during contact sports. Predisposition to dislocation, previous dislocations. Inherited conditions like Ehlers-Danlos syndrome and Marfan syndrome.
S: Sudden and extreme pain, bruising, swelling, deformed joint, unable to weight-bear, numbness adn tingling.
D: X-ray, physical examination.
T: Analgesia, Reduction, Rehabilitation and prevention of further dislocations, Surgery if ligaments have been damaged.
Frozen shoulder
Thickening and contraction of the glenohumeral joint capsule and formation of adhesions cause pain and loss of movement.
C: Spontaneously with no known cause, rotator cuff lesions/injury, immobility.
S: Begins as severe generalised pain associated with stiffness, daily activities are limited (9 months). Pain subsides, stiffness remains, further reduction in ROM (4-12 months). Stiffness reduces and ROM increased (1-3 months).
D: Inability to do passive external rotation (diagnostic). Radiology and blood tests.
T: Parcetamol, NSAIDs, Tens machine, Physiotherapy, Corticosteroid injections, Oral steroids, Distension therapy involves injecting large volumes of fluid (saline or local anaesthetic, with or without steroid) into the shoulder joint, surgery.
Rotator cuff disorders
Three types: rotator cuff tears (minor/partial or full/complete depending on the degree of damage), subacromial impingement (minor tears or overuse of mean that the humeral head is not pushed down appropriately when you raise your arm, this means it goes too close to the acromion) and calcific tendonitis (calcium builds up in the rotator cuff tendon and cause an increased pressure and pain).
C: Falling on the affected arm (usually under 40) or without any obvious cause (usually over 40).
S: Subacromial pain, difficulty moving the shoulder, pain is worst when you use your arm for activities above your shoulder level, pain may be worse at night and affect sleep, may feel weak.
D: Shoulder examination, X-ray, ultrasound, MRI scan.
T: Analgesia, NSAIDs, Physiotherapy, Steroid injections. Arthroscopic subacromial decompression (ASD) for subacromial impingement, ‘Ultrasound-guided barbotage’ for calcific tendonitis, surgery may be needed for RCTs.
Chronic shoulder instability
When the acromion is loose and vulnerable to easily slipping out of the glenohumeral joint.
C: Severe injury or trauma causes the initial shoulder dislocation, can lead to continued dislocations, repetitive overhead motion loosens ligaments, multidirectional instability.
S: Pain, persistent sensation of the shoulder feeling loose, slipping in and out of the joint, or just “hanging there”.
D: Shoulder examination, X-ray, MRI scan.
T: Activity modification, NSAIDs, Physiotherapy, Arthroplasty, Open surgery, Rehabilitation post-surgery.
Trigger finger
AKA stenosing flexor tenosynovitis.
A finger that becomes ‘locked’ after it has been flexed.
C: Unknown. Inflammation causes swelling of tendon/tendon sheath. Increased risk in those who use a screwdriver or tools that press on the palm. Associated with rheumatoid arthritis, amyloidosis, diabetes, and carpal tunnel syndrome and in people on dialysis.
D: Physical examination.
T: Rest, analgesia, plastic splint, steroid injection, surgery to widen the tendon sheath, percutaneous trigger finger release using a needle.
Dupuytren’s Contracture
Excessive myofibroblast proliferation and altered collagen matrix composition lead to thickened and contracted palmar fascia.
C: Unknown but genetic predisposition, trauma, inflammatory response, ischaemia, environmental factors, alcohol, smoking, DM, raised lipids, occupational exposure to hand-transmitted vibration.
S: Begins with pitting and thickening of the palmar skin, formation of a nodule, a cord then develops which contracts over months to years, leads to aprogressive flexion deformity.
D: Clinical diagnosis, drinking history, LFTs, fasting blood glucose/HbA1c.
T: Significantly compromised - local hand surgery service, or to a specialist in plastic surgery or orthopaedic surgery. Injectable collagenase Clostridium histolyticum and radiotherapy.
Closed fasciotomy or fasciectomy. Finger amputation in sever cases.
De Quervain’s tenosynovitis
A painful inflammation of tendons on the side of the wrist at the base of the thumb.
C: Chronic overuse of the wrist, direct injury to your wrist or tendon. Associated with rheumatoid arthritis and pregnancy.
S: Pain and swelling near the base of the thumb, difficulty grasping or pinching, a ‘sticking’ sensation in your thumb, pain may spread into your forearm.
D: Hand examinaton. Finkelstein test - you bend your thumb across the palm of your hand and bend your fingers down over your thumb. Then you bend your wrist toward your little finger. Causes pain on the thumb side of your wrist.
T: Splint, rest, ice, physiotherapy exercises, NSAIDs, corticosteroid injections, surgery - to widen the tendon sheath.
Epicondylitis
Tennis elbow and golfer’s elbow are considered to be overload tendon injuries, which occur after minor and often unrecognised trauma to the proximal insertion of the extensor (tennis elbow) or flexor (golfer’s elbow) muscles of the forearm.
C: T (heavy lifting, heavy tools, squeezing and twisting movements or new strains like DIY, gardening, lifting a new baby, moving house, carrying luggage)
G (golf and other sports involving gripping or throwing, jobs and hobbies using repetitive elbow movements).
S: T (pain and tenderness over the lateral epicondyle of the humerus, exacerbated by active and resisted movements of the extensor muscles). G (pain and tenderness over the medial epicondyle of the humerus, aggravated by wrist flexion and pronation).
D: potentially CRP, elbow X-ray, MRI, nerve conduction study and electromyography if ulnar nerve involvement is suspected.
T: Modify activities. Local corticosteroid injection. Autologous blood products. Hyaluronan gel injection. Botulinum toxin. Physiotherapy. Glyceryl trinitrate patches. Surgery.
Thoracic back pain
Discomfort in the middle and upper part of the back.
C: Trauma, sudden injury, strain, poor posture, muscular irritation, osteoporosis, Ankylosing spondylitis, osteoarthritis, intervertebral disc prolapse, disc hernia.
S: Pain
D: Spine examination
T: Resolution without treatment
Treat underlying cause
Thoracic pain emanating from facet joint pathology may respond to imaging-guided intra-articular injection
Percutaneous thoracic intervertebral disc nucleoplasty for thoracic spine herniation.
