Week 11- MSK Flashcards

1
Q

What are the key pathological features on an X-ray in osteoarthritis?

A
Subchondral sclerosis
joint space narrowing
osteophytes 
cyst formation
LOSS
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2
Q

What are the management options in osteoarthritis?

A

Stage 1 - Lifestyle (weight loss & exercise), Chondroitin, glucosamine
Stage 2 - Physio (muscle strength &aerobic conditioning), braces and support, walking aid, analgesics
Stage 3 - NSAIDs, Codeine or oxycodone, intra-articular injections
Stage 4 - surgery - replacement, realignment, erosion and fusion

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3
Q

What can happen if there is incorrect alignment in a joint replacement?

A

Compromise function, patellar femoral problems, premature loosening, abnormal wear

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4
Q

What vessels does Giant cell artery vasculitis affect?

A

Aorta and its major branches

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5
Q

What is the gold standard investigation in Giant cell artery vasculitis?

A

Temporal artery biopsy

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6
Q

Name some drugs used in treating Gout?

A

Colchicine

Allopurinol, febuxostat

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7
Q

What malignancies are highly suspicious in back pain?

A

Lung, Prostate, thyroid, breast, kidney

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8
Q

What is the pain like in inflammatory back pain?

A

Early morning stiffness >30min
Gets better with exercise
Sore at rest
May wake at night

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9
Q

What is ankylosing spondylitis

A

Chronic inflammatory rheumatic disease of unknown cause. HLA B27
bilateral sacroilitis, bamboo spine

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10
Q

Define osteonecrosis or Avascular necrosis.

A

Bone infarction near a joint
There is death of subchondral bone
Crescent sign on X-ray

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11
Q

What are some risk factors for avascular necorosis

A
Cushing's or corticosteroid use
Sickle cell anaemia or haemaglobinopathies
History of trauma
Alcohol abuse
HIV, bisphosphonates, renal failure, SLE
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12
Q

Give some examples of Sclerotic metastasis

A

Breast carcinoms
Prostate carcinoma
Carcinoid tumour

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13
Q

Give some examples of Solitary bone mestastasis

A

Renal carcinoma

Thyroid carcinoma

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14
Q

What is compartment syndrome?

A

Elevated interstitial pressure within a closed fascial compartment, resulting in microvascular compromise.

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15
Q

What is spondylolithesis?

A

Slip of one vertebrae on the one below. Defect in the Pars interarticularis.

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16
Q

What is pagets disease?

A

Increased bone turnover. osteoclastic and osteoblastic activity
Raised alkaline phosphatase (OB produce it)

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17
Q

What is the blade of grass sign?

A

Indicates the lytic phase of pagets disease

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18
Q

How might Psoriatic arthritis present on X-ray?

A

DIP joints
Pencil in cup deformity
Resorption of distal phalanges

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19
Q

How can you differentiate gout from pseudo-gout?

A

Gout- sodium rate crystals. Smaller joints- usually big toe (MTP), negative birefringent crystals, needle shaped crystals
Pseduo- Calcium pyrophosphate. Larger joints like knee, wrist, shoulder, positive birefringent crystals, smaller, sparse rhomboid crystals. chondrocalcinosis. serum rate levels normal

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20
Q

What is reactive arthritis?

Seronegative, Strong HLA-B27 associaiton

A

A sterile arthritis, typically affecting the lower limb following a precious infection. Eneteric - salmonella, shigella, campylobacter. GU- mycoplasma genitalium, n.gonorrhoea

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21
Q

What are some signs of reactive arthritis

A

Urethritis, conjunctivitis, arthritis
Warm, swollen, tender, asymmetrical, systemically unwell
Plantar fasciitis, keratoderma blenorrhagica

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22
Q

What are some systemic manifestation of RA?

A
Feltys syndrome (splenomegaly, leukopenia, lymphadenopathy)
Pericarditis, vasculaires, SC nodules, malaise, weight loss
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23
Q

How do NSAIDs inhibit F# healing?

A

Reduce local vascularity at the fracture site

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24
Q

What does Azathioprine do?

A

It incorporates itself into DNA and RNA chains leading to termination of the strand. Suppresses growth and metabolism of cells. Can inhibit T-cell co-stimulation via CD28

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25
Why must you check for TPMT before administering Azathioprine?
It is an enzyme that reduces active drug in cells. Without it there is accumulation of active metabolites in cells- severe toxicity
26
What does cyclosporin so?
Inhibits Calcineurin. Inhibits T cell activation
27
What are some causes of non-specific lower back pain?
Lumbar strain/sprain, degenerative disc, degenerative facet joint, disc prolapse, spinal stenosis, compression fracture
28
What Sx might someone get in a compression fracture?
Sudden, severe onset pain radiating in a belt around the chest/abdomen. associated with osteoporosis
29
What are some causes of referred back pain?
Aortic aneurysm, acute pancreatitis, peptic ulcer disease, renal colic, endometriosis
30
What is Osteocartilaginous exostosis?
Benign outgrowth of cartilage with endochondral ossification
31
What is systemic lupus erythematous?
Multisystemic inflammatory, autoimmune connective tissue disease. HLA-B8, -DR2, -DR3
32
What autoantibodies may be present in SLE?
Anti-Nuclear antibodies >95% Anti-dsDNA antibody -specific to SLE - kidney involvement Anti-phosphlipid antibodies Anti-ribosomal antibodies - CNS involvement
33
What is first line treatment in mild SLE?
Hydroxychloroquine (DMARD) - blocks toll like receptors on PDCs - reducing IFN Then (for mild) NSAIDs, aspirin for clots, topical or low dose oral corticosteroids
34
What is compartment syndrome?
Elevated interstitial pressure within a closed fascial compartment, resulting in microvascular compromise
35
What is vasculitis?
An inflammatory condition of the blood vessel walls causing destruction or stenosis
36
How would you characterise Wegner's granulomatosis (Granulomatosis with polyangiitis)?
Granulomatous necrotising inflammatory lesions of the upper and lower respiratory tract often with pauci-immun glomerulonephritis.
37
What condition shows pencil in cup deformity on Xray?
Psoriatic arthritis
38
What HLA might be associated with SLE?
HLA- B8, - DR2, - DR3
39
List some clinical features included in the diagnostic criteria for lupus.
Malar rash, discoid rash, photosensitive rash Reynauds Haemolytic anaemia, leukopenia, thrombocytopenia Dry mouth and dry eyes Seizures, arthritis, pericarditis, pleuritis
40
Explain the immunological findings in SLE?
``` Anti-nuclear antibody Anti-dsDNA indicates kidney involvement Antiphospholipid antibody - Predispose to blood clots Anti-ribosomal - CNA involvement Reduction in C3 and C4 ```
41
How might you treat severe SLE?
DMARDs - Azathioprine, cyclophosphamide High dose corticosteroids Immunosuppressants Omeprazole, Aspirin
42
What causes gout (Sodium urate crystals)? | Recurrent attacks of a red, swollen, hot tender joint
Primary - genetic predisposition to hyperuricaemia - Lesch-nyhan syndrome Secondary - Myeloproliferative disease, leukaemia treated by chemo, chronic renal disease
43
What does Probenecid do?
Uricosuric agent - increases secretion of uric acid into the urine. Used in Gout
44
Define RA.
Inflammatory process characterised by polyarticular, symmetrical arthritis involving the hands, following a chronic course and can result in disability. Persistent for 6 weeks
45
What are some signs of systemic involvement of RA?
Weight loss, malaise, fever Subcutaneous nodules Pulmonary fibrosis, Anaemia, Pericarditis Felty's syndrome - splenomegaly, leukopenia, lymphadenopathy Vasculitis
46
What is first line treatment in RA? HLA- DR4 ** HLA- DR1
Conventional DMARDs - Suppress disease activity, slow progression Methotrexate - Folate antagonist, DNA replication and synthesis inhibitor. Monitor LFTs Sulfasalazine - immunomodulatory - inhibits T and B cells SE rash, headache. Monitoring. safe in preg Hydroxychloroquine - block toll like receptors on PDCs - IFN reduced. safe in pregnancy. SE muscles pain, rash
47
What are the treatment options in RA?
cDMARDs, bDMARDs (rituximab, infliximab, entercept) | Reduce inflammation - NSAIDs, steroids
48
bDMARDs are used in RA when failed on >/= 2 cDMARDs, list some bDMARDs.
TNF-alpha - Adalimumab, infliximab, entercept Anti- IL6 - Tocilizumab, Sarilumab Jak inhibitors - Tofactinib, Baricitnib
49
Define OA
Degenerative disease of the joints affecting all weight bearing joints, there is progressive degeneration of the articular cartilage.
50
What clinical features might be seen in OA? Early morning stiffness that worsens throughout the day
Haberden nodes - DIP Bouchards nodes - PIP Squaring of the base of the thumbs Swelling, crepitus, deformity
51
What are some complications of a joint replacement.
DVT, infection, swelling, stiffness, failure of the joint Hip - leg length discrepancy, f#, dislocation, hip noises Knee- F#, problems kneeling, dislocation, failure Aseptic loosening
52
How might osteonecrosis present?
Pain on weight bearing and with motion, night pain or rest pain. in later stages a limp, tenderness or restricted movement.
53
What are some causes of Osteonecrosis?
Sickle cell anaemia - rigid shape causes mechanical blockage Vascular damage in creases the intraosseous pressure - mechanical stress
54
How might giant cell vasculitis/ temporal arteritis present?
Jaw claudication - pain on chewing Visual loss - acute ischaemic optic neuritis - sudden painless loss of vision Temporal headache with tenderness (subacute, constant) Polymyalgia rheumatic symptoms Scalp tenderness noticed when brushing hair joint pain, more common in females
55
What are some clinical findings of giant cell arteritis?
Temporal artery asymmetry, thickening and loss of pulsatility
56
What would investigations of giant cell arteritis show? | Oral prednisolone
Gold standard - Temporal artery biopsy - multinucleated giant cells Temporal US - hypo echoic halo sign (mural thickening due to inflammation)
57
What are the classic features of Henoch Schönlein purpura? Associated with an UPPER RESP tract infection Common in children under 10 self-limiting to 4-16 weeks
``` Purpuric rash on the bum or lower legs Joint pain Abdominal pain IgA nephropathy ANCA negative, IgA deposits in BV ```
58
In a clinical setting how might you distinguish Granulomatosis with polyangitis from microscopic polyangitis (or eosinophilic graulomatosis with polyangitis)?
GPA - cANCA with proteinase 3 | MPA (or EGPA) - pANCA with myeloperoxidase
59
What is the classical triad of GPA? (use to be called Werner's granulomatosis) ANCA positive
upper airways - Rhinitis, chronic otitis media, saddle nose deformity (granulomatous necrotising inflammatory lesions of upper and lower tracts) lower airways - alveolar haemorrhage renal - pauci-immune glomerulonephritis
60
What tests would you get if you has suspected vasculitis?
ELISA - detecting ANCA for specific proteinase 3 (cANCA) and myeloperoxidase (pANCA) Indirect immunofluorescence of normal peripheral blood neutrophils (ANCA)
61
How would you manage vasculitis?
3-6 months Prednisolone in moderate ADD methotrexate or mycophenolate mofetil in severe ADD cyclophosphamide or rituximab Remission maintenance - 2+ years - Azathioprine or methotrexate
62
What is the MoA of Tacrolimus and what might it be used for?
Inhibits calcineurin, inhibiting T cell activation | Topical for eyes and skin, inflammatory conditions, organ transplant
63
Give an example of an anti-CD86 and a risk of taking it.
Abatacept | Increased risk of pneumonia and respiratory tract infections
64
Give an example of an anti-IL-1 and a risk of taking it.
Anakinra | Increased risk of pneumonia and respiratory tract infections
65
What is a risk of taking Rituximab?
Reactivation of Hep B
66
Explain how administration of fluid, bleeding or swelling in a compartment might cause compartment syndrome.
Increased pressure Venous flow decreases but arterial inflow continues to increase Fluid leaks - Oedema Increased pressure Arterial flow reduces and there is hypoxia After 4 hours may cause necrosis
67
What tests could you do to confirm compartment syndrome?
Examination - pallor, shiny, swelling, pulses, sweating tachycardia Exam- intracompartmental pressure - > 30mmHg Urinalysis - tea coloured due to increased myoglobin Lab test - big increase in CK and myoglobin
68
A woman has pain that radiates down her leg (radiculopathy), it increases when she coughs. The straight leg sign is positive and she has reduced reflexes. What could this be?
Disc prolapse - herniated nucleus pulposus
69
What is the clinical criteria to diagnose Ankylosing spondylitis? HLA-B27
Lower back pain and stiffness form >/=3 months which improves with exercise, but not relived by rest Limited motion of the lumbar spine Limited chest expansion
70
What is the radiological criteria to diagnose Ankylosing spondylitis?
Sacrolitis Grade >/=2 bilaterally Grade 3-4 unilaterally
71
How might you test for Sjögrens?
Schirmer's test to measure eye moisture using blotting paper. Anti-ro and Anti-Ia Ab ANA, Ig and RF may be raised
72
What skin presentation may indicate Anti-phospholipid antibody is present? (and so can indicate lupus)
Levido reticularis skin rash
73
What is the commonest primary bone tumour?
Myeloma
74
What are some clinical effects of myeloma?
Punched out lytic foci and generalised osteopenia Marrow replacement - anaemia, infections Ig excess - Bence jones protein Pepper pot skull (multiple tiny lucencies on X-ray)
75
What are some features of Osteosarcoma? | look at pic of it
``` A Malignant tumour who's cells form osteoid ** 10-25 years Site: Metaphysis of the long bones FH of Rb and Hx of pagets 'Sun burst sign' ```
76
What are some features of Pagets disease?
Elderly Excessive bone turn over, increased osteoclasts, increased bone formation, structurally weak bones with disorganised bone architecture. Vertebrae, skull, pelvis, femur Bone pain, deafness, bowing of long bones, pathological f#, pagets sarcoma*
77
What is osteocartilaginous exostosis?
Benign outgrowth of cartilage with endochondral ossification. Probably derived from growth plate. Adolescence. AD Metaphysis of long bone
78
What is Enchondroma?
Benign lobulated mass of cartilage within the medulla. | Hands and feet
79
Chondrosarcoma may arise from a pre-existing enchondroma or exostosis (osteocartilaginous exostosis) how would you differentiate?
CS - Axial skeleton, pelvis, ribs, shoulder girdle, pros femur OE - Metaphysis of long bones
80
Who may Ewings sarcoma affect?
5-15 year olds Diaphysis of long bones Early metastasis to lungs, bone marrow and bone t(11, 22) done on FISH