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Revision Qs > Musculoskeletal Medicine > Flashcards

Musculoskeletal Medicine Flashcards

1
Q

3 chronic inflammatory arthropathies?

A

Psoriatic arthritis
Rheumatoid arthritis
Ankylosing spondylitis

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2
Q

2 chronic non-inflammatory arthropathies?

A

Osteoarthritis

Scoliosis

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3
Q

What is the pathophysiology behind gout?

A

Monosodium urate crystal deposition in joints due to increasing levels in bloodstream. Deposition occurs based on temperature so more common distally

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4
Q

What are the common reasons for high circulating monosodium urate?

A

Genetic under excretion
Obesity
Metabolic syndrome - high cholesterol, high BP
Renal disease and diuretic use

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5
Q

What things can precipitate acute attacks of gout?

A 
Alcohol
Injury
Illness
Surgery
Dehydration
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6
Q

Presentation of gout?

A

Most commonly affected is 1st MTP joint or MCP joint
Red, swollen, painful, hot joints
Shiny peeling skin
Worse at night

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7
Q

Investigations for gout?

A

Blood urate levels (in clinical context)

Aspirate synovial fluid and look for MSU crystals/exclude septic arthritis

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8
Q

Management of acute gout attack?

A

NSAIDs, steroids or injections

Colchicine - not at same time as NSAIDS. Increase MSU excretion in pee

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9
Q

Long term management of gout?

A

Allopurinol (can precipitate an acute attack)

Febuxostat

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10
Q

Long term complications of gout?

A

Tophi deposition

Joint damage

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11
Q

What crystals are implicated in pseudogout?

A

Calcium pyrophosphate

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12
Q

What joints are most commonly affected by pseudogout?

A

Knees, wrists

Shoulders, ankles, elbows etc.

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13
Q

What organism is most commonly implicated in septic arthritis in older adults?

A

Staph aureus

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14
Q

What organism is most common in septic arthritis in younger, sexually active adults?

A

Neisseria gonorrhoea

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15
Q

What non-articular feature of gonococcal septic arthritis is pathognomonic?

A

Maculopapular rash over trunk

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16
Q

Most common causative organism of septic arthritis in non-immunised children?

A

Haemophilus influenzae

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17
Q

Risk factors for septic arthritis?

A

Joint replacement
Immunosuppression incl DM, HIV
Prev joint damage incl RA, gout, connective tissue disease

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18
Q

Typical presentation of septic arthritis?

A

Acute inflammatory monoarthropathy (usually)
Intense pain on any movement, redness, swelling, warmth
Systemic features incl fever, rigors
On exam may be effusion

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19
Q

Most commonly affected joints for septic arthritis?

A

Knee
Hip
Shoulder, ankle, wrists

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20
Q

Appropriate investigations for septic arthritis?

A

FBC ESR CRP
Joint XR
Blood cultures if systemically unwell
FNA of joint and culture

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21
Q

Management of septic arthritis?

A

Drain joint - if a prosthetic joint it will need replacing
Broad spectrum IV Abx -> narrow spec
Splints, physio follow up etc.

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22
Q

What is reactive arthritis?

A

An acute inflammatory oligoarthropathy as a result of an autoimmune response following infection (no HLA B27 link)

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23
Q

Common infections that can precede reactive arthritis?

A

Campylobacter, shigella, salmonella
Chlamydia, HIV
Viral infections

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24
Q

2 most common sites of infection that precede reactive arthritis? How long after initial infection may it take to precipitate?

A

Gut, sexual organs (enteric or venereal)

1-3 weeks

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25
Q

What is the triad that characterises Reiter’s syndrome?

A

Uveitis, conjunctivitis
Urethritis and circinate balanitis
Keratoderma blenorrhagica and plantar fasciitis (arthritis)

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26
Q

What joints does reactive arthritis classically affect?

A

Large joints e.g. Inflammatory back pain, asymmetric oligoarthritis

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27
Q

Onset of reactive arthritis?

A

Acuteish 1-3 weeks post infection - typically with malaise, fever, fatigue

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28
Q

Acute phase management of reactive arthritis?

A

Rest, NSAIDs, steroids, analgesia and symptomatic relief
Aspirate synovial effusions
Physiotherapy
Abx of identifiable cause may prevent long-term complications
DMARDs e.g. Sulfasalazine

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29
Q

Prognosis and complications of reactive arthritis?

A

Usually self limiting within 12 months
Can be long term or recurrent (more common if HLA B27 +ve)
CV complications e.g. Aortic regurge, pericarditis

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30
Q

What is the pathophysiology behind rheumatoid arthritis?

A

Autoimmune disorder with HLA DR4 link causing a chronic, systemic inflammatory response primarily causing a symmetrical polyarthritis
-> synovial inflammation and hyperplasia, nerve ending irritation and capsule stretching

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31
Q

Non-articular features of RA?

A

Fatigue, depression, flu-like symptoms
Rheumatoid nodules
Dermatology - pyoderma gangrenosum, erythema nodosum
Lung, kidney, heart and GI involvement

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32
Q

Triad of signs classical of RA?

A

Swelling
Morning stiffness >30 mins (often >1 hour)
Positive MCP/MTP squeeze test

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33
Q

Investigations for rheumatoid arthritis?

A

ESR, CRP
Rheumatoid factor
Anti-CCP
Joint X Rays

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34
Q

Joint deformities characteristic of RA?

A

Z thumb
Boutonierre
Swan-neck
Ulnar deviation

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35
Q

Management of RA?

A

Conservatively physio, exercise, footwear etc is important
Medically - NSAIDs, analgesia, DMARDs e.g. Azathioprine Sulfasalazine methotrexate, steroids and anti-TNFs (infliximab)
Surgical e.g. Joint replacement

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36
Q

What is Felty’s syndrome?

A

Triad of seropositive rheumatoid arthritis (usually long standing), neutropenia and splenomegaly

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37
Q

Common presentation of Felty’s syndrome?

A

Leg ulcers, recurrent or bad infection
Systemic features - malaise, fatigue, weight loss
Sjorgrens

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38
Q

In whom is Felty’s syndrome more common?

A

Severe long standing RA, lots of extra-articular disease

Positive for HLA DR4, Rheumatoid factor and anti-CCP

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39
Q

Potential complications of Felty’s syndrome?

A

Life threatening infection
Splenic rupture
Hepatic involvement
Visual complications

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40
Q

What is ankylosing spondylitis?

A

A type of spondyloarthropathy

Chronic inflammation of spine and sacro-iliac joints (axial skeleton)

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41
Q

In whom is ankylosing spondylitis most common?

A

Men, age 15-25 typically

HLA B27 positive

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42
Q

Pathophysiological features of ankylosing spondylitis?

A

Vertebral joint and ligament inflammation

Syndesmophytes laid down, bony protuberances and disc fusion

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43
Q

Presentation of ankylosing spondylitis?

A

Lower back pain with inflammatory features worsening over months
Radiation down into buttocks, thighs
Other joints and ligaments e.g. Achilles may be involved

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44
Q

Eponymous test that can be done to investigate ankylosing spondylitis by quantification of lumbar flexion?

A

Schobers test

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45
Q

Important investigations of ankylosing spondylitis?

A

XR

MRI - better shows sacroiliac inflammation

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46
Q

Management of ankylosing spondylitis?

A

Conservative - physio, exercise
Medical - NSAIDs and steroids
Immunomodulation e.g. Methotrexate, anti TNFa (etanercept)

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47
Q

Major complications of ankylosing spondylitis?

A

Osteoporosis and compression fractures

Vertebral and sacroiliac fusion

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48
Q

4 acute inflammatory arthropathies?

A

Septic arthritis
Gout
Reactive arthritis
Discitis

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49
Q

Pathophysiology behind osteoarthritis?

A

A chronic, degenerative non-inflammatory arthritis characterised by synovial inflammation and hyperplasia, cartilage erosion and a thick stretched capsule

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50
Q

Presentation of osteoarthritis?

A 
Pain, stiffness, loss of function, +/- swelling
Crepitus on movement
Effusions
Locking of joints
Worse at end of day or after use
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51
Q

Commonly affected joints in osteoarthritis?

A

Knees, hips

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52
Q

Typical patient affected by osteoarthritis?

A

Old obese woman with previous joint injury or overuse

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53
Q

2 nodes characteristic of osteoarthritis?

A 
Heberdens nodes (distal IP joints)
Bouchards nodes (proximal IP joints)
54
Q

4 characteristic features on joint XR of osteoarthritis?

A

Joint space narrowing
Osteophytes
Subchondral sclerosis
Subchondral cysts

55
Q

Common complications of osteoarthritis?

A

Dislocation

Need for replacement

56
Q

What is the pathophysiology behind osteopenia/osteoporosis?

A

Decrease in bone mass and density -> breakdown of trabecular (spongy/cancellous) bone in the middle of bones

57
Q

RFs for osteoporosis?

A

Female post menopause/oophorectomy/low oestrogen
Long term progestogen contraception e.g. Depo
Age
FH
Steroid use
Alcoholism, smoking
Malabsorbative disorders - coeliac, CF, IBD
Underweight or inactive
Rheumatic disorders
Hyperthyroidism

58
Q

Common presentations of osteoporosis?

A 
Atypical or recurrent fractures
Decreasing height (vertebral collapse)
59
Q

Postural changes associated with osteoporosis?

A 
Gibbus deformity (mega kyphosis)
'Dowager's hump'
60
Q

Appropriate investigations for osteoporosis?

A

XR any fractures and look for osteoporotic changes
DEXA scans
?biomarkers - calcium, magnesium, phosphate, PTH etc

61
Q

Medical management of osteoporosis/osteoporosis risk?

A

HRT if early menopause

Bisphosphonates - alendronic acid, risedronate

62
Q

Signs of rheumatoid arthritis on joint XR?

A

Soft tissue swelling
Narrowing of joint spaces
Subluxation of joints
Bony erosion

63
Q

What joints in the hand and wrist are typically affected by RA?

A

MCPs/PIPs, triquetrum, ulnar styled

64
Q

Which arthritis commonly affects the ulnar styloid?

A

RA

65
Q

2 key XR changes in psoriatic arthritis?

A 
Prominent erosion -> pencil in cup deformities
Bony proliferation (fuzzy edges)
66
Q

What are dactylitis, prominent erosive features and pencil in cup deformities associated with?

A

Psoriatic arthritis

67
Q

Types of fractures more common in kids?

A

Buckle/torus

Greenstick

68
Q

Mnemonic for remembering the carpal bones?

A

Some Lads Try Positions That They Can’t Handle

69
Q

Carpal bones in order from lateral to medial, proximal row then distal?

A 
Scaphoid
Lunate
Triquetrum 
Pisiform
Trapezium
Trapezoid
Capitate
Hamitate
70
Q

What is the bone shaft otherwise known as?

A

Diaphysis

71
Q

What is the most common distal radial fracture? Describe it

A

Colles fracture - caused by FOOSH with wrist dorsiflexed, leading to distal radial fracture with dorsal angulation and impaction of distal fragment

72
Q

What else should be considered in an old man presenting with a Colles fracture following a fall?

A

Osteoporosis - hip fracture?

73
Q

What fracture of the radius is often sustained by a FOOSH with the wrist in a natural position to break the fall?

A

Colles

74
Q

What is a Barton fracture of the radius?

A

A distal radial fracture that extends to the articulate surface of the radius

75
Q

2 extra-articular fractures of the radius?

A

Colles

Smiths

76
Q

2 fracture-dislocations of the radius/ulna?

A

Galeazzi

Monteggia

77
Q

What is Smiths fracture?

A

A backwards Colles - fall on a flexed wrist or trauma to back of wrist resulting in distal radial fracture with anterior/volar displacement of distal segment

78
Q

What is a Chauffeur/Hutchinson fracture?

A

An intra articular fracture of the distal radius which involves the radial styloid process

79
Q

What 2 types of fracture may be caused by direct trauma to the back of the wrist?

A

Smiths

Chauffeur/Hutchinson

80
Q

What is a Galeazzi fracture-dislocation?

A

Distal radial fracture with dislocation of distal radio-ulnar joint (intact ulna)

81
Q

What is a Monteggia fracture-dislocation?

A

Ulnar shaft fracture with dislocation of the radial head at the elbow

82
Q

What classification system is used for ankle fractures? Which is the worst type?

A

Weber classification - C being the worst

83
Q

What typifies a type C weber fibular fracture?

A

Fracture above the ankle joint
Unstable
Often with medial malleolar damage and avulsion

84
Q

Describe the major arterial supply to the femoral head?

A

Retrograde blood supply - mostly from medial (and lateral) femoral circumflex arteries which form an anastomotic ring around femoral neck and ascend via ascending and transverse branches
Also superior and inferior gluteal, artery of lig of head and retinacular arteries

85
Q

What type of hip fracture is most implicated with AVN of the femoral head? Why?

A

Intracapsular because the retrograde blood supply ascends under the joint capsule and is sheared in an intracapsular fracture

86
Q

What is the major blood vessel responsible for blood supply to the femoral head and therefore implicated in AVN if restricted?

A

Medial circumflex femoral

87
Q

What are the 3 types of intracapsular NOF fracture?

A

Subcapital
Transcervical
Basicervical

88
Q

Criteria involved in describing intracapsular NOF fractures?

A

Garden criteria

89
Q

What is the classical position of the leg in someone with an intracapsular #NOF?

A

Externally rotated because of increased traction on greater trochanter

90
Q

2 types of extracapsular #NOF?

A

Intertrochanteric

Subtrochanteric

91
Q

How might external rotation of the femur due to hip fracture manifest on XR?

A

Increasingly visible lesser trochanter

92
Q

What bones form shentons line?

A

Inferior border of superior pubic ramus and medial edge of femoral head and neck

93
Q

What things can be done to assess osteoporosis?

A

Frax score

DEXA scan of BMD

94
Q

What is a fragility fracture?

A

One sustained from a fall at standing height or lower

95
Q

What surgery definitely needs to be done for a displaced intracapsular NOF?

A

Hemiarthroplasty or THR for younger, fitter placements

96
Q

Options for management of undisplaced intracapsular NOF?

A

Hemiarthroplasty/THR

Internal sliding screw fixation

97
Q

Management of extracapsular NOF?

A

Internal sliding screw fixation or hemiarthroplasty

98
Q

What is the key indication for arthroplasty?

A

Pain

99
Q

5 extra things done in pGALS but not in GALS?

A 
3 fingers in mouth (spine)
Arms in air
Look up at ceiling
Prayer and reverse prayer signs
Walk on tippy toes and heels
100
Q

Most common cause of an acute limp in kids who are just starting to walk? (Age 1-3)

A

Transient synovitis/irritable hip

101
Q

What is irritable hip otherwise known as?

A

Transient synovitis

102
Q

What is transient synovitis otherwise known as?

A

Irritable hip

103
Q

Causes of an acute limp at any childhood age?

A

Septic arthritis/osteomyelitis
Trauma
NAI
Malignancy

104
Q

What is the long term implication of childhood osteomyelitis?

A

May destroy physis/epiphysis and so limit growth

105
Q

What is the reason MRI is often used in MSK?

A

Best modality for differentiating bone from soft tissue injury e.g. And best for stuff like osteomyelitis

106
Q

What signs are visible on radiography for osteomyelitis?

A

Subperiosteal pus/abscess, causing periosteal elevation

107
Q

Presentation of irritable hip/transient synovitis?

A

2-12 year olds, acute non-weight bearing limp following or alongside viral infection
Doesn’t appear unwell, fever mild or absent
Pain on movement only (particularly internal rotation)

108
Q

What are bloods finding like in transient synovitis?

A

Normal or slightly high CRP

Wbc fine

109
Q

Most common cause of acute hip pain in children?

A

Transient synovitis

110
Q

What investigation is best for transient synovitis? What does it show?

A

USS - shows effusion of affected hip

111
Q

What cause of acute limp often follows or coincides with a viral infection?

A

Transient synovitis

112
Q

What is the pathophysiology behind perthes disease?

A

Avascular necrosis of capital femoral epiphysis

113
Q

Any long term complications of transient synovitis?

A

May precede perthes disease

114
Q

What disease may precede perthes disease?

A

Transient synovitis

115
Q

Who does perthes disease affect?

A

Young pre-pubescent boys

116
Q

What sidedness is perthes disease?

A

Most often unilateral

117
Q

Investigation for perthes disease?

A

XR including frog leg view

118
Q

What is a slipped capital femoral epiphysis?

A

Postero-inferior displacement of capital femoral epiphysis which can potentially cause AVN

119
Q

In whom does slipped capital femoral epiphysis occur?

A

Typically older adolescent boys, age 10-15 often of higher BMI

120
Q

What is the most common arthritis overall in kids?

A

Reactive arthritis

121
Q

Commonest chronic inflammatory joint disease in kids?

A

JIA

122
Q

What is JIA?

A

Persistent joint swelling, pain for at least 6 weeks in absence of any other cause in kids

123
Q

Most common reasons for hip replacement failure?

A 
Osteolysis and aseptic loosening (late)
Instability/deep infection (early)
Component failure
Wear/erosion through acetabulum
Periprosthetic fractures
124
Q

Four types of knee replacement?

A

Total
Unicompartmental (partial)
Patellofemoral (kneecap)
Complex/revision

125
Q

Requirements for uni compartments knee replacement?

A

Damage affecting only one compartment (often medial)

Needs strong healthy ligaments etc.

126
Q

In whom are PMR and GCA most common?

A

Older women - over 50 but more commonly 70/80

127
Q

Sx of PMR?

A

EMS >30mins of hips, shoulders
Constitutional - fever, malaise, depression, night sweats
Muscles are tender but passive movement fine
Mildly raised ESR

128
Q

PMR exam findings?

A

Tenderness of axial muscles but fine on passive movement

129
Q

Sx of GCA?

A

New onset temporal/occipital headache with visible temp arteries, non-pulsatile and tender to touch e.g. Combing, scalp touch
Jaw/TMJ irritation and claudication on eating
Ameurosis fugax
PMR and constitutional Sx

130
Q

Ix GCA?

A

Give steroids anyway if suspected to preserve vision
Send of ESR
Temp artery biopsy is gold standard - narrowed lumen, thickened Tunica intima

Revision Qs (28 decks)

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