MSK Flashcards

Question

Prevention of osteoporosis?

Answer 1

For patients taking oral/high-dose inhaled steroids for \>3 months, or frequent courses, in addition: * Add bone protection (bisphosphonates) for patients \>65y or with history of fragility fracture, or * Refer patients \<65y without history of fragility fracture for DEXA scan, and add bone protection agent if T-score is \<1.5.

Answer 2

**_Early_** * Swollen MCP, PIP, wrist or MTP joints (symmetrical) **_Later_** * Ulnar deviation of fingers and dorsal wrist subluxation. * Boutonniére and swan-neck deformities of fingers, or Z-deformity of thumbs * Hand extensor tendon rupture

Answer 3

* Peripheral joints affected – symmetrical joint pain, effusions, soft tissue swelling, early morning stiffness. * ↓Grip strength and function --\> disability

Answer 4

* Weight loss, fever, malaise. * **Rheumatoid nodules** (extensor forearm) * **Vasculitis** – digital infarction, skin ulcers, mononeuritis * **Eye** – Sjogren’s syndrome, episcleritis, scleritis * **Lungs** – pleural effusions, fibrosing alveolitis, nodules * **Heart** – pericarditis, mitral valve disease, conduction defects * **Skin** – palmar erythema, vasculitis, rashes * **Neurological** – nerve entrapment (carpal tunnel, mononeuropathy) * **Felty’s syndrome** – RA, splenomegaly and leucopenia

Answer 5

Physical disability, depression, osteoporosis, infections, lymphoma, cardiovascular disease, amyloidosis, side effects of treatment

Answer 6

**_Bloods_** * FBC (anaemia of chronic disease), ↑ESR/CRP, ↑platelets * Rheumatoid factor (RhF) is +ve in the majority (associated with severe disease) * ACPA/anti-CCP = highly specific for RA. **_Imaging_** * X-rays = soft tissue swelling, juxta-articular osteopenia, ↓joint space. * Later may show bony erosions, subluxation or complete carpal destruction.

Answer 7

**_Analgesia_** * NSAIDs/PCM - alter as necessary **_Steroids_** * Intra-articular injections (triamcinolone) can settle local flares and can be used up to 3x/year in any one joint. * Daily low-dose oral steroids – can help symptoms and modify disease progression, but have adverse side-effects. **_DMARDs_** * Methotrexate, gold, sulfasalazine, penicillamine, azathioprine, leflunomide, hydroxychloroquine, ciclosporin, cyclophosphamide * Biologic therapies = rituximab, infliximab, etanercept, adalimumab * Can take months to show any effect * Before starting, ***baseline bloods***: U+E, creatinine, eGFR, LFTs, FBC, urinalysis

Answer 8

Aims to relieve pain and improve function – joint fusion, replacement or excision, tendon transfer and repair, nerve decompression

Answer 9

* Elderly * Female * 50% of GCA have PMR, 15% of PMR have GCA

Answer 10

Malaise, anorexia, fever, night sweats, weight loss and depression.

Answer 11

1. Age \>50y; duration \>2 wks 2. Bilateral shoulder or pelvic girdle aching, or both 3. Morning stiffness duration \>45 min 4. Evidence of acute phase response (↑ESR or CRP) Can make diagnosis without inflammatory markers if classical clinical picture and rapid response to steroid treatment

Answer 12

**_Bloods_** * **ESR/CRP** * FBC, U+E, eGFR, LFT, TFT, CK **_Others_** * Bone profile (Ca²⁺, phosphate, PTH, albumin, alk phos) * Protein electrophoresis (urinary Bence-Jones protein) * Rheumatoid factor **_Imaging_** * Consider CXR and/or hip/pelvis/shoulder/cervical spine x-ray (rule out malignancy)

Answer 13

* Inflammatory arthritis (RA) * OA * Neoplasia (myeloma) * Fibromyalgia * Connective tissue/vaculitis (SLE)

Answer 14

**_Steroids_** * Prednisolone 15mg OD – rapid response (within 1 week) – ESR/CRP should normalise within 4 weeks. Continue for 3 weeks. * ↓Dose to 12.5mg OD for 3 weeks * Then 10mg OD for 4-6 weeks, * Then reduce by 1mg every 4-8 weeks (1-2y of treatment usually needed) * Give osteoporosis prophylaxis and supply with steroid card.

Answer 15

* CV disease, HTN, DM and CKD * Patients with gout should be screened for these

Answer 16

* FH * Obesity * Alcohol * High-purine diet * Plaque psoriasis * Diuretics * Acute infection * Surgery * Renal failure

Answer 17

Chronic gout --\> recurrent attacks, tophi (urate deposits) in pinna, tendons and joints, and joint damage. Refer to rheumatology.

Answer 18

**_Bloods_** * WCC, ESR, blood urate (all raised but may be normal) **_Microscopy of Synovial Fluid_** * Polarised light microscopy of synovial fluid --\> negatively bi-refringent urate crystals. **_X-Rays_** * Show soft tissue swelling only.

Answer 19

**_Conservative_** * Exclude infection * Rest and elevate joint - apply ice pack **_Pharmacological_** * NSAIDs – naproxen 500mg BD * Colchicine - 500 mcg BD, increased slowly to QDS until pain relieved. * ***NO NSAIDs OR COLCHICINE IN RENAL IMPAIRMENT*** * Steroids – joint injection or IM steroids

Answer 20

**_Conservative_** * Lose weight; avoid purine-rich foods (offal, red meat, yeast extracts, pulses, mussels) * Avoid thiazide diuretics and aspirin **_Medical_** * Allopurinol 100-300mg daily – wait until 1mo after acute attack and co-prescribed colchicine or NSAID for first 1-3mo to avoid precipitation of another acute attack * Febuxostat is alternative

Answer 21

big toe, feet, ankles most commonly

Answer 22

**_Calcium Pyrophosphate Deposition Disease (CPPD)_** * Inflammatory arthritis due to deposition of pyrophosphate crystals. * Associated with OA, hyperparathyroidism and haemochromatosis. * Attacks are less severe than gout. Knee, wrist and shoulder are most commonly affected. Acute attacks can be triggered by intercurrent illness and metabolic disturbance. Rhomboid-shaped calcium pyrophosphate dihydrate crystals – Pseudogout = **Positive birefringence** in polarised light * Treat acute attacks like gout

Answer 23

**Serious** – cord compression, cauda equina, metastases, myeloma, infection, fracture, aortic aneurysm **Common** – mechanical back pain, renal colic, prolapsed disc, postural, trauma

Answer 24

**If suspect mechanical back pain and no worrying features, no investigations required.** **Bloods** – FBC, ESR, CRP, Ca²⁺, ALP, PSA **CXR** - +/- spinal X-ray if post-trauma or risk of pathological fracture **MRI spine** – as emergency if cord compression or cauda equina suspected; urgent if suspect malignancy, infection or fracture; routine if suspect inflammatory disorder. **DEXA** **Do not X-ray for back pain routinely**

Answer 25

* Early mobilisation, avoid lifting, maintain good posture * Analgesia (consider tricyclic or strong opioids if paracetamol, NSAIDs and weak opioids ineffective) * Diazepam 2mg/8h PO for muscular spasm * Safety-net – if bilateral symptoms or incontinence **_Cord Compression/Cauda Equina_** * Neurological emergencies

Answer 26

Chronic inflammatory disease of the spine and sacroiliac joints (HLA-B27 +ve)

Answer 27

**PAIR** * Psoriaiss * Ank spond * IBD * Reactive arthritis

Answer 28

♀:♂ = 1:6 at 16 years old, 2:1 at 30 years old men present earlier

Answer 29

* Gradual onset low back pain, worse at night, spinal morning stiffness relieved by exercise. * Pain radiates from sacroiliac joints to hips/buttocks, usually improves towards end of day. * Progressive loss of spinal movement (all directions) --\> ↓thoracic expansion.

Answer 30

Spinal kyphosis, sacroiliac joint fusion, neck hyperextension, neck rotation.

Answer 31

* ↓Chest Expansion * Chest Pain * Hip/Knee Arthritis * Plantar fasciitis * Iritis * Crohn’s/UC * Heart disease – carditis, aortic regurg, conduction defects * Osteoporosis * Psoriaform rashes

Answer 32

**_Bloods_** * FBC – normochromic or microcytic hypochromic anaemia. * ESR – may be normal * RF – usually -ve **_X-Ray_** * Initial – widening of SI joints and marginal sclerosis * Later – SI joint fusion and bamboo spine (vertebral squaring/fusion)

Answer 33

**_Conservative_** * Exercise for backache – regimens to maintain posture and mobility. **_Pharmacological_** * NSAIDs – relieve pain and slow progression * TNF-a blockers – indicated if NSAIDs fail * Local steroid injections – temporary relief * Bisphosphonates due to increased risk of osteoporotic spinal fractures. **_Surgery_** Hip replacement if hips involved – sometimes spinal osteotomy.

Answer 34

1. GCA 2. Takayasu's Arteritis 3. Buerger's Disease

Answer 35

1. Polyarteritis Nodosa 2. Kawasaki's Disease

Answer 36

**_pANCA_** * Churg-Strauss Syndrome **_cANCA_** * Wegener's Granulomatosis * Microscopic Polyangiitis **_ANCA -ve_** * HSP * Goodpasture's Disease

Answer 37

**_Epidemiology_** * Rare outside Japan * F\>M * 20-40 yrs **_Features_** * Constitutional symptoms (Fever, fatigue, weight loss) * Weak pulses in upper limbs * Visual disturbance * HTN

Answer 38

Strongly associated with smoking * Extremity ischaemia: intermittent claudication, ischaemic ulcers etc. * Superficial thrombophlebitis * Raynaud's phenomenon

Answer 39

**_Epidemiology_** * Rare in UK * M\>F * Young adults **_Features_** * Associated with hep B * Constitutional symptoms * Rash * Renal --\> HTN * GI --\> melena and abdo pain **_Management_** * Prednisolone and cyclophosphamide

Answer 40

Childhood PAN variant **_Features_** FEVER AND CREAM * 5-day fever * Conjunctivitis (bilateral) * Rash (polymorophic, trunk) * Extremity changes (erythema, desquamation) * Adenopathy (cervical) * Mucositis (oral) *Complication* = coronary artery aneurysms **_Management_** * IV Ig and aspirin

Answer 41

* Late-onset asthma * Eosinophilia * Paranasal sinusitis * Heart disease, skin lesions/ nasal polyps * Granulomatous small-vessel vasculitis * Rapidly progressing glomerulonephritis * Palpable purpura * GI bleeding May be associated with montelukast

Answer 42

* Rapidly progressing glomerulonephritis * Haemoptysis * Palpable purpura

Answer 43

Necrotising granulomatous inflammation and small vessel vasculitis --\> URT, LRT and kidneys **_URT_** * Chronic sinusitis * Epistaxis * Saddle-nose deformity **_LRT_** * Cough * Haemoptysis * Pleuritis **_Renal_** * Rapidly progressing glomerulonephritis * Haematuria/proteinuria **_Other_** * Palpable purpura * Ocular: conjunctivitis, keratitis, uveitis

Answer 44

* cANCA * Dipstick * CXR - bilateral nodular and cavity infiltrates

Answer 45

Childhood IgA nephropathy variant - 3-8 yrs * Post URTI * Palpable purpura on buttocks * Colicky abdo pain * Arthralgia * Haematuria Self-limiting - need to dip urine for a year after.

Answer 46

* Rapidly progressive glomerulonephritis * Haemoptysis * Anti-GBM Ab * CXR --\> bilateral lower zone infiltrates (haemorrhage) Rx = Immunosuppression and plasmapheresis

Answer 47

**_Bedside_** * Urine Dip **_Bloods_** * FBC, U+E, LFT, CRP, ESR, ANCA **_Imaging_** * Depends on syndrome - CXR, renal USS, doppler, angiogram of large vessels **_Other_** * Angiography/biopsy may be diagnostic

Answer 48

**1-4 weeks after..**. * Urethritis (chlamydia) * Dysentery (campylobacter, salmonella, shigella)

Answer 49

* Iritis * Keratoderma blenorrhagica (brown, raised plaques on soles and palms) * Circinate balanitis (painless penile ulceration secondary to Chlamydia) * Mouth ulcers * Enthesitis

Answer 50

**Bloods** * Raised ESR and CRP **Others** * Stool MC+S if diarrhoea * Infectious serology * Sexual health review

Answer 51

**_General_** * Splint affected joints acutely **_Pharmacological_** * NSAIDs * Local steroid injections * Consider sulfalazine or methotrexate if symptoms \>6 months

Answer 52

Increased bone turnover with resultant remodelling, bone enlargement, deformity and weakness.

Answer 53

\>40yrs, incidence increases with age

Answer 54

* Usually asymptomatic * Deep, boring pain * Bony deformities and enlargement * Pelvis, lumbar spine, skull, femur, tibia (bowed sabre tibia Complications * Pathological fractures, OA, hypercalcaemia, nerve compression, high output CCF, osteosarcoma

Answer 55

**_Bloods_** * Ca²⁺ and PO₄^3-normal * Alk phos VERY raised **_Imaging_** * Localised enlargement of bone; patchy cortical thickening with sclerosis, osteolysis and deformity * Cotton wool skull appearance

Answer 56

Normal amount of bone but mineral content low (opposite of osteoporosis) * Rickets = this process during bone growth * OM = after fusion of the epiphyses

Answer 57

* Vitamin D deficiency * Renal osteodystrophy * Drug induced * Vitamin D resistance * Liver disease * Tumour induced

Answer 58

**_Rickets_** * Growth retardation, hypotonia, apathy * Knock-knee/bow-leg and deformitites of metaphyseal-epiphyseal junction **_Osteomalacia_** * Bone pain, tenderness, fractures (especially femoral neck), proximal myopathy

Answer 59

**_Bloods_** * Mild ↓Ca²⁺, ↓PO43-, ↑alk phos, PTH high, ↓25(OH)-vitamin D **_Imaging_** * Cortical bone loss (lucency) * Looser’s zone = apparent partial fractures without displacement – esp on lateral border of scapula, inferior femoral neck and medial femoral shaft.

Answer 60

* Autoantibodies are made against a variety of autoantigens. * Immunopathology --\> polyclonal B-cell secretion of pathogenic autoantibodies causing tissue damage * Immune complex formation/deposition, complement activation, other direct effects Anitbodies = ANA, RhF (others = Anti-Ro, Anti-La, Anti-RNP)

Answer 61

* Non-specific constitutional symptoms (malaise, fatigue, myalgia and fever) * 95% = ANA +ve * Increased risk of CV disease/osteoporosis * Antiphospholipid syndrome associated with SLE * Malar rash (butterfly rash) * Discoid rash * Photosensitivity * Oral ulcers * Non-erosive arthritis * Serositis * Renal disorder * CNS disorder (seizures/psychosis) * Haematological disorder * Immunological disorder * ANA +ve

Answer 62

* More common type of SSc. * Only the face, forearms and lower legs up to the knee. * AKA CREST syndrome Antibodies = ANA (anti-centromere), RhF

Answer 63

* **C**alcinosis * **R**aynaud's disease * **E**sophageal dysmotility * **S**clerodactyly * **T**elangiectasia

Answer 64

* Less common * Also upper arms, thighs or trunk * Higher risk of mortality – early organ fibrosis (lung, cardiac, GI, renal). Anti-Scl70

Answer 65

* Excessive collagen production and deposition * Vascular damage * Immune system activation via autoantibody production and cell-mediated autoimmune mechanisms

Answer 66

Tears in supraspinatus tendon (or adjacent subscapularis and infraspinatus) * Can present insidiously from degeneration in elderly or after trauma in younger patients (more rare) * Shoulder weakness and pain * Night pain may affect sleep as patient is unable to keep arm in comfortable position. **_Imaging_** --\> US/MRI **_Management_** --\> surgery (arthroscopic)

Answer 67

Painful arc --\> occurs as supraspinatus tendon catches under the acromion during abduction (70-140)

Answer 68

No obvious triggers. Pain may be severe and worse at night. Natural history can be divided into: 1. Painful phase (up to 1 year) – active and passive movement range reduced 2. Frozen phase (6-12 months) – pain usually settles but shoulder remains stiff 3. Thawing phase (1-3 years) – shoulder slowly regains range of movement. Can be associated with cervical spondylosis, diabetes and thyroid disease. **_Management_** = early physio and NSAIDs. Steroid injections may reduce pain in early phases. Surgical release is most effective treatment.

Answer 69

Inflammation where forearm extensor tendon arises from lateral epicondyle. * Usually clear history of repetitive strain * Pain is felt at the front of the lateral condyle, and is exacerbated when the tendon is most stretched (wrist and finger flexion with hand pronated). * Ask the patient to extend the wrist, and then to resist extension of the middle finger: is pain elicited? **_Management_** --\> Restriction of activities that overload the tendons à usually lasts 6-24 months; 90% recover in 1 year.

Answer 70

Inflammation of forearm flexor muscles at insertion on medial epicondyle * Most common cause of medial elbow pain, but 1⁄5 as common as tennis elbow. * Pain is exacerbated by pronation and forearm flexion. * Occasionally associated with ulnar neuropathy as the ulnar nerve runs behind the epicondyle. Same treatment and prognosis as LE

Answer 71

* **Temperature** * **Bloods -** FBC, CRP, ESR, Blood cultures, RF, ANA, ASOT – anti streptolysin titre, HLA B27 * **Urine** * Dipstick + MSU * **X-rays** * AP/ Lateral frog imaging * **USS** * Can demonstrate effusion * **MRI/bone scan** * May aid diagnosis

MSK Flashcards

(100 cards)