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MSK Flashcards

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1
Q

Osteoporosis aetiology

A

Loss of bone mineral density
Increased risk of fragility fractures - E.g. NOF

I’M SHATTERED

  • Important - Myeloma
  • Steroids
  • Hyperthyroid / HyperPTH
  • Age
  • Thin - BMI < 25
  • Testosterone
  • Early menopause
  • Renal/liver disease
  • Erosive - RA/IBD
  • Drugs - AD’S TOP SHAG
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2
Q

Osteoporosis aetiology (drugs)

A

AD’S TOP SHAG

Aromatase inhibitors 
Depo injection
Steroids
Thyroxine
OCP
PPI
SSRI's
Heparin
AED's
Glitazone
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3
Q

Osteoporosis clinical features and investigations

A 
Back pain
Kyphosis
Impaired vision
Impaired gait / balance
Lower-extremity weakness

Diagnostic - FRAX score + DEXA = T-score > 2.5

Investigate cause

  • Calcium profile - VITAMIN D
  • TFTs
  • ESR/CRP
  • U&E, FBC, protein electrophoresis - Myeloma?
  • FSH/LH
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4
Q

FRAX score

A

10 year risk of developing a fragility fracture

Age
Sex
BMI
Previous fracture
Parental fragility fracture
Smoking status
Glucocorticoids
RA
Secondary osteoporosis
Alcohol intake
BMD - DEXA - Optional?
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5
Q

Osteoporosis management

A

PT - Bone strengthening
OT - Falls prevention

Bisphosphonates

  • PO - Alendronic acid
  • IV - Zolendronic acid
  • Bind to osteoblasts
  • Send stop signals to osteoclasts
  • S/E - Jaw osteonecrosis, oesophagitis, photosensitivity

Vit D - Ergocalciferol
Calcium - Calcitriol
RANK-L inhibitor - Denosumab
Oestrogen - Raloxifene

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6
Q

Osteomalacia aetiology

A

VItamin D deficiency

  • Diet - Oily fish, liver, egg
  • Malabsorption - IBD, etc.
  • Lack of sunlight

Incomplete mineralisation of underlying bone matrix
“Soft bones”
Low vitamin D - Less calcium absorption from kidneys/gut

Before fusion of epiphysis = Rickets

  • Knock knees
  • Bow legs
  • Hypocalcaemia

Renal failure
Drug induced - Anticonvulsants
Vit D resistant - Inherited
Liver disease - Cirrhosis

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7
Q

Osteomalacia clinical features / investigations / management

A

Hypocalcaemia - Tetany, PO anaesthesia, long QT
Hypophosphataemia - Weakness
Bone pain
Fractures

Calcium profile

  • Calcium - LOW
  • Phosphate - LOW
  • Vit D - LOW
  • ALP ^
  • PTH ^

XR - Translucent bands

Management

  • Ergocalciferol
  • Calcium carbonate
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8
Q

Paget’s disease aetiology / pathophysiology / clinical features

A

Increased uncontrolled bone turnover
Rapid bone formation
Disorganised lamellar bone

RFs

  • Age ^
  • Male
  • Northern latitude
  • Family Hx

5% symptomatic

  • Axial bone pain - Lower back and hips
  • Bony deformities - Bowing of the tibia / Skull bossing
  • Increased local temperature
  • Hearing loss
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9
Q

Paget’s disease investigations / management / complications

A

Calcium profile - ALP ^
Tech-99 scan
XR - Calvarium thickening + Cotton wool sign
Rule out myeloma / bony mets

Management - Symptomatic

  • Alendronic acid
  • Calcitonin

Complications

  • Deafness (SN) - CN8 compression
  • Fractures
  • HF
  • Osteosarcoma
  • Deformity
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10
Q

Back pain DDx

A 
MSK
Fracture - Normal or osteoporotic
Ankylosing spondylitis
Myeloma
Bony mets
Disc prolapse
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11
Q

Back pain red flags

A

< 20 or > 55

Eye symptoms - Anky spond?

Paraesthesia - Lower limb
Decreased anal tone
Urinary/faecal incontinence
Saddle anaesthesia

History of malignancy
B-symptoms
Worse at night

Worse lying down
Cardiorespiratory symptoms

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12
Q

Describing paeds fractures

A

SALTER - Harris
(In relation to growth plate)

  1. Straight through
  2. Above
  3. Lower
  4. Through Everything
  5. cRush
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13
Q

NOF aetiology / presentation / initial management

A

Previous hip fracture
Osteoporosis
Mobility / falls risk
Family history

Unable to weight bear
Leg shortened and externally rotated

Initial management

  • Immobilise
  • Analgesia - Morphine / Fascia-iliaca block
  • ABCDE
  • Cross-match / Group+Save
  • Prep for surgery
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14
Q

NOF grading and blood supply

A

Intracapsular - Garden classification

  1. Incomplete
  2. Complete - No displacement
  3. Complete < 50% displacement
  4. Complete > 50% displacement

Extracapsular

  • Trochanteric
  • Subtrochanteric

Blood supply
- Medial circumflex artery < Femoral < External iliac

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15
Q

NOF management and complications

A

Intracapsular

  • Comorbidities + Less mobile = Hemi
  • Less comorbidities + More mobile = Total

Extracapsular

  • Trochanteric - DHS
  • Subtrochanteric - IM nail

Complications

  • Second hip fracture
  • AVN femoral head
  • Pneumonia
  • VTE
  • Site infection
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16
Q

Scaphoid fracture

A

FOOSH

Anatomical snuffbox tenderness

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17
Q

Shoulder dislocation

A

Anterior - Most common

  • Usually glenoid-humeral
  • AC - Rare
  • Head of humerus is medial - Under coracoid process
  • Aetiology - Trauma / Joint laxity (ED)

Posterior

  • More common in epilepsy
  • Light bulb sign - Medial rotation of humeral head

Check axillary nerve sensation - Regimental patch

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18
Q

Rotator cuff muscles

A

Supraspinatus - ABduction 0-15 degrees
Infraspinatus - External rotation
Subscapularis - Internal rotation
Teres minor - External rotation in ABduction

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19
Q

Frozen shoulder

A

Adhesive capsulitis

All ROM limited - Due to pain
External rotation first to be affected
More common in DM

Management - PT ± Surgery

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20
Q

Impingement

A

Supraspinatus tendonitis

Classically painful arc
Tender over acromion

Aetiology

  • Bursitis
  • Osteophytes
  • Degnerative bone disease

Management - PT

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21
Q

RA clinical features

A 
HOT SWOLLEN JOINT
Symmetrical 
DIP sparing
Z-thumb
Boutonnieres deformity
Swan neck deformity
Ulnar deviation
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22
Q

RA systemic disease

A

Eyes

  • Anterior uveitis
  • Episcleritis

Lungs

  • Lower zone fibrosis - Methotrexate or RA nodules
  • Pleural effusions

Neuro - Peripheral nerve entrapment

Cardio

  • Pericarditis
  • IHD risk ^

Felty syndrome

  • RA
  • Splenomegaly
  • Neutropenia
  • Leg ulcers
  • Lymphadez
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23
Q

RA investigations

A

XR - LESS

  • Loss of joint space
  • Erosions
  • Soft tissue swelling
  • Softening of bone - Osteopenia
Rheumatoid factor 
Anti-CCP!!!!!!!
ANA +ve
CRP/ESR
FBC - AoCD

Questionnaire - DAS28 score

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24
Q

RA management

A

PT

DMARD + Prednisolone

  • Methotrexate
  • Sulfasalazine
  • Hydroxychloroquine

2x DMARD

Biologics - After 2x DMARD

  • Infliximab - Anti-TNF
  • Rituximab - Anti CD20
  • Tocilizumab - Anti IL6
  • Baricitinib - JAK inhibitor
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25
Methotexate SE and monitoring
``` Renal impairment - U&E Hepatic impairment - LFT Pulmonary fibrosis - LuFT + CXR Bone marrow suppression Teratogenic ```
26
Gout
Hyperuricaemia Deposition of urate crystals Decreased uric acid excretion - Diuretics - Ciclosporin - Tacrolimus - Pyrazinamide - CKD Increased uric acid production - Myelo/Lymphoproliferative disorder - Cytotoxic drugs - Psoriasis Lesch-Nyhan syndrome - X-linked - HGPRTase deficiency ``` Male Diet - Red meat, seafood, alcohol, etc. Aspirin Obesity Family Hx ```
27
Gout triggers and presentation
Diuretics Dehydration Alcohol Chemotherapy - TLS Presentation - 1st MTP joint ± Ankle, wrist, knee - Red - Hot - Swollen - Painful
28
Gout investigations
XR - Tophi - Joint space widening - Joint effusion - Punched out erosions Joint aspiration + Light microscopy - Negatively bifringent needles - Rule out septic arthritis Urate levels - Low during attack - Any other time - HIGH
29
Gout management
Acute - NSAIDs / Colchicine ± PPI - Severe -Intra-articular steroid injection Long-term - Allopurinol - Xanthase oxidase inhibitor - Febuxostat Lifestyle changes - Reduce alcohol intake - Lose weight Avoid food high in purines - Liver - Kidneys - Seafood - Oily fish - Yeast products
30
Pseudogout aetiology and clinical features
Calcium pyrophosphate dihydrate crystals ``` Haemochromatosis HyperPTH Acromegaly Wilson's Hypomagnesaemia Hypophosphatasia ``` HOT SWOLLEN JOINT
31
Pseudogout investigations and management
XR - Chrondrocalcinosis - Linear white lines Joint aspiration + Light microscopy - Positively bifringent rhomboid crystals - Rule out septic arthritis Management - NSAIDs / Colchicine - Intra-articular steroids
32
Septic arthritis aetiology
Staph A Young adults - N.Gonorrhoea Risk factors - Immunocompromise - IVDU - Alcohol - DM
33
Septic arthritis clinical features
HOT SWOLLEN JOINT NWB Fever Frog leg - Shortened, flexed, externally rotated KOSHER criteria - WENT - WCC > 12 - ESR - NWB - Temperature > 38
34
Septic arthritis investigations and management
``` Joint aspiration + MC&S XR - Loss of joint space Blood cultures ± Septic screen FBC ESR/CRP U&E LFT ``` Management - ABCDE - IV Flucloxacillin - 6-12 weeks - Needle aspiration - Arthroscopic lavage
35
Osteomyelitis aetiology
Common sites - Children - Metaphysis of long bone - Adults - Vertebrae Aetiology - Staph A - E Coli - Sickle cell - Salmonella Risk factors - Sickle cell - IVDU - Immunocompromise - Cellulitis - Local spread - Recent trauma / surgery - DM
36
Osteomyelitis clinical features / investigations / management
``` Bone pain Inflammation Fever NWB Reduced ROM Malaise Fatigue Back pain - Vertebral ``` Investigations - Septic screen - MRI Management - ABCDE - Flucloxacillin - 6 weeks - Clindamycin if allergic
37
Ankylosing spondylitis aetiology
Chronic progressive inflammatory arthropathy Associated with HLA-B27 Typically males aged 20-40
38
Ankylosing spondylitis clinical features
Lower back pain Stiffness - Worse in the morning - Improves with exercise - Painful at night Decreased spine ROM - Reduced lateral flexion - Reduced forward flexion - Schober's test Reduced chest expansion All the As - Apical fibrosis - Anterior uveitis - Aortic regurgitation - Achilles tendonitis - AV node block - Amyloidosis - AI bowel disease
39
Ankylosing spondylitis investigations
All the S's... - Severity scoring system - BASDAI - Schober's test - Spirometry - Restrictive XR - Sacroiliitis - Syndesmophytes - Squaring of lumbar vertebrae - Spine - Bamboo + Dagger sign Assess chest expansion HLA-B27
40
Ankylosing spondylitis management
NSAIDs PT - Regular exercise Anti-TNF - After 2x NSAIDs... - Etanercept - Infliximab - Adalimumab
41
Reactive arthritis aetiology and clinical features
Inflammatory arthritis Exposure to GI/GU infections Associated with HLA-B27 STI - Chlamydia - Reiter's syndrome Post-dysentery - Campylobacter - Shigella - Salmonella CAN'T SEE - Anterior uveitis CAN'T PEE - Urethritis ± Balanitis CAN'T CLIMB TREE - Arthritis
42
Reactive arthritis investigations and management
ESR/CRP ^ NAAT swab - Positive for chlamydia Blood cultures Rule out differentials - Joint aspiration - ANA/RF Management - NSAIDs - Persistent - DMARD - Sulfasalazine - Treat STI - Doxy - Symptoms may last 4-6 months
43
Psoriatic arthritis
``` Asymmetrical oligoarthritis - Hands and feet + Psoriasis DIP joint disease Arthritis mutilans - Telescoping fingers Nail changes - Onycholysis and pitting ``` Investigations - XR - Pencil in a cup (DIP erosion + periarticular bone formation) - PSARC score - ESR/CRP - ANA/RF Management - Treat as RA - NSAIDs - DMARDs - IA steroids - Anti-TNF
44
Fibromyalgia
Risk factors - Women - 5x more likely to be affected - Age 30-50 - Lower socioeconomic status - Divorced Clinical features - Chronic pain at multiple sites - 11/18 points! - Myalgia - Headache - Fibro-fog - Memory loss / Cognitive impairment Management - Biopsychosocial - Education - PT - Aerobic exercsise - CBT - Pregabalin / Duloxetine / Amitriptyline
45
Dermatomyositis Polymyositis
Idiopathic inflammatory myopathy Associated with connective tissue disorders Possible underlying malignancy - Ovarian, breast, lung Polymyositis - Variation WITHOUT skin manifestations
46
Dermatomyositis clinical features
Symmetrical proximal muscle weakness - Rising from chair - Combing hair - Climbing stair Skin manifestations - Gottron's papules - Rough red papules over extensor surfaces of fingers - Heliotrope rash - Orbital - Photosensitivity - Shawl rash - Mechanic's hands - Dry, cracked, scaly - Nail fold capillary dilatation GI - Dysphagia Respiratory - Fibrosing alveolitis / Pneumonia Raynaud's
47
Dermatomyositis investigations and management
Better CAll Jo'S MuM - CK ^ - ANA +ve - Anti-Jo antibodies - Serum aldolase ^ - Muscle biopsy - Perivascular or interfascicular inflammation - Screen for malignancy! Prednisolone Suncream! DMARD - Methotrexate
48
Polyarteritis aetiology and clinical features
Vasculitis of medium-sized vessels Associated with Hep B Clinical features - Fever - Arthralgia - Weight loss - Mononeuritis multiplex - Sensorimotor polyneuropathy - Renal failure - Haematuria - HTN - Diastolic > 90 - Testicular pain - Livedo reticularis - Mottled skin discolouration
49
Polyarteritis investigations and management
``` ESR / CRP ^ FBC - Normocytic anaemia HBV serology Angiography Biopsy LFTs Urinalysis - Haematuria ``` Prednisolone DMARD - Azathioprine
50
Marfan's
AD - Connective tissue disorder Loss of elastic tissue Clinical features - TALL and THIN - Long fingers - High arched palate - Retinal detachment - Pectus excavatum - Scoliosis - Pes planus - Cardio - AR, MVP, dissection - Resp - Pneumothorax - Dural ectasia - Ballooning of dural sac at LS level Investigations - TTE - Check for cardiac pathology - Ophthalmic assessment Management - Manage CV risk - BB - Metoprolol - Losartan
51
Ehlers Danlos
AD - Type III collagen Increased elasticity Clinical features - Joint laxity - Hypermobility + Dislocations - Skin thinning / splitting - Bruising - Neuro - SAH risk ^ - Tinnitus - Ossicle laxity - Cardio - AR, MVP, dissection Investigations - TTE - Cardiac pathology Management - Manage CV risk - Screen for SAH
52
Sjogren's syndrome aetiology / clinical features
AI - Exocrine glands affected Primary or secondary to RA / Connective tissue disorders Clinical features - Dry eyes - Dry mouth - Dry vagina - Parotiditis - Arthritis - RTA - Raynaud's - Sensory neuropathy
53
Sjogren's syndrome investigations / management / complications
Schirmer's test - Tears Anti-Ro Anti-La HLA-DR3 Management - Artificial tears - Artificial saliva - Pilocarpine - May stimulate saliva production Complications - Non-Hodgkin's lymphoma risk ^
54
Systemic sclerosis Scleroderma CREST Clinical features
AI - Multi-system Diffuse cutaneous systemic sclerosis - Trunk and proximal limbs - Resp - ILD and P.HTN - Renal - HTN - Poor prognosis Scleroderma - Without internal organ involvement - Tightening and fibrosis of skin - Plaques or linear CREST - Limited cutaneous systemic sclerosis - Face and distal limbs - Calcinosis - Raynaud's - oEsophageal dysmotility - Sclerodactyly - Telangiectasia
55
Systemic sclerosis Scleroderma CREST Investigations / Management
ANA +ve Anti-topoisomerase Diffuse - Anti-Scl 70 CREST - Anti-centromere U&Es LuFTs Barium swallow - Oesophageal dysmotility Management - Topical - Hydrocortisone - Oral - Prednisolone Symptom management - Raynaud's - CCB - Nifedipine - GI - PPI - Arthritis - NSAIDs / Steroid
56
SLE aetiology
AI - Type 3 hypersensitivity HLA-DR2/3 Immune complex deposition - Skin, joints, kidney, brain Risk factors - Females aged 20-40 - AC / Asian communities - Isoniazid
57
SLE clinical features
General - Fatigue - Fever - Mouth ulcers - Lymphadenopathy Skin - Malar - Butterfly rash - Discoid rash - Scaly demarcated rash in sun-exposed areas - Photosensitivity - Raynaud's - Livedo reticularis - Alopecia Neuropsych - Anxiety - Depression - Psychosis - Seizures MSK - Arthralgia / Arthritis CV - Pericarditis / Myocarditis Resp - Pleurisy / Fibrosing alveolitis Renal - Proteinuria / Glomerulonephritis
58
SLE criteria
4 or more of SOAP BRAIN MD... Serositis Oral ulcers Arthritis Photosensitivity ``` Blood disorders - APLS Renal impairment ANA +ve Immunological - HLA-DR2 Neuro - Seizures ``` Malar rash Discoid rash
59
SLE investigations and management
SOAP BRAIN MD ``` ANA +ve Anti-dsDNA Anti-Smith Anti-Ro Anti-La ``` Management - Hydroxychloroquine - NSAIDs - Prednisolone - DMARD - Methotrexate
60
Takayasu's arteritis aetiology and clinical features
Chronic granulomatous vasculitis Large vessels Asian females - 20-40 Primarily the aorta and its branches - Granulomatous thickening ``` Systemic features - Malaise, headache, etc. Pulseless limb Intermittent claudication BP differences - Upper vs Lower Vascular bruits Fever Dizziness Myalgia HTN Renal artery stenosis ```
61
Takayasu's arteritis investigations and management
ESR / CRP ^ CT angiography - Aorta Prednisolone Aspirin Alendronic acid
62
Antiphospholipid syndrome
Aetiology - Primary or secondary to SLE Clinical features - Venous/arterial thromboses - Recurrent miscarriages - Thrombocytopenia - Livedo reticularis - Pre-eclampsia - P.HTN Investigations - Platelets - LOW - Anti-cardiolipin antibodies Management - Primary thromboprophylaxis - Low-dose Aspirin - Secondary thromboprophylaxis - Warfarin (INR target 3-4)
63
Polymyalgia rheumatica
Vasculitis of arteries supplying muscle Older females / GCA Clinical features - Proximal pain and stiffness - Shoulders and hips - B-symptoms Investigations - Corticosteroid trial - Rapid response - ESR / CRP ^ Management - Prednisolone + Alendronic acid + Colecalciferol + Calcium carbonate
64
Raynaud's aetiology
Exaggerated vasoconstriction of digital arteries In response to cold or emotional stress ``` Connective tissue disorders - Scleroderma, RA, SLE Leukaemia Cryoglobulinaemia - Cold agglutins Vibrating tools OCP Cervical rib ```
65
Raynaud's clinical features / investigations / management
PD - Painful Digits ``` Digit pain / discomfort Paraesthesia Pallor Discolouration - Red/blue - Well-defined Dilated nailbed capillaries - Magnification ``` Management - Treat cause - CCB - Nifedipine - IV Prostacyclin
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