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MSK > Pathology > Flashcards

Pathology Flashcards

1
Q

Describe connective tissue diseases

A

Autoimmune conditions - autoantibodies present
Starts an inflammatory process leading to symptoms
May be associated with hypersensitivity
Affects 1-2% of the population

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2
Q

How do connective tissue diseases present

A

Often with MSK symptoms

Many also come with systemic symptoms

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3
Q

What is rheumatoid arthritis

A

Inflammation of the joint caused by rheumatoid factor and an autoantibody against Fc IgG

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4
Q

What happens in the acute phase of RA

A

Pannus formation - granular tissue forms on articular surfaces
Hyperplastic and reactive synovium

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5
Q

How is cartilage affected by RA

A

It is destroyed by the inflammatory process

This leads to a loss of joint space

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6
Q

What happens in chronic phase of RA

A

Fibrosis occurs

This can lead to joint deformity

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7
Q

What is SLE

A

Systemic Lupus Erythema

A systemic autoimmune condition

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8
Q

What is the cause of SLE

A

Autoantibodies are formed that attack the structural parts of DNA
Most specific is anti-double stranded DNA but may be other types (anti-RO etc)

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9
Q

What are the acute features of SLE

A

Oedema
Fibrin
Reactive features in the synovial cells

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10
Q

How is uric acid formed in the body

A

The end product of purine synthesis

So formed in the production of adenine and guanine - during DNA synthesis

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11
Q

What can lead to increased production of uric acid

A 
Idiopathic - unknown enzyme defect 
Know defect - LN syndrome 
Increased cell turnover - e.g. psoriasis or cancer 
Alcohol 
High dietary purine - red meat etc
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12
Q

What can cause reduced excretion of uric acid

A

Drug side effects
Common with thiazide diuretics
Hypothyroidism
Chronic renal impairment

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13
Q

What causes gout

A

Precipitation of urate crystals, usually in joints

This elicits an acute inflammatory response leading to symptoms

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14
Q

What is gouty tophus

A

Deposition of urate crystals in the soft tissues

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15
Q

The presentation of gout is dependant on the level of urate in the body - true or false

A

False

Not necessarily related to level, more dependant on the solubility of the crystals

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16
Q

What are some complications of gout

A

Can cause secondary degenerative changes in the joint
Deposition in soft tissues (gouty tophus)
Can lead to renal disease

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17
Q

How would you diagnose gout

A

Take an aspirate of joint fluid and examine under a cross polarized light to look for the negatively bifrigent needle shaped crystals
Can also look for raised inflammatory markers and serum uric acid - not specific enough
Link to renal impairment - kidney tests

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18
Q

What causes pseudogout

A

Deposition of calcium pyrophosphate crystals in the joint
May be associated with hypercalcemia, haemochromatosis, hyperthyroidism etc
Age also contributes

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19
Q

Where does pseudogout usually affect

A

older individuals
in the large joints
Affects fibrocartilage

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20
Q

What are the symptoms of pseudogout

A

May present with joint pain
Usually asymptomatic and is an incidental finding on x-ray
Will have raise in inflammatory markers

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21
Q

what do calcium pyrophosphate crystals look like

A

Rhomboid shaped

Thicker and bigger than urate

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22
Q

What is Paget’s disease of bone

A

Caused by abnormality of bone turnover
Increase in osteoclastic activity
Get more bone but not normally structured - often weaker but thicker
Can affect all bones

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23
Q

What can cause Paget’s

A

Unknown
May have genetic component
Can be caused by viral infection

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24
Q

How does Paget’s present

A

Pain - due to fracture or nerve compression
Enlargement of bones leading to abnormal shape
Increased metabolism – heat in area

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25
Q

What are some complications of Paget’s

A

Heart failure - due to high metabolic requirement

Increased risk of malignancy

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26
Q

What is Osteomalacia

A

Abnormal vitamin D metabolism
Bones become weaker
Causes rickets in children

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27
Q

What LFT results may suggest Paget’s

A

Raised Alk Phos

Everything else normal

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28
Q

What can a pathological fracture be a sign of

A

Underlying bone pathology
Osteoporosis is most common cause
Potentially malignancy

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29
Q

What is a pathological fracture

A

When a fracture occurs with a non-severe trauma

So injury is out of proportion with event

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30
Q

Describe the initial phases of bone repair after a break

A

Haematoma – fibrin mesh
Influx of inflammatory cells
Cytokine release
After 1 week a callus forms and remodelling begins

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31
Q

How does bone heal after the initial phase

A

Woven bone starts to be deposited next to the cortical bone
Some cartilage is deposited at the break site which later undergoes ossification
Woven bone is remodelled to return bone to normal

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32
Q

Why might healing of a bone be delayed

A

Poor blood supply and poor nutrition.

Too much movement, Too great a distance

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33
Q

Which cancers commonly metastasise to bone

A

Lung
Kidney
Breast
Prostate

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34
Q

What is avascular necrosis

A

Infarction of bone

Leads to necrosis of tissue

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35
Q

How does avascular necrosis present

A

Usually asymptomatic

May lead to hip replacement once joint is severely damaged

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36
Q

What can cause avascular necrosis

A 
Trauma 
Alcohol 
Steroid injections 
Sickle cell 
Infection
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37
Q

What can cause degenerative diseases like osteoarthritis

A

Mechanical injury
Wear and tear with age
Secondary to previous joint issues

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38
Q

What joint changes occur in degenerative disease

A

Small cracks in cartilage
Fibrillation
Cartilage is completely worn away and surface of bone becomes polished
Cysts form in the bone due to leaking synovial fluid
Bone remodelling leads to abnormal outgrowths - osteophytes

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39
Q

What genetic investigation can be used to diagnose MSK lesions

A

Karyotyping - gives overview of chromosome structure
– good for large, more obvious mutations

FISH - detects more subtle, specific mutations
- used for known translocations

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40
Q

How does immunohistochemistry work

A

You place a pigment or florescent tag onto an antibody for a specific protein
If the protein is present in the cell type it will show up

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41
Q

What are ganglion cysts

A

Caused by degenerative change within connective tissue
Presents as a lump that does not go away
In peripheral areas, near a joint capsule or tendon sheath
Common on wrist

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42
Q

Ganglion cysts are not true cysts - true or false

A

True

The do not have an epithelial lining

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43
Q

What are superficial fibromatoses

A

Due to proliferation of fibroconnective tissue
Common condition
Occurs in the hand, feet and penis (rarely)

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44
Q

What is dupuytren’s contracture associated with

A

Alcohol

Anticonvulsants

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45
Q

What is Dupuytren’s contracture

A

Superficial fibromatosis in the hand
Caused one finger to become drawn to palm - excess tissue tightens
Usually idiopathic

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46
Q

What is deep fibromatosis

A

Deep seated fibromatosis that occurs in more visceral areas
Often in the mesentery or pelvis
Comes with increased risk of colon cancer as associated with FAP

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47
Q

What are the different types of Giant cell tumour

A

Pigmented villonodular synovitis
Giant cell tumour of the tendon sheath
Giant cell tumour of the bone

48
Q

Describe pigmented villonodular synovitis

A

Occurs in the synovium of large joints
Can spread out with the joint
Most destructive and diffuse GST
Difficult to excise and will often recur

49
Q

Describe giant cell tumours of the tendon sheaths

A

Small nodules
Occur in the digits
common and benign
Easily excised

50
Q

Name the different types of lipoma

A

Fibrolipoma- contain lots of fibrous tissue
Angiolipoma – contain blood vessels
Spindle cell lipoma - contain spindle cell
Pleomorphic – cells look odd
Atypical lipoma

51
Q

What is a lipoma

A

A fat tumour

52
Q

What are the most common MSK causes of painful lumps in the superficial tissue

A 
Angiolipoma
Neuroma (traumatic)
Glomus tumour (nail beds etc.)
Eccrine spiradenoma (skin adnexal tumour)
Cutaneous leiomyoma
53
Q

What tumours can occur in the smooth muscle

A

Leiomyomas - common and benign
Leiomyosarcoma - malignant version, uncommon
Can occur anywhere in the body

54
Q

What are tumours of skeletal muscle called

A

Rhabdomyomas
Benign lesions
Very rare

55
Q

What are rhabdomyosarcomas

A

Malignant tumours of skeletal muscle
Can occur in GU tract or bile duct in childhood
Hard to diagnose

56
Q

What are enchondroma

A

Benign cartilage tumours

Common in the digits

57
Q

What are chondrosarcoma

A

Tend to affect older population - 40-50s

Common in the axial skeleton

58
Q

What are common benign tumours of the bone

A

Osteoma - common in cranial bones

Multiple tumours can occur in Gardner’s syndrome

59
Q

Describe malignant tumours of the bone

A

osteosarcoma
Usually in paediatrics
Affects the long bones

60
Q

What is Ewing’s sarcoma

A 
Malignant cells that can appear in any soft tissue or bone 
Small round blue cell tumours 
Most common in children and adolescents 
Destructive and highly malignant 
Unknown origin
61
Q

What is nodular fasciitis

A

Rapid growth that can effect any age
Sometimes occurs after trauma
Chaotic appearance with large atypical cells
Haemorrhage is common

62
Q

What is myositis ossificans

A

Lesion that occurs after preceding trauma

Affects the big muscles

63
Q

Which joints does gout most often occur in

A

Peripheral joints
Thought to be due to lower temperatures allowing crystals to precipitate
Big toe is the commonest site

64
Q

How common is gout in the UK

A

Prevalence of 1.4%
increasing due to obesity
More common in women
Rare before menopause

65
Q

Why is gout uncommon before menopause

A

Oestrogen has a protective effect as it promoted uric acid excretion

66
Q

How does acute gout present

A

Monoarthropathy - pain and inflammation
Swollen, red joint
Abrupt onset
Will settle in 10 days without treatment or 3 with

67
Q

How do you treat acute gout

A

NSAIDs - diclofenac, naproxen
Use for symptom control until it self-resolves

Colchicine - used if they cannot take NSAIDs

Steroids - oral or injected into joint (very effective)

Stop diuretics as can precipitate and switch to a new drug

68
Q

What can be used for prophylactic treatment of gout

A

Allopurinol
Febuxostat
Cover with NSAID for symptom control - stop after 6 weeks

Stop diuretics if possible
Lifestyle changes - lose weight, less alcohol and red meat

69
Q

When do you use prophylactic treatment for gout

A

If the patient has 2 or more acute attacks in a year
Start 2-4 weeks after attack
If they have tophi
If they have renal impairment or history of renal calculi
Those with HF on diuretics who keep getting gout

70
Q

How do you treat pseudogout

A

NSAIDS
Colchicine
Steroids
Rehydration

71
Q

What causes Milwaukee shoulder and what are its effects

A

Deposition of hydroxyapatite crystals in or around joint
More common in women
Get an acute and fast deterioration of joint

72
Q

How do you treat Milwaukee shoulder

A

NSAIDs
Intra-articular steroid injection
Physiotherapy
Partial or total arthroplasty

73
Q

What is soft tissue rheumatism

A

Term used to describe pain caused by inflammation/damage to ligaments/tendons/muscles/nerves near a joint
Pain is confined to specific site

74
Q

what are some common causes of soft tissue rheumatism in the shoulder

A 
Adhesive Capsulitis
Rotator cuff tendinosis
Calcific tendonitis
Impingement 
Partial rotator cuff tears
Full rotator cuff tears
75
Q

How do you investigate soft tissue pain

A

Usually tests are not necessary
X-ray if suspect calcific tendonitis
MRI if it doesn’t settle

76
Q

How do you treat soft tissue pain

A 
Pain control
Rest and Ice compressions
Physio
Steroid injections
Surgery
77
Q

Who commonly has joint hypermobility syndrome

A

More common in women
Usually presents in childhood or 3rd decade
Associated with some rare genetic conditions -e.g. Marfan’s

78
Q

How does joint hypermobility syndrome present

A

Arthralgia - pain
Premature osteoarthritis
Can be generalised or localised
Investigations will be normal

79
Q

How do you treat joint hypermobility syndrome

A

Physio

Patient education

80
Q

What abnormalities can cause intoeing

A

Femoral neck anteversion
Internal Tibial Torsion
Metatarsus adductus
Can be a combination

81
Q

What is femoral neck anteversion

A

When the femur is orientated more anteriorly than normal

Usually doesn’t cause major issues, just slight knee problems or intoeing

82
Q

What is internal tibial torsion

A

inward twisting of the tibia

Seen in 1-3 y/o and usually resolves by age 6

83
Q

What metatarsus adductus

A

Common and benign deformity
Usually resolves but may need casting
Front of foot curves inwards

84
Q

What is meant by flat feet

A

No defined arch in foot - should have developed in childhood
Usually asymptomatic
Can be flexible or fixed

85
Q

Osteopenia is defined as a T-score of what?

A

Between −1 and −2.5 SD

The T-score is the number of SD (standard deviations) below the mean BMD of young adults at their peak bone mass

86
Q

What is the SINGLE MOST appropriate initial treatment in general practice for giant cell arteritis in a patient presenting with visual manifestations

A

Prednisolone 60 mg daily

87
Q

Why might a serum urate level be normal in acute gout

A

During an acute attack most of the uric acid is deposited in the joints and therefore serum levels can be completely normal or even low
Should repeat test a week after the episode has settled

88
Q

Why shouldn’t you start allopurinol or other urate lowering drugs during acute gout

A

Any sudden changes in uric acid levels can
precipitate further attacks of gout or prevent the acute episode from
settling down

89
Q

What other diagnosis must be ruled out if you suspect gout

A

Septic arthritis
Presents similarly
If really unsure treat as sepsis until proven otherwise

90
Q

An acute presentation is suggestive of which rheum diseases

A

Acute = less than 6 weeks

Gout, septic arthritis etc.

91
Q

A chronic presentation is suggestive of which rheum diseases

A

Chronic = over 6 weeks

RA, psoriatic arthritis etc

92
Q

How does a rheum issue within the joints present

A

Pain, swelling, stiffness and limitation of movement

93
Q

How does a rheum issue within the muscle present

A

myositis or myopathy

Pain in affected muscle, weakness, wasting if prolonged, no stiffness

94
Q

How does a rheum issue within the soft tissue present

A

Localised pain, joint will function normally, only some movement affected.

Includes rotator cuff issues, trochanteric bursitis, epicondylitis.

95
Q

Which rheum diseases are more likely to complain pf widespread pain rather than localised

A

Autoimmune issues or fibromyalgia

96
Q

Which MSK conditions typically involve the spine

A

OA, spondyloarthropathies

97
Q

Pain in RA is always constant - true or false

A

False

Whilst this is the most common presentation you can get palindromic RA which presents with intermittent pain

98
Q

What is a monoarthropathy and give examples

A

Disease affecting one joint

Gout, reactive arthritis, septic etc

99
Q

What is a oligoarthropathy and give examples

A

Disease affecting between 1-4 joints

Reactive arthritis, ankylosing spondylitis, psoriatic (seronegative spondylarthropathy)

100
Q

What is a monoarthropathy and give examples

A

Disease affecting more than 4 joints

OA or RA

101
Q

RA is typically symmetrical - true or false

A

True

102
Q

List common symptoms of chronic pain syndromes

A

Poor sleep pattern, headaches, low mood or anxiety, IBS, irritable bladder, muscle spasms, brain fog

103
Q

Which type of pain is worse at rest

A

Inflammatory pain

104
Q

Which type of pain is worse on movement

A

Mechanical

105
Q

Prolonged early morning stiffness (>1 hour) is suggestive of what

A

Inflammatory process

106
Q

Alcohol use is associated with which joint issue

A

Associated with gout

107
Q

Which MSK symptoms can be caused by statins

A

Muscle pain

tendon tears and tenosynovitis

108
Q

Which MSK symptoms can be caused by gliptins and tamoxifen

A

Arthralgia

109
Q

Which MSK symptoms can be caused by checkpoint immunotherapy (e.g. in cancer)

A

Arthritis

110
Q

Which MSK symptoms can be caused by quinolones

A

tendon tears and tenosynovitis

111
Q

Which MSK symptoms can be caused by diuretics

A

Gout - they reduce urate excretion

112
Q

Which MSK symptoms can be caused by beta-blockers

A

Raynaud’s

113
Q

HLA diseases can run in families - true or false

A

True

Things like RA etc

114
Q

Methotrexate is hepatotoxic - true or false

A

True

Be careful in alcoholics

115
Q

Ankylosing spondylitis progresses slower in smokers - true or false

A

False

Progresses more rapidly

116
Q

Why is menstrual history relevant in MSK/rheum histories

A

Gout is rare pre-menopause
OA can be worse during or after menopause
Early menopause increases risk of osteoporosis

MSK (21 decks)

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