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Third year > Week 11- MSK > Flashcards

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
Q

Why must you check for TPMT before administering Azathioprine?

A

It is an enzyme that reduces active drug in cells. Without it there is accumulation of active metabolites in cells- severe toxicity

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26
Q

What does cyclosporin so?

A

Inhibits Calcineurin. Inhibits T cell activation

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27
Q

What are some causes of non-specific lower back pain?

A

Lumbar strain/sprain, degenerative disc, degenerative facet joint, disc prolapse, spinal stenosis, compression fracture

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28
Q

What Sx might someone get in a compression fracture?

A

Sudden, severe onset pain radiating in a belt around the chest/abdomen. associated with osteoporosis

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29
Q

What are some causes of referred back pain?

A

Aortic aneurysm, acute pancreatitis, peptic ulcer disease, renal colic, endometriosis

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30
Q

What is Osteocartilaginous exostosis?

A

Benign outgrowth of cartilage with endochondral ossification

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31
Q

What is systemic lupus erythematous?

A

Multisystemic inflammatory, autoimmune connective tissue disease.
HLA-B8, -DR2, -DR3

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32
Q

What autoantibodies may be present in SLE?

A

Anti-Nuclear antibodies >95%
Anti-dsDNA antibody -specific to SLE - kidney involvement
Anti-phosphlipid antibodies
Anti-ribosomal antibodies - CNS involvement

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33
Q

What is first line treatment in mild SLE?

A

Hydroxychloroquine (DMARD) - blocks toll like receptors on PDCs - reducing IFN
Then (for mild)
NSAIDs, aspirin for clots, topical or low dose oral corticosteroids

34
Q

What is compartment syndrome?

A

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

35
Q

What is vasculitis?

A

An inflammatory condition of the blood vessel walls causing destruction or stenosis

36
Q

How would you characterise Wegner’s granulomatosis (Granulomatosis with polyangiitis)?

A

Granulomatous necrotising inflammatory lesions of the upper and lower respiratory tract often with pauci-immun glomerulonephritis.

37
Q

What condition shows pencil in cup deformity on Xray?

A

Psoriatic arthritis

38
Q

What HLA might be associated with SLE?

A

HLA- B8, - DR2, - DR3

39
Q

List some clinical features included in the diagnostic criteria for lupus.

A

Malar rash, discoid rash, photosensitive rash
Reynauds
Haemolytic anaemia, leukopenia, thrombocytopenia
Dry mouth and dry eyes
Seizures, arthritis, pericarditis, pleuritis

40
Q

Explain the immunological findings in SLE?

A 
Anti-nuclear antibody 
Anti-dsDNA indicates kidney involvement
Antiphospholipid antibody - Predispose to blood clots
Anti-ribosomal - CNA involvement 
Reduction in C3 and C4
41
Q

How might you treat severe SLE?

A

DMARDs - Azathioprine, cyclophosphamide
High dose corticosteroids
Immunosuppressants
Omeprazole, Aspirin

42
Q

What causes gout (Sodium urate crystals)?

Recurrent attacks of a red, swollen, hot tender joint

A

Primary - genetic predisposition to hyperuricaemia - Lesch-nyhan syndrome
Secondary - Myeloproliferative disease, leukaemia treated by chemo, chronic renal disease

43
Q

What does Probenecid do?

A

Uricosuric agent - increases secretion of uric acid into the urine. Used in Gout

44
Q

Define RA.

A

Inflammatory process characterised by polyarticular, symmetrical arthritis involving the hands, following a chronic course and can result in disability.
Persistent for 6 weeks

45
Q

What are some signs of systemic involvement of RA?

A

Weight loss, malaise, fever
Subcutaneous nodules
Pulmonary fibrosis, Anaemia, Pericarditis
Felty’s syndrome - splenomegaly, leukopenia, lymphadenopathy
Vasculitis

46
Q

What is first line treatment in RA?
HLA- DR4 **
HLA- DR1

A

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
Q

What are the treatment options in RA?

A

cDMARDs, bDMARDs (rituximab, infliximab, entercept)

Reduce inflammation - NSAIDs, steroids

48
Q

bDMARDs are used in RA when failed on >/= 2 cDMARDs, list some bDMARDs.

A

TNF-alpha - Adalimumab, infliximab, entercept
Anti- IL6 - Tocilizumab, Sarilumab
Jak inhibitors - Tofactinib, Baricitnib

49
Q

Define OA

A

Degenerative disease of the joints affecting all weight bearing joints, there is progressive degeneration of the articular cartilage.

50
Q

What clinical features might be seen in OA?

Early morning stiffness that worsens throughout the day

A

Haberden nodes - DIP
Bouchards nodes - PIP
Squaring of the base of the thumbs
Swelling, crepitus, deformity

51
Q

What are some complications of a joint replacement.

A

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
Q

How might osteonecrosis present?

A

Pain on weight bearing and with motion, night pain or rest pain. in later stages a limp, tenderness or restricted movement.

53
Q

What are some causes of Osteonecrosis?

A

Sickle cell anaemia - rigid shape causes mechanical blockage
Vascular damage in creases the intraosseous pressure - mechanical stress

54
Q

How might giant cell vasculitis/ temporal arteritis present?

A

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
Q

What are some clinical findings of giant cell arteritis?

A

Temporal artery asymmetry, thickening and loss of pulsatility

56
Q

What would investigations of giant cell arteritis show?

Oral prednisolone

A

Gold standard - Temporal artery biopsy - multinucleated giant cells
Temporal US - hypo echoic halo sign (mural thickening due to inflammation)

57
Q

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

A 
Purpuric rash on the bum or lower legs
Joint pain
Abdominal pain
IgA nephropathy 
ANCA negative, IgA deposits in BV
58
Q

In a clinical setting how might you distinguish Granulomatosis with polyangitis from microscopic polyangitis (or eosinophilic graulomatosis with polyangitis)?

A

GPA - cANCA with proteinase 3

MPA (or EGPA) - pANCA with myeloperoxidase

59
Q

What is the classical triad of GPA?
(use to be called Werner’s granulomatosis)
ANCA positive

A

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
Q

What tests would you get if you has suspected vasculitis?

A

ELISA - detecting ANCA for specific proteinase 3 (cANCA) and myeloperoxidase (pANCA)
Indirect immunofluorescence of normal peripheral blood neutrophils (ANCA)

61
Q

How would you manage vasculitis?

A

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
Q

What is the MoA of Tacrolimus and what might it be used for?

A

Inhibits calcineurin, inhibiting T cell activation

Topical for eyes and skin, inflammatory conditions, organ transplant

63
Q

Give an example of an anti-CD86 and a risk of taking it.

A

Abatacept

Increased risk of pneumonia and respiratory tract infections

64
Q

Give an example of an anti-IL-1 and a risk of taking it.

A

Anakinra

Increased risk of pneumonia and respiratory tract infections

65
Q

What is a risk of taking Rituximab?

A

Reactivation of Hep B

66
Q

Explain how administration of fluid, bleeding or swelling in a compartment might cause compartment syndrome.

A

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
Q

What tests could you do to confirm compartment syndrome?

A

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
Q

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?

A

Disc prolapse - herniated nucleus pulposus

69
Q

What is the clinical criteria to diagnose Ankylosing spondylitis?
HLA-B27

A

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
Q

What is the radiological criteria to diagnose Ankylosing spondylitis?

A

Sacrolitis
Grade >/=2 bilaterally
Grade 3-4 unilaterally

71
Q

How might you test for Sjögrens?

A

Schirmer’s test to measure eye moisture using blotting paper.
Anti-ro and Anti-Ia Ab
ANA, Ig and RF may be raised

72
Q

What skin presentation may indicate Anti-phospholipid antibody is present? (and so can indicate lupus)

A

Levido reticularis skin rash

73
Q

What is the commonest primary bone tumour?

A

Myeloma

74
Q

What are some clinical effects of myeloma?

A

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
Q

What are some features of Osteosarcoma?

look at pic of it

A 
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
Q

What are some features of Pagets disease?

A

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
Q

What is osteocartilaginous exostosis?

A

Benign outgrowth of cartilage with endochondral ossification. Probably derived from growth plate. Adolescence. AD Metaphysis of long bone

78
Q

What is Enchondroma?

A

Benign lobulated mass of cartilage within the medulla.

Hands and feet

79
Q

Chondrosarcoma may arise from a pre-existing enchondroma or exostosis (osteocartilaginous exostosis) how would you differentiate?

A

CS - Axial skeleton, pelvis, ribs, shoulder girdle, pros femur
OE - Metaphysis of long bones

80
Q

Who may Ewings sarcoma affect?

A

5-15 year olds
Diaphysis of long bones
Early metastasis to lungs, bone marrow and bone
t(11, 22) done on FISH

Third year (15 decks)

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