Week 11- MSK Flashcards
What are the key pathological features on an X-ray in osteoarthritis?
Subchondral sclerosis joint space narrowing osteophytes cyst formation LOSS
What are the management options in osteoarthritis?
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
What can happen if there is incorrect alignment in a joint replacement?
Compromise function, patellar femoral problems, premature loosening, abnormal wear
What vessels does Giant cell artery vasculitis affect?
Aorta and its major branches
What is the gold standard investigation in Giant cell artery vasculitis?
Temporal artery biopsy
Name some drugs used in treating Gout?
Colchicine
Allopurinol, febuxostat
What malignancies are highly suspicious in back pain?
Lung, Prostate, thyroid, breast, kidney
What is the pain like in inflammatory back pain?
Early morning stiffness >30min
Gets better with exercise
Sore at rest
May wake at night
What is ankylosing spondylitis
Chronic inflammatory rheumatic disease of unknown cause. HLA B27
bilateral sacroilitis, bamboo spine
Define osteonecrosis or Avascular necrosis.
Bone infarction near a joint
There is death of subchondral bone
Crescent sign on X-ray
What are some risk factors for avascular necorosis
Cushing's or corticosteroid use Sickle cell anaemia or haemaglobinopathies History of trauma Alcohol abuse HIV, bisphosphonates, renal failure, SLE
Give some examples of Sclerotic metastasis
Breast carcinoms
Prostate carcinoma
Carcinoid tumour
Give some examples of Solitary bone mestastasis
Renal carcinoma
Thyroid carcinoma
What is compartment syndrome?
Elevated interstitial pressure within a closed fascial compartment, resulting in microvascular compromise.
What is spondylolithesis?
Slip of one vertebrae on the one below. Defect in the Pars interarticularis.
What is pagets disease?
Increased bone turnover. osteoclastic and osteoblastic activity
Raised alkaline phosphatase (OB produce it)
What is the blade of grass sign?
Indicates the lytic phase of pagets disease
How might Psoriatic arthritis present on X-ray?
DIP joints
Pencil in cup deformity
Resorption of distal phalanges
How can you differentiate gout from pseudo-gout?
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
What is reactive arthritis?
Seronegative, Strong HLA-B27 associaiton
A sterile arthritis, typically affecting the lower limb following a precious infection. Eneteric - salmonella, shigella, campylobacter. GU- mycoplasma genitalium, n.gonorrhoea
What are some signs of reactive arthritis
Urethritis, conjunctivitis, arthritis
Warm, swollen, tender, asymmetrical, systemically unwell
Plantar fasciitis, keratoderma blenorrhagica
What are some systemic manifestation of RA?
Feltys syndrome (splenomegaly, leukopenia, lymphadenopathy) Pericarditis, vasculaires, SC nodules, malaise, weight loss
How do NSAIDs inhibit F# healing?
Reduce local vascularity at the fracture site
What does Azathioprine do?
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
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
What does cyclosporin so?
Inhibits Calcineurin. Inhibits T cell activation
What are some causes of non-specific lower back pain?
Lumbar strain/sprain, degenerative disc, degenerative facet joint, disc prolapse, spinal stenosis, compression fracture
What Sx might someone get in a compression fracture?
Sudden, severe onset pain radiating in a belt around the chest/abdomen. associated with osteoporosis
What are some causes of referred back pain?
Aortic aneurysm, acute pancreatitis, peptic ulcer disease, renal colic, endometriosis
What is Osteocartilaginous exostosis?
Benign outgrowth of cartilage with endochondral ossification
What is systemic lupus erythematous?
Multisystemic inflammatory, autoimmune connective tissue disease.
HLA-B8, -DR2, -DR3
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
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
What is compartment syndrome?
Elevated interstitial pressure within a closed fascial compartment, resulting in microvascular compromise
What is vasculitis?
An inflammatory condition of the blood vessel walls causing destruction or stenosis
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.
What condition shows pencil in cup deformity on Xray?
Psoriatic arthritis
What HLA might be associated with SLE?
HLA- B8, - DR2, - DR3
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
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
How might you treat severe SLE?
DMARDs - Azathioprine, cyclophosphamide
High dose corticosteroids
Immunosuppressants
Omeprazole, Aspirin
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
What does Probenecid do?
Uricosuric agent - increases secretion of uric acid into the urine. Used in Gout
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
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
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
What are the treatment options in RA?
cDMARDs, bDMARDs (rituximab, infliximab, entercept)
Reduce inflammation - NSAIDs, steroids
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
Define OA
Degenerative disease of the joints affecting all weight bearing joints, there is progressive degeneration of the articular cartilage.
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
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
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.
What are some causes of Osteonecrosis?
Sickle cell anaemia - rigid shape causes mechanical blockage
Vascular damage in creases the intraosseous pressure - mechanical stress
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
What are some clinical findings of giant cell arteritis?
Temporal artery asymmetry, thickening and loss of pulsatility
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)
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
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
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
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)
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
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
Give an example of an anti-CD86 and a risk of taking it.
Abatacept
Increased risk of pneumonia and respiratory tract infections
Give an example of an anti-IL-1 and a risk of taking it.
Anakinra
Increased risk of pneumonia and respiratory tract infections
What is a risk of taking Rituximab?
Reactivation of Hep B
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
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
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
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
What is the radiological criteria to diagnose Ankylosing spondylitis?
Sacrolitis
Grade >/=2 bilaterally
Grade 3-4 unilaterally
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
What skin presentation may indicate Anti-phospholipid antibody is present? (and so can indicate lupus)
Levido reticularis skin rash
What is the commonest primary bone tumour?
Myeloma
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)
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'
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*
What is osteocartilaginous exostosis?
Benign outgrowth of cartilage with endochondral ossification. Probably derived from growth plate. Adolescence. AD Metaphysis of long bone
What is Enchondroma?
Benign lobulated mass of cartilage within the medulla.
Hands and feet
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
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
