Rheumatology Flashcards
1
Q
Give 3 causes of inflammatory joint pain.
A
- Autoimmune disease e.g. RA, spondyloarthropathy, connective tissue disease, vasculitis.
- Crystal arthritis.
- Infection.
2
Q
Give 2 causes of non-inflammatory joint pain.
A
- Degenerative e.g. osteoarthritis.
2. Non-degenerative e.g. fibromyalgia.
3
Q
What are the 5 cardinal signs of inflammation?
A
- Rubor (redness).
- Calor (heat).
- Dolor (pain).
- Tumor (swelling).
- Loss of function.
4
Q
How does inflammatory pain differ from degenerative non-inflammatory pain?
A
Inflammatory pain tends to ease with use whereas degenerative pain increased with use.
5
Q
Are you more likely to see swelling in inflammatory or degenerative pain?
A
In inflammatory pain you are likely to see synovial swelling. There is often no swelling in degenerative pain.
6
Q
Name 2 inflammatory markers that can be detected in blood tests.
A
- ESR (erythrocyte sedimentation rate).
2. CRP (C reactive protein)
7
Q
Explain why ESR levels are raised in someone with inflammatory joint pain.
A
Inflammation leads to increased fibrinogen which means the RBC’s clump together. The RBC’s therefore fall faster and so you have an increased ESR.
8
Q
Explain why CRP levels are raised in someone with inflammatory joint pain.
A
Inflammation leads to increased levels of IL-6. CRP is produced by the liver in response to IL-6 and therefore is raised.
9
Q
Describe the ESR and CRP levels in someone with lupus.
A
both elevated
10
Q
With what tissue type are all spondyloarthritis conditions associated?
A
They are all associated with tissue type HLAB27.
11
Q
Give 5 conditions that fall under the umbrella term spondyloarthritis.
A
- Ankylosing spondylitis.
- Reactive arthritis.
- Psoriatic arthritis.
- Enteropathic arthritis.
- Juvenile idiopathic arthritis.
12
Q
What is the function of HLAB27?
A
It is an antigen presenting cell (WBC)
13
Q
Describe the ‘molecular mimicry’ theory for explaining why HLAB27 is associated with spondyloarthritis.
A
Infectious agents have peptides very similar to HLAB27. An auto-immune response is triggered against HLAB27.
14
Q
Name a theory that can explain why HLAB27 is associated with spondyloarthritis.
A
Molecular mimicry.
15
Q
Give 6 signs of spondyloarthritis.
A
- Arthritis (asymmetrical)
- Inflammatory spine and buttock pain.
- Good response to NSAIDS.
- Enthesitis.
- Psoriasis.
- Crohn’s/colitis associated.
- Uveitis.
16
Q
What is the general treatment for all spondyloarthritis?
A
1) Analgesia: NSAIDs (Ibuprofen) -> steroids (Prednisolone) during flare ups
2) DMARDs (Methotrexate)
3) Anti-TNF (Etanercept)
4) physiotherapy
17
Q
Describe the pathophysiology of ankylosing spondylitis.
A
Inflammation of spine -> erosive damage -> repair/new bone formation -> irreversible fusion of spine.
18
Q
Give 5 symptoms of ankylosing spondylitis.
A
- BACK PAIN! (+ sacroiliac pain)
- Morning stiffness, improves with movement.
- Waking in the second half of the night.
- Can affect other systems: chest pain, Dactylitis, IBD
young adult male in late teens/early 20s
19
Q
What investigations might you do in someone who you suspect to have ankylosing spondylitis?
A
- X-ray of spine and sacroiliac joint (bamboo spine)
- MRI (bone marrow oedema)
- HLAB27 test (present in 90%)
- ESR + CRP (might be raised)
20
Q
What is the diagnostic criteria for ankylosing spondylitis?
A
- > 3 months back pain.
- X-ray changes (bamboo spine)
- MRI changes (bone marrow oedema)
- HLAB27 genetic testing (+ve)
- Plus one of the SPINEACHE symptoms
21
Q
Give 3 locations that psoriasis commonly occurs at.
A
- Elbows.
- Knees.
- Fingers.
22
Q
What is reactive arthritis?
A
Sterile inflammation of the synovial membrane, tendons and fascia triggered by an infection at a distant site, usually GI or genital.
23
Q
What gut infections are associated with reactive arthritis?
A
Salmonella, shigella.
24
Q
What sexually transmitted infections are associated with reactive arthritis?
A
Chlamydia.
25
What is the triad of symptoms for reactive arthritis?
1. Arthritis.
2. Conjunctivitis.
3. Urethritis.
Cant see, pee, or climb a tree
26
What type of spondyloarthritis occurs in 20% of patients with IBD?
Enteropathic arthritis.
27
What is the criteria for making a clinical diagnosis of juvenile idiopathic arthritis?
Joint swelling/stiffness >6 weeks in children <16 and no other cause is identified.
28
What is the aetiology of JIA?
Unknown - idiopathic!
| However, it is autoimmune so there are genetic factors associated.
29
Why is it important to check the eyes in JIA?
The lining of the eyes and the joints is very similar. Children with JIA are at a high risk of developing uveitis!
30
What type of JIA affects <4 joints and is usually ANA positive?
Oligoarthritis.
High risk of developing uveitis!
31
What JIA is similar to adult ankylosing spondylitis?
Enthesitis related JIA - inflammation of where the tendon joins a bone. HLAB27 positive.
32
Describe the non-medical treatment for JIA.
1. Information.
2. Education.
3. Support.
4. Liaison with school.
5. Physiotherapy.
33
Describe the medical treatment for JIA.
1. NSAIDs (Ibuprofen)
2. Steroids (Prednisolone)
3. DMARD (methotrexate)
4. Anti-TNF (entanercept)
34
Give 5 potential consequences that can occur if you fail to treat JIA.
1. Damage.
2. Deformity.
3. Disability.
4. Pain.
5. Bony overgrowth.
6. Uveitis.
35
What is the diagnostic criteria for fibromyalgia?
- Chronic widespread pain lasting for >3months
- Other causes excluded
- Pain is at 11 of 18 tender point sites.
36
Give 3 factors that increase the volume of pain.
1. Substance P.
2. Glutamate.
3. Serotonin.
37
Give 3 factors that decrease the volume of pain.
1. Opioids.
2. GABA.
3. Cannabanoids.
38
Name 4 diseases that fibromyalgia is commonly associated with.
1. Depression.
2. Chronic fatigue.
3. Chronic headache.
4. IBS.
39
Give 5 symptoms of fibromyalgia.
1. Neck and back pain.
2. Pain is aggravated by stress, cold and activity.
3. Generalised morning stiffness.
4. Subjective swelling of extremities.
5. Frequent waking during the night.
6. Waking unrefreshed.
7. Low mood, irritable, weepy.
8. Headache and IBS common.
40
Give 5 triggers of fibromyalgia.
1. Physical trauma.
2. Distress.
3. Hormonal alterations e.g. hypothyroid.
4. Infections.
5. Certain catastrophic events e.g. wars.
41
Give 3 diseases might be included in the differential diagnosis for fibromyalgia?
1. Hypothyroidism.
2. SLE.
3. Low vitamin D.
42
Describe the management for fibromyalgia.
1. Educate the patient and family.
2. Exercise
3. Low does amitriptyline (tricyclicantidepressant) can help with sleep, avoid caffeine
4. reduce stress
43
What 2 things are essential in the management of fibromyalgia?
1. Explaining that sleep disturbance is central to what they're feeling.
2. Emphasising the importance of exercise and fitness.
44
What is vasculitis?
Inflammation and necrosis of blood vessel walls with subsequent impaired blood flow.
45
What cells might you see on a histological slide taken from someone with vasculitis?
Neutrophils and giant cells.
46
Chapel Hill classification: give an example of a large artery primary disorder.
Giant cell arteritis.
47
Chapel Hill classification: give an example of a large artery secondary disorder.
Aortitis in RA.
48
Chapel Hill classification: give an example of a medium/small artery primary disorder.
granulomatosis with polyangiitis
49
Chapel Hill classification: give an example of a medium/small artery secondary disorder.
Vasculitis secondary to autoimmune disease, malignancy, drugs.
50
What does ANCA stand for?
Anti-neutrophil cytoplasmic antibodies.
51
Describe the epidemiology of giant cell arteritis.
- Affects those >50y/o.
- Incidence increases with age.
- Twice as common in women.
52
Give 5 symptoms of giant cell arteritis.
1. Headache.
2. Scalp tenderness.
3. Jaw claudication.
4. Acute blindness.
5. Malaise.
53
What might you find on clinical investigation in someone with giant cell arteritis?
1. Palpable and tender temporal arteries with reduced pulsation.
2. Sudden monocular visual loss, the optic disc is pale and swollen.
3. raised ESR
54
What is the diagnostic criteria for giant cell arteritis?
1. New Headache
2. Raised ESR
3. Temporal artery tenderness.
4. Abnormal artery biopsies.
55
What investigations might you do in someone who you suspect has giant cell arteritis?
1. Bloods for inflammatory markers e.g. CRP, ESR.
2. Temporal artery biopsy.
3. sight test
56
Describe the treatment for giant cell arteritis.
- Prompt high dose corticosteroids - prednisolone.
- Methotrexate is sometimes added.
- Osteoporosis prophylaxis is important (bisphosphonates) and gastric ulcer prophylaxis (PPI - omeprazole)
ongoing: continue steroids and ween off, plus prophylaxis
57
Is Wegener's granulomatosis associated with c-ANCA or p-ANCA?
c-ANCA.
58
What organ systems can be affected by granulomatosis with polyangitis?
1. URT (nose) think about that guy bean was talking aboot
2. Eyes
3. Kidneys.
4. Skin.
59
What is the affect of Wegener's granulomatosis on the URT?
- Nasal crusting, nose bleeds
- cough with wheeze + haemoptosis.
- Sinusitis.
- Otitis (middle ear infection.
60
What is the affect of Wegener's granulomatosis on the lungs? what imaging are they seen on ?
- Pulmonary haemorrhage/nodules (CT- Chest)
| - Inflammatory infiltrates are seen (CXR)
61
What is the affect of granulomatisis with polyangitis on the kidney?
Glomerulonephritis.
62
What is the affect of Wegener's granulomatosis on the skin?
Ulcers.
63
What is the affect of Wegener's granulomatosis on the eyes?
- Uveitis.
| - Scleritis.
64
What is the treatment for Granulomatosis with polyangiitis?
- high dose corticosteroids (prednisolone)
- immunosuppression (methotrexate)
- ongoing: reduce the doses, + osteoporosis and Gastric ulcer prophylaxis
65
What is rheumatoid arthritis?
An auto-immune inflammatory synovial joint disease.
symmetrical, inflammatory, chronic, erosive, poly arthritis
66
Describe the epidemiology of RA.
- 2 to 3 times more common in women.
- Approximately 1% of the population affected
- most common inflammatory arthritis
67
Describe the aetiology of RA.
Auto-antibodies e.g. RF and anti-CCP lead to a defective cell mediated immune response.
68
Describe the pathophysiology of RA.
1. Chronic inflammation. B/T cells and neutrophils infiltrate.
2. Proliferation -> pannus formation.
3. Pro-inflammatory cytokines -> proteinases -> cartilage destruction.
69
Give 5 symptoms of RA.
1. Early morning stiffness (>60 mins).
2. Pain eases with use.
3. Swelling.
4. General fatigue, malaise.
5. Extra-articular involvement.
symmetrical distal polyarthropathy (usually wrist, ankle, MCP, PIP
NOT DIP
70
Give 5 signs of RA.
1. Symmetrical.
2. Deforming.
3. Polyarthropathy (wrist, ankle, MCP, PIP)
4. Erosion on X-ray.
5. 80% are RF positive.
71
RA extra-articular involvement: describe the effect on soft tissues.
- Nodules.
- Bursitis.
- Muscle wasting.
72
RA extra-articular involvement: describe the effect on the eyes.
- Dry eyes.
- Scleritis.
- Episcleritis.
73
RA extra-articular involvement: describe the neurological effects.
- Sensory peripheral neuropathy.
- Entrapment neuropathies e.g. carpal tunnel (bilateral) syndrome.
- Instability of cervical spine.
74
RA extra-articular involvement: describe the haematological effects.
- Palpable lymph nodes (lymphadenopathy)
- Splenomegaly.
- Anaemia.
75
RA extra-articular involvement: describe the pulmonary effects.
- Pleural effusion.
76
RA extra-articular involvement: describe the effects on the heart.
- Pericardial rub.
| - Pericardial effusion.
77
RA extra-articular involvement: describe the effect on the kidneys.
Amyloidosis (amyloid build up in kidneys)
78
What is rheumatoid factor?
An antibody against the Fc portion of IgG.
79
What investigations might you do in someone who you suspect has rheumatoid arthritis?
- Bloods for inflammatory markers; ESR and CRP will be raised.
- Test for anaemia.
- Test for RF and anti-CCP.
80
Describe the treatment for rheumatoid arthritis.
- initially and during flare ups: NSAIDs (ibuprofen) and corticosteroids (hydrocortisone) (+PPI)
- ongoing DMARDs (methotrexate)
- TNF inhibitor, Rituximab (mab)
- physiotherapy
81
Define osteoarthritis.
A non-inflammatory degenerative disorder of moveable joints characterised by the deterioration of articular cartilage and the formation of new bone.
82
Why does the prevalence of OA increase with age?
Due to the cumulative effect of trauma and a decrease in neuromuscular function.
83
Give 5 risk factors for developing OA.
1. Genetic predisposition.
2. Trauma to joint
3. Occupation e.g. manual labour.
4. Obesity; pro-inflammatory state.
5. increased age
84
What are the most important cells responsible for OA?
Chrondrocytes.
85
Give 5 symptoms of OA.
1. Morning stiffness (<30 minutes).
2. Pain - aggravated by activity.
3. Tenderness.
4. Walking and ADLs affected.
5. Joint swelling and bony enlargement.
6. Deformities.
7. Crepitus.
86
Give 5 radiological features associated with OA.
LOSS
1. Loss of joint space
2. Osteophyte formation.
3. Sub-chondral sclerosis.
4. Sub-chondral cysts.
5. Abnormalities of bone contour.
87
Name 3 joints of the hand that are commonly affected in osteoarthritis.
1. Distal interphalangeal joint.
2. Proximal interphalangeal joint.
3. Carpal metacarpal joint.
88
Which surface of the knee is most commonly affected by OA?
The medial surface.
89
What is the primary investigation used to make a diagnosis of OA?
X-ray.
Look for asymmetric loss of joint space; sclerosis; cysts and osteophytes.
90
Describe features of the non-medical management for OA.
- Education.
- Exercise.
- Weight loss.
- Physiotherapy.
- Occupational therapy.
- Walking aids.
91
Describe the pharmacological management for OA.
- Paracetamol + topical NSAID (diclofenac)
- add oral NSAID (ibuprofen) + PPI (lansoprazole)
- Consider opiates: codeine or morphine
- Intra-articular steroid injections.
92
Describe the surgical management for OA.
- Arthroscopy for loose bodies.
- Osteotomy (changing bone length).
- Arthroplasty (joint replacement).
93
Give 3 indications for surgery in OA
1. Significant limitation of function.
2. Uncontrolled pain.
3. Waking at night from pain.
94
A patient complains of 'locking', what is the most likely cause of this?
This is probably due to a loose body e.g. a bone or cartilage fragment.
95
What is the treatment for loose bodies?
Arthroscopy.
96
Give an example of an inherited connective tissue disease.
1. Marfan's syndrome.
| 2. Ehler Danlos syndrome.
97
Give an example of an autoimmune connective tissue disease.
1. SLE.
2. Systemic sclerosis.
3. Sjögren's syndrome.
4. Dermatomyositis.
98
What is SLE?
Systemic Lupus Erythematosus is an inflammatory multi-system disease characterised by the presence of serum anti-nuclear antibodies (ANA).
99
Describe the epidemiology of SLE.
- 90% of cases are in young women.
- More common in asians
- Genetic association.
100
Describe the pathogenesis of SLE.
characterised by anti-nuclear antibodies (antibodies to proteins within persons own cell nucleus) => immune system target these proteins => inflammatory response
101
What can cause thrombosis in patients with SLE?
The presence of antiphospholipid antibodies.
102
What autoantibody is specific to SLE?
Anti-dsDNA.
103
Give 5 symptoms of SLE.
1. Butterfly rash.
2. Mouth ulcers.
3. Raynaud's phenomenon/'cold pale fingers'.
4. Fatigue.
5. Depression.
6. Weight loss.
104
What investigations might you do in someone who you suspect has SLE?
1. Blood count may show normocytic anaemia; neutropenia; thrombocytopaenia. Raised ESR, normal CRP.
2. Serum autoantibodies: ANA, anti-dsDNA.
105
Describe the non-medical treatment for SLE.
- Education and support.
- UV protection.
- Screening for organ involvement.
- Reduce CV risk factors e.g. smoking cessation.
106
Describe the pharmacological treatment for SLE.
- NSAIDS (Ibuprofen)
- Corticosteroids (prednisolone)
- hydroxychloroquine
more severe
- Biological therapy targeting B cells e.g. rituximab.
- Methotrexate
107
What is scleroderma?
A multi-system disease characterised by skin hardening and Raynaud's phenomenon.
108
Give 5 signs of limited scleroderma.
CREST
1. Calcinosis.
2. Raynaud's phenomenon.
3. oEsophageal reflux.
4. Sclerodactyly (thickening and tightening of the skin).
5. Telangectasia (visible small red blood vessels).
6. Pulmonary arterial hypertension.
109
Give 4 signs of diffuse scleroderma.
1. Proximal scleroderma.
2. Pulmonary fibrosis.
3. Bowel involvement.
4. Renal crisis.
CVD, lung + kidney problems
110
Describe the pathophysiology of scleroderma.
- There is excessive collagen deposition (skin hardening), inflammation and auto-antibody production.
111
Describe the management of scleroderma.
1. Immunosuppression (methotrexate or rituximab)
| 2. symptomatic treatment: Raynauds (vasodilators), GORD (PPIs)
112
What is the pathophysiology of sjögren's syndrome?
Immunologically mediated destruction of epithelial exocrine glands, especially lacrimal and salivary glands.
113
What does sjögren's syndrome often occur secondary to?
Other auto-immune disorders e.g. SLE, RA, scleroderma, primary biliary cirrhosis.
114
Give 5 symptoms of sjögren's syndrome.
1. Dry eyes and dry mouth.
2. Inflammatory arthritis.
3. Rash.
4. Neuropathies.
5. Vasculitis.
115
Why does someone with sjögren's syndrome have dry eyes and a dry mouth?
There is immunologically mediated destruction of epithelial exocrine glands meaning the lacrimal and salivary glands produce fewer secretions.
116
What investigations might you do in someone who you suspect to have sjögren's syndrome?
- Look for serum auto-antibodies e.g. anti-RO (+ve), anti-LA (+ve), RF(+ve), ANA(+ve).
- Schirmers test (measures tears)
- Also, raised immunoglobulins and ESR.
117
What is the treatment for sjögren's syndrome?
- Tear and saliva replacement.
- Immunosuppression for systemic complications
(hydroxychloroquine)
118
What is dermatomyositis?
A rare disorder of unknown aetiology. There is chronic inflammation and necrosis of skeletal muscle fibres and skin.
119
Give 3 symptoms of dermatomyositis.
1. Rash.
2. Muscle weakness (bilateral, developed over weeks)
3. gottron lesions
4. purple rash on face
120
What investigations might you do in someone who you suspect has dermatomyositis?
1. clinical presentation
2. raised creatinine kinase
3. autoantibodies
4. EMG
121
What is the treatment for dermatomyositis?
- Steroids (prednisolone)
| - Immunosuppressants (methotrexate)
122
What is the name given to inflammation of an entire digit?
Dactylitis.
123
What is the approach used for managing trauma patients?
ATLS - treat the greatest threat to life first (ABCDE).
124
Describe the physiological pathway that leads to monosodium urate formation.
Purines -> hypoxanthine -> xanthine -> uric acid -> monosodium urate.
125
What enzyme converts hypoxanthine to xanthine?
Xanthine oxidase.
126
Give 5 factors that can lead to increased levels of monosodium urate.
1. Increased intake e.g. alcohol, red meat, seafood.
2. Cell turnover (increased production).
3. Cell damage e.g. due to surgery.
4. Cell death e.g. due to chemotherapy.
5. Reduced excretion (renal problems).
6. Drugs e.g. bendroflumethiazide - diuretics impair urate excretion.
7. High insulin.
127
Name a drug that can lead to increased monosodium urate.
Bendroflumethiazide.
Diuretics impair urate excretion.
128
Describe the epidemiology of gout.
Gout is most common in men over 75 y/o.
129
Give a symptom of gout.
Hot and swollen, painful joints (unilateral)
| The toes are commonly effected.
130
What are gouty tophi?
subcut deposits of uric acid under the skin (rather than in the joint)
131
Name 4 diseases that someone with gout might have an increased risk of developing.
1. Hypertension.
2. CV disease e.g. stroke.
3. Renal disease.
4. Type 2 diabetes.
132
What is the aim of treatment for gout?
To get urate levels < 300μmol/L.
133
Name 4 treatment options for gout.
1. Lifestyle modification e.g. diet, weight loss, reduced alcohol.
2. Allopurinol (blocks xanthine oxidase).
3. Colchicine or NSAIDS.
4. Switch from bendroflumethiazide to cosartan.
134
Name a drug used in the treatment of gout that blocks xanthine oxidase.
Allopurinol.
135
You see a patient with gout who is taking bendroflumethiazide. What drug might you replace this with to help treat their gout?
You would switch bendroflumethiazide to cosartan as bendroflumethiazide is a diuretic and so impairs urate excretion.
136
Name 6 factors that can cause an acute attack of gout.
1. Sudden overload.
2. Cold.
3. Trauma.
4. Sepsis.
5. Dehydration.
6. Drugs.
137
Describe the pathophysiology of calcium pyrophosphate arthropathy (pseudogout).
Calcium pyrophosphate crystals are deposited on joint surfaces. The crystals elicit an inflammatory response.
138
What can cause pyrophosphate arthropathy (pseudogout)?
1. Spontaneous (most common)
2. direct trauma
3. blood transfusion
4. Surgery
139
Give a symptom of pyrophosphate arthropathy (pseudogout).
Acute, hot and swollen joints. Typically the wrists and knees.
140
What investigations might you do in someone who you suspect might have pyrophosphate arthropathy (pseudogout)?
1. Aspiration: fluid for crystals (positively birefringent of polarised light) and blood cultures (no bacteria)
2. X-rays: can show chondrocalcinosis (diagnostic) and signs similar to OA
141
What is the most likely differential diagnosis for pyrophosphate arthropathy (pseudogout)?
septic arthritis
142
Describe the treatment for pyrophosphate arthropathy (pseudogout).
- Treat the underlying cause
| - NSAID, (or colchicine)
143
Define osteoporosis.
A systemic skeletal disease characterised by low bone mass and micro-architectural deterioration. The patient is at increased risk of fracture.
144
Describe the epidemiology of osteoporosis.
50% of women and 20% of men over 50 are affected. The incidence increases with age.
145
What 2 factors are important for determining the likelihood of osteoporotic fracture?
1. Propensity to fall -> trauma.
| 2. Bone strength.
146
Give 4 properties of bone that contribute to bone strength.
1. Bone mineral density.
2. Bone size.
3. Bone turnover.
4. Bone micro-architecture.
5. Mineralisation.
6. Geometry.
147
Name a hormone that can control osteoclast action and so bone turnover.
Oestrogen.
148
Why are so many women over 50 affected by osteoporosis?
Women over 50 are likely to be post-menopausal; they therefore have less oestrogen and so osteoclast action isn't inhibited. There is a high rate of bone turnover -> bone loss and deterioration -> fracture risk.
149
What happens to bone micro-architecture as we get older that leads to a reduction in bone strength?
Trabecular thickness decreases; especially in the horizontal plane. There are fewer connections between trabecular and so an overall decrease in trabecular strength -> increased risk of fracture.
150
Why can RA cause osteoporosis?
RA is an Inflammatory disease. There are high levels of IL-6 and TNF; these are responsible for increased bone resorption.
151
Name 3 endocrine diseases that can be responsible for causing osteoporosis.
1. Hyperthyroidism and primary hyperparathyroidism: TH and PTH -> increased bone turnover.
2. Cushing's syndrome: cortisol leads to increased bone resorption and osteoblast apoptosis.
3. Early menopause, male hypogonadism: less oestrogen/testosterone to control bone turnover.
152
What is the affect of high cortisol levels on bone turnover?
Cortisol increases bone turnover. It leads to increased bone resorption and it also induces osteoblast apoptosis.
153
Give 5 risk factors for osteoporosis.
1. Previous fracture.
2. FHx.
3. Excessive alcohol.
4. Smoking.
5. Medications e.g. steroids
6. Immobility
7. increasing age
8. female (post menopausal)
9. low BMI
154
What investigation might you do in someone who you suspect to have osteoporosis?
- FRAX tool
- DEXA scan.
A T score will be generated.
155
Name 2 areas of the skeleton commonly affected by osteoporosis that the DEXA scan focuses on.
1. Lumbar spine.
| 2. Hip.
156
What is a T score?
A T score is a standard deviation that is compared to a gender-matched young adult mean.
157
What T score signifies that a patient has osteoporosis?
T < -2.5
158
What T score signifies that a patient has osteopenia?
-2.5 < T < -1
159
What is a normal T score?
more than -1
160
What tool can be used to assess someones risk of osteoporotic fracture?
FRAX.
161
Give 2 examples of anti-resorptive treatments used in the management of osteoporosis.
1. Bisphosphonates.
2. HRT.
Anti-resorptive treatments decrease osteoclast activity.
162
Give an example of an anabolic treatment used in the management of osteoporosis.
Teriparatide.
Anabolic treatments increase osteoblast activity.
163
What cells do anti-resorptive treatments target in people with osteoporosis?
They decrease osteoclast activity.
164
What cells do anabolic treatments target in people with osteoporosis?
They increase osteoblast activity.
165
Give 3 advantages of HRT.
1. Reduces fracture risk.
2. Stops bone loss.
3. Prevents menopausal symptoms.
166
Give 3 disadvantages of HRT.
1. Increased risk of breast cancer.
2. Increased risk of stroke and CV disease.
3. Increased risk of thrombo-embolism.
167
Give an example of a bisphosphonate.
Alendronate.
168
What pathway do bisphosphonates target?
interfere with osteoclast activity
169
What is the physis?
The physis is the growth plate in paediatric bone.
170
What feature of paediatric bone means it can heal rapidly?
The thick periosteum.
171
Describe the 3 initial steps in the management of fractures.
1. mechanical alignment
2. Immobilise.
3. Rehabilitate.
172
What is often the first line management option for paediatric fractures?
Non-operative management e.g. traction, casts, splints. This is because paediatric bone heals quickly due to the thick periosteum.
173
What can happen if the physis is damaged?
Physis damage -> growth arrest -> deformity.
174
Give 2 'red flag' signs of non-accidental injury in children.
1. Long bone fracture in a child unable to walk.
| 2. Multiple bruises and fractures.
175
Describe the management for non-accidental injury in children.
1. Admit the child!
2. Skeletal survey.
3. Referral to paediatric medics and safeguarding services.
176
Give 4 potential complications of fractures.
1. damage to local structures
2. haemorrhage
3. doesn't heal
4. avascular necrosis
177
Define osteomyelitis.
Bone inflammation secondary to infection.
178
Describe the epidemiology of osteomyelitis.
- Increasing incidence of chronic OM.
- Bimodal age distribution; Children (bones still developing), elderly (comorbidities, immune system not working as well)
179
What can cause osteomyelitis (aetiology)
1. S.aureus!
2. Coagulase negative staphylococci e.g. s.epidermidis.
3. Aerobic gram negative bacilli.
4. Mycobacterium TB.
180
Name 2 predisposing conditions for osteomyelitis.
1. Diabetes.
| 2. PVD.
181
Pathophysiology of osteomyelitis: describe the 3 ways in which the pathogen can get into bone.
1. Easy: inoculation of infection into the bone e.g. trauma/open wound.
2. Quite easy: contiguous spread of infection to bone from adjacent tissues.
3. Difficult: hematogenous seeding e.g. due to cannula infection.
182
What bones are likely to be affected by hematogenous seeding in adults?
Vertebrae.
183
What bones are likely to be affected by hematogenous seeding in children?
Long bones.
184
Why do vertebrae tend to be affected by hematogenous seeding in adults?
With age, the vertebrae become more vascular meaning bacterial seeding is more likely.
185
Why do long bones tend to be affected by hematogenous seeding in children?
In children the metaphysis of long bones has a high blood flow and BM are absent meaning bacteria can move from the blood to bone.
186
Name a group of people who are at risk of hematogenous osteomyelitis.
IVDU and other groups at risk from bacteraemia.
187
Give 4 host factors that affect the pathogenesis of osteomyelitis.
1. Behavioural e.g. risk of trauma.
2. Vascular supply e.g. arterial disease.
3. Pre-existing bone/joint problems e.g. RA.
4. Immune deficiency.
188
Acute osteomyelitis: what changes to bone might you see histologically?
1. Inflammatory cells.
2. Oedema.
3. Vascular congestion.
189
Chronic osteomyelitis: what changes to bone might you see histologically?
1. Necrotic bone - 'sequestra'.
2. New bone formation.
3. Neutrophil exudates.
190
Why does chronic osteomyelitis lead to sequestra and new bone formation?
Inflammatory exudate ruptures periosteum -> blood supply impaired -> necrosis -> sequestra -> new bone forms.
191
Give 5 signs of osteomyelitis.
1. Fever.
2. Rigors.
3. Sweats.
4. Malaise.
5. Tenderness.
6. Warmth.
7. Swelling.
8. Erythema.
192
Give a sign specific to chronic osteomyelitis.
Sinus formation.
193
What investigations might you do on someone who you suspect may have osteomyelitis?
1. Bloods: raised WBC, ESR, CRP
2. Blood cultures
3. MRI.
4. Bone biopsy.
194
What is the differential diagnosis for osteomyelitis?
1. Cellulitis.
2. Avascular necrosis.
3. Gout.
4. septic arthritis
195
Describe the usual treatment for osteomyelitis.
- Large dose IV antibiotics tailored to culture findings (often flucloxacillin- 6 weeks).
- Surgical treatment: debridement.
196
Give 4 ways in which TB osteomyelitis is different to other osteomyelitis.
1. Slower onset.
2. Epidemiology is different.
3. Biopsy is essential - caseating granuloma.
4. Longer treatment.
197
What is the most common cause of septic arthritis?
Staphylococcus aureus.
198
Give 3 causes of septic arthritis.
1. Staphylococcus aureus.
2. Streptococci (strep progenies)
3. Neisseria gonorrhoea
Consider the clinical context of the patient! (sexually acitive ? => 3)
199
Give 5 risk factors for septic arthritis.
1. Any cause of bacteraemia e.g. cannula, UTI.
2. Local skin breaks/ulcers.
3. prosthetic joints.
4. RA.
5. Elderly, increased age
6. immunosuppression
200
Give 4 symptoms of septic arthritis.
usually mono arthritis (often knee)
1. Painful.
2. Red.
3. Swollen.
4. Hot.
5. Systemic symtoms (Fever, lethargy, signs of sepsis)
201
Describe the treatment for septic arthritis.
- Aspirate joint (prior to Abx) (gram stain, crystal microscopy, culture, Abx sensitivity)
- Empirical Abx (2 weeks IV, 4 weeks oral): Flucloxacillin + rifampicin
- aspirate joint to dryness
- analgesia (Paracetamol, ibuprofen)
202
What is bacteraemia?
Bacteria in the blood.
203
What is debridement?
The removal of damaged tissue.
204
What is the most serious complication of arthroplasty surgery?
Prosthetic joint infection.
205
Give 2 ways in which prosthetic joint infections can be prevented.
1. Aseptic environment and laminar air flow.
| 2. Systemic prophylactic antibiotics.
206
What investigations might you do on someone who you suspect might have a prosthetic joint infection.
1. Aspirate (prior to Abx) -> gram staining, crystal microscopy, cultures, Abx sensitivity
2. Bloods for inflammatory markers and FBC.
3. X-rays.
207
What must you never do before aspirating a joint?
Never give antibiotics before aspiration!
208
What are the three aims of treatment for prosthetic joint infections?
1. Eradicate sepsis.
2. Relieve pain.
3. Restore function.
209
Prosthetic joint infections: what treatment might you choose for a patient that is unfit for surgery?
Antibiotic suppression.
210
What is the gold standard treatment for prosthetic joint infections?
Exchange arthroplasty.
- Radical debridement of all infected and dead tissue.
- Systemic and local antibiotic cover.
- Sufficient joint and soft tissue reconstruction.
211
Define sarcoma.
a malignant connective tissue neoplasm.
212
Soft tissue sarcomas make up what percentage of overall sarcomas?
80%. The remaining 20% are boney.
213
Name 3 soft tissue sarcomas.
1. Liposarcoma.
2. Leiomyosarcoma.
3. Rhabdomyosarcoma.
214
What is liposarcoma?
A malignant neoplasm of adipose tissue.
215
What is leiomyosarcoma?
A malignant neoplasm of smooth muscle.
216
What is rhabdomyoscarcoma?
A malignant neoplasm of skeletal muscle.
217
Name 3 boney sarcomas.
1. Osteosarcoma.
2. Ewing's sarcoma.
3. Chondrosarcoma.
218
What is chondrosarcoma?
A malignant neoplasm of cartilage.
219
Give 3 features of osteosarcoma.
1. Fast growing.
2. Aggressive.
3. Typically affects 15 - 17 y/o.
220
Name a boney sarcoma that responds well to chemotherapy.
Ewing's sarcoma.
221
Give 2 red flag symptoms for sarcoma.
1. systemically unwell
| 2. Pain at night.
222
Give 4 signs that suggest malignancy and can be used to make a diagnosis of soft tissue sarcoma.
1. Lump > 5cm.
2. Lump is increasing in size.
3. Lump is deep to fascia.
4. Pain.
223
What investigations might you do in someone who you suspect to have a sarcoma?
1. MRI.
2. Core needle biopsy.
3. CT scan.
224
What is the treatment for sarcomas?
1. MDT meeting.
2. Surgery for localised soft tissue sarcomas; ensure a wide margin.
3. Amputation.
4. If non resectable, chemotherapy and radiotherapy.
225
If it is not possible to get a wide margin when resecting a sarcoma what might you do?
Give adjuvant radiotherapy.
226
Name 2 NSAIDs.
1. Ibuprofen.
| 2. Naproxen.
227
Give 3 side effects of NSAIDs.
1. Peptic ulcer disease.
2. Renal failure.
3. Increased risk of MI and CV disease.
228
What can you do to reduce the risk of gastric ulcers and bleeding in someone taking NSAIDs?
1. Co-prescribe PPI.
| 2. Prescribe low doses and short courses.
229
Give 5 potential side effects of steroids.
1. Diabetes.
2. Muscle wasting.
3. Osteoporosis.
4. Fat redistribution.
5. Skin atrophy.
6. Hypertension.
7. Acne.
8. Infection risk.
230
How do DMARDs work?
Non-specific inhibition of inflammatory cytokine cascade = reduced joint pain, stiffness and swelling.
231
Give an example of a DMARD.
Methotrexate = gold standard.
Hydroxychloroquine.
Sulfasalazine.
232
How often should methotrexate be taken?
Once weekly.
233
Give 3 potential side effects of methotrexate.
1. Bone marrow suppression.
2. Abnormal liver enzymes.
3. Nausea.
4. Diarrhoea.
5. Teratogenic.
234
What can be co-prescribed with methotrexate to reduce the risk of side effects?
Folic acid.
235
What are cytokines?
Short acting hormones.
236
Name a TNF blocker.
rituximab
237
Name a monoclonal antibody that binds to CD20 on B cells.
Rituximab: binds to CD20 -> B cell depletion.
238
Describe the mechanism of action of abatacept?
Inhibits T cell activation.
239
Give one reason why osteomyelitis is difficult to treat.
The antibiotics struggle to penetrate bone and bone has a poor blood supply.
240
With what disease would you associate the 'pencil-in-cup erosion' seen on a plain XR with?
Psoriatic arthritis.
241
With what disease would you associate the Schirmer's test?
Sjögren's syndrome.
242
You do some investigations on a 30 y/o woman who has presented with painful, red and swollen MCP and PIP joints. The XR shows swelling of soft tissues, deformity and loss of joint space. What auto-antibodies would you expect to see in the serum?
Anti-CCP and RF positive.
This patient has rheumatoid arthritis.
243
How does alendronate work?
Alendronate reduces bone turnover by inhibiting osteoclast mediated bone resorption.
244
What class of drug is alendronate?
Bisphosphonate.
245
Name 2 drugs that act on the HMGCoA pathway.
1. Bisphosphonates e.g. alendronate.
| 2. Statins e.g. simvastatin.
246
Describe the treatment for an acute attack of gout.
1. NSAIDs or
2. Colchicine or
3. Corticosteroids - IM or IA.
247
What auto-antibodies are often present in people with RA?
RF and anti-CCP.
248
Nodal osteoarthritis can affect the DIP and PIP joints. What are the two terms used for nodes on these joints?
1. PIP - Bouchard's nodes.
| 2. DIP - Herbeden's nodes.
249
What joint is commonly affected in gout?
The MTP joint of the big toe.
250
A patient presents with an acute mono-arthropathy of their big toe. What are the two main differential diagnoses?
1. Gout.
| 2. Septic arthritis.
251
A patient presents with an acute mono-arthropathy of their big toe. What investigations might you do?
Joint aspirate.
If septic arthritis - high WCC and neutrophilia and bacteria on gram stain.
If gout - urate crystals - needle shaped negatively bi refringent
252
What joints tend to be affected in seronegative spondyloarthropathies?
Asymmetrical large joints.
253
What joints tend to be affected in RA?
1. MCP.
2. PIP.
3. Wrist.
254
Antiphospholipid syndrome is often characterised by 2 key clinical features. What are they?
Recurrent miscarriage (due to blood clots) and thrombosis.
255
What is polymyalgia rheumatica (PMR)?
A condition that causes pain, stiffness and inflammation in the muscles around the shoulders, neck and hips
256
How can you differentiate between polymyalgia rheumatica (PMR) and fibromyalgia?
PMR will show raised inflammatory markers.
257
What disease is giant cell arteritis associated with?
Polymyalgia rheumatica.
258
What class of drugs can cause Raynaud's?
Beta blockers.
259
What class of drugs does Nifedipine fall into and why can it be used to treat Raynaud’s?
Nifedipine - CCB.
It relaxes blood vessels and stops vasospasm.
260
Psoriatic arthritis commonly involves swelling of what joint?
DIP joint.
261
How would describe the swelling of fingers seen in psoriatic arthritis?
Dactylitis, sausage like swelling.
262
Describe a psoriatic plaque.
Pink, scaling lesions. Occur on extensor surfaces of the limbs.
263
Give 3 differences between RA and psoriatic arthritis.
- Psoriatic: psoriatic lesions; sausage like swelling around DIP joint; pencil in cup erosion on XR; HLAB27 associated.
- RA: hands and wrists typically affected; peri-articular erosion on XR; rheumatoid nodules.
264
What 2 features would be seen on an X-ray taken from someone with ankylosing spondylitis.
1. Sacroiliitis.
| 2. Syndesmophytes (bamboo spine).
265
What condition must be always ruled out in a acutely inflamed joint?
Septic arthritis.
Aspirate the joint!
266
Give 3 symptoms of osteomlacia.
1. Bone pain and tenderness.
2. Fractures.
3. Wadding gait.
267
An elderly man presents with worsening bone pain and is found to have an enlarged and bowed tibia. What is the most likely diagnosis?
Paget's disease of bone.
268
An elderly lady with bone pain is found to have hypocalcaemia, hypophosphataemia and a raised ALP. What is the most likely diagnosis?
Osteomalacia.
269
What cells secrete RANK ligand?
Osteoblasts.
270
What is the function of RANK ligand?
It binds to osteoclasts and is essential for their formation, function and survival.
271
What protein inhibits RANK ligand?
OPG.
272
What is the function of OPG?
OPG inhibits osteoclast formation, function and survival by binding RANK ligand; it prevents RANK ligand from binding to osteoclasts.
273
What is the affect of unopposed RANK ligand?
Unopposed RANK ligand leads to increased bone loss. More osteoclasts are stimulated due to a lack of OPG.
274
What enzyme, expressed by osteoclasts, is responsible for bone resorption?
Cathepsin K.
275
What provides the best relief for the symptoms associated with ankylosing spondylitis?
Exercise.
276
With which disease would you associate positively birefringent crystals?
Pseudogout - pyrophosphate crystals that are rhomboid shaped.
277
With which disease would you associate negatively birefringent crystals?
Gout - monosodium urate crystals that are thin and needle shaped.
278
What kind of crystals do you see in gout?
Monosodium urate crystals - negatively birefringent.
279
What kind of crystals do you see in pseudogout?
Calcium pyrophosphate crystals - positively birefringent.
280
Give 5 signs of SLE.
1. Glomerulonephritis.
2. Thrombocytopenia.
3. Photosensitivity.
4. Vasculitis.
5. Anaemia.
6. Deforming arthritis.
7. Pericarditis.
