Flashcards in General MSK Deck (87):
Red flags of back pain?
• Use of IV drugs --> epidural abscesses
• Hx of cancer
• Steroid use
• Age over 50 years
• Night time pain
• Unresponsive to therapy
• Hx of AAA
• Saddle anaesthesia
• Bladder/bowel incontinence or retention
• Duration of pain greater than 1 month
• Unexplained weight loss, night sweats and fever
• Mid back pain
differential diagnosis for acute mono arthritis?
1. bacterial septic arthritis
2. Crystal arthritis- like gout or pseudo gout
3. subchondral bone lesion due to fracture, osteonecrosis, osteomyelitis
4. haemarthrosis (trauma)
risk factors for joint sepsis?
-Very young or advanced age
- recent joint aspirate, penetrating injury
- portals for bacteramia
- previous joint damage
- DM, chronic renal or liver disease
what do you think if there are multiple joints affected with septic arthritis?
immune complex response to a systemic infection. OR neisseria meningitis dissemination
what bacteria is most commonly associated with septic arthritis?
what is the acute management of septic arthritis?
arthroscopic wash out
what Ix do we order for osteoporosis?
2.Blood tests- calcium, phosphate, magnesium, Vit d, TFT, 3 3.LFT
5.need a bone DEXA scan to monitor osteoporosis
what is torticollis?
how do OB interact with OC? and how is the balance affected in post menopausal women?
OB express RANKL which binds to OC RANKL receptor. OB produces OPG to inhibit RANKL receptor on OC. Post menopausal women have E2 deficiency and this leads to overexpression of RANKL as compared to OPG, further activating OC and leading to bone resorption.
risk factors for osteoporosis?
Risk factors include an older age, female gender, white ancestry, low BMI, FHx of maternal hip fracture, postmenopause, glucocorticoid use, prior fracture, hypogonadism, loss of height, secondary amenorrhoea, smoking, excessive alcohol use, prolonged immobilisation, vitamin D deficiency, hyperthyroidism, weight loss of >10% of body weight, androgen deprivation treatment (in men), aromatase inhibitor treatment (in women), tobacco use, heparin use, anticonvulsant use, or kidney stone disease.
What T score from DEXA test will indicate osteoporosis?
T-score of ≤-2.5 indicates osteoporosis; T-score ≤-2.5 with fragility fracture(s) indicates severe (or established) osteoporosis
what does DEXA test screen for?
risk of fracture and osteoporosis
whats the difference between a T score and a Z score for the Dexa test?
T score- compared to a healthy 30 year old adult male
Z score- compared to another healthy individual of the same age group
Describe the Ottawa ankle rules for suspected ankle fracture thus requiring X-ray
Ottawa ankle rules:
1. Tenderness posterior borders lower 6 cm of malleoli
2. Tenderness base 5th metatarsal
3. Tenderness navicular
4. Unable to fully bear weight for 4 steps
If all four present- then must XRAY
what does enthesitis mean?
Inflammatory process affecting the sites of insertion of ligaments and tendons into bone. The lower limbs with the heel, knee, and ischial tuberosities are most commonly affected.
what are the 3 phases of paget's disease of the bone?
1. An initial, short-lived burst of multinucleate osteoclastic activity causing bone resorption
2. A mixed phase of both osteoclastic and osteoblastic activity, with increased levels of bone turnover leading to deposition of structurally abnormal bone
3. A final chronic sclerotic phase, during which bone formation outweighs bone resorption.
some features of paget's disease?
- skull, femur, pelvis involvement
- hearing loss and facial pain
- pathological fractures
complications of paget's disease
• Malignant fibrosarcoma
• Pathological fractures
• Spinal stenosis
High output cardiac failure
difference between osteoporosis and osteomalacia?
In osteoporosis, there is decreased bone mass with a normal ratio of mineral to matrix
In osteomalacia, the ratio of mineral to matrix is decreased (ie there is too much matrix relative to the amount of bone)
what is the difference between osteopenia and osteoporosis?
osteopenia also refers to reduced bone density but not to the extent as osteoporosis
how do we treat psoriatic arthritis?
• NSAIDs first line- naproxen, ibuprofen, diclofenac
• DMARDs- methotrexate, sulfasalazine, cyclosporin
• Adjunct physiotherapy, intra-articular corticosteroids
In severe cases upgrade to biological agents like inflixamab
what are some radiological findings of psoriatic arthritis?
The hallmark of PsA is the combination of erosive change with bone proliferation, in a predominantly distal distribution (i.e. interphalangeal more than MCP joints). The disease most commonly involves the hands, followed by feet. It can also affect sacroiliac joints and spine.
what are the key differences between psoriatic arthritis and RA?
how are they similar?
PA is usually seronegative -ve RF -Anti CCP
PA affects distal joints whereas RA predominantly affects proximal joints
RA is symmetrical whereas PA may or may not be symmetrical
Both inflammatory pain conditions
Both have erosions on plain film
what is the mutation associated with Paget's disease of bone?
what is the main driver of osteoclastic activity in Paget's disease of bone
NFKB induces OC activity
treatment for Paget's disease of bone?
• Calcium supplementation
Vitamin D supplementation
what is another name for avascular necrosis?
2 key causes of avascular necrosis?
trauma and corticosteroid use
what part of the bone does avascular necrosis usually affect?
medullary part of the bone usually has infarcts bc the cortex area has collateral blood supply and the medulla doesn't
what are the most common bacteria associated with osteomyelitis?
pyogenic bacteria (staph aureus)
what do we mean by osteosarcoma
a malignant mesenchymal tumour in which the tumour cells produce bone
where does osteosarcoma commonly metastasise to?
what conditions predispose pathological fractures?
malignancy (bony mets)
what are the mutations associated with osteosarcoma
RB and p53 mutations
what are the main types of soft tissue tumours?
skeletal muscle tumours
smooth muscle tumours
what is a ganglion?
cysts around joints and arising from tendon sheaths
2 descriptions of fractures in femurs?
intracapsular or extracapsular
what levels are most affected for lumbar spondylosis?
L4-L5, L5- S1
what does a positive tredenlenberg test indicate
weakness of the gluteal medius muscle
what is another name for vertebral osteomyelitis?
diskitis or discitis
what might cause genu varum and genu valgus?
rheumatoid arthritis- valgus
the most common site for hip pain?
laterally around the hip
What pain refers to the buttock?
lumbosacral spine, hip joint
what pain refers to the groin?
hip joint, lumbosacral spine, SI joint
what sort of things do we think when a patient presents with lateral hip pain?
what nerves innervate the hip joint?
femoral, obturator, gluteal nerves
what does GALS stand for?
is there any need for a blood test to dx OA?
management of OA?
exercise, reduce body weight
analgesia--> paracetamol used regularly--> opiates
indications for total hip replacement?
disabling pain with failed non operative treatment
- impaired ADLS
-reduced ROM and fn
-pain at night
will you do a THR on a patient with UTI
no bc risk of bacteremia. So always need to do a UTI screen (MSU) preoperatively
complications of THR?
• Intra op- injury to NV structures
• Early post op- haematoma, infection
• Late post op- dislocation, fracture, loosening, heterotropic ossification
when do we use a dynamic hip screw?
when there is a hip fracture (NOF)
what do we mean by gluteus medius tendinopathy syndrome
degeneration of muscle fibres in the gluteus medius--> tearing and oedema of the gluteus medius tendon
can be associated with greater trochanteric bursitis
define impingement syndrome
Impingement may be defined as the encroachment of the acromion, coracoacromial ligament, coracoid process, or AC joint on the rotator cuff as it passes beneath them during glenohumeral motion.
define baker's cyst
a synovial fluid-filled mass located in the popliteal fossa. The most common synovial popliteal cyst is considered to be a distention of the bursa located beneath the medial head of the gastrocnemius muscle.
OA typically affects which compartment in the knee?
which is stronger in the knee- ACL or PCL
what is mechanism of injury of ACL injury
knee extended, impact, internal rotation of tibia on fibula
what is mechanism of injury of PCL injury?
falling on knee whilst bent, hitting knee on dashboard
-high impact injuries
what is tennis elbow?
inflammation of the lateral epicondyle
what is meralgia parasthetica?
compression of lateral cutaneous nerve of thigh--> sensory loss in lateral area
risk factors for carpal tunnel syndrome?
• Radial fractures
• Strenuous overwork
• RA, acromegaly
• Diabetes, CCF sometimes
Menopause and pregnancy
first line ix for carpal tunnel syndrome?
nerve conduction tests
or MRI and U/s wrist
risk factors for osteoporosis
low exercise levels
poor nutrition/calcium intake
vitamin D insufficiency
prolonged amenorrhoea in younger years
post menopausal at age 42-53
never reached peak bone density
what does the DEXA scan use as its reference
normal BMD in a 30 year old healthy woman
what bones does the DEXA scan analyse?
measures BMD of spine and proximal femur and total hip
if you have vitamin d deficiency, what do you expect the PTH levels to be?
What are the bone turnover markers?
Serum B-CTX indicates bone resorption (cleared by the kidneys)
P1NP indicates bone formation (cleared by the liver)
What are the SECONDARY causes of osteoporosis?
Excessive alcohol use
Malabsorption (coeliac, IBD)
Primary or secondary hypogonadism
how do we calculate absolute fracture risk?
using calculation tools like the Garvan absolute fracture risk
do we use HRT for osteoporosis? why?
NO. Increases risk of breast and endometrial ca and increases risk of CVD
what are some therapies for osteoporosis
Bisphosphonates (alendronate, risedronate, zoledronate)
Raloxifine (women only)- SERM not often used anymore
tell me about raloxifine and why we do not use it much anymore
main action is- reducing vertebral fractures
strongly predisposes the patient to DVT and clots
why might teriparatide be used in osteoporosis?
intermittent PTH therapy can actually reduce bone resorption
SE of strontium
negative cardiovascular effects
which bisphosphonate is given intravenously once a yr?
how do we administer denosumab?
SC injections at the GP every 6 months
SE of denosumab
Osteonecrosis of the jaw
slight increased risk of infection
what are the main side effects of bisphosphonates (oral)?
Osteonecrosis of the jaw
do we prescribe bisphosphonates in patients with CKD?
no, because the drug are renally cleared
what is adynamic bone disease?
condition where there is static bone- not forming bone or not resorbing bone
should we use denosumab post renal transplant?
no. bc it increases the risk of infection in immunosuppressed patients
what actually is osteonecrosis of the jaw?
exposed necrotic bone of more than 8 weeks
how might we assess a patient's risk of atypical bone fractures due to bisphosphonate use?
ask the patient if they have experienced mid thigh pain. If they say yes, then cease bisphosphonates immediately.
causes for vitamin D deficiency
inadequate sunlight exposure