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MSK Flashcards

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1
Q

What is synovitis and what are some common causes ?

A

It is an inflammation of a synovial membrane
It can be a feature of arthritis in which there is active inflammation.
Common causes include :
RA
Gout
Sometimes OA

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2
Q

Define stiffness and explain its clinical significance of early morning stiffness ?

A

Stiffness is slowness or difficulty moving one or more joints.
Early morning stiffness is used to describe stiffness on getting out of bed or staying in one position.
It is an indicator of inflammatory arthritis.
Stiffness which is generalised and lasts more than 30 minutes on waking up is a feature of RA.

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3
Q

What are the likely causes of limited or painful active movement but with full, pain-free passive movement ?

A

The range of passive movement of a joint is usually higher than what the person can achieve themselves through active movement.
As passive movement does not require the person to use their own nerves, muscles and tendons to produce movement, a reduction in passive range or pain on passive movement indicates a problem with the joint itself.
In active movement muscles and tendons function. Therefore if there is a problem with the muscles and tendons there would be a reduced range of movement and / or pain on active movement only.

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4
Q

What are the mechanical symptoms of the knee ?

A

Symptoms such as locking or catching of the knee on movement were traditionally thought to indicate a mechanical problem with the knee such as a loose body or meniscal tear obstructing the knee. However it is thought know that this is common in knee disease even without obstruction.

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5
Q

What is bursitis of the knee and how does it differentiate from knee effusion ?

A

Like other joints the knee is surrounded by small fluid filled sacs called bursae which reduce friction between moving tendons and provide cushioning for the joint.
By contrast a knee effusion is swelling due to excess synovial fluid in the joint capsule itself. In knee effusion fluid can be moved across the knee ( bulge test ) and pressure over the patella causes fluid to move ( patellar tap ).
In bursitis the swelling is localised to the bursa that is affected.

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6
Q

Which causes of hip pain would tend to produce pain in anterior, lateral and posterior hip area ?

A

Anterior - true hip pain - OA
Lateral - trochanteric bursitis
Posterior - lumbosacral spine or gluteal muscles

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7
Q

What are the clinical features of plantar fasciitis ?

A

Typically causes pain at the insertion of the plantar fascia into the calcaneum. It tends to occur in people who spend a lot of time on their feet.
Pain is marked with the first few steps on getting out of bed and then worsens again to the end of the day.

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8
Q

What is metatarsalgia ?

A

Pain in the mid-foot and has a wide range of causes

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9
Q

What are the clinical features of gout ?

A

Gout is a form of inflammatory arthritis due to uric acid crystal deposition in the joint. It usually affects the great toe and is often recurrent. It has a rapid onset of severe pain and often causes swelling.

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10
Q

What is a painful arch ?

A

Painful arch is pain in the mid-range ( 45 - 120 degrees ) of abduction of the shoulder which eases with greater range of abduction.
It indicates impingement of the shoulder in the sub-acromial space with movement. The pain is felt more on active movement than passive.

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11
Q

Other than shoulder pathology what can cause pain in the shoulders ?

A

Referred pain from the neck - cervical spine radiculopathy
MI or angina
Pancoast’s tumour
Polymyalgia rheumatica

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12
Q

How does the appearance of OA and RA differ in the hands ?

A

OA - heberdens nodes in the distal IP joints

RA - acute episodes which usually affect the proximal IP joints, metacarphalangeal and wrist joints.
In chronic disease you see ulnar deviation of the fingers, swan neck and boutonnière deformities.

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13
Q

What is tennis elbow ?

A

Lateral epicondylitis - suspect if pain in lateral elbow with tenderness over the common extensor origin

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14
Q

What is golfer’s elbow ?

A

Medial epicondylitis - suspect if pain in medial elbow with tenderness over the common flexor origin

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15
Q

What is OA ?

A

A disease of the synovial joints which is due to a loss of articular cartilage and overgrowth of underlying bone.

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16
Q

What joints are most likely affected in OA ?

A

Knee
Hips
Small hand joints

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17
Q

What is seen on X-ray in OA ?

A

Loss of joint space
Osteophytes
Subchondral sclerosis
Sub-cortical cysts

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18
Q

What is the management of OA ?

A

Etoricoxib 60mg/day and Diclofenac 250mg/day seem to be the most effective oral NSAIDs for pain and function in patients with OA.
Topical Diclofenac 70-81 mg/day

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19
Q

What is the presentation of RA ?

A

Insidious polyarthritis characterised by inflammatory changes in the synovial membranes and articular structures leading to deformity and ankylosis.
Typically the small joints are affected

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20
Q

How does RA present ?

A

Insidious polyarthritis
Typically small joints of the hand and feet
Symmetrical

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21
Q

What are the clinical features of RA ?

A

Pain
Swelling
Stiffness
Weight loss
Fatigue
Malaise

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22
Q

What are some differentials for RA ?

A

Viral arthritis
Reactive arthritis
Polymyalgia rheumatica
Gout
OA
Septic arthritis
Fibromyalgia

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23
Q

What are some investigations for RA ?

A

Examination
ESR or CRP
Presence of rheumatoid factor
Anti-CCP antibodies
Anticitrilline anitbodies
Urinalysis

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24
Q

What is the medical management of RA ?

A

DMARD
Biologics
Methotrexate
Pain relief

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25
When should you refer a patient to rheumatology urgently if suspecting RA ?
Small joints of hands or feet are affected More than one joint affected
26
What is the pathogenesis of RA ?
It is autoimmune disease that causes the immune system to attack the synovial membrane of the mainly small joints causing inflammation.
27
What is gout ?
A painful and potentially disabling form of inflammatory arthritis. It is a disorder of purine metabolism characterised by hyperuricaemia and the deposition of mono sodium urate crystals in articular or peri-articular tissues and in the renal tract.
28
What are the risk factors for gout ?
Hyperuricaemia Gender - men Diet Alcohol Drugs Obesity
29
What are some clinical features of gout ?
Rapid onset of severe pain Redness and swelling Tophi Most commonly 1 or both metatarsophalangeal joints
30
What investigations can be made for gout ?
Serum urate Aspiration of the synovial fluid Radiology Leucocytosis and raised ESR and CRP during the acute attack
31
What are some differentials for gout ?
Infection - cellulitis, septic bursitis RA Bunion
32
What is the treatment options for gout ?
Acute flares of gout - offer NSAIDS or a short course of oral corticosteroids . Consider adding a PPI Long term management - start urate lowering therapy
33
When should you consider referral to rheumatology when considering gout ?
Diagnosis is uncertain Treatment is contra-indicated, not tolerated or ineffective They have CKD stages 3b to 5 They have had an organ transplant
34
What is psoriatic arthritis ?
It is synovitis which occurs in individual with psoriasis but without serum rheumatoid factor.
35
What clinical features are seen in psoriatic arthritis ?
Gradual : Stiffness Pain Swelling tenderness Asymmetrical
36
What investigations are there for psoriatic arthritis ?
WBC - raised ESR and CRP - raised Hypergammaglobulinaemia Rheumatoid factor X ray
37
What is the management of psoriatic arthritis ?
Local corticosteroids injections Offer DMARDs NSAIDs can be used as an adjunct to standard DMARDs Biologics - infliximab
38
What is reactive arthritis ?
It is defined as a joint inflammatory process in which the infection is known originating either in the urinary or digestive tract but where bacterial product is not detected in the joint.
39
What is the management of reactive arthritis ?
Most patients repsond to treatment with NSAIDs Some may require treatment with biological agents
40
what is the prognosis for reactive arthritis ?
Variable Most people will remain symptomatic and develop long term disease Some go into permanent remission
41
What is septic arthritis ?
A suppurative inflammation within a joint space, most commonly due to haematogenous spread but sometimes due to direct spread from a penetrating wound or neighbouring infection. Mainly it is mono articular and affects the hip and knee.
42
What is the predisposing factors for septic arthritis ?
Debilitating disease Infection elsewhere Rheumatoid arthritis Immunosuppression DM Recent joint surgery Penetrating injury
43
What are the common infectious agents for septic arthritis ?
Staphylococcus aureus Streptococcus pyogenes Pneumococcus Haemophilus influenzae
44
What are the clinical features of septic arthritis ?
Red and warm Swollen and painful Pain on movement Tachycardia Pyrexia
45
What investigations are needed when suspecting septic arthritis ?
Blood cultures FBC ESR CRP Aspiration of synovial fluid
46
Why should you admit someone immediately with suspected septic arthritis ?
Joint damage can be very rapid so it is important to admit patients to hospital immediately.
47
What is the treatment for septic arthritis ?
Synovial fluid should be obtained for gram-staining, culture and crystal analysis Following joint aspiration empirical IV antibacterial therapy should be started. Surgical drainage is indicated
48
What complications are there for septic arthritis ?
Chondrolysis Septic dislocation Avascular necrosis Shortening Late degenerative change
49
What is ankylosing spondylitis ?
Part of the group of inflammatory rheumatic diseases It is a common seronegative spondylitis typically affecting the spine and sacroiliac joints
50
What are some of the causes of ankylosing spondylitis ?
Tends to run in the family or other arthritis diseases Associated with HLA B27
51
What are the extra-articular clinical features of ankylosing spondylitis ?
Cardiac - aortic valve disease - conduction defects - carditis Pulmonary fibrosis Amyloidosis Neurological complications - spinal fractures - cauda equina syndrome
52
What are the articular manifestation of ankylosing spondylitis ?
Backache and stiffness Painful heels and tenderness Pain over the iliac crest Osteoporosis
53
What investigations are there for ankylosing spondylitis ?
FBC - leucocytosis ESR - elevated CRP - raised Hypergammaglobulinaemia Negative rheumatoid factor X ray MRI
54
What is the management of axial spondylitis ?
NSAIDs Biologic DMARDs Surgery for spondyloarthritis
55
What is sciatica ?
Pain in the distribution of the sciatic nerve - felt in the thigh and most importantly below the knee. Pain is not felt below the knee
56
What exacerbates sciatica ?
Coughing Straining Sneezing Laughing
57
What are some indications of sciatica ?
Unilateral leg pain greater than low back pain Pain radiating to foot or toes Numbness and paraesthesia in the same distribution Straight leg raising test induces more leg pain Local neurology
58
What are some risk factors for sciatica ?
Age ( 45 - 64 ) Increasing risk with height Smoking Psychological stress Vibration of the whole body
59
What are the causes of sciatica ?
Disc herniation Malignancy Infection Vascular compression Bony compression Muscular compression
60
What investigations could be performed for sciatica ?
Rule out malignancy and infection MRI is best imaging and most likely to reveal a prolapsed disc
61
What is the management of sciatica ?
Reassure patients that symptoms are self limiting and will usually disappear. Analgesia
62
When do most ankle ligament injuries occur ?
When a patient stumbles and the supporting foot is twisted and usually inverts
63
What are the clinical features of an ankle sprain ?
Swollen ankle Bruising Pain on movement
64
What is the treatment for a partially and complete ankle sprain ?
Partial tear - bandage is applied and exercises to mobilise the joint Complete tear - plaster immobilisation for 6 weeks
65
What are some complications for an ankle sprain ?
Recurrence of the injury Adhesions Recurrent subluxation
66
What is fibromyalgia ?
A condition characterised by chronic widespread pain together with multiple muscular tender points or associated fatigue, sleep disturbance, cognitive dysfunction in the absence of a well defined underlying organic disease
67
What are some potential causes of fibromyalgia ?
Aetiology is unknown but - altered central pain processing - dysfunction of the HPA axis - sleep disturbances - genetic factors - psychiatric element - trigger factors = infections, physical trauma, chemical substances
68
What are the clinical features of fibromyalgia ?
Vague Fatigue Pain Non-restorative sleep Cognitive dysfunction Mood disorder
69
What are the differentials for fibromyalgia ?
Hypothyroidism SLE Hyperparathyroidism Polymyalgia rheumatica Sleep disorders Anxiety Depression
70
What is the management of fibromyalgia ?
Physical therapies Acupuncture Psychological therapies Analgesia Opioids Antidepressants
71
What is polymyalgia rheumatica ?
A chronic inflammatory disease of unknown aetiology which presents with pain and stiffness that is worst in the morning and particularly affects the shoulders and hips.
72
What is the aetiology of polymyalgia rheumatica ?
Unknown Susceptibility factors could include : - genetic causes - environmental causes
73
What are the clinical features of polymyalgia rheumatica ?
Pain and stiffness of the shoulder girdle, hip girdle and neck muscles Malaise Weight loss Most commonly seen in 70s + Bilateral
74
What are some differentials for PMR ?
RA GCA Hyperparathyroidism Motor neurone disease Infections Malignancy
75
What are some investigations for PMR ?
ESR - raised CRP - elevated FBC - anaemia Other investigations to rule out other pathology
76
What is the treatment for PMR ?
Steroid therapy - prednisolone
77
What should be assessed for if a patient has PMR ?
Giant cell arteritis
78
What is bursitis ?
Inflammation in the bursa. It can result from injury, infection or rheumatoid synovitis.

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