MSJ

Question 1

Myalgia

Answer 1

Muscle pain

Can be due to

• Viral infection
• Drugs (e.g statins)

Question 2

Tennis elbow

Golfer’s elbow

Answer 2

Tennis elbow
- Lateral epicondylitis

Golfer’s elbow
- Median epicondylitis

Question 3

Worldwide impact of MSK disorders

Answer 3

MSK
- 2nd cause of disability worldwide

Lower back pain
- Leading cause of disability

Question 4

Financial cost of MSK problem

Answer 4

10 billion cost on NHS

- 20% of GP complaints is MSK problem

Question 5

Septic arthritis

Answer 5

Presentation

• Monoarthritis
• Hot, swollen joint

Diagnosis

• Joint aspiration
• Gram staining for infection–> mainly Strep. infection

Mortality rate- 11% mortality rate, 50% if polyarticular

Question 6

Gout

• Cause
• Risk factors

Answer 6

Most common inflammatory arthropathy worldwide

Cause:

• High serum urate levels (>408)–> precipitation of monosodium rate crystals (negatively birefringent rods)
• 10% with hyperuricaemia develop it

Risk factors

• Men, >40
• Women >65
• Genetics
• CKD
• Metabolic syndrome
• Oestoarthritis
• Dietary factors (alcohol, red meat, cauliflower, spinach, shellfish, muscles)
• Loop and thiazide diuretics use

Question 7

Pseudogout

Answer 7

Precipitation of calcium pyrophosphate crystal in joints. (positively birefringent rods)

Question 8

Management of gout

Answer 8

Acute attacks

• NSAIDs (naproxen)
• Colchicine
• Steroids [intrarthticular, systemic)

Long term treatment
- Urate-lowering therapy: allopurinol, febuxostat

Question 9

Rheumatoid arthritis epidemiology

Answer 9

0.5-1% word

More common in women (3:1)
- Peak 45-65

30% genetic susceptibility w/ environmental factors

Question 10

RA pathophysiology

Answer 10

Changes first occur in synovial

Smoking is the most important triggering environmental factor.
- Triggers generation of ACPA (Ab) which triggers RA

Mechanism

1. Lymphocyte invade synovium–> acute inflammation
2. Vascular permeability increases= synovial proliferation, panes formation
3. Cartilage destruction and bone erosion

Question 11

RA signs and symptoms

Answer 11

Symmetrical pain

Swelling of small joints of the hands and feet
- MCP, PIP, wrist, MTP, not DIPs

Early morning stiffness (>1 hour)

Systemically unwell

Malaise, fatigue

Question 12

Extra-articular manifestation of RA

Answer 12

Nodules

Bursitis/ tenosynovitis

Eye problems: secondary Sjogren’s syndrome, scleritis

Splenomegaly

Atlanto-axial subluxation

Carpal tunnel syndrome

Renal amyloidosis

Increases risk of CVD

Anaemia

Lung fibrosis

Question 13

RA investigations

Answer 13

FBC- anaemia of chronic disease
- Normocytic normochromic

Rheumatoid factor positive
- IgM ab against Fc component of IgG (1 in 20 is raised in normal population)

Anti CCP Ab
- 98% specific

ESR and CRP

X-ray of hands and feet

• initially periarticular osteoporosis and reduced joint space
• Cysts

Question 14

RA management

Answer 14

NSAIDs for short peroids

Corticosteroids

• 1/2 joints infected= intra-articular injection
• Systemic if more joints affected (tablet/ intramuscular)

DMARDs (disease modifying Anti-Rheumatic drugs)

• Methotrexate
• Sulfasalazine
• Hyrdoxychloroquine
• Leflunomide

If not responding to DMARDs= biologic agents

• Anti-TNF agents
• Anti-B cell
• Anti-IL-6R blocker
• Anti-T cells
• JAK-2 inhibitor (tablet)

Physiotherapy, occupation therapy, podiatry

Question 15

Osteoarthritis

- Epidemiology

Answer 15

70% of people >65

common joints affected

• 1st carpometacarpal joint
• PIP, DIP

Question 16

Osteoarthritis pathophysiology

Answer 16

Metabolically active, starting in the cartilage
- Articular cartilage focally destroyed

Remodelling of adjacent bone causes formation of osteophytes

Further remodelling and repair

Secondary synovial inflammation and crystal deposits.

Question 17

Osteoarthritis clinical features

Answer 17

Clinical diagnosis, blood test and imaging not very helpful

Morning stiffness, <30 minds

Persistent joint pain aggravated on use

Crepitus

Bony enlargement and tenderness

No clinical correlation in X-rays with symptoms

Question 18

SLE epidemiology

Answer 18

97:100k

More common in females (10-20 times more than males)

More common in afro-carribeans

Question 19

SLE pathophysiology

Answer 19

Genetic susceptibility and UV light exposure= abnormal immune response
- Immune complexes attack many tissues in the Body.

Question 20

SLE presentation

Answer 20

Malar rash

Inflammation of lung and heart

• Pericarditis
• Serositis
• Endocarditis

Arthritis

Glomerulonephritis

Anaemia, thrombocytopenia

Question 21

SLE investigations

Answer 21

Urinanlaysis
- protein: creatinine ratio

FBC

ESR high

Not high CRP (unless serositis)

Antibodies

• Anti-nuclear
• Lupus anticoagulant

C3, C4 (low)