Year 5 MSK questions Flashcards
Is septic arthritis more common in native or prosthetic joints
more common in prosthetic joints
what is the most common causative agents for spetic arthritis
1) streptococci
2) Staphylocccus aureus
3) Neisseria gonorrhoea
4) HIB in children
5) TB
S. Aureus is the most common causative agent
but all other options here are also common causative agents –> streptococci 2nd most common
What is the most important diagnostic investigation for septic arthritis
1) FBC
2) CRP/ESR
3) urgent joint aspiration
4) X-ray of affected joint
5) Skin swabs/sputum/throat swab/urine culture
most important investigation =urgent joint aspiration –> for synovial fluids gram stain and culture & synovial fluids WBC
all options here are required investigations
Which of the following is the most appropriate & common management for septic arthritis
1) immobilise joint to prevent muscle stiffness and wasting
2) flucloxacillin & sodium fusidate for 1-2 weeks
3) flucloxacillin & gentamicin for 1-2 weeks
4) Oral penicllin, ciprofloxacin for 2 weeks
flocloxacillin and sodium fusidate for 1-2 weeks = most common initial treatment for S.aureus infection
immobilise joint to prevent muscle stiffness and wasting - should do in all scenarios
flucloxacillin & gentamicin for 1-2 weeks = if immunosuppressed
Oral penicllin, ciprofloxacin for 2 weeks = if gonococcus/meningocccus
Ticoplanin = if MRSA
what is another name for temporal arteritis
giant cell arteritis
which artery does temporal arteritis most commonly affect
1) abdominal aorta
2) internal carotid artery
3) external carotid artery
external carotid artery whcih supplies the temporal side of the face, jaw and back of haed
which of the following symptom is most resemblant for late stage temporal artertitis?
1) temproal headahce
2) scalp tenderness
3) Dipolar/blurred vision/amaurosis fugax
4) facial pain
5) jaw/tongue claudication
3) Dipolar/blurred vision/amaurosis fugax - can also lead to perminant vision loss
all other options are symptoms of temproal arteririts but much earlier stage
which of the following conditon is associated with temproal arteritis?
1) polymyalgia rheumatica
2) aortic aneruysm/dissection
3) intermittent or persistent brain ischaemia/brain stem stroke
4) subclavian steal syndrome
5) all of the above
5) all of the above
polymyalgia rheumatica - same spectrum of disease
subclavian steal syndriome = intermittent or persistent brain ischaemia/brain stem stroke
what is the most important investigation for temporal arteritis
temporal artery biopsy
what does temporal artery biopsy show
vasculitis characterised bt predominance of mononuclear cell infiltration or ganulomatous inflammation, giant cell
which of the following is the most appropriate initial treatment for tmproal arteritis without visual symptoms
1) prednisolone 60mg + aspirin 75 mg
2) prednisolone 40mg + aspirin 75 mg
3) prednisolone 20mg + aspirin 75 mg
4) prednisolone 60mg + aspirin 150 mg
5) prednisolone 40mg + aspirin 150 mg
2) prednisolone 40mg + aspirin 75 mg - for TA without visual symptoms
prednisolone 60mg + aspirin 75 mg - for TA with visual symptoms + urgent same day opatham referral
what are some of the symptoms of cauda equina syndrome
pain
radicular sensory changes
loss of sensation in perianal area
leg weakness
loss of bowel and bladder function
what are some of the clinical features of spinal cord compression
backpain
numbness/paraesthesia
weakness or paralysis
bladder and bowel dysfunction
hyper-reflexia
sensory loss
muscle weakness or wasting
loss of tone below the level of suspected injury
hypotension and bradycardia (neurogenic shock)
which of the following is the most important investigation for spinal cord compression in the event of a trauma
1) MRI spine
2) CT head
3) CT Spine
CT spine
Management of spinal cord compression caused by acute trauma
Immobilisation + decompression/stabilisation surgery
IV corticosteroid –> dexamethasone
VTE prophylaxis
maintenance of volume and BP
prevention of gastric ulcers
nutritional support
Management of non-traumatic intervertebral disc compression
decompressive laminectomy
VTE prophylaxis
Management of SCC caused by malignant spinal compression
16 mg dexamethasone +/- surgery +/- radiotherapy
Is male or female more susceptive for osteoarthritis
Female is 3 x male
what is the pathophysiology of osteoarthritis
damage to cartilage –> repair attempt but is disordered –> cartilage ulceration exposes underlying bone to inc stress –> bone attempts to repair but produces abnor sclerotic subchondral bone and overgrowth at join margins (osteophytes)
which of the following secondary causes of osteoarthitis
1) RA
2) Gout
3) Seronegative spndyloarthropathy
4) Paget’s disease of bone
5) all of the above
RA gout seronegative spondyloarthropathy Paget's disease of bone vascular necrosis eg corticosteriod therapy haemarthrosis
which of the following symptom is not commonly associated with osteoarthritis
1) relieved by rest
2) worse on exercise
3) worse on rest
4) involvement of PIP joint
worse on rest - it is more common associated with RA
what are the acronym “LOSS” stands for when it is related to radiological changes caused by osteoarthritis
Loss of joint space
Osteophytes
Subarticular sclerosis
Subchondral cysts
which of the following is an appropriate management for osteoarthritis
1) azathioprine
2) vit D - calcium supplement
3) Bisophopnates
4) topical capsaicin
4) None of the above
topical capsaicin
which T score describes osteoporosis
1) -1.4
2) -1.9
3) -2.4
4) -2.9
5) -3.4
4) T score of -2.5 or less (ie 2.5 SD lower to the median number) = osteoporosis
- 1 to -2.5 = osteopenia
- 1 = normal
T score of -2.5 or less & 1 fracture = severe osteoporosis
what is the single most important clinical feature of osteoporosis
low-trauma fragility fracture
what is the most used risk assessment of osteoporosis fracture risk
FRAX risk assessment (10 - year risk of fracture)
what is the most important investigation conducted for osteoporosis
DEXA scan - bone density scan conducted in either the hip, wrist and spine
what is the general regime of managing osteoporosis
Vit D + calcium = colecalciferol
Bisphosphonates (alendronate) reduced activity of osteocast
What is the main pathology/aetiology of ankylosing Spondylitis
a from of chronic inflammation of bones which results in fusion of the bones, especially common in the spine and iliosacro joint
aetiology unknown
what is the gene affected in ankylosing spondylitis
HLA B27
what are some of the most common intra-articular symptoms of ankylosing spondylitis
back/buttock pain which is worsen by rest and improved by exercise.
morning pain is common
Chest pain can be present due to involvment of costosternal / costovertebral joints
reduced range of movment
Question Mark Posture –> loss of lumbar lordosis, exaggravated thoracis kyphosis with neck sticking forward like a question mark
Peripheral enthesitis –> where tendon and ligament insert into bone –> causing plantar fascilitis & Achilles tedonitis
Peripheral athritis –> hip, shoulder and chest wall
what are some of the most common extra-articular symptoms of ankylosing spondylitis
fever, weight loss, fatigue
acute anterior uveitis
aortitis & aortic regurgitation & heart block
IgA nephropathy & amyloidosis
cauda equina syndrome, atlanto-axial subluxation
osteopenia nad osteoporosis
investigation for ankylosing spondylitis
FBC - normochromic normocytic anaemia of chronic disease
U&E - kidney damage
ALP - elevated due to chronic disease
CRP - often elevated
X-ray of the joint involved - most helpful
MRI - for early AS
DEXA - osteoporosis
Schober’s test
which creteria is used to diagnose AS
modiefed New York Criteria
Clinical criteria
1) low back pain for > 3 months - worsened by rest and improve by exercise
2) limitation of lumbar spine motion
3) limit to chest wal expanision
Radiological criteria
1) sacroiliitis in X-ray
Definite AS = radiological + at least 1 of clinical criteria
Possible AS = all 3 clinical criteria or just radiological criteria
Management for anklosing spondylitis ?
symptoms control
1st line - NSAIDs + PPI +/- pain ladder
2nd line - TNF-alpha inhibitos (etanercept) / mnoclonal antibody against TNF eg (adelimumab)
oral corticosteriods for short term measurement
Is male more common to get RA or OA
Neither - female more common to get both
what is the pathophysiology of RA
production of rheumatoid factor in synovium by plasma cells
rheumatoid factor interact with macrophages, T and B cells –> overproduction of TNF & macrophages also releases chemoattrants to de-activate osteoblast but activate osteoclast –> bone erosion & further bone damages
which genes are more susceptible to RA
HLA-DR4 and HLA-DRB
what are the most prominent associating symptoms of RA
joint pain most commonly affecting the MCP, PIP (DIP is usually OA and never affected)
worse with rest and better with exercise
progressive, symmetricla, peripheral polyarthritis
ulnar deviation, Z thrumb, swan neck & Boutonniere deformity
what are some of the common extra-artiuclar problem of RA
fatigue and weakness
vasculitis
fibrosing alveolitis
pleural and pericardial effusions
Raynaud’s
carpel tunnel syndrome
splenomegaly
osteoporosis
amyloidosis
which criteria is used to diagnose RA
the ACR/EULAR 2010 criteria for RA
if more than 6/10 = diagnostic
what are some of the investigations for RA
FBC - anaemia
U&E
CRP/ESR - acute phase proteins
Serology - rheumatoid factors & anti citrullinated peptide antibodies
X-ray of affected joints
aspiration of joint to exclude septic arthritis
what is the mainstay management of RA
simple analgesia +/- NSAIDs or COX2 inhibitors
DMARDs - disease modifying antirhuematic rugs eg methotrexate, sulfaszalazine, leflunomide
corticosteroids - short term measure - oral/intra-articular injection
what is the treatment
Methotrexate + 1x DMARDs + glucocorticoids (cortisone)
which drug can you use if RA fails to response
if 2 x 6 month trial of traditional DMARDs therapy fails to control symptoms
Definition of Polymyalgia Rheumatica
inflammatory condition of unknown cause which is characterised by severe bilateral pain and morning stiffness of the shoulder neck and pelvic girdle
what is the earliest age which polymyalgia rheumatica has been reported?
50 yrs old
what are the 4 diagnostic criteria for polymyalgia rheumatica
1) 50 yrs old
2) subacute/acute onset of bilateral, severe and persistent pain in the neck, shoulder and pelvic girdle
3) morning stiffness > 45 min
4) evidence of acute phase response (raised ESR/CRP) - can still be diagnosed if ESR/CRP normal if classic clinical picture & response to steroids
what are some of the clinical features of polymyalgia rheumatica
pain in the neck, shoulder and pelvic girdle
morning stiffness
proximal weakness
systemic - low grade fever, malaise, fatigue, anorexia, weight loss, depression
upper arm tenderness
carpal tunnel syndrome
investigations for polymyalgia rheumatica
basically a diagnosis of exclusion
ESR/CRP
FBC, U&Es, LFT, Bone profile, TFTs, CK
protein electrophoresis
Rheumatoid factors
Urinary Bence Jones’ protein (multiple myeloma)
Anti-nuclear antibody (SLE)
USS of shoulder +/- hip if uncertain subdeltoid bursitis
what is the treatment for polymyalgia rheumatica
prednisolone
weak 1-3 15mg daily prednisolone then reducing dose
what causes gout
accumulation of uric acid which results in crystal in the joint space –> can be explained by increase purine intake from cheese, meat and red wine
is male or female more likely to get gout
male 3.6:1
which joint is the most commonly affected joints in Gout
big toe, metattatso-phalangeal joint (then ankle, wrist, base of thumb)
what are some of the clinical features of gout
sudden onset severe pain associated with swelling, redness, warmth and tenderness –> reach max pain in 24 hours
Tophi maybe able to be felt
what are the investigations for gout
asppiration of joints –> -ve birefringence polarised light
joint x-ray - space between joint maintined, lytic lesions, punched out erosions,
serum uriac acid - not acute phase investigation
management of gout
acute flare
- NSAIDs (diclofenac) + PPI
- colchicine
prophylaxis
- allopurionol/ febuxostat
which molecules cause pseudogout
calcium pyrophosphate
which of the following is a risk factor for pseudogout
1) inc meat consumption.
2) hypoparathyroidism
3) infection
4) haemochromatosis
5) CKD
Haemochromatosis
other causes • Dehydration • intercurrent illness • hyperparathyroidism • long-term use of steroids • hypothyroidism • any causes of arthritis • haemochromatosis • Wilson’s disease • Acromegaly • Dialysis
single most prominent clinical features for pseudogout
sudden onset, red, hot, tender joint & swelling in one joint
which does pseudogout affects the most?
knee –> wrist –> shoulders –> ankles –> hands and feet
investigation for pseudogout?
join spiration –> _ve bifringement in polarised light
joint x-ray –> linear opacification of articular cartilage
serum calcium - elevated
serum PTH - elevated
management of pseudogout
supportive + symptomatic control - RICE, NSAIDs, colchicine
