Musculoskeletal + Rheumatology Flashcards
1
Q
List the risk factors for gout
A
- Age
- Male
- Alcohol
- Obesity
- Diet (purines - sardines, red meat)
- Hypertension
- Hyperparathyroidism
- CKD
- Psoriasis
- Chemotherapy
- CHD
- Heart failure
- Metabolic syndrome
- Medications (eg. diuretics)
- Recent infection, recent surgery, polycythaemia, trauma
2
Q
List risk factors for pseudogout
A
- Haemochromatosis
- Hyperparathyroidism
- Acromegaly
- Low magnesium
- Low phosphate
- Wilsons
- Hypothyroidism
- Elderly women
- Trauma, illness
3
Q
List the 4 radiographic features of osteoarthritis
A
- Loss of joint space
- Sclerosis
- Cyst formation
- Chondrocalcinosis
4
Q
What is first line treatment in osteoarthritis?
A
- Weight loss
- Social support
- Education
- Refer to physio
- Refer to occupation therapist
5
Q
How is polymyalgia rheumatica diagnosed?
A
ESR over 40mm/hr
6
Q
How is polymyalgia rheumatica treated initially?
A
Oral prednisolone for 1-2 years
7
Q
Define gout
A
- Disorder of purine metabolism characterised by hyperuricaemia
- Depositition of urate crystals in joints and other tissues
8
Q
List symptoms and signs of gout
A
- Pain associated with swelling, redness, warmth and tenderness (max intensity within 24 hours)
- Most commonly in first MTPJ of the big toe, midfoot, ankle, knee, fingers, wrist and elbow
- Usually monoarticular
- Tophi (nodular masses which are urate crystal deposition)
9
Q
Describe investigations of gout
A
- Usually not needed, diagnosed clinically
- Exclude differentials (septic, pseudogout, RA, OA)
- Blood tests (FBC, U andE, LFT, HbA1c, lipids)
- Serum urate (may be useful, can be normal, measured 4-6 weeks after acute attack)
- Joint aspiration finds negative birefringent crystals, needle like crystals
- X ray (swelling, subcortical cysts, punched out erosions)
- Cardiovascular and renal risk factors
10
Q
Describe management of gout
A
- RICE (rest, ice, compression, elevation)
- Lifestyle advice (diet, alcohol, alcohol, exercise, weight reduction, fluid intake)
- In acute attack NSAIDs (naproxen), colchicine, steroids, PPI (to protect stomach episode)
- Prevented with allopurinol (don’t start during the acute episode, start alongside something in case of acute flair)
11
Q
Define pseudogout
A
A form of microcrystal synovitis caused by deposition of calcium pyrophosphate dihydrate crystals in the synovium
12
Q
List signs and symptoms of pseudogout
A
- Asymptomatic
- Acute synovitis affecting the knee wrist and/or shoulder
13
Q
List investigations in pseudogout
A
- X ray showing chondrocalcinosis
- Joint aspiration showing positive birefringent crystals on microscopy, rhomboid crystals
14
Q
Describe management of pseudogout
A
- Exclude differential (eg. septic arthritis)
- Rest, ice, compression, elevation
- NSAIDs
15
Q
Define rheumatoid arthritis
A
A chronic systemic inflammatory disease (>6 weeks)
16
Q
List symptoms and signs of RA
A
- Affects hands and feet (PIPJ, MCPJ, MTPJ)
- Large joints rarely affected
- Morning stiffness over 30 mins, improving with use
- Symmetrical polyarthritis
- Systemic symptoms
- Extra-articular features (eyes, heart, lung, vasculitis, neuropathies)
- Rheumatoid nodules
- Joint deformity (swan necking, hyperextension, ulnar deviation, Z thumb, boutonniered deformity)
- DIP sparing
17
Q
List risk factors for RA
A
- More common in females
- Age 30-50
- Family history
- HLA-DR4, HLA DR1 occassionally
- Smoking
18
Q
Describe investigations in RA
A
- Blood test for rheumatoid factor (can be seronegative, can be false positive, 70% pts, IgM targets Fc of IgG), anti- CCP (more sensitivt, specific), CRP, ESR, anaemia, low albumin
- X-ray hands and feet (joint space narrowing, bony erosions, juxta/periarticular osteopenia, soft tissue swelling)
- Specialist referral
19
Q
Define polymyalgia rheumatica
A
Chronic, systemic rheumatic inflammatory disease
20
Q
Describe risk factors for polymyalgia rheumatica
A
- Highest incidence over 65, more common in females
21
Q
List symptoms and tenderness of polymyalgia rheumatica
A
- Rapid onset less than 1 month
- Muscle stiffness and tenderness of proximal limbs (shoulder or pelvic girdle)
- Worse with movement
- Bilateral
- Sleep interference
- Stiffness for at least 45 mins in the morning
- Low grade fever, fatigue, anorexia, weight loss and depression may also be symptoms
- Check for temporal arteritis
22
Q
Describe diagnosis of polymyalgia rheumatica
A
- Typical symptoms
- Blood tests ESR and CRP
- Exclude other causes
- Subchondral and trochanteric bursitis, synovitis in the shoulder and hips
- Look for response to treatment (responds to steroids within 1-2 days)
23
Q
Describe treatment of polymyalgia rheumatica
A
- 15mg oral prednisolone
- Assess response in 1 week
- Weaned off steroids over time
- Safety-net
24
Q
Define giant cell arteritis
A
Chronic vasculitis characterised by granulomatous inflammation in the walls of medium and large arteries, commonly affecting the external carotid artery
25
Q
List symptoms of giant cell arteritis
A
- New onset, localised headache, usually in temporal area with tenderness, thickening or nodularity
- Systemic features (fever, fatigue, anorexia, weight loss and depression)
- Features of PMR
- Jaw claudication, visual disturbances
- Limb claudication
26
Q
Describe management of giant cell arteritis
A
- Same day referral to opthalmologist if eye involvement
- High dose steroids (prednisolone) before confirmation of biopsy. Assess initial response within 48 hours. Reduce dose slowly over many months.
- Osteoporosis prophylaxis
- Treatment is often required for 1-2 years
- Frequent follow ups for relapses and steroid side effects
27
Q
List risk factors for giant cell arteritis
A
- Unknown cause
- Age. Giant cell arteritis affects adults only, and rarely those under 50. Most people with this condition develop signs and symptoms between the ages of 70 and 80.
- Women are about two times more likely to develop the condition than men are.
- Giant cell arteritis is most common among white people in Northern European populations or of Scandinavian descent.
- Polymyalgia rheumatica.
- Family history.
28
Q
Describe epidemiology of giant cell arteritis
A
- The annual incidence of giant cell arteritis in the UK population is approximately 20 per 100,000 people
- A full-time GP is likely to see a new case every 1–2 years
- It is rare before 50 years of age and the highest incidence is in people aged 70–79 years
- It is seven times more common in white people than in black people and is particularly common in Scandinavian people, with an annual incidence of approximately 30 per 100,000 people in Norway
- It is 2–3 times more common in women than in men
29
Q
List investigations of giant cell arteritis
A
- Blood tests: full blood count, urea and electrolytes, liver function tests, C-reactive Protein (CRP) and erythrocyte sedimentation rate (ESR). There is often evidence of an acute-phase response on blood tests, ie raised ESR, CRP, platelets, abnormal liver chemistry (particularly alkaline phosphatase)
- ESR first line investigation (over 50mm/hr)
- Chest X-ray
- Urinalysis.
- Temporal artery biopsy (multinuclear giant cells)
- Ultrasound of temporal artery (halo sign)
30
Q
List signs of GCA
A
- Temporal artery may be tender, thickened, beaded. It may be difficult to feel the pulse
- They may complain of scalp tenderness brushing the hair, touching the forehead
- Jaw claudication leading to pain eating food
- Evidence of large vessel vasculitis should be sought – delayed or absent pulses in upper limbs, subclavian or carotid bruits, blood pressure asymmetry
- An ophthalmological exam should be carried out – look for transient or permanent visual loss, visual field defect, relative afferent papillary defect, anterior ischaemic optic neuritis, central retinal artery occlusion
- Look for evidence of upper cranial nerve palsies.
31
Q
Describe complications of giant cell arteritis
A
- Total or partial loss of vision may occur in up to 20% of people with giant cell arteritis
- The risk of vision loss was greater in older people.
- Large artery complications include aortic aneurysm, aortic dissection, large artery stenosis, and aortic regurgitation.
- Cardiovascular disease (such as myocardial infarction, heart failure, stroke, and peripheral arterial disease) is more common in people with giant cell arteritis.
- Peripheral neuropathy.
- Depression.
- Confusion and encephalopathy (in about 30% of people).
- Deafness.
- Complications of long-term corticosteroid treatment (for example weight gain, bruising, osteoporosis and fractures, and diabetes).
32
Q
Describe prognosis of giant cell artertis
A
- Relapses are common and can occur if corticosteroid treatment is reduced or withdrawn too quickly
- About 30–50% of people have spontaneous exacerbations of disease, especially during the first 2 years, that are independent of the corticosteroid regimen
33
Q
Define ankylosing spondylitis
A
- Axial spondyloarthritis characterized by sacroiliitis on x-ray. Axial spondyloarthritis can also occur in the absence of x-ray changes and this is classified as non-radiographic axial spondyloarthritis (although changes may be visible on magnetic resonance imaging).
- Spondyloarthritis is a term describing a group of clinically heterogeneous inflammatory rheumatologic conditions. It may be axial, affecting the sacroiliac joints and the spine, or peripheral (psoriatic arthritis, reactive arthritis, or enteropathic spondyloarthritis)
34
Q
Describe epidemiology of ankylosing spondylitis
A
- Prevalence of ankylosing spondylitis is believed to range from 0.05% to 0.23%
- Estimates of the prevalence of ankylosing spondylitis vary between countries with mean prevalence per 10,000 of 31.9 in North America, 23.8 in Europe, 16.7 in Asia, 10.2 in Latin America, and 7.4 in Africa
- Uveitis of 25.8% (95% CI 24.1 to 27.6).
- Psoriasis of 9.3% (95% CI 8.1 to 10.6).
- Inflammatory bowel disease of 6.8% (95% CI 6.1 to 7.7).
35
Q
List risk factors for ankylosing spondylitis
A
- Around twice as many men have ankylosing spondylitis compared with women, although this varies depending on
- It most commonly begins between 20 and 30 years of age, with 90–95% of people aged less than 45 years at disease onset
- Spondyloarthritis (particularly axial disease) is associated with the HLA-B27 antigen, although axial spondyloarthritis can occur in people without HLA-B27
36
Q
List symptoms of ankylosing spondylitis
A
- Episodic Pain – usually in the buttocks and/or lower back. The pain is:
- Worse in the morning
- Relieved by exercise
- May wake the patient during the night – particularly in the second half of the night – after about 2am.
- May be felt in the buttocks – especially if the sacroiliac joints are affected
- Stiffness is typically worse in the mornings
- Fever and weight loss may occur during episodes of pain
- Anterior chest pain
- 1/3 patients get anterior uveitis
- Enesthitis
37
Q
List signs of ankylosing spondyitis
A
- Spinal stiffness – can be measured with Schoeber’s test where you measure 10cm above the dimples of Venus with the patient standing upright.
- Place a dot here. As the patient to flex forward (touch their toes). Then re-measure the gap with the patient in this position. Normally, the gap should increase to >15cm. In AS, the gap increases less than this
- Wall to tragus distance increased
- Increased thoracic kyphosis – “question mark posture”
- Retention of lumbar lordosis in flexion
- Paraspinal muscle wasting
- Uveitis
- Pain when pressing on lower sacrum
38
Q
Describe investigations of ankylosing spondylitis
A
Diagnosis requires any of:
- 1 clinical criteria + radiological criteria met
- 3 clinical criteria present
- Radiological criteria present
- Diagnosis does not require radiological evidence
Clinical criteria
- Low back pain >3 months, improves with exercise, not relieved by rest
- Limited chest expansion relative to normal values for age and sex
- Limited lumbar spine motion in both the fontal and sagittal planes
- Radiological criteria – sacroiliitis on x-ray, bamboo spine (ossification of ligaments)
Can also measure HLA B27, raised CRP and ESR, seronegative
39
Q
Define osteoporosis
A
A disease characterized by low bone mass and structural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.
40
Q
List risks for osteoporosis
A
- Age (bone breakdown by osteoclasts increases, and is not balanced by new bone formation)
- Endocrine diseases
- GI conditions causing malabsorption
- CKD
- chronic liver disease
- COPD
- Menopause
- Immobility
- Low BMI
- Oral corticosteroids
- Smoking
- Alcohol
- Fragility fracture
- Rheumatological conditions
- SSRI, PPI, Anticonvulsant drugs
41
Q
Describe the epidemiology of osteoporosis
A
- Women at increased risk at menopause
- 2% at age 50 to 50% at age 80
- 2 million women have osteoporosis
- 1 in 3 women and 1 in 5 men will sustain an osteoporotic fracture in their lifetime
- White men and women at increased risk
42
Q
List signs and symptoms of osteoporosis, and common fracture sights
A
- Stooped posture
- Often fragility fracture is the first sign
Common fractures:
- Neck of femur
- Wrist (colles)
- Lumbar spine (vertebral wedge fractures)
- Shoulder (neck of humerus)
43
Q
List investigations of osteoporosis
A
- DEXA scan in at risk patients
- T-score -2.5 or less is indicative of osteoporosis
- T score is healthy young patient, Z score is age matched
44
Q
Define osteoarthritis
A
Osteoarthritis is defined as a disorder of synovial joints which occurs when damage triggers repair processes leading to structural changes within a joint.
- Localised loss of cartilage
- Remodeling and formation of osteophytes
- Mild synovitis
45
Q
Describe prevalence of osteoarthritis
A
- 8.5 million people age over 45in the UK
- 18% of over 45s have sought treatment for osteoarthritis of the knee
- 8% of the UK population age over 45 have sought treatment for osteoarthritis of the hip
- 6% of over 45 have sought treatment for the hand and hip
- 1/3 women and 1/4 men between 45-64
- Half of people age over 75
46
Q
List risk factors for osteoarthritis
A
- Genes
- Increasing age
- Female sex
- Obesity
- High bone density
- Low bone density
- Joint injury and damage
- Joint laxity and reduced muscle strength
- Joint malalignment
- Exercise stresses
- Occupational stresses
