rheumatology/MSK Flashcards
1
Q
MSK complaint epidemiology
A
1/4 GP consultations
more common cause of severe long term pain and disability
prevalence increases with age
2
Q
inflammatory vs. degenerative: stiffness
A
inflammatory- early morning/at rest, usually >60mins
degenerative- morning/evening, <30 mins
3
Q
inflammatory vs. degenerative: presentation
A
inflammatory: swelling= synovial joints, can be bony, hot/red
degenerative- no swelling
4
Q
inflammatory vs. degenerative: patient demographics
A
inflammatory: young, psoriasis, family history
degenerative- older, prior occupation/sport
5
Q
inflammatory vs. degenerative: NSAIDS
A
inflammatory: responds
degenerative- no response
6
Q
bone pain- patterns of pain
A
pain at rest and night
usually tumour/infection/fracture
7
Q
inflammatory arthritis patterns of pain
A
pain and stiffness in morning/at rest
inflammatory/infection
8
Q
osteoarthritis patterns of pain
A
pain on use/at end of day
9
Q
neuralgic patterns of pain
A
pain and paraesthesia in dermatomal distribution, worsened by specific activity
root or peripheral nerve compression
10
Q
joint distribution in rheumatoid arthritis
A
bilateral
symmetrical
hands and feet
11
Q
joint distribution in osteoarthritis
A
1st metacarpal joint (base of thumb) distal interphalangeal joint hips knees large toe
12
Q
joint distribution in psoriatic arthritis
A
joints
enthesitis
dactylitis- sausage digit
13
Q
rheumatoid arthritis presentation
A
symmetrical polyarthritis deformity erosion of bone on x-ray bone nodules
14
Q
osteoarthritis presentation
A
bouchard’s nodes- proximal interphalangeal joints
heberden’s nodes- distal interphalangeal joints
bowed legs
15
Q
connective tissue disease presentation
A
non-erosive arthritis butterfly rash photosensitivity mouth ulcers raynaud's- circulatory changes in response to temperature changes
16
Q
inflammatory markers
A
erythrocyte sedimentation rate
C reactive protein
17
Q
erythrocyte sedimentation rate
A
rises with infection/inflammation
fibrinogen=RBCs stick together=fall faster so ESR rises
18
Q
inflammatory markers: C reactive protein
A
acute phase protein
released in inflammation/infection
produced in liver in response to IL-6
19
Q
auto-antibodies in inflammatory joint pain
A
immunoglobulins that bind to self-antigens
rheumatoid arthritis
systemic lupus erythematosus
20
Q
systemic lupus erythematosus auto-antibodies
A
ANA- anti nuclear antibody, binds to antigens with cell nucleus, most people test positive
21
Q
rheumatoid arthritis auto-antibodies
A
RF- IgM or IgG
CCP
22
Q
seronegative spondyloarthropathies
A
umbrella term for inflammatory disease that involve joints and entheses
axial inflammation, asymmetrical peripheral arthritis, no RF, association with HLA-B27
23
Q
seronegative spondyloarthropathies: conditions
A
ankylosing spondylitis acute anterior uveitis psoriatic arthritis enteropathic arthritis (crohn's/UC) JIA undifferentiated SpA reactive arthritis
24
Q
seronegative spondyloarthropathies: HLA-B27
A
class I surface antigen (on all cells except RBCs)
immunity and self-recognition
either HLA +ve or -ve
main theory is infection triggers immune response and infectious agent has peptides similar to HLA so auto-immune response against it
25
seronegative spondyloarthropathies: SPINEACHE
```
Sause digit (dactylitis)
Psoriasis
Inflammatory back pain
NSAID=good response
Enthesitis
Arthritis
Crohn's/colitis/elevated CRP
HLA-B27
Eye (uveitis)
```
26
ankylosing spondylitis
chronic inflammatory disorder of the spine, ribs and sacroiliac joints
ankylosis= abnormal stiffening and immobility of a joint due to new bone formation
27
ankylosing spondylitis: epidemiology
more common and severe in males
presents at 16 y/o, <30 y/o
88% are HLA-B27 +ve
28
ankylosing spondylitis: risk factors
HLA-B27
klebsiella
salmonella
shigella
29
ankylosing spondylitis: pathophysiology
local erosion of bone and its attachments
syndesmophyte: new bone formation and vertical growth from anterior vertebral corners
sacroilitis: sclerosis, loss of joint space, joint fusion
30
ankylosing spondylitis: typical patient
man, <30 y/o
gradual onset of lower back pain
worse at night with morning spinal stiffness
relieved by exercise
31
ankylosing spondylitis: presentations
episodic inflammation of sacroiliac joint in late teens
pain radiates from sacroiliac to hips and improves through the day
progressive loss of spinal movement
asymmetrical joint pain
32
ankylosing spondylitis: spinal abnormalities
loss of lumbar lordosis and increased kyphosis (curvature of C spine/ upper T)
limitation of lumbar spine mobility in sagital and frontal planes
33
ankylosing spondylitis: enthesitis
inflammation at site of insertion of a tendon or ligament into bone
34
ankylosing spondylitis: investigations
blood: ESR raised, CRP raised (can be normal), normocytic anaemia, HLA
Xray- can be normal, erosion, blurring of vertebral rims, new bone formation, fusion of sacroiliac joints
MRI- shows early sacrolitis
35
ankylosing spondylitis: treatment
```
treat quickly to prevent irreversible syndesmophyte formation
morning exercise to maintain posture
NSAIDS
methotrexate
steroid injections
surgery
```
36
psoriatic arthritis: epidemiology
can occur without psoriasis
| occurs in 10-40% of those with psoriasis and can present before skin changes
37
psoriatic arthritis: risk factors
family history of psoriasis
38
psoriatic arthritis: 5 patterns of disease
```
asymmetrical oligoarthritis
symmetrical seronegative polyarthritis
spondylitis
distal interphalangeal arthritis
arthritis mutilans
```
39
psoriatic arthritis: spondylitis
unilateral or bilateral sacrolitis and early cervial spine involvement
similar to AS but only 50% are HLA-b27 +ve
40
psoriatic arthritis: distal interphalangeal arthritis
DIPJs involvement only
often adjacent with nail dystrophy, reflecting enthesitis extending into nail root
dactylitis- an entire digit is swollen
41
psoriatic arthritis: arthritis mutilans
5% of those with PA
| causes periarticular osteolysis (bone resorption) and shortening (telescope fingers)
42
psoriatic arthritis: hidden sites
behind/inside ear
scalp
pitting nails
umbilicus
43
psoriatic arthritis: diagnosis
xray- it is erosive but central in the joint, pencil in cup deformity
44
psoriatic arthritis: treatment
```
similar to rheumatoid arthritis
NSAIDS
DMARDS
methotrexate and ciclosporin
anti-tnf alpha
```
45
reactive arthritis
sterile inflammation of synovial membrane, tendons and fascia
triggered by infection at distant site (GI/GU)
typically lower limb
46
reactive arthritis: epidemiology
males HLA-B27 positive (30-50 fold increased risk)
47
reactive arthritis: causes
```
GI infections (salmonella, shigella)
STIs
```
48
reactive arthritis: pathophysiology
bacterial antigens or bacterial DNA found in inflamed synovium of affected joints
persistent antigenic material is driving inflammatory response
49
reactive arthritis: classic triad
arthritis, 2 days- 2 weeks post infection
conjunctivitis
urethritis
50
reactive arthritis: skin lesions
circinate balantis- ulceration of glans of uncircumcised penis, in circumcised it is raised, red and scaly
keratoderma blennorrhagica- skin of feet and hands, similar to pustular psoriasis
51
reactive arthritis: investigations
```
ESR and CRP raised
culture stool if diarrhoea
sexual health review
aspirate spinal fluid
xray
```
52
reactive arthritis: treatment
NSAIDS for joint inflammation
treat infection
screen sexual partners
relapse- methotrexate
53
rheumatoid arthritis: epidemiology
1% of population affected
peak prevalence 30-50 y/o
not seen as much in elderly compared to OA
more common in females
54
rheumatoid arthritis: risk factors
female
family history
smoking
55
rheumatoid arthritis: inflammation
chronic inflammatory reaction
| infiltration of lymphocytes, macrophages and plasma cells
56
rheumatoid arthritis: proliferation
tumour like mass- pannus
| grows over articular cartilage
57
rheumatoid arthritis: bone loss
focal erosion
periarticular osteoporosis
generalised osteoporosis in skeleton
58
rheumatoid arthritis: cartilage loss
joint space narrows due to loss of cartilage
| TNF and IL-1 release proteinases with damages cartilage
59
rheumatoid arthritis: clinical manifestations
symmetrical, swollen painful, stiff joints
usually warm
morning stiffness >30 mins
hand deformities
60
rheumatoid arthritis: soft tissue manifestations
nodules
bursitis
tenosynovitis
muscle wasting
61
rheumatoid arthritis: lung manifestations
pleural effusions
| pneumoconiosis
62
rheumatoid arthritis: cardiac manifestations
rare
pericarditis
raynaud's
63
rheumatoid arthritis: eye manifestations
dry eyes, episcleritis
| scleritis
64
rheumatoid arthritis: neurological manifestations
peripheral sensory neuropathies
compression/entrapment neuropathies
cord compression
65
rheumatoid arthritis: kidney manifestations
amyloidosis
nephrotic syndrom
CKD
66
rheumatoid arthritis: skin manifestations
subcut nodules
| vasculitis
67
rheumatoid arthritis: haematological manifestations
lymph nodes palpable
spleen enlargement
anaemia
68
rheumatoid arthritis: blood tests
normochromic normocytic anaemia
ESR/CRP raised
RF factor
anti CCP
69
rheumatoid arthritis: radiology
xray
| MRI
70
rheumatoid arthritis: anti-CCP
marker of disease
presents early in disease
those who are positive have worse prognosis
71
rheumatoid arthritis: treatment
```
no cure
lifestyle modification
pain management
corticosteroids
DMARDS
```
72
DMARDS
inhibit inflammatory cytokines
this suppresses immune system so risk of infection
take 6 weeks to start working
regular blood tests required
73
methotrexate
gold standard drug
contraindicated in pregnancy due to reducing folate
nausea, mouth ulcers, diarrhoea, neutropenia, renal impairment
74
biological therapy
```
expensive
TNF-alpha blockers (infliximab)
B-cell inhibitor (rituximab)
interleukin blockers
T cell activation blockers
```
75
vasculitis
inflammation and necrosis of blood vessel wall with subsequent impaired blood flow
76
vasculitis damage
vessel wall destruction- aneurysm, rupture, stenosis
| endothelial injury- thrombosis, ischaemia, infarction
77
vasculitis classification
```
by blood vessel involved
size of vessel
presence or absence of anti-neutrophil cytoplasmic antibodies (ANCA)
target oran
primary vs. secondary
```
78
vasculitis histology
vessel wall infiltration
neutrophils, mononuclear cells and or giant cells
fibrinoid necrosis
leukocytoclasis (dissolution of leukocytes)
79
infective conditions associated with vasculitis
subacute infective endocarditis
80
non infective conditions associated with vasculitis
```
SLE
scleroderma
polymyositis
inflammatory bowel diseases
RA
```
81
primary large vessel vasculitis
```
giant cell (temporal) arteritis
takayasu's arteritis
```
82
giant cell arteritis
inflammatory granulomatous arteries of large cerebral arteries as well as other large vessels such as aorta
83
giant cell arteritis: epidemiology
primarily in those >50
incidence increases with age
more common in females
84
giant cell arteritis: risk factors
over 50
female
RA, SLE, scleroderma
85
giant cell arteritis: pathophysiology
arteries inflamed and thicker
obstruction in blood flow
particularly cerebral and ophthalmic arteries
86
giant cell arteritis: presentation
```
headaches
tenderness of scalp
claudication of jaw
sudden painless vision loss (emergency)
malaise
weak pulses
```
87
giant cell arteritis: signs
temporal arteries- palpable, tender, reduced pulsation
88
giant cell arteritis: differential diagnosis
migraine
tension headache
trigeminal neuralgia
89
giant cell arteritis: investigations
3 or more of: >50, new headache, temporal artery tenderness, ESR raised, abnormal artery biopsy
90
giant cell arteritis: temporal artery biopsy
```
definitive diagnostic test
should be done before taking high dose corticosteroids
lesions are patchy so large biopsy
inflammatory infiltrates present
breaking up of internal elastic lamina
```
91
giant cell arteritis: treatment
high dose corticosteroids
bone protection, bisphosphantes, ca2+ and vit d
monitor treatment progress
92
primary small vessel vasculitis
granulomatosis with polyangiitis
eosinophilic granulomatosis with polyangiitis
microscopic polyangiitis
93
granulomatosis with polyangiitis
necrotising granulomatous vasculitis of arterioles, capillaries and post capillary venules
associated with ANCAs
94
granulomatosis with polyangiitis: epidemiology
age 25-60 y/o
| prevalence 5-7/100,000
95
granulomatosis with polyangiitis: vasculature affected
all organ systems but limited if no renal involvement
resp tract (sinusitis, nasal bleeding, pulmonary haemorrhage)
kidneys (glomerulonephritis)
skin (purpura/ulcers)
96
granulomatosis with polyangiitis: eye disease
scleritis
granulomatous orbital disease
marked bilateral periorbital oedema
97
granulomatosis with polyangiitis: investigations
bloods- ESR, CRP, anaemic, renal impairment, ANCA
98
granulomatosis with polyangiitis: treatment
untreated mortality= 90% at 2 years
severe= high dose steroids
non-end organ threatening= moderate dose steroids and methotrexate
99
osteoarthritis
cartilage loss with periarticular bone response
| non-inflammatory degenerative arthritis
100
osteoarthritis: epidemiology
```
most common type of arthritis
all tissues of joint involved
increases with age
majority= primary, no obvious cause
secondary= obesity or occupational
after age of 55 more common in females
```
101
osteoarthritis: risk factors
```
hypermobile joints
insufficient joint repaire
diabetes
increasing age
female
obesity
manual labour/farming
trauma
```
102
osteoarthritis: pathophysiology
balance between cartilage degradation and production is lost
focal erosion of cartilade occurs and surface becomes fibrillated and fissured
ulceration exposes underlying bone to increased stress- microfractures
103
osteoarthritis: main pathological features
loss of cartilage
| disordered bone repair
104
osteoarthritis: presentation
```
joint pain worse on movement
stiff after rest
distal interphalangeal joints
muscle wasting
nodes
```
105
osteoarthritis: investigations
deformity and bone enlargement of joints
CRP may be elevated
RF and antinuclear antibodies are negative
MRI to see cartilage injury
106
osteoarthritis Xray- LOSS
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
107
non- pharmacological treatment of osteoarthritis
```
exercise to improve muscle strength
lose weight
local heat or ice packs
bracing devices
walking aids
phsyio
```
108
pharmacological treatment of osteoarthritis
paracetamol before NSAIDs
weak opioids
corticosteroid injections
109
surgical treatment of osteoarthritis
arthroscopy
arthroplasty
osteotomy
fusion
110
inherited connective tissue diseases
Marfan
| Ehlers-danlos
111
auto-immune connective tissue diseases
systemic lupus erythematosus
systemic sclerosis
primary sjogren's
polymyositis
112
systemic lupus erythematosus
inflammatory, multisystem autoimmune disorder with arthralgia and rashes
113
systemic lupus erythematosus: epidemiology
more common in females
peak age of onset is 20-40 years
more common in African-Caribbean's and asians
114
systemic lupus erythematosus: risk factors
cause unknown
family history
UV light triggers flare ups
115
systemic lupus erythematosus: pathophysiology
cell apoptosis- cell remnants appear on cell surface as blebs (self antigens)
removal of blebs by phagocytosis is inefficient so transferred to lymph tissues to be taken up by APCs
the blebs are presented to B/T cells so autoantibodies produced
116
systemic lupus erythematosus: joint presentation
90% of cases
| similar to RA
117
systemic lupus erythematosus: skin presentation
```
85% of cases
erythemia in butterfly distribution
vasculitis on fingertips and nails
photosensitive rash
alopecia
raynaud's
```
118
systemic lupus erythematosus: lung presentation
50% of cases
recurrent pleural effusions and pleurisy
pulmonary fibrosis rarely
119
systemic lupus erythematosus: cardiac presentation
25% of cases
| pericarditis and pericardial effusions
120
systemic lupus erythematosus: CNS presentation
```
60% cases
depression
epilepsy
migraines
psychosis
```
121
systemic lupus erythematosus: eye presentation
15% cases
| retinal vasculitis
122
systemic lupus erythematosus: kidney + GI presentation
```
kidney= 30% of cases, glomerulonephritis with persistent proteinuria
GI= mouth ulcers
```
123
systemic lupus erythematosus: tests
ESR raised, CRP normal
leukopenia, lymphopenia, thrombocytopenia
anaemia
124
systemic lupus erythematosus: autoantibodies
anti-nuclear antibodies, 95% +ve
raised anti-double strand DNA antibody is specific but positive in 60%
RF +ve 40%
125
systemic lupus erythematosus: treatment
```
reduce sunlight exposure
reduce CVD risk factors
NSAIDS
topical corticosteroids for rashes
treat anaemia
immunosuppressants
```
126
systemic lupus erythematosus: treating severe
immunosuppressants
high dose oral corticosteroids
treat renal or cerebral disease and anaemia
127
systemic sclerosis
multisystem disease with involvement of skin and Raynaud's (100% of cases)
distinct from localised sclerosis that do not involve internal organ disease
128
systemic sclerosis: epidemiology
highest case of mortality of any autoimmune rheumatic disease
occurs worldwide
more common in females
peak incidence 30-50 y/o
129
systemic sclerosis: risk factors
exposure to vinyl chloride, silica dust, adulterated rapeseed oil
bleomycin
genetic
130
systemic sclerosis: pathophysiology
widespread vascular damage
continued vascular damage and increased vascular permeability
uncontrolled and irreversible proliferation of connective tissue and thickening of vascular walls with narrowing of the lumen
131
systemic sclerosis: limited cutaneous scleroderma
70% cases
skin involvement limited to hands, face, feet and forearms
tight over fingers and produces flexion deformities
GI involvement is common with oesophageal dysmotility
132
systemic sclerosis: diffuse cutaneous scleroderma
30% cases
skin changes develop more rapidly
early involvement of other organs (GI, renal, lung, cardiac)
133
systemic sclerosis: blood tests
normochromic normocytic anaemia
microangiopathic haemolytic anaemia
urea and creatine rise
134
systemic sclerosis: autoantibodies
limited= speckled or anti-centromere antibodies, 70% cases
diffuse= anti-RNA polymerase 20%, anti-topoisomerase-1 antibodies, 30% cases
RF +ve in 30%
135
systemic sclerosis: imaging
CXR to exclude other pathology
hand xr- calcium deposits
barium swallow- confirms impaired oesophagus
high res CT- fibrotic lung
136
systemic sclerosis: treatment
```
no cure
treat raynaud's
lansoprazole for oesophageal involvement
nutritional supplements
prevention of renal crisis- ACE inhibitors, ramipril
immunosuppressants
```
137
Sjogren's syndrome
chronic inflammatory autoimmune disorder
| characterised by immunologically mediated destruction of epithelial exocrine glands
138
primary Sjogren's syndrome: epidemiology
dry eyes in absence of other autoimmune disease
more common in females
onset in 40s/50s
139
secondary Sjogren's syndrome: epidemiology
associated with connective tissue disease
140
Sjogren's syndrome: pathophysiology
lymphocytic infiltration and fibrosis of exocrine glands, especially lacrimal and salivary glands
141
Sjogren's syndrome: presentations
```
dry eyes
dry mouth
salivary and parotid gland enlargement
dryness of skin and vagina
fatigue
```
142
Sjogren's syndrome: systemic presentation
```
arthralgia
raynaud's
other autoimmune diseases
renal tubular defects
vasculitis
```
143
Sjogren's syndrome: investigations
schirmer tear test
rose bengal staining
raised Ig levels, RF +ve, ANA in 80%, anti-Ro Ab in 60-90%
144
Sjogren's syndrome: treatment
artificial tears and saliva replacement
| NSAIDS
145
polymyositis/dermatomyositis
PM rare muscle disorder of unknown aetiology, inflammation and necrosis of skeletal muscle fibres
when skin is involved it is DM
146
polymyositis/dermatomyositis: epidemiology
rare
adults and children
more common in females
147
polymyositis: presentation
symmetrical progressive muscle weakness and wasting affecting proximal muscles of shoulder and pelvic girdle
difficulty squatting, going upstairs and standing from sitting involvement of resp and laryngeal muscles- dysphagia and resp failure
148
dermatomyositis: presentation
heliotrope (purple) skin, discolouration of eyelids and plaques on knuckles
arthralgia, dysphagia from oesophageal muscle involvement
increased incidence of underlying malignancy
149
polymyositis/dermatomyositis: investigations
muscle biopsy
muscle enzymes
ESR not usually raised
150
polymyositis/dermatomyositis: serum antibodies
ANA positive in DM
RF +ve in 50%
myositis-specific antibodies
151
polymyositis/dermatomyositis: treatment
bed rest with exercise
oral prednisolone for at least 1 month after it is enzymatically inactive
hydroxychloroquine or topicals to help with skin
relapse: oral- methotrexate, ciclosporin
152
Raynaud's
intermittent spasm of arteries supplying fingers and toes
no underlying cause- raynaud's disease
underlying cause- phenomenon
153
Raynaud's: epidemiology
5% of population
| more common in females
154
Raynaud's: risk factor
the cold
| smoking can aggravate symptoms
155
Raynaud's: pathophysiology
peripheral digit ischaemia due to vasospasm
| usually bilateral and fingers affected more than toes
156
Raynaud's: presentation
skin pallor followed by cyanosis, then redness due to hyperaemia (white, blue then red)
duration is variable
numbness, burning and pain
157
Raynaud's: when it can exhibited
connective tissue disorders (SLE, systemic sclerosis, RA)
vibrational tools
beta blockers, smoking
158
Raynaud's: treatment
avoid cold by wearing gloves
stop smoking and beta blockers
vasodilators
159
high risk activities for MSK problems
```
heavy manual handling >20kg
lifting above shoulder
lifting from below knee
incorrect handling techniques
forceful repetitive work
```
160
work related MSK conditions of the arm
```
tennis elbow
golfers elbow
tenosynovitis
carpal tunnel
hand-arm vibration
seamstress' finger
RSD
```
161
carpal tunnel syndrome: epidemiology
0.6% men, 8% women
| associated with obesity, pregnancy, diabetes, hypothyroidism and RA
162
carpal tunnel syndrome: pathology
compression of median nerve by flexor tendons
| seen in jobs with forceful, repetitive work done with abnormal wrist postures
163
carpal tunnel syndrome: presentation
pain, numbness, tingling, weakness and wasting of muscles supplied by median nerve
164
carpal tunnel syndrome: investigation
Tinel's and Phalen's provoking tests
165
hand-arm vibration syndrome
aka raynaud's phenomenon of industrial origin
| eligible for state benefit
166
hand-arm vibration syndrome: pathology
excessive exposure to hand transmitted vibration
| chain saws, grinders, jack jammers and drills
167
hand-arm vibration syndrome: presentation
blanching
| tingling, numbness and loss of dexterity
168
hand-arm vibration syndrome: investigation
distinguish from primary raynaud's and other secondary causes
exclude neuropathy in hands
169
tenosynovitis: epidemiology
more common in females
| jobs that have forceful and repetitive hand movements- hammering
170
tenosynovitis: pathology
local tenderness and swelling of the wrist
| inflammation of APL and EPB tendon sheath
171
tenosynovitis: presentation
crepitus- crackling of tendons
| pain on resisted movements
172
tenosynovitis: investigations
Finkelstein's test
173
tenosynovitis: treatment
NSAIDs, steroid injection and rest
| change job
174
medial epicondylitis: presentation
golfer's elbow
common flexor tendon
pain against resisted flexion of wrist
175
lateral epicondylitis: presentation
tennis elbow
common extensor tendon
pain against resisted extension of wrist
176
medial and lateral epicondylitis: pathology
repetitive bending and straightening of elbow
177
medial and lateral epicondylitis: investigations
Cozen's test
178
medial and lateral epicondylitis: treatment
NSAIDs, steroid injection and rest
179
Repetitive strain disorder
non specific pain in hand
180
Repetitive strain disorder: treatment
rest breaks
job rotation
ergonomically neutral postures
181
thoracic outlet syndrome: presentation
pain or tingling down arms or blanching of fingers related to posture of arm
wasting of hands
Roo's sign
182
thoracic outlet syndrome: pathology
compression of trunks of brachial plexus
may be due to a cervical rib, cervical band or other abnormal anatomy in the neck
poor posture, loading of shoulders and working at a keyboard
183
thoracic outlet syndrome: investigations
neck x ray
| MRI scan
184
thoracic outlet syndrome: treatment
surgery
185
rotator cuff tendonitis: pathology
rotator cuff tendon tears leading to swelling
| usually supraspinatus tendon
186
rotator cuff tendonitis: presentation
painful arc
| jobs include those with heavy manual handling, throwing and lifting above shoulders
187
rotator cuff tendonitis: investigations
Hawkin's sign
188
mechanical back pain: epidemiology
associated with:
| heavy manual handling, stooping and twisting while lifting, whole body vibration and smoking
189
mechanical back pain: pathology
normal MRI findings:
disc degeneration
bulging discs
190
mechanical back pain: investigations
distinguish from sciatica
191
mechanical back pain: treatment
avoid prolonged inactivity and maintain normal activity within limits of pain
analgesics or NSAIDs
192
mechanical lower back pain
common and self-limiting
| traumatic or work related
193
mechanical lower back pain: red flags
```
onset <20 y/o or >55y/o
violent trauma
constant and progressive pain
thoracic pain
steroids, drug abuse or HIV
unwell/weight loss
restriction of lumbar flexion
structural deformity
```
194
mechanical lower back pain: epidemiology
common in 20/55 y/o
| heavy manual handling, stooping and twisting
195
mechanical lower back pain: causes
```
lumbar disc prolapse
osteoarthritis
fractures
spondyloisthesis
heavy manual handling
```
196
mechanical lower back pain: risk factors
```
psychosocial distress
smoking
female
increasing age
fibromyalgia
```
197
mechanical lower back pain: presentation
stiff and scoliosis may be present when standing
muscle spasm can be visible or palpable
pain is often unilateral and helped by rest
sudden onset
pain worse in evening
morning stiffness is absent
198
mechanical lower back pain: pathophysiology
spinal movement occurs at the disc and posterior fact joints
stability is achieved by spinal ligaments and muscles
any of those structures can be a source of pain
199
mechanical lower back pain: lumbar spondylosis
most common site= L5/S1 and L4/5
discs become thin and less compliant with age
circumferential bulging of the ligaments
reactive changes occur in adjacent vertebrae- bone becomes sclerotic and osteophytes form around rim of vertebra
200
mechanical lower back pain: facet joint syndrome
pain is worse on bending backwards and straightening from flexion
can be unilateral or bilateral, radiates to buttock
facet joints well seen on MRI and may show osteoarthritis, effusion or ganglion cyst
treat with corticosteroid injections and physio
201
mechanical lower back pain: fibrositic nodulosis
uni/bilateral pain in low back/buttock
tender nodules in upper buttock along iliac crest
treat with intralesional corticosteroid injections
202
mechanical lower back pain: pregnancy
common
reflects altered spinal posture and increase ligamentous laxity
weight control and exercises help
pain settles after delivery
203
mechanical lower back pain: investigations
spinal xrays for red flags
MRI
bone scans
204
mechanical lower back pain: treatment
urgent neurosurgical referral if any neuro deficit
analgesia
avoid excessive rest
training in manual handling
205
bone and joint infections
usually caused by bacteria and rarely fungi
206
septic arthritis
medical emergency
acutely inflamed joint which can be destroyed in under 24 hours
knee affected in >50% of cases
207
septic arthritis: epidemiology
increases with age
| 45% >65 y/o
208
septic arthritis: causes
staph aureus = most common causes
streptococci
gonorrhoea
209
septic arthritis: risk factors
```
pre-existing joint disease
diabetes
immunosuppression
renal failure
joint surgery
prosthetic joints
IV drug abuse
```
210
septic arthritis: presentation
painful, red, swollen, hot joint
fever
mechanical dysfunction
211
septic arthritis: differential diagnosis
gout
| psuedogout
212
septic arthritis: investigation
```
joint aspiration
check for gout
gram stain and culture
inflammation markers
Xray
skin wound swabs
```
213
septic arthritis: treatment
```
stop any methotrexate and anti-TNF alpha
if on prednisolone, double dose
double any steroids
joint drainage
NSAIDS
IV antibiotics
```
214
septic arthritis: IV arthritis
```
only start after aspiration
flucloxacillin- gram -ve, e.coli
erythromycin- if allergic to penicillin
vancomycin for MRSA
cefotaxime- gram -ve or gonococcal
```
215
gonococcal arthritis
```
one or several joints, secondary to genital, rectal or oral infection
gram -ve neisseria gonorrhoea
most common cause in fit young adults
fever and pustules on distal limbs
culture blood to diagnose
```
216
meningococcal arthritis
complicates meningococcal septicaemia and presents as migrating polyarthritis
deposition of circulating immune complexes and containing meningococcal antigens
treat with penicillin
217
tuberculous arthritis
1% of those with TB have joint/bone involvement
caseating granulomas and rapid destruction of cartilage and adjacent bone
fever, night sweats, weight loss
218
joint infection in infants
haemophilus influenzae was most common, now rare in infants due to standard childhood immunisation in UK
219
osteomyelitis
infection localised to bone
| either due to metastatic haematogenous spread or local infection
220
osteomyelitis: epidemiology
predominantly occurs in children, especially acute
adults tend to get secondary due to infection or trauma
increasing incidence
221
osteomyelitis: causes
staph aureus, 90%
coag -ve staphylococci
haemophilus influenzae
222
osteomyelitis: risk factors
```
diabetes
peripheral vascular disease
malnutrition
inflammatory arthritis
immunosuppression
sickle cell
trauma
```
223
osteomyelitis: entering bone
```
direct inoculation of infection into bone through trauma or surgery (easy)
contiguous spread into bone (medium)
haematogenous seeding (hard)
```
224
osteomyelitis: contiguous spread into bone
no breaking of skin
infection of adjacent soft tissue spreads to bone
seen in elderly who have diabetes, ulcers, vascular disease or joint replacements
225
osteomyelitis: haematogenous seeding
where bone has large blood supply
infection from skin spreads to blood then to bone
in children tend to be long bones in metaphysis
in adults it is vertebra
226
osteomyelitis: acute changes, histopathology
inflammatory changes
oedema
vascular congestion
small vessel thrombosis
227
osteomyelitis: chronic changes, histopathology
necrotic bone
new bone formation
neutrophil exudates
lymphocytes and histiocytes
228
osteomyelitis: process of pathology
inflammatory exudate in the marrow leads to increased intramedullary pressure with extension of exudate into bone cortex
rupture through the periosteum and interruption of periosteal blood supply
necrosis leaves separated dead bone known as sequestra
229
osteomyelitis: presentation
dull pain at site
fever, sweats, rigors and malaise
can present as septic arthritis
230
acute osteomyelitis: presentation
tenderness
warmth
erythema
swelling
231
chronic osteomyelitis: presentation
```
tenderness
warmth
erythema
swelling
draining sinus tract which is associated with deep ulcers that fail to heal
```
232
osteomyelitis: differential diagnosis
```
charcot joint- damage due to sensory nerves affected by diabetes
soft tissue infection
avascular necrosis of bone
gout
fracture
malignancy
```
233
osteomyelitis: blood investigations
blood culture to determine aetiology
ESR and CRP raised
acute has raised WCC
chronic can have normal WCC
234
osteomyelitis: imaging investigations
plain xray to show osteopenia
MRI may show marrow oedema
bone scan helpful
235
osteomyelitis: treatment
immobilisation
antimicrobial therapy
surgical debridement
236
prosthetic infections
most serious complication of arthroplastic surgery
| hips and knees
237
prosthetic infections: epidemiology
increasing due to increasing age, diabetes and obesity
238
prosthetic infections: causes
staph. aureus
coag -ve staphylococci
gram +ves mainly
239
prosthetic infections: risk factors
poor infection control
old age
diabetes
obesity
240
prosthetic infections: presentation
majority aren't acutely infected
systemically well
tender, hot, swollen joint
241
prosthetic infections: investigations
```
joint aspiration
tissue sample
x-ray
inflammation marker
alpha defensin- 95% sensitive
```
242
prosthetic infections: joint aspiration
gold standard diagnostic
identifies organism and antibiotic sensitivities
must be done with patient off antibiotics for 2 weeks minimum
243
prosthetic infections: aim of treatment
eradicate sepsis
relieve pain
restore function
244
prosthetic infections: treatments
```
antibiotic suppression
debridement and retention of prosthesis
excision arthroplasty
one stage arthroplasty exchange
two stage arthroplasty exchange
amputation
```
245
prosthetic infections: antibiotic suppression
if they're unfit for surgery
multiple prosthetic infections
does not eliminate sepsis
246
prosthetic infections: debridement and retention of prosthesis
for early post-op infections
| not for chronic infections
247
prosthetic infections: excision arthroplasty
for high risk, frail and multiple co-morbidities whose infection is not controlled by antibiotic suppression
248
prosthetic infections: one stage arthroplasty exchange
```
radical debridement
implantation of new prosthesis with antibiotic cement
systemic and local antibiotics
avoids bone grafts
85% success
```
249
prosthetic infections: two stage arthroplasty exchange
radical debridement
local antibiotic spacer with systemic antibiotics
interval stage
implantation of new prosthesis with antibiotic cement
90-95% success
250
prosthetic infections: amputation
if severe infection
| if all else fails
251
fibromyalgia: definition
widespread musculoskeletal pain when other diseases have been excluded
symptoms present for at least 3 moths with pain at 11 or 18 tender point sites on digital palpation
252
fibromyalgia: epidemiology
can develop any age, often over 60 y/o
more common in females
12% with RA have fibromyalgia
253
fibromyalgia: associations
depression
chronic headache
IBS
chronic fatigue syndrome
254
fibromyalgia: risk factors
```
female
middle age
low household income
divorced
low educational status
```
255
fibromyalgia: presentation
chronic pain
non-restorative sleep
fatigue
anxious
256
fibromyalgia: non-restorative sleep
```
frequent waking during night
waking unrefreshed
poor concentration and forgetfulness
low mood, irritable, weepy
lack of non-REM sleep causes functional pain
```
257
fibromyalgia: pain
chronic- >3months
widespread
aggravated by stress, cold and activity
associated with morning stiffness
258
fibromyalgia: areas that pain focuses on
```
lower front of neck
base of skull
upper edge of breast
neck and shoulder
upper, inner shoulder
upper, outer buttock
hip
upper, inside knee
```
259
fibromyalgia: differential diagnosis
```
hypothyroidism
SLE
polymyalgia rheumatics
high calcium
low vitamin D
inflammatory arthritis
```
260
fibromyalgia: investigations
```
digital palpation of 18 tender point sites
thyroid function test
ANAs and DsDNA to exclude SLE
ESR and CRP
Ca2+
Vit D
```
261
fibromyalgia: treatment
educate patient on pain doesn't always mean damage
avoid unnecessary investigations
correct sleep
low dose antidepressants such as amitriptyline
262
fractures: pattern
transverse, oblique and spiral= low energy
comminuted= high energy
torus and greenstick= common in children
263
fractures: joint involvement
```
extra-articular= not involving joint
intra-articular= involving joint
```
264
fractures: skin involvemnet
open- breach in skin
265
fractures: management
```
analgesia
neurovascular examination- pre and post immobilisation
reduce
immobilise
rehabilitate
```
266
fractures: immobilisation techniques
cast, splint, brace, halo
| internal- wires, screws, plates, nails
267
fractures: healing stages
haematoma
fibrocartilaginous callus formation
bony callus formation
bone remodelling
268
fractures: haematoma
```
hours
bleeding as endosteal and periosteal vessels torn
decreased blood blow
periosteal stripping
osteocyte death due to ischaemia
```
269
fractures: inflammation
days
fibrin clot organisation
neurovascularisation
cellular invasion
270
fracture healing: inflammation and cellular invasion
haematopoieitic cells- clear debris and express repair cytokines
osteoclasts- resorb dead bone
mesenchymal stem cells- building cells for repair
271
fractures: repair
hard callus formation- reduces movement
fibroblasts produce fibrous tissue, chondroblasts cartilage and osteoblasts osteoid
progressive matrix mineralisation
high vascularity
272
fractures: remodelling
```
months- years
woven bone replaced by lamella bone
increased bone strength
vascularity returns to normal
healing without scar
```
273
vertebral disc degeneration
prolapse of intervertebral disk resulting in acute back pain
274
vertebral disc degeneration: epidemiology
disease of younger people, 20-40 y/o as degenerated discs in elderly cannot prolapse
275
vertebral disc degeneration: presentation
sudden onset of severe back pain, often following strenuous activity
muscle spasm leads to sideways tilt when standing
radiation of pain and findings depend on disc affected
most common to be affected are the lower 3 discs (L4-S1)
276
vertebral disc degeneration: investigations
Xrays often normal
| MRI when surgery considered
277
vertebral disc degeneration: treatment
acutely= bed rest on firm mattress, analgesia and epidural corticosteroid injection
surgery for severe or increasing neurological impairments
physio in recovery phase
278
Root lesion @ L4: pain, reflex lost and other signs
pain= lateral aspect of thigh and medial side of calf
reflex lost= knee jerk
positive femoral stretch test
279
Root lesion @ L5: pain, reflex lost and other signs
pain= buttock to lateral aspect of leg and top of foot
no reflex lost
diminished straight leg rising
280
Root lesion @ S1: pain, reflex lost and other signs
pain= buttock down back of thigh to ankle/foot
reflex lost= ankle jerk
diminished straight leg rising
281
chronic disc disease
associated with degenerative changes in lower lumbar discs and facet joints
pain is mechanical
sciatic radiation may occur with pain in buttocks radiating into posterior thigh
282
chronic disc disease: treatment
NSAIDS, physio and weight reduction
| surgery can be done if pain arises from a single identifiable level
283
bone tumours: epidemiology
the most common tumours are metastases from other cancers
| primary bone tumours are rare and usually only seen in children or young adults
284
bone tumours: presentation
symptoms usually related to anatomical position of tumour with local bone pain
systemic= malaise, pyrexia, aches and pains- related to hypercalcaemia
285
bone tumours: red flag signs
```
rest pain
night pains
lump present
loss of function
neurological symptoms
weight loss
```
286
bone tumours: benign vs. malignant examples
```
benign= osteoid osteoma, osteoblastoma, osteochondroma
malignant= osteosarcoma
```
287
cartilage tumours: benign vs. malignant examples
```
benign= enchondroma, chondroblastoma
malignant= chondrosarcoma
```
288
fibrous tumours: benign vs. malignant examples
```
benign= fibrous dysplasia, non- ossifying fibroma
malignant= fibrosarcoma
```
289
cystic tumours examples
unicameral bone cyst
| aneurysmal bone cyst
290
bone tumours with unknown aetiology: benign vs. malignant examples
giant cell tumour
ewing tumour
adamantinoma
291
osteoid osteoma
bone-forming lesion in the young
localised pain and self-limiting <7yrs
produces high levels of prostaglandin E2
proximal femur, tibial diaphysis, spine
292
osteoid osteoma: investigation
x-ray: active reactive bone and nidus (5-10mm)
| best appreciated on CT
293
osteoid osteoma: treatment
medical- NSAIDs are 50% successful
| surgical- radiofrequency ablation
294
osteoblastoma
rare bone producing tumour
| spine lesions can present with neurology
295
osteoblastoma: epidemiology
M:F=3:1
296
osteoblastoma: presentation
pain
not self-limiting
spine, proximal humerus and sacrum
297
osteoblastoma: investigation
X rays- bone destruction surrounded by reactive new bone
| histology- interlacing trabeculae and loose fibrovascular stroma
298
osteoblastoma: treatment
excision with at least a marginal line of excision
299
osteosarcoma
spindle cell neoplasms that produce osteoid
300
osteosarcoma: types
intramedullary osteosarcoma- high grade
parosteal osteosarcoma- low grade
periosteal sarcoma- high grade
telangiectatic osteosarcoma
301
secondary osteosarcomas: causes
Paget's
post radiation
fibrous dysplasia
302
osteosarcoma: secondary to Paget's
older population
paget's is present in 0.7-0.9% so it is rare
high risk for pulmonary metastasis
303
osteosarcoma: secondary to irradiation
60-70% survival for extremity lesions, 27% for axial
children treated with high dose radiotherapy are greatest risk
high grade tumours, high risk of pulmonary mets
304
high grade intramedullary osteosarcoma: presentation
most common type
in the knee, proximal humerus and proximal femur
children and young adults
90% are high grade and penetrate cortex early
305
osteosarcoma: management
multi-agent chemo, pre-op for 8-12 weeks
| aims to reduce or treat pulmonary mets
306
osteosarcoma: current survival
```
if untreated it is fatal
with treatment:
-overall= 60-70% for 5 years
-if tumour necrosis is >90% after chemo, 5 yr survival is 80-90%
-if necrosis is <90%, 5 yr survival <15%
```
307
enchondromas
lesions tend to occur in small bones- hand and feet, but can occur anywhere
do not destroy bone
308
enchondromas: investigations
x-ray for metaphyseal popcorn
| histology- island of cartilage
309
aneurysmal bone cyst
always biopsy if large or any doubt
usually <20 y/o
metaphyseal and eccentric
310
aneurysmal bone cyst: investigation
x ray- eccentric, lytic and expansile lesion
| MRI- fluid levels
311
aneurysmal bone cyst: treatment
simple curettage has 86% success
312
giant cell tumours
locally destructive neoplasm with poorly defined cells
20-40 y/o, F>M
benign but 2% metastasise to lungs
313
giant cell tumours: presentation
lesions are 50% in knee, 30% vertebrae and sacrum
314
giant cell tumours: investigation
histology shows multinucleated cells
| x rays- destructive lesion, no sclerotic rim
315
giant cell tumours: treatment
curettage, wash out, dental burr- 90% success rate
316
Ewing's sarcoma
small round cell tumour
arise from neural crest cells
children and young adults
317
Ewing's sarcoma: lesion types
classic= diaphyseal lesion, commonly on femur, also pelvis, tibia and humerus
destructive lytic lesion= periosteum may be lifted off in multiple layers giving an onion skin appearance
318
Ewing's sarcoma: bone marrow biopsy
monotonous blue cell tumour
indistinct cell borders
no matrix production by tumour cells
319
Ewing's sarcoma: treatment
chemo, radiotherapy and surgical excision/reconstruction
320
Ewing's sarcoma: prognosis
poor if large tumour/pelvic/mets and Dx
| 70% survival overall, 30% if mets present
321
bony metastasis: most common tumours
```
breast
lung
prostate
kidney
thyroid
```
322
bony metastasis: presentation
bone pain
generally unwell
pathological fracture
323
bony metastasis: management
correct metabolic abnormalities
full length x rays
liase with oncology
324
crystal deposition
local inflammatory response and tissue damage
joints= crystal arthopathies
kidney and gallbladder= stones
325
crystal arthropathy
arthritis caused by crystal deposition in joint lining
326
crystal arthropathy: presentation
acutely hot and swollen joints
| chronically with longer term damage
327
crystal arthropathy: diagnosis
history, pattern and aspiration of joint
328
gout
inflammatory arthritis associated with hyperuricaemia and intra-articular monosodium urate crystals
329
gout: epidemiology
common
more common in males
most common arthritis in men >40 y/o
330
gout: risk factors
```
high alcohol intake
purine rich food
high saturated fat intake
low-dose aspirin
ischaemic heart disease
family history
```
331
gout: serum uric acid levels increase with..
```
age
obesity
diabetes
ischaemic heart disease
hypertension
```
332
gout: pathogenesis
```
renal excretion reduced
excessive urate
urate crystals
phagocyte activation
inflammation
```
333
gout: joint involvement
```
big toe
ankle/foot
knee
finger
elbow
wrist
```
334
gout: precipitants of an attack
aggressive introduction/cessation of hypouricaemic therapy
alcohol/shellfish binges
sepsis/MI/severe illness
335
acute gout: presentation
sudden onset of agonising pain, swelling and redness of first MTP joint
usually one joint affected but can be multiple
336
chronic gout: presentation
rare except in elderly- on long term diuretics in renal failure of if they started on allopurinol too soon
337
gout: differential diagnosis
exclude septic arthritis
338
gout: investigations
joint fluid aspiration
serum uric acid levels
creatinine
339
gout: lifestyle treatment
lose weight
less alcohol
avoid purine rich food
increase dairy
340
gout: medical treatment
NSAIDS- naproxen or ibuprofen
| if they're not tolerated then colchicine or prednisolone
341
gout: prevention
stop diuretics
allopurinol
febuxostat
342
gout: allopurinol
inhibits xanthine oxidase so less uric acid production
| side effects are rash, fever and low WCC
343
gout: febuxostat
non-purine xanthine oxidase inhibitor
| use when allopurinol is contraindicated or because of it's side effects
344
pseudogout
deposition of calcium pyrophosphate crystals on joint surface
345
pseudogout: epidemiology
affects elderly women
346
pseudogout: risk factors
```
old age
diabetes
osteoarthritis
joint trauma
hyperparathyroidism
```
347
pseudogout: pathophysiology
deposition of calcium pyrophosphate in articular cartilage and periarticular tissue producing radiological appearance of chonedrocalcinosis
348
pseudogout: triggers of acute attack
```
direct trauma
intercurrent illnesses
surgery- parathyroidectomy
blood transfusion
T4 replacement
joint lavage
most are spontaneous
```
349
pseudogout: presentation
resembles acute gout but more common in elderly women and affects knee or wrist
350
pseudogout: diagnosis
joint aspiration
xray
bloods- raised WCC
351
pseudogout: joint aspiration
small rhomboidal crystals
| positively bifringent
352
pseudogout: treatment
high dose NSAIDs
colchicine if NSAIDs not tolerated
prednisolone
joint aspiration
353
pseudogout: treatment
high dose NSAIDs
colchicine if NSAIDs not tolerated
prednisolone
joint aspiration
354
osteoporosis definition
systemic skeletal disease characterised by low bone mass and amicro-architectural deterioration of bone tissue
consequent increase in bone fragility and susceptibility to fracture
355
osteopenia definition
pre cursor to osteoporosis characterised by low bone density
356
osteoporosis: T score definition
standard deviation score ascertained using a dual energy x ray absorptiometry (DEXA) scan
357
osteoporosis: T score ranges
normal >-1
osteopenia= -1 to -2.5
osteoporosis
358
osteoporosis: epidemiology
>50 y/o and females= more common
| caucasian and asian races are particularly at risk
359
osteoporosis: risk factors
```
old age
women
family history
previous bone fracture
smoking/alcohol
```
360
osteoporosis: SHATTERED (risk factors)
```
Steroid use
Hyperthyroidism/hyperparathyroidism
Alcohol/tobacco
Thin, BMI<22
Testosterone decreased
Early menopause
Renal/liver failure
Erosive/inflammatory bone disease
Dietary calcium decrease/diabetes
```
361
osteoporosis: pathophysiology
start to lose bone mass after the age of 25
increased breakdown by osteoclasts and decreased formation by osteoblasts
genes involved= callagen type A1, vitamin D receptor and oestrogen receptor genes
nutritional factors, sex hormone status and physical activity
362
osteoporosis: bone strength determinants
BMD
bone size
bone quality
363
osteoporosis: bone strength and BMD
how much mineral is in bone
| determined by the amount gained during growth and amount lost during ageing
364
osteoporosis: bone strength and bone size
short and fat is stronger than long and thin
| distribution of cortical bone
365
osteoporosis: bone strength and bone quality
bone turnover, architecture and mineralisation
not enough mineral= break easy
too many minerals= too stiff and shatter
366
osteoporosis: oestrogen deficiency
postmenopausal osteoporosis
results in increased numbers of remodelling units (osteoclasts), premature arrest of osteoblastic synthetic activity and perforation of trabeculae with a loss of resistance to fracture
367
osteoporosis: changes in trabecular architecture
decrease in trabecular thickness
| strain on bones is head to toe so we preserve vertical trabeculae and lose horizontal ones
368
osteoporosis: presentation
fracture is the only cause of symptoms
369
osteoporosis: investigations
xray- fractures
bloods- Ca, phosphate and alkaline phosphate all normal
DEXA
370
osteoporosis: DEXA scan
low radiation dose
measures important fracture sites (lumbar spine and proximal femur)
gold standard for measuring bone density and diagnosing osteoporosis
371
osteoporosis: liftestyle management
quite smoking and reduce alcohol consumption
weight bearing exercise
calcium and vitamin D rich diet
balance exercises
372
osteoporosis: bisphosphonate treatment
1st line treatment
inhibit bone resorption through inhibiting an enzyme- reduces osteoclast activity
oral aldendronate= most common
should be taken fasting with a large drink of water
373
osteoporosis: denosumab treatment
osteoblasts produce RANK to activate osteoclasts and thus resorption
this is a monoclonal antibody that inhibits RANK signal
reduces fracture risk
374
osteoporosis: HRT treatment
2nd line- used in menopausal women
reduces fracture risk and stops bone loss
prevents hot flushes and other menopausal symptoms
375
osteoporosis: raloxifene treatment
selective oestrogen receptor modulator- activates oestrogen receptor on bone whilst having no stimulatory effect on endometrium
376
osteomalacia
normal amount of bone but mineral content is low
defective mineralisation after fusion in epiphyses
clinical manifestation of profound vitamin D deficiency
377
osteomalacia: aetiology
hypophosphataemia due to hyperparathyroidism , secondary to vitamin D deficiency
liver/renal disease
drugs
tumour induced
378
osteomalacia: caused by liver disease
leading to reduced hydroxylation of vitamin D to 25-hydroxy vitamin D
379
osteomalacia: caused by drugs
anticonvulsants may induce liver enzymes- breakdown of 25-hydroxy vitamin D
rifampicin (antibiotic)
380
osteomalacia: caused by renal disease
renal failure means there is inadequate conversion of 25-hydroxy vitamin D to 1,24- hydroxy vitamin D
381
osteomalacia: caused by vitamin D deficiency
malabsorption since vitamin D is fat soluble
poor diet- not enough oily fish or egg yolks
lack of sunlight
382
osteomalacia: presentation
muscle weakness
widespread bone pain
bone tenderness
fractures, especially femoral neck
383
rickets presentation
growth retardation
knock knees, bowed legs
widened epiphyses at wrists
hypocalcaemic tetany
384
osteomalacia: investigations
bloods
biopsy- gold standard as shows incomplete mineralisation, but not practical
Xray
385
osteomalacia: blood test results
low Ca2+ and phosphate
raised serum alkaline phosphatase
elevated parathyroid hormone
low 25-hydroxy vitamin D
386
osteomalacia: treatment
Vitamin D:
- dietary insufficiency= calcium D3 forte
- malabsorption/hepatic disease= oral ergocalciferol or IM calcitriol
- renal disease- alfacidol or calcitriol
387
Paget's disease of bone
aka osteitis deformans
| focal disorder of bone remodelling
388
Paget's disease of bone: epidemiology
increases with age, rare under 40
10% of those aged 90
UK has highest prevalence in the world
F>M
389
Paget's disease of bone: risk factors
may result from latent viral infection but aetiology unknown
390
Paget's disease of bone: pathophysiology
increased osteoclast bone resorption followed by weaker new bone
new woven bone is weak and leads to deformity and increased fracture risk
391
Paget's disease of bone: presentation
pelvis, lumbar spine, femur, thoracic spine, skull and tibia are common sites
60-80% asymptomatic
bone/joint pain
392
Paget's disease of bone: neurological complications
never compression- deafness from 8th cranial never involvement. paraparesis, partial paralysis of lower limbs
hydrocephalus due to blockage of aqueduct of sylvius
393
Paget's disease of bone: investigations
increased serum alkaline phosphatase with normal calcium and phosphate shows increased bone turnover
urinary hydroxyproline excretion is raised
394
Paget's disease of bone: radiography investigations
x ray- localised bony enlargement and distortion, sclerotic changes, osteolytic areas
isotope bone scans- determine skeletal involvement
395
Paget's disease of bone: treatment
bisphosphonates
NSAIDS
monitor disease activity
396
Rickets definition
Rickets is defective mineralisation during bone growth at the epiphyseal growth plate
clinical manifestation of profound vitamin D deficiency
