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JL Musculoskeletal > Week 2 > Flashcards

Week 2 Flashcards

1
Q

What is the definition of rheumatoid arthritis?

A

A chronic systemic inflammatory disease, characterised by potentially deforming symmetrical polyarthritis and extra-articular features (systemic disease)

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2
Q

What age group does rheumatoid arthritis tend to develop in and what is the female to male ration?

A

30-50

3:1

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3
Q

What genes may contribute to the cause of rheumatoid arthritis?

A

HLA, DR4 and DR1

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4
Q

Give two factors which may contribute to rheumatoid arthritis?

A
  1. Cigarette smoking

2. Infective aetiology

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5
Q

Name two differences between a normal joint and a rheumatoid arthritis affected joint?

A
  1. Tendon sheath becomes inflamed

2. Synovial membrane is inflamed

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6
Q

In relation to the pathology of rheumatoid arthritis: what does the synovium become laden with?

A

Macrophages, fibroblasts and multi-nucleated giant cells (resemble osteoclasts)

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7
Q

In relation to the pathology of rheumatoid arthritis: what does the synovial membrane do?

A

Expands, actively invades and erodes surrounding bone and cartilage

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8
Q

Give four articular symptoms of rheumatoid arthritis?

A
  1. Joint pain worst on waking and improve with activity
  2. Stiffness
  3. Joint swelling
    4, malaise and fatigue
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9
Q

Give four signs of rheumatoid arthritis?

A
  1. Swelling
  2. Tenderness
  3. Reduced range of movement
  4. Deformities
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10
Q

In teh arthritis classification criteria - what is definite RA defined by (3 things)?

A
  1. Presence of synovitis in at least 1 joint
  2. Absence of alternative better diagnosis explaining synovitis
  3. Achievement of total score of 6 or more
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11
Q

In the arthritis classification criteria - what are the 4 point scoring systems?

A
  1. Number and site of involved joint (0-5)
  2. Serological abnormality (0-3)
  3. Elevated acute phase response (0-1)
  4. Symptom duration (0-1)
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12
Q

Give four investigations for rheumatoid arthritis?

A
  1. Anti CCP (cyclic citrullinated peptide); RF (rheumatoid factor)
  2. Inflammatory markers - PV, CRP
  3. Anaemia of chronic disease
  4. Radiology - ultrasound
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13
Q

Give four late complications of RA?

A
  1. Infection
  2. Cervical myelopathy
  3. Interstitial lung disease
  4. Peripheral neuropathy
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14
Q

Is it a good prognosis if you are male and young at age of RA onset?

A

No

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15
Q

In RA what is the window of opportunity for treatment?

A

3 months

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16
Q

What is the first step treatment for RA?

A

Early initiation of disease modyfyfing drugs (DMARDs) with steroids to cover ‘lag phase’

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17
Q

What drugs used for RA are slow avting (weeks to months), reduce rate of joint damage?

A

DMARDs

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18
Q

Give a few examples of DMARDs?

A
  1. Methotrexate
  2. Sulfasalazine
  3. Leflumamide
  4. Hydroxychloroquine
  5. Penicillamine
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19
Q

4 biologic approaches have achieved major impact in RA - what do infliximab, adalimumab and etanercept belongto?

A

Tumour necrosis factor alpha inhibition

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20
Q

4 biologic approaches have achieved major impact in RA - what do Rituximab belong to?

A

B cell depletion

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21
Q

4 biologic approaches have achieved major impact in RA - what do Abatacept belong to?

A

Disruption of T cell costimulation

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22
Q

4 biologic approaches have achieved major impact in RA - what do anankira and tocilizumab belong to?

A

IL-1 inhibition and IL-6 inhibition

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23
Q

What four features define osteoarthritis?

A
  1. Articular cartilage failure
  2. Subchondral sclerosis
  3. Loss of joint space
  4. Subchondral cyst formation
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24
Q

What consists of predominantly collagen type 2 fibres linked by covalent bonds, conferring tensile strength?

A

Cartilage

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25
Q

In osteoarthritis what is there a loss of and release of?

A

Loss of matrix, release of cytokines (IL-1, TNF) and mixed metalloproteinases, prostaglandins

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26
Q

What occurs once there has been a loss of matrix in OA?

A

Fibrillation of the cartilage surface and attempted repair with osteophyte formation

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27
Q

What is the last stage process of OA?

A

No cartilage left so synovial fluid goes into bone causing cysts

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28
Q

What can previous injury, RA, genetic elements, acromegaly and calcium crystal deposition disease all lead to?

A

Secondary OA

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29
Q

Is OA more common in females or males?

A

Females

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30
Q

Name two occupations more at risk of OA?

A

Hairdressers and farmers

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31
Q

Describe the pain in OA?

A

Worse on activity and relieved by rest.

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32
Q

What is the stiffness like in OA?

A

Usually morning stiffness lasting less than 30 minutes. Inactivity gelling.

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33
Q

What 4 features can be found on examination in a patient with OA?

A
  1. Crepitus
  2. Bony enlargements due to osteophytes
  3. Joint tenderness
  4. Joint effusion
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34
Q

What spine segment is OA rarely seen in?

A

Thoracic

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35
Q

Name three joints in the hand affected by OA?

A

DIP, PIP and 1st CMC

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36
Q

In OA of the hands - where might bony enlargements be seen?

A

DIPs (Heverdens nodes)

PIPs (Bouchards nodes)

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37
Q

Give 2 features of OA in the knee?

A

Genu varus and valgus deformities

Bakers cysts

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38
Q

Give three features of the hip in OA?

A
  1. pain may be felt in groin or radiating to knee
  2. pain felt in hip may be radiating from the lower back
  3. hip movements restricted
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39
Q

In OA of the spine - what might osteophytes impinge on and what might happen in the lumbar section?

A

Nerve roots

Can cause spinal stenosis if encroach on spinal canal

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40
Q

What three pharmacological measures are done for OA?

A
  1. Analgesia
  2. NSAIDS
  3. Pain modulators - tricyclics
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41
Q

Name two intra-articular mananagements for OA?

A

Steroids and hyaluronic acid

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42
Q

What is the most effective treatment for OA?

A

Joint replacement

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43
Q

What is inflammation in the joint triggered by uric acid crystals?

A

Gout

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44
Q

Is gout more common in males or females?

A

Males

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45
Q

What stage in life is gout common to occur in?

A

After menopause

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46
Q

At what level of uric acid does it become insoluble?

A

> 0.42 mmol/l

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47
Q

What do inherited enzyme defects, myeloproliferative disorders, psoriasis, haemolytic disorders, alcohol and high dietary purine intake (red meat, seafood, corn)?

A

Increased urate production

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48
Q

What does chronic renal impairment, volume depletion (heart failure), hypothyroidism, diuretics and cytotoxics (cyclosporin)?

A

Reduced urate excretion

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49
Q

What three joints does acute gout present in?

A

1st MTP > ankle > knee

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50
Q

Does gout settle without treatment?

A

10 days without treatment

3 days with treatment

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51
Q

What condition is chronic joint inflammation, often diuretic associated and involves high serum uric acid?

A

Chronic tophaceous gout

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52
Q

What is tophi - found in chronic tophaceous gout?

A

Swelling in fingers and toes

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53
Q

What two things are raised in chronic tophaceous gout?

A
  1. Serum uric acid raised - may be normal during acute attack
  2. Raised inflammatory markers
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54
Q

What is the key investigation for chronic tophaceous gout?

A

Polarised microscopy of synovial fluid

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55
Q

What does chronic tophaceous gout look like on an x-ray?

A

Dense shadow streching from base of DIP to middle of pharynx

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56
Q

What are the three treatments for acute gout?

A
  1. NSAIDs
  2. Colchicine
  3. Steroids
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57
Q

What two drugs are used for the prophylaxis of gout?

A

Allopurinol

Febuxostat

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58
Q

When should you start prophylaxis treatment for gout?

A

2-4 weeks after acute attack

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59
Q

What condition is commoner in the elderly, chondrocalcinosis increases with age, is related to osteoarthritis and affects fibrocartilage - knees, wrists and ankles?

A

Calcium pyrophosphate deposition disease

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60
Q

What is another name for calcium pyrophosphate deposition disease?

A

Pseudo-gout

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61
Q

What are acute attacks of pseudo-gout due to?

A

Calcium pyrophosphate crystals

62
Q

What is the difference between uric acid crystals and pseudogout crystals?

A

Pseudogout - envelope shaped

Uric acid - long, sharp, needle like

63
Q

What are four treatments of psuedogout?

A
  1. NSAIDS
  2. Colchicine
  3. Steroids
  4. Rehydration
64
Q

What condition is Milwaukee shoulder associated with?

A

Hydroxyapatite

65
Q

In hydroxyapatite what is released?

A

Collagenases, serine proteinases and IL-1

66
Q

What are four treatments for hydroxyapatite?

A

NSAIDs
Intra-articular steroid injection
Physioltherapy
Partial or total arthroplasty

67
Q

What is the general term to describe pain that is caused by inflammation/damage to ligaments, tendons, muscles or nerve near a joint rather than either the bone or cartilage?

A

Soft tissue rheumatism

68
Q

What is the term for more generalised soft tissue pain?

A

Fibromyalgia

69
Q

Where is the commonest area for soft tissue pain?

70
Q

Where does cubital tunnel syndrome occur?

71
Q

Where does de-quervains tenosynovitis occur?

72
Q

Name two joint hypermobility syndromes?

A

Marfan’s

Ehlers Danlos

73
Q

What is the modified beighton score used for?

A

hyperextension and flexion

74
Q

What type of cause of muscle disease are polymyositis, dermatomyositis, inclusion body myositis, polymyalgia rheumatica?

A

Inflammatory

75
Q

What type of cause of muscle disease are hypo/hyperperthyroidism, cushings, hyperparathyroidism and diabetes mellitus?

76
Q

What type of cause of muscle disease are hypokalaemia, hypocalcaemia and hyponatraemia?

A

Electrolyte disorders

77
Q

Name a non-inflammatory cause of muscle disease?

A

Fibromyalgia

78
Q

Name two idiopathic inflammatory myopathies?

A

Polymyositis and dermatomyositis

79
Q

Are Polymyositis and dermatomyositis more common in females or males and what age group?

A

Females

40 - 50 years

80
Q

What is the most common presenting feature of polymyositis and dermatomyositis?

A

Muscle weakness - insidious onset, worsening over months, usually symmetrical and proximal muscles

81
Q

Name a cutaneous disease that has Gottrons sign, shawl sign and heliotrope rash?

A

Dermatomyositis

82
Q

Name a lung disease, oesophageal problem, cardiac disease associated with dermatomyositis?

A

Interstitial lung disease
Dysphagia
Myocarditis

83
Q

What is there a 15% incidence of in dermatomyositis?

A

Malignancy - risk greatest in men over 45 (ovarian, breast, stomach, lung etc)

84
Q

What two drugs can influence dermatomyositis?

A

Steroids and statins

85
Q

Is Raynauds indicative of dermatomyosiits?

86
Q

Name two examinations used to help diagnose dermatomyositis?

A

Confrontational testing - power

Isotonic testing - 30 second sit to stand test

87
Q

What investigation is mainly used for diagnosis of dermatomyositis?

A

Blood tests

88
Q

What four things are looked for in blood tests for dermatomyositis?

A

Muscle enzymes - CK
Inflammatory markers
Electrolytes, calcium, PTH, TSH
Autoantibodies

89
Q

What two autoantibodies are looked for in dermatomyositis?

A

ANA, Anti-Jo-1

90
Q

What other test (involves a probe) can be used to help diagnose dermatomyositis?

A

Electromyography - increased fibrillations, abnormal motor potentials, complex repetitive discharges

91
Q

In diagnosing dermatomyositis - what test is definitive and shows perivascular inflammation and muscle necrosis?

A

Muscle biopsy

92
Q

What investigation for dermatomyositis shows muscle inflammation, oedema, fibrosis and calcification?

93
Q

Give 5 treatments for dermatomyositis?

A
  1. Glucocorticoids
  2. Azathioprine
  3. Methotrexate
  4. Ciclosporin
  5. IV immunoglobulin
94
Q

What can be misdiagnosed in patients over 50 as polymyositis, is commoner in men and involves distal muscle weakness?

A

Inclusion body myositis

95
Q

Give two points on weakness in inclusion body myositis?

A
  1. Weakness wrist and finger flexors, quadriceps and anterior tibial muscles in legs
  2. Often asymmetrical weakness
96
Q

Are CK levels higher in polymyositis or inclusion body myositis?

A

Higher in PM

97
Q

What does a muscle biopsy for inclusion body myositis show?

A

Inclusion bodies and rimmed vacuoles

98
Q

What skin findigns are found in polymyositis?

99
Q

What is the difference between classic muscle biopsy findings in poly and dermatomyositis?

A

Poly - CD8 T cells

Derm - CD4 T cells

100
Q

What muscle disease occurs almost exclusively in >50s and is associated with temporal arteritis/giant cell arteritis?

A

Polymyalgia Rheumatica

101
Q

What is normal in polymyalgia rheumatica?

A

Muscle strength

102
Q

Where is ache felt in polymyalgia rheumatica?

A

In shoulder and hip girdle

103
Q

Give 5 clinical manifestations of temporal arteritis and giant cell arteritis?

A
  1. Headache
  2. Scalp tenderness
  3. Jaw claudication
  4. Visual loss
  5. Tende, enlarged, non-pulsatile temporal arteries
104
Q

What two conditions invole granulomatous arteritis of large vessels?

A

Temporal arteritis and giant cell arteritis

105
Q

What is raised in polymyalgia rheumatica?

A

Raised ESR, plasma viscosity and CRP

106
Q

How is polymyalgia rheumatica diagnosed?

A

Exclusion of other diagnoses

107
Q

How is polymyalgia rheumatica treated?

A

With low dose steroids - higher dose if temporal arteritis

108
Q

What is a common cause (more common in women) of chronic musculoskeletal pain and is not associated with inflammation?

A

Fibromyalgia

109
Q

What might fibromyalgia begin after?

A

Emotional or physical trauma

110
Q

What do fibromyalgia symptoms worsen on?

A

Exertion, fatigue and stress

111
Q

What are some clinical manifestations of fibromyalgia?

A

Pins and needles, headaches, depression, abdo pain (IBS), poor concentration anad memory

112
Q

Give two clinical findings of fibromyalgia?

A
  1. Excessive tenderness on palpitation of soft tissues

2. 11/18 tender points

113
Q

What is the definition of spondyloarthropathy?

A

Family of inflammatory arthritides characterised by involvement of both the spine and joints, principally in genetically predisposed (HLA B27) individuals.

114
Q

What are the four subgroups of spondyloarthropathy?

A
  1. Ankylosing spondylitis
  2. Psoriatic arthritis
  3. Reactive arthritis (Reiter’s)
  4. Enteropathic arthritis
115
Q

What is the difference between mechanical and inflammatory back pain?

A

Mechanical - worse on activity, worse at end of day, better with rest
Inflammatory - worse with rest, better on activity, early morning stiffness

116
Q

What is dactylitis? - it is shared by all spondyloarthropathies

A

Inflammation of entire digit

117
Q

Other than dactylitis - what three other features are shared by the spondyloarthropathies?

A

Sacroiliac and spinal involvement
Enthesitis
Inflammatory arthritis

118
Q

What is enthesitis?

A

Inflammation at insertion of tendons into bones - achilles tendinitis, plantar fasciitis

119
Q

Give four shared extra-articular features of spondyloarthropathies?

A
  1. Ocular inflammation (anterior uveitis, conjuntivitis)
  2. Mucocutaneous lesions
  3. Rare aortic incompetence or heart block
  4. No rheumatoid nodules
120
Q

What is the definition of ankylising spondilitis?

A

Chronic systemic inflammatory disorder that primarily affects the spine.

121
Q

What is the hallmark of ankyolising spondilitis?

A

Sacroiliac joint involvement (sacroiliitis)

122
Q

What disorder invilves peripheral arthritis (uncommon), enthesopathy, is more common in men and occurs in late adolescence or early adulthood?

A

Ankylosing spondilytis

123
Q

What is the 5 criteria for diagnosis of ankylosing spondylitis?

A
  1. Limited lumbar motion
  2. Lower back pain for 3 months - improved with movement
  3. Reduced chest expansion
  4. Bilateral sacroiliitis
  5. Unilateral sacroillitis
124
Q

Is amyloidosis a clinical feature of ankylosing spondylitis?

125
Q

Ankylosing spondylitis is the ‘A’ disease - give the 7 relations.

A 
Axial arthritis
Anterior uveitis
Aortic regurgitation
Apical fibrosis
Amyloidosis
Achilles tendinitis
plAntar fasciitis
126
Q

Give three examinations for ankylosing spondylitis?

A
  1. Tragus/occiput to wall
  2. Chest expansion
  3. Modified Schober test
127
Q

What bloods are checked in ankylosing spondylitis?

A

ESR, CRP, PV

HLA B27

128
Q

What three things are looked for on an x-ray of ankylosing spondylitis?

A

Sacroiliitis
Syndesmophytes
Bamboo spine

129
Q

What four drug treatments are used for treating AS?

A
  1. NSAID
  2. Disease modifying drugs
  3. Anti TNF
  4. Corticosteroids
130
Q

What drug is used in severe AS (BASDAI>4)?

A

Etanercept

131
Q

Give the definition for psoriatic arthritis?

A

Inflammatory arthritis associated with psoriasis, but 10-15% can have PsA without it

132
Q

Is psoriatic arthritis RF negative? and does it have rhematoid nodules?

A

It is negative

No nodules

133
Q

In Psoriatic arthritis - what happens to nails?

A

Pitting

Onycholysis

134
Q

Give four x-ray features of psoriatic arthritis.

A
  1. Marginal erosions and whiskering
  2. Pencil in cup deformity
  3. Osteolysis
  4. Enthesitis
135
Q

Give four treatment options for psoriatic arthritis.

A
  1. NSAIDS
  2. Corticosteroids
  3. Disease modifying drugs
  4. Anti-TNF
136
Q

What is an infection induced systemic illness characterised primarily by an inflammatory synovitis from which viable micro-organisms cannot be cultured?

A

Reactive arthritis (Reiter’s)

137
Q

In reactive arthritis - when do the symptoms occur?

A

1-4 weeks after infection

138
Q

Name four most common infections in reactive arthritis?

A

Urogenital - chalmydia

Enterogenic - salmonella, shigella, yersinia

139
Q

What is the triad for Reiter’s syndrome?

A

Urethritis
Conjuctivitis/uveitis/iritis
Arthritis

140
Q

In reactive arthritis is it symmetrical or asymmetrical monoarthritis?

A

Asymmetrical

141
Q

Name four musculocutaneous lesions in reactive arthritis?

A
  1. Keratodema
  2. Circinate balanitis
  3. Painless oral ulcers
  4. Hyperkeratotic nails
142
Q

Name two ocular clinical features of reactive arthritis?

A
  1. Conjuntivitis

2. Iritis

143
Q

Name two visceral manifestations of reactive arthritis?

A
  1. Mild renal disease

2. Carditis

144
Q

In reactive arthritis - how is it diagnosed?

A 
Inflammatory parameters (ESR, CRP, PV)
Cultures - blood, urine, stool
Joint fluid analysis
145
Q

In what time frame can reactive arthritis spontaneously resolve?

146
Q

Name the main treatment for reactive arthritis?

147
Q

What type of arthritis is associated with IBD?

A

Enteropathic arthritis

148
Q

What will 20% of patients with Crohns have in relation to enteropathic arthritis?

A

Sacroiliitis

149
Q

Give 5 ways to investigate enteropathic arthritis?

A
  1. GI endoscopy with biopsy
  2. Joint aspirate
  3. Raised CRP, PV
  4. X-rray showing sacroiliitis
  5. USS showing synovitis
150
Q

What should not be used to treat enteropathic arthritis?

151
Q

Give three pharmacological treatments for enteropathic arthritis?

A
  1. Steroids
  2. DMRDS
  3. Anti-TNF

JL Musculoskeletal (35 decks)

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