Musculoskeletal conditions Flashcards
What is Ankylosing Spondylitis?
Chronic, seronegative, inflammatory arthropathy.
Patients present with severe pain and spinal stiffness. It primarily involves the axial skeleton. Involves the whole spine but mostly the sacro-illiac joint.
What is the cause of ankylosing spondylitis?
97% heterability
HLA-B27
Infective triggers and antigen-cross reactivity with self-peptides hypothesised
Mainly affects spine and sacroiliac joint
What is the pathophysiology of ankylosing spondylitis?
Inflammation at start of entheses
Persistent inflammation leads to reactive new bone formation
Changes begin in lumbar vertebrae and progress superiorly
Syndesmophytes (vertial ossifications bridging margins between adjacent vertebrae)
Fusion of syndesmophytes and facet joints
Calcificaiton of anterior and lateral spinal ligaments
What are Risk factors for Ankylosing spondylitis?
HLA-B27
Endoplasmic reticulum aminopeptide 1 and IL-23 receptor genes
Family history
Klebsiella Pneumoniae
What are the symptoms of Ankylosing spondylitis?
Inflammatory back pain Iritis/Uveitis Lower back and sacroiliac pain Pain pattern (worse in morning, better with activity, worse when resting) Progressive loss of spinal movement Assymetrical peripheral arthritis Pleuritic chest pain Head pain Non-specific symptoms Blindness due to acute iritis in 1/3
What are the signs of Ankylosing spondylitis?
Reduced range of spinal movement
Reduced lateral spine flexion
Schober’s test (fingers move on patient’s back)
Tenderness over sacroiliac joints
Later: Thoracic kyphosis, spinal fusion
What are signs of extra articular disease for Ankylosing spondylitis?
Anterior uveitis Apical lung fibrosis Achilles tendinitis Amyloidosis Aortic regurgitation
What investigations are done for Ankylosing spondylitis?
FBC (anaemia of chronic disease) Rheumatoid factor (Negative) ESR (High) CRP (High) HLA B27 (Positive but not diagnostic)
Radiograph (MRI best)
What is seen on imaging of ankylosing spondylitis?
Anteroposterior and lateral radiographs:
- Vertical syndesmophytes
- Bony proliferation due to enthesitis between ligaments and vertebrae
Anteroposterior radiographs of sacroiliac joints:
- show symmetrical blurring of joint margins
Later stages: Erosions, sclerosis, sacroiliac joint fusion
Lung function test: Assessmechanical ventilatory impairment due to kyphosis
What is carpal tunnel syndrome?
Symptoms arising from copression of the median nerve in the carpal tunnel
What causes carpal tunnel syndrome?
Idiopathic but if secondary than multifactiorial
What are the secondary causes?
MEDIAN TRAPS M - Myxoedema E - Enforced flexion D - Diabetic Neuropathy I - Idiopathic A - Acromegaly N - Neoplasms T - Tumours (benign) R - Rheumatoid arthritis A - Amyloidosis P - Pregnancy S - Sarcoidosis
What are the Risk Factors for Carpal tunnel syndrome?
30+ High BMI Female Fractures wrist/carpal bones Square wrist Rheumatoid arthritis Diabetes Dialysis Pregnancy Congenital carpal tunnel stenosis Occupation involving exposure to repetitive bending Mobility aids Smoking ciggarettes White Thyroid disorders HRT Physical inactivity
What are the symptoms of carpal tunnel syndrome?
Paraesthesia in hands/fingers
Weakness
Clumsiness
What are the signs of Carpal tunnel syndrome?
Sensory impairment in median nerve distribution
Weakness and wasting of thenar eminance
Tinel’s sign (tapping carpal tunnel causes tingling in nerve distribution)
Phalen’s test (flexion for 1 min causes tingling)
Signs of underlying (acromegaly, hypothyroidism)
What investigations are done for Carpal tunnel syndrome?
Clinical diagnosis
- EMG (Slowing of conduciton)
- US/MRI of wrist (Rarely done)
What is Gout?
A disorder of uric acid metabolism causing recurrent bouts of acute arthritis caused by deposition of monosodium urate crystals in joints, soft tissues and kidneys
What is the cause of gout?
Main metabolic disturbance is hyperuricaemia
Monosodium urate crystals deposit in joints leading to inflammation an dpain
May be caused by:
Increased urate intake or production
- Increased dietary intake of purines - shellfish
- Increased nucleic acid turonover
- Increased synthesis of urate (e.g. Lesch-Nylan syndrome)
Decreased renal function
- Idiopathic
- Dehydration
- Drugs (e.g ciclosporin)
- Renal dysfunction
What are the risk factors for Gout?
Older age Male sex Menopausal status Consumption of meat, seafood and alcohol Use of diuretics Use of ciclosporin or tacrolimus Use of pyrazinamide Use of aspirin Genetic susceptibility Renal insufficiency DM Hyperlipidaemia
What are the signs and symptoms of gout?
Sudden excruciating monoarticular pain
Peak at 24 hrs
Resolve over 7-10 days
Sometimes present with cellulitis, polyarticular or periarticular movement
Intercritical gout: asymptomatic period between attacks
Chronic trophaceous gout: Repeated acute attack - persistent low grade fever, polyarticular pain with painful trophi (urate deposits), urate urolithiasis
What are the investigations for gout?
Synovial fluid aspirate
- Monosodium urate crystals seen (Needle-shaped, NEGATIVE birefringence)
- Microscopy and culture to exclude septic arthritis
FBC - Leucocytosis
U&Es
Raised Urate
Raised ESR
AXR/KUB film - uric acid renal stones may be seen
What is Pseudogout?
Arthritis associated with deposition of calcium pyrophosphate dihydrate (CPPD).
Also causes acute monoarthropathy typically in larger joints in elderly patients
Also known as acute CPP crystal arthritis
What is the cause of Pseudogout?
Spontaneous and self-limiting but provoked illness, surgery or trauma
CPPD crystal formation initiated in cartilage located near the surface of chondrocytes
Linked with excessive calcium pyrophosphate, leading to formation of CPPD crystals
Shedding of crystals in joint cavity cause arthritic pain
What are the risk factors for Pseudogoutt?
Advanced age Injury Hyperparathyroidism Haemochromatosis Family history of CPPD Hypomagnesia Hypophosphatasia Gout Other metabolic conditions
What are the symptoms of pseudogout?
Acute arthritis (Painful, swollen joint) Chronic arthropathy (Pain, stiffness, functional impairment) Uncommon presentations: Tendonitis, tendosynovitis, bursitis
What are the signs of Pseudogout?
Acute arthritis (Red, hot, tender, restricted range of movement, fever) Chronic arthropathy
What are the investigations of Pseudogout?
Bloods (High WCC, High ESR, blood culture)
Joint aspiration of synovial fluid (Rhomboid, brick-shaped crystals, Positive birefringence, culture of gram-staining to exclude septic arthritis)
Plain radiograph of the joint (Chondrocalcinosis - CPPD deposition, signs of osteoarthritis)
What is Fibromyalgia?
Chronic pain disorder with unknown cause, part of a diffuse group of overlapping syndromes with chronic fatigue syndrome
Tenderness of at least 11/18 designated tender point sites
What is the cause of fibromyalgia?
Unknown cause
Thought to be something to do with altered pain perception
What are the Risk Factors for Fibromyalgia?
Family history Rheumatological conditions Age 20-60 Female sex Presence of associated conditions
What are the signs and symptoms of fibromyalgia?
Pain at multiple sites Fatigue Sleep disturbance Morning stiffness Feeling of swollen joints Problems with cognition Headaches Light headedness Anxiety Depression
What investigations are done for Fibromyalgia?
Widespread pain involving both sides of body above and below waist for at least 3 months
Presence of 11 tender points of the 18
Exclude RA, vasculitis or something else
What is Giant cell arteritis?
Granulomatous vasculitis of large and medium-sized external carotid artery and is the most common form of systemic vasculitis in adults
What is the cause of Giant cell arteritis?
Genetic and environmental factors are throught to contribute
HLA-DRB 104 and HLA-DRB101
Mycoplasma pneumonia, parvovirus B-19, parainfluenza virus, chlamydia pneumoniae and varicella zoster virus
What are the Risk factors for GCA?
Age > 50 years Female Smoking (6-fold increase in women - not seen in men) Atherosclerosis Environmental factors European background
What are the symptoms for GCA?
Temporal headache Myalgia Malaise/fever Scalp tenderness Transient visual disturbances Unexplained facial pain Jaw claudication Anorexia Weight loss Depression May have AAA or dissection
What are the signs of GCA?
Palpation of temporal artery often abnormal
Fundoscopic evidence of ischaemia
Temporal artery may be prominent, beaded, tender or pulseless
Bruits heard in carotid, axillary or brachial arteries
Fever
Muscles and joints may be tender
What is the diagnostic criteria for GCA?
>/= age of 50 New headache / new localised pain in head Temporal artery abnormality ESR >/= 50 Abnormal artery biopsy
What are the investigations for GCA?
Temporal artery biopsy (abnormal) ESR (>/=50) CRP (Sometimes raised) FBC (anaemia and thrombocytosis) LFTs (ALP elevated) Colour duplex ultrasonography
How do you manage GCA?
Anyone with suspected GCA should promptly start high-dose steroids
Steroids
Low-dose aspirin
Glucocorticoid therapy:
What is steroid management for GCA?
High dose corticosteroids immediately (40mg), if claudication symptoms - 50mg.
If they have visual symptoms, admit with IV methylprednisolone
What is the low-dose aspirin management for GCA?
Aspirin 75mg daily, unless contraindicated
Start gastroprotection with a PPI with high-dose steroids and aspirin
Reduces rate of visual loss and strokes in those with GCA
What is the gluccocorticoid therapy for GCA?
Leads to significant toxicity in >80% of patients.
Need osteoporosis prophylaxis for those on long-term treatment
What are the complications for GCA?
Loss of vision, permanent visual loss, partial or total, occurs in up to 20% and often first manifestation of the disease
Aneurysms, dissections and stenotic lesions of aorta and its major branches
CNS
Steroid-related complications are common
What are idiopathic inflammatory myopathies?
Insidious onset of progressive symmetrical proximal muscle weakness and AI mediated striated muscle inflammation (Myositis) associated with myalgia +/- arthralgia
What causes idiopathic inflammatory myopathies?
AI basis, viral infection implicated in its pathogenesis
Dermatomyositis features myositis plus skin changes
What are the symptoms of polymyositis?
Inflammatory myopathy with onset over weeks or months Steady progression of symptoms Diffuse weakness in proximal muscles Distal muscles are spread Pharyngeal weakness > Dysphagia Dysphonia Respiratory weakness NO rash
What are the symptoms of dermatomyositis?
Inflammatory myopathy with onset over weeks or months
RASH
Systemic upset with fever, arthralgia, malaise and weight loss
Possible cardiac disease
GI ulcers and infections
Interstitial lung disease (30-50%)
Children have more non-muscular features (e.g. GI ulcers and ifnections)
What are the signs for polymyositis?
Fever Muscle weakness Not painful in most Proximal myopathy Extraocular muscles and distal muscles are spread Weak forced flexion of the neck Muscular atrophy Muscles may be tender on palpation
What are the signs of Dermatomyositis?
RASH characteristics
- Macular rash: Shawl sign
- Lilac-purple heliotrope rash on eyelids often with oedema
- Nailfold erythema
- Gottron’s papules (Roughened red papules over knuckles, elbows and knees)
Rash may affect knees, shoulders, back and upper arms
Rash may be exacerbated by snlight
Proximal myoptahy
Muscle pain and tenderness in early disease
Fever
What are the investigations for Polymyositis?
Creatinine Kinase (50x higher than norm)
EMG
Muscle biopsy (definitive)
Autoantibodies e.g. myositis specific antibodies, anti-Jo-1 antibodies
Enzymes e.g. SGOT, SGPT and LDH, ALT, AST, adlolase
What are the investigations for dermatomyositis?
Creatinine Kinase
Enzymes (SGOT, SGPT, LDH, ALT, AST, aldolase)
Autoantibodies (ANA, Anti-Mi-2, Anti-Jo-1)
EMG may be helpful but can be normal too
Muscle biopsy
What is Osteoarthritis?
Age-related irreversible loss of articular cartilage, causing pain and disability.
Commonest joints affected: Knees, Hips, small joint of the hand
Localised loss of cartilage, remodelling of adjacent bone and associated inflammation
