MSK Flashcards
1
Q
Function of type 1 collagen
A
Elasticity
2
Q
Where is type 1 collagen found
A
Skin, tendon, organic component of bone
3
Q
Where is type 2 collagen found
A
Cartilage
4
Q
Where is type 3 collagen found
A
Connective tissue
5
Q
Where is type 4 collagen found
A
Epithelial layer of Basement membrane
6
Q
Where is type 5 collagen found
A
Hair
Placenta
7
Q
Define ligaments
A
Bone - bone attachment
8
Q
Define tendons
A
Muscle - bone attachment
9
Q
Give an example of fibrous joints
A
Skull suture
- Immoveable
10
Q
Give an example of cartilageneous joints
A
Intervertebral discs
- Partially moveable
11
Q
Give an example of synovial joints
A
Most joints in the body
Knees, hips, fingers shoulder
- Moveable
12
Q
Components / anatomy of synovial joints
A
Articular cartilage - Lines the end of the periosteum (bone part with pain receptors)
Joint capsule - Inner lining of the synovial membrane
Joint cavity filled with synovial fluid
13
Q
Define osteoarthritis
A
Most common arthritis
Non-inflammatory, degenerative mechanical shearing of synovial joints
14
Q
Risk factors for osteoarthritis
A
Increased age (50+ ; women >50 affected a lot)
Obesity
Occupation / sports
Genetics (COL2A1; genetic predisposition)
15
Q
Pathophysiology of osteoarthritis
A
Imbalanced cartilage breakdown > repair
Where you get increased chrondrocyte metaleoproteinase secretion
Degrades collagen type 2 + forms cysts
Bone attempts to overcome with type 1 collagen but get abnormal bony growths (osteophytes) + remodelling
16
Q
Signs and Sx of osteoarthritis
A
Transient (< 30/60 mins) morning pain —> worsen as day goes on
Heberdens + Bouchard’s nodes on fingers
Assymetrical, hard non-inflamed joints
No extra-articular Sx
Crepitus - crackling or grating sensation when moving a joint
17
Q
In which condition are heberdens nodes found and where in the body
A
Distal interphalangeal joints
Osteoarthritis
18
Q
In which condition are bouchards nodes found and where in the body
A
Found in proximal interphalangeal joints
- osteoarthritis
19
Q
Investigation and Dx of osteoarthritis
A
Xray changes:
Loss of joint space
Osteophytes
Subchondral cysts
Subchondral sclerosis
Bloods - normal
20
Q
Tx for osteoarthritis
A
Lifestyle management:
Weight-bearing, physio
Medical:
1st line - Paracetamol + topical NSAIDs
2nd line - Oral NSAIDS + PPIs ± topical capsaicin (chilli pepper extract)
Consider
Last resort - Arthroplasty
21
Q
Define rheumatoid arthritis
A
Inflammatory autoimmune symmetrical polyarthritis
22
Q
Who does RA affect more
A
Women
30-50y/o
x3 more likely than males; pre menopause
Post menopause - m=f
23
Q
Risk factors for rheumatoid arthritis
A
Women >
Age
Smoking
Genetics - HLADR1 + 4
24
Q
Pathophysiology of rheumatoid arthritis
A
Arginine —> citruline mutation in type 2 collagen
Anti-CCP (cyclic citrullinated peptide) formation against citrullinated molecules.
TNFa causes further pro-inflammatory recruitment to synovium
- synovial lining expands and tumour-like mass (pannus) grows past joint margins
- Pannus destroys subchondral bone + articular cartilage
25
Signs and symptoms of rheumatoid arthritis
**Morning stiffness > 30/60mins (eases as day goes on)
Boutenieres deformity
Swans neck deformity
Ulnar deviation
Z-thumb deformity**
*Remember as an anomaly; DIP joints are often spared, unlike **psoriatic arthritis**.*
*Bakers cyst might occur behind knee when the inflamed synovium moves posterior creating a cyst*
**Symmetrical, hot, inflamed joints**
26
What extra-articular complications are seen in rheumatoid arthritis
Lungs - pulmonary fibrosis
Skin - rheumatoid skin nodules
Heart - increased IHD risk
Eyes - Episcleritis
27
Define felty syndrome
Triad of: rheumatoid arthritis, granulocytopenia, splenomegaly
*Life-threatening; high risk of infection*
28
Investigation and Dx of rheumatoid arthritis
Bloods:
Increased CRP & ESR (*Used for monitoring disease*)
Normacytic normochromic anaemia (chronic disease)
Serology:
+ve Anti-CCP (80%; specific), +ve rhematoid factor (non-specific)
Xray:
**L**oss of joint space
**E**rosions
**S**oft tissue swelling
**S**oft bones (osteopenia)
29
Tx for rhematoid arthritis
_First line_ is monotherapy with **methotrexate** (gold standard), leflunomide or sulfasalazine.
Hydroxychloroquine can be considered in mild disease and is considered the “mildest” anti rheumatic drug.
_Second line_ is 2 of these used in combination.
_Third line_ is **methotrexate** plus a biological therapy, usually a TNF inhibitor - **influximab**
_Fourth line_ is **methotrexate plus rituximab** - B-cell inhibitor; CD20 target
_Flare-up management_
NSAIDs (1º care analgesia) - ibuprofen + Glucocorticoids injections
30
Classification used to Dx rheumatoid arthritis
ACR
*American College of Rheumatoid Arthritis*
Or
EULAR
*European League Against Rheumatism*
31
Tx for RA flare ups
NSAIDs (1º care analgesia) - ibuprofen + Glucocorticoids injections
32
Which score is used to assess RA management
DAS28
*Disease activity score 28*
33
Define gout
Gout is an **inflammatory arthritis** caused by deposition of **monosodium urate** crystals within joints.
34
Who does gout typically affect
Middle aged overweight men
35
Which joint is most affected in gout
first metatarsophalangeal joint (MTP).
*Base/bottom of big toe*
36
Pathophysiology of gout
Urate is a metabolite of **purine synthesis**
Purines ————> uric acid ————> monosodium urate
I
I
Xanthine Oxidase
Uric acid is usually excreted via kidneys but if there’s **impaired excretion (*CKD*) OR over-production**… causes gout
*Hyperuricaemia increases risk of gout but not guaranteed for getting gout*
37
Risk factors for gout
**Purine rich diets**: fish/seafood, meat, beer
*Dairy can be Anti-gout*
**CKD
Diuretics**
38
Signs and Sx of gout
**Mono-articular**; big toe typically (metotarsophalangeal joint)
- *sudden onset, hot, swollen red toe. Can’t put weight on it.
**Gouty tophi** - *nodular masses of urate crystals form, usually as a late complication*
39
Differential diagnosis for gout
Septic arthritis
40
Investigation and Dx of gout
**Joint aspirate + polarised light microscopy** - gold standard
* **Needle-shaped, Negative bifringement monosodium urate crystals**.*
Xray:
Punched out erosions
Lytic lesions - sclerotic borders with overhanging edges
41
Tx for gout
1st line: NSAIDs (+ PPIs)
2nd line: Cholcicine
3rd line: corticosteroid intracellular-articular injection
_Prophylaxis_
Allopurinol - *xanthine oxidase inhibitors* - decreased uric acid conversion
42
Define pseudogout
The deposition of **calcium pyrophosphate crystals** in long bone joint capsules
*Chondrocalcinosis*
43
Who does pseudogout typically affect
Elderly females (> 70y/o)
44
Joints most affected in pseudogout
**Knee**
Shoulder
Hip
Wrist
45
Risk factors for pseudogout
**Increasing age
Diabetes**
OA
HyperPTH
46
Signs and Sx for pseudogout
Often **polyarticular** (knee commonly affected)
- Swollen, red, hot joint
47
Differential Dx for pseudogout
Septic arthritis
48
Investigation and Dx of pseudogout
**Joint aspiration +polarised light microscopy**:
_Rhomboid shaped, Positive bifringement of calcium pyrophosphate crystals_
*Gold standard*
Xray:
**Chondrocalcinosis** - white line inbetween the synovial joint
LOSS - same as osteoarthritis in Xray ∆
49
Tx for pseudogout
Only Acute management :
NSAIDs, then cholcicine, then corticosteroid injection
*No prevention drug here!*
50
Give examples of connective tissue disorders
Marfans
Ehlers danlos syndrome
51
Define marfans syndrome
**Connective tissue disorder**
- decreased connective tissue tensile strength
52
Inheritance pattern for marfans
Autosomal dominant
- mutation in FBN1
53
Signs and Sx of marfans
*Marfans body habitus*
- Tall and thin
- Long fingers (arachnodactyly)
- Pectus excavation / cannaturn (sternum pressed in / puffed cut)
+
AORTIC COMPLICATIONS -
**AAA / aortic dissection
Aortic regurgitation murmur**
54
Investigation / Dx for marfans
Clinical Px + FBN-1 mutation
55
Define ehlers donlos syndrome
Autosomal dominant mutations affecting collagen proteins
13ish subtypes
56
Signs and Sx of EDS
Joint hypermobility + CV complication (*AAA / Aortic dissection ‘ Mitral regurgitation*)
57
Investigation / Dx for EDS
Clinical + collagen mutations
**THESE CONNECTIVE TISSUE DISORDER WILL MEAN WEAK VALVES, WEAK VESSELS**
58
What could cause mechanical lower back pain
Normal between ages 20-55
Could be trauma / work related
Signs of serious pathology:
Elderly - could indicate myeloma / neuropathic pain (spinal cord compression)
59
Define lumbar spondylosis
Degeneration of intervertebral disc; loses its compliance + thins over time
Seen in older Px
Most commonly affects - L4/5 OR L5/S1
Tx: Analgesia + physiotherapy if simple mechanical pain
60
Structure of bone: what is the hard external layer
Cortical bone
61
Structure of bone: what is the internal layer of bone called
Spongy / trabecular bone
62
Structure of bone: Role of trabeculae
Structural beams giving **support** to the spongy / trabecular bone
63
Structure of bone: What is cortical bone made of
Small functional units - **Osteons**
64
Structure of bone: what allows blood supply to pass through hard bone
Osteons have a hollow canal - **Haversian canal** which allows blood vessels and nerve innervation to run through the bone
65
Structure of bone: what surrounds the Haversian canal?
*Haversian canal is hole in osteon centre carrying blood supply etc….*
**Lamellae** surrounds this and has an *organic component* - Collagen
And an *inorganic component* - hydroxyapatite (calcium phosphate)
66
Structure of bone: what’s found inbetween lamellae
Inbetween lamellae we find **lacunae** where bones cells (**Osteocytes**) are found
67
Steps of bone remodelling
Bone resorption
*Osteoclast break down bone*
Bone formation
*Osteoblast form new bone*
68
What does bone remodelling depend on
Serum calcium levels
- controlled by PTH, calcitonin and Vit D
69
When is calcitonin released
When serum calcium is too high… calcitonin secreted by thyroid gland.
- promotes bone formation and decreases bone resorption
70
Define osteoporosis
Reduced bone density resulting in porous bone with increased fragility
71
Difference between osteoporosis and osteomalacia
Reduction in bone density but **no mineralisation** in **osteoporosis**. But there is in osteomalacia
72
Who does osteoporosis mainly affect
50+ y/o postmenapausal Caucasian women
73
Risk factors for osteoporosis
Remember **SHATTERED**
**S**teroids / _Smoking_
_**H**yperparathyroid_
**A**lcohol
_**T**hin (reduced BMI)_
_**T**estosterone decreased_
**E**arly _menopause_
**R**enal failure
**E**rosive / inflammatory disease
_**D**MT1_
74
Signs and Sx of osteoporosis
Asymptomatic
**Fractures** may indicate it
• Vertebrae / compression fractures (may have kyphosis)
• Proximal femurs
• Colles’ (forked wrists - fallen on outstretched wrists)
75
Investigation and Dx of osteoporosis
**DEXA scan** - gold standard
*Dual energy Xray Absorptiometry*
- gives a T-score (comparing BMD of Px to reference)
**frax tool** - fracture risk assessment tool
*Asses10yr fracture risk in osteoporotic Px*
76
Which scan is used in osteoporosis
DEXA
77
Tx for osteoporosis
1st line: **Bisphosphonates**
*Aledronate (aledronic acid)
Risondronate (Risodronic acid)*
2nd line:
**mAb - Denosumab**
**H**ormone **R**eplacement **T**herapy - oestrogen & testosterone
Oestrogen receptor modulator - **Raloxafine**
78
What is the range for dexa score and what condition is it used in
Used for osteoporosis
T score:
Normal: > -1
Osteopenia: between -1 and -2.5
Osteoporosis: < -2.5
Severe osteoporosis: < -2.5 + fractures
79
Define osteopenia
Osteopenia refers to a less severe reduction in bone density than osteoporosis
80
Why are bisphosphonates used in osteoporosis
Inhibit RANK-L signalling so osteoclast activity is inhibited
81
When is denosumab used
2nd line for osteoporosis
It’s a monoclonal antibody - inhibits RANK-L
82
Give examples of autoimmune rheumatological disorders
**Systemic lupus erythmatosis
Antiphospholipid syndrome
Sjogren syndrome**
Scleroderma
Polymyositis
83
A 30-year-old African-American lady presents to her GP with increasing fatigue and joint pain. On examination, she has a butterfly rash across her face. What is the Dx?
Systemic lupus erythmatous
84
Define SLE
_Type 3 hypersensitivity reaction_ - **autoimmune systemic inflammation** due to Antigen:Antibody complex deposition.
85
Who is SLE typically seen in
Females
Afrocarribean descent
20-40y/o (premenopausal)
86
Risk factors for SLE
Female (12x more than M)
HLADR2/3 or HLAB8
Drugs
Environmental factors - UV rays
87
Pathophysiology of SLE
Damage to cells leading to impaired apoptosis. Apoptotic debris is presented to Th2 Cell *Especially nuclear antibodies* and *double-stranded DNA*
—> B cell activation —> antigen-antibody complexes deposition in tissue.
*SO, SLE can be characterised by **Anti-Nuclear Antibodies** (ANA) and anti-dsDNA*
88
Signs and Sx of SLE
**Malar butterfly rash on face + photosensitivity**
**Glomerulonephritis** (Nephritic syndrome)
Mouth ulcers
Reynauds phenomenon
Joint pain
89
Investigation and Dx for SLE
FBC: **INCREASED ESR NORMAL CRP**
Serology:
**ANA +ve** - v. Sensitive
**Anti-dsDNA** - v. Specific (Also used to monitor SLE progression)
*Essentially diagnostic using these*
**Reduced C3+C4**: Due to active disease
Prolonged APTT: in lupus Px is hypercoaguable
90
Tx for SLE
Lifestyle changes: reduced uv ray exposure / reduce triggering drugs
1st line:
**Corticosteroids** - prednisolone
Then:
+ Hydroxychloroquine (DMARD)
+ NSAIDs
+ immunosuppressant if severe (Azathioprine)
*Note: Aim is to taper off the other drugs so Px is left with hydroxychloroquine once stable*
91
Define Antiphospholipid syndrome
Syndrome characterised by thrombosis, pregnancy complications (recurrent miscarriages) and Antiphospholipid antibodies
Can be 1º (idiopathic ) or 2º (to other autoimmune conditions - especially **SLE**)
92
Who’s affected in Antiphospholipid syndrome
Females
93
Signs a and Sx of Antiphospholipid syndrome
**CLOTS**
- Px is in hyper-coaguable state
- venous thrombosis (DVT / PE)
- arterial thrombosis (stroke, MI, renal thrombosis)
**Livedo reticularis** - purple discolouration of skin
94
Investigation and Dx of Antiphospholipid syndrome
Sx + Hx of thrombosis etc… + persistent antibodies presentation
Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies
95
Which antibodies seen in lupus
Lupus anticoagulant
Anticardiolipin antibodies
Anti-beta-2 glycoprotein I antibodies
96
Tx for Antiphospholipid syndrome
1st line: **Warfarin** long-term if Px had a thrombus
If pregnant give LMWH + aspirin
**Prophylaxis: Aspirin** - if not had a thrombus formation yet
97
Define Sjogren syndrome
Dry! Dry! Dry! - autoimmuneexocrine gland dysfunction
1º Sjogren’s is where the condition occurs in isolation.
2º Sjogren’s is where it occurs related to SLE or rheumatoid arthritis.
98
Which antibodies is Sjogrens related to
It is associated with anti-Ro and anti-La antibodies.
99
Signs or Sx of Sjogrens
Dry eyes, mouth and vagina
100
What test is used in Sjögren’s syndrome
**Schirmer test** - induce tears + and place filter paper under eyes.
Measure the travel of the tear (< 10mm = sjogrens)
*Should be 20mm+*
101
Tx for sjogrens
Artificial tears, saliva + lubricant for sexual activity
*Sometimes can give hydroxychloroquine*
102
What condition does Sjogrens directly increase the risk of
Lymphomas
103
Give examples of 1º bone tumours
Osteosarcoma
Ewing’s sarcoma
Fibrosarcoma
Chondrosarcoma
104
SECONDARY BONE TUMOURS
Osteolytic: Breast and Lung
Osteosclerotic: Prostate, Thyroid, RCC
+ myeloma - can cause back pain; *old CRAB*
105
What is the most common 1º bone malignancy
Osteosarcoma
Px: 15-19y/o
106
What condition is osteosarcoma associated with
Paget’s disease
107
Where does osteosarcoma most commonly metastasise to
Lungs
108
Xray signs of osteosarcoma
Sunburst appearing bone
109
Define ewings sarcoma
From mesenchymal stem cell
Affects 15y/o
110
Define chondrosarcoma
Malignancy of cartilage
111
Tx for bone tumour
Chemo/radiotherapy
Bisphosphonates
112
Define osteomalacia
Defective bone mineralisation
- before epiphyseal fusion : rickets
- after epiphyseal fusion : osteomalacia
113
Main cause of osteomalacia
Vitamin D deficiency
- reduced a calcium and phosphate
- reducing hydroxyapatite mineral of bone
114
Causes of osteomalacia
Vit d deficiency
HyperPTH
CKD
Liver failure
Anticonvulsant drugs - increased CYP450 metabolism of Vit d
115
Sx of osteomalacia
Fractures
Proximal weakness
_Rickets:_
Skeletal deformities
- bowed legs
- wide epiphysis
116
Investigation and Dx of osteomalacia
**BM biopsy** (gold standard)
*Incomplete mineralisation*
Bloods:
**Decreased 25-hydroxyVitamin D**
Increased PTH (low Vit D —> low Ca2+ —> increased PTH —>2º hyperPTH)
Raised ALP
XRay:
Loser’s zones *(defective mineralisation - low-density bone surrounded by sclerotic borders)*
117
Tx for osteomalacia
Calcitriol - Vit D replacement
Increase dietary intake - supplements / eggs
118
Define vasculitis
Inflammation of the blood vessels
*There’s many types affecting different sized vessels leading to different damage depending on the tissue being supplied.*
119
Types of vasculitis affecting small blood vessels
Henoch-Schonlein purpura
Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss syndrome)
Microscopic polyangiitis
Granulomatosis with polyangiitis (GPA - Wegerners disease)
120
Types of vasculitis affecting medium blood vessels
Polyarteritis nodosa
Buergers disease
Kawasaki Disease
121
Types of vasculitis affecting large blood vessels
Giant cell arteritis
Takayasu’s arteritis
122
Define giant cell arteritis
*Aka temporal arteritis*
As it typically presents in temporal artery…
So Px presents with… **unilateral temple headache, jaw claudication, _vision ∆ leading to vision loss_** - affecting a 50+ y/o Caucasian female.
123
Key complication of giant cell arteritis
**Vision loss** - sudden and painless
Usually in one eye
If temporary - may cause Amourosis fugax *(more typically seen in TIA)*
May become permanent if not treated ASAP -
High dose **IV METHYLPREDNISOLONE**
124
Give general Sx of vasculitis
Fever
Weight loss
Fatigue
Muscle aches
125
Investigation and Dx of GCA
1st line:
**Raised ESR** ± CRP
Diagnostic:
Temporal artery biopsy: **Multinucleated giant cells** *(Hence its name GCA)* - seen as granulomatous inflammation of intima and media.
*Note: GCA presents as skip lesions so take a bigger chunk for biopsy*
126
Which condition presents with raised ESR normal CRP
SLE
127
Tx of giant cell arteritis
Corticosteroids - **Prednisolone**
±
Aspirin - *decreases visual loss and strokes*
PPIs - *for gastric damage prevention*
128
What’s Takayatsu disease
Similar to GCA but **Aorta** is affected more in this condition, not temporal vessels.
*May get arm claudication or syncope* - use Doppler USS to see carotids or CT/MRI angiography
129
Define polyarteritis nodosa
Medium vessel vasculitis
*Associated with **Hep B**.*
Immune cells affect endothelium lining of medium vessels leading to transmural inflammation —> overtime all 3 layers die (**Fibrinoid necrosis**) —> wall is therefore weakened leading to **Aneurysms**
130
Signs and Sx of polyarteritis nodosa
Severe systematic Sx:
GI bleeds
CKD / pre-renal AKI
Subcutaneous skin nodules + haemorrhage
Get **Livedo reticularis** - rash
131
Investigation and Dx of polyarteritis nodosa
Ct angiogram- *Beads on string* (micro aneurysms) - looks like a tasbeeh [ -o-o-o-o- ]
**Biopsy** of affected area
132
Tx of polyarteritis nodosa
Corticosteroids - prednisolone
Controls htn —> ACEi
Tx Hep B after
133
Which vasculitis is c ANCA +ve
Granulomatosis with PolyAngitis i.e.
**wegeners granulomatosis**
134
Classic sign for wegeners granulomatosis
Saddle shaped nose
- may also cause glomerulonephritis / pulmonary renal syndrome
135
Define henloch schonlein purpura
An IgA vasculitis
- presents with IgA antibody deposition in kidney
4 classic features: **purpura** (100%), **joint pain** (75%), **abdominal pain** (50%) and **renal involvement** (50%).
136
General tx for vasculitis
Corticosteroids
+ PPIs
+ Bisphosphonates
137
Define spondyloarthropathies
**Assymetrical seronegative arthritis
Associated with HLAB27**
*An MHC-1 serotype - interacts with Tc (i.e. inflammatory)*
138
General features of spondyloarthropathies
Remember **SPINE ACHE**
**S**ausage fingers (dactylitis)
**P**soriasis
**I**inflammatory back pain
**N**SAIDs have good response
**E**nthesitis (inflammation at site of tendon attachment)
**A**rthritis
**C**rohn’s / collitis
**H**LA B27
**E**yes (Uveitis)
139
What are the types of spondyloarthropathies
**Ankylosing spondylitis
Psoriatic arthritis
Reactive arthritis**
Enteropathic arthritis
Juvenile idiopathic arthritis
140
Define Ankylosing spondylitis
Abnormal stiffening of pints (**sacroiliac + vertebral**) due to new bony formation…
141
Typical Px of Ankylosing spondylitis
Young male
HLA B27 +ve
142
Pathophysiology of Ankylosing spondylitis
Inflammation of the spine leads to erosive damage —> repair & new bone formation —> leads to irreversible fusion of spine —> reduced mobility of the spine
**Syndesmophytes formation (*vertical abnormal bony growths*)**
143
Signs and Sx of Ankylosing spondylitis
Back pain (stiffness in morning + at night)
Anterior uveitis
Enthesitis
Dactylitis
Decreased natural lumbar lordosis (more kyphosis)
144
Investigation and Dx of Ankylosing spondylitis
XRay: bamboo spine + sacroiliac (squared vertebral bodies)
MRI
Bloods: raised ESR + CRP
Genetic testing: HLA B27 +ve
145
Tx for Ankylosing spondylitis
NSAIDs
DMARDs - TNF-a blockers (*Inflixamab*)
146
Define psoriatic arthritis
10-40% with psoriasis develop within 10y
147
Sx of psoriatic arthritis
_Moderate:_
Inflamed distal interphalangeal joints (DIPJ)
+ nail dystrophy, dactylitis, enthesitis
Psoriatic rash on skin —> behind ears, scalp, under nails and penile
_Severe:_
**Arthritis mutilans** = pencil in cup deformity (*osteolysis of bone, shortening fingers **telescope** in on themselves*)
148
Tx for psoriatic arthritis
NSAIDs
DMARDS - methotrexate
If fails: *TNF-a blocker - infliximab*
If this fails: IL 12+23 inhibitor
149
Define reactive arthritis
Sterile inflammation of synovial membrane + tendon reacting to distant infection; usually GI or genitals
150
Types of gastroenteritis causing reactive arthritis
Salmonella
Shigella
151
Which sexual;LH transmitted organism can cause reactive arthritis
Chlamydia trachomatis
152
Sx of reactive arthritis
_Reiter’s triad_ **Cant see, can’t pee, can’t climb a tree **
Uveitis, urethritis, arthritis
*+ browny discolouration g rash on sides of foot*
153
Main differential for reactive arthritis
Septic arthritis
*Painful, hot, swollen and red joints + signs of infection Hx*
154
Investigation and Dx for reactive arthritis
**Joint aspirate** (MC+S) and polarised light microscopy
- no organism
- negative for crystal arthropathies
**HLAB27** +ve genetic testing
155
Tx for reactive arthritis
NSAIDs
DMARDS - methotrexate
± anti-TNFa (infliximab)
156
Types of infective arthritis
Septic arthritis
Osteomyelitis
157
What test is conducted for Ankylosing spondylitis
Do the schobers test
*Measure 10 cm above and 5 cm below **L5** if <20cm after bending forwards, then could be indicative of Ankylosing spondylitis*
158
Define septic arthritis
Direct bacterial infection of the joint
*Could have been either by direct exposure / haematogenous spread*
**Medical emergency**; Acutely inflamed joint with a fever, typically of the knee.
*Knee could be destroyed if not Tx ≤24hrs*
159
Organisms that can cause septic arthritis
Staphylococcus aureus (most common)
H. Influenza (children; but now rare because of vaccination)
N. Gonorrhoea
Ecoli / pseudomonas (IVDU)
160
Risk factors for septic arthritis
IVDU
Immunosuppression
Trauma
Prosthetic joints; mainly infected by S.Epidermidis
161
Investigation and Dx of septic arthritis
**URGENT JOINT ASPIRATION** using MC+S & polarised light microscopy -
*Septic arthritis: identified causative organism
Reactive arthritis: sterile, crystal-free
Gout: sterile, -ve birefringent Needle crystals
Pseudogout: sterile, +ve birefringent rhomboid crystals*
Raised ESR + CRP in bloods
162
Tx for septic arthritis
**Do joint aspiration drainage + empirical antibiotics:**
Flucloxacillin (**Gram -ve; ecoli / auriginosa / *staph aureus*.**)
… OR …
Vancomycin (**MRSA**)
IM Ceftriaxone + Azithromycin (**Gonorrhoea**)
If on DMARDS (methotrexate), stop!!!
If on steroids, double dose (to increase the *stress* response)
**NSAIDs for analgesia**
163
Define osteomyelitis
Inflammation in a bone and bone marrow, usually caused by bacterial infection.
Spread of pathogen could have been **haematogenous** or **direct contamination** of the bones *(during a fracture/surgery)*
164
What type of organisms could cause osteomyelitis
Staph Aureus *(90% - most common)*
Salmonella in *sickle cell Px*
165
Risk factors for osteomyelitis
Immunosuppression
IVDU
Open fractures / trauma
Diabetes; especially diabetic foot ulceration
PVD
166
Pathophysiology of osteomyelitis
Osteomyelitis (OM) is an inflammatory condition affecting any bone in the skeleton, usually as a result of bacterial infection. Infection may occur due to haematogenous spread or result from direct penetration by a causative microorganism e.g. trauma. OM can be both acute or chronic in its presentation.
**The most common organisms causing OM are:**
Staphylococcus aureus: most common causative organism
Coagulase-negative staphylococcus
Streptococcus pneumonia: more common in children
Haemophilus influenzae: more common in unvaccinated children
Pseudomonas aeruginosa: increased risk with intravenous drug use
Salmonella species: most common cause in sickle-cell disease patients
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Signs and Sx of osteomyelitis
_Acute_
Dull bony pain + hot swollen area (± joint ) —> worse with movement
_Chronic_
Above Sx + **Deep ulceration - sequestrae (*neotic bone embedded in pus*)**
Involucrum (*Thick sclerotic bone placed around the sequestra to compensate for support*)
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Differential Dx for osteomyelitis
**Charcot’s joint**
*Damage to sensory nerves due to diabetic neuropathy
Causes progressive degeneration of weight bearing joint + bony destruction. Affects the foot, presents with diabetic foot*
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Investigation and Dx of osteomyelitis
**Bone marrow biopsy (MC+S):**
Identify causative organism
Bloods: raised ESR and CRP
X-ray of affected area:
*Osteopenia
Bone destruction
Periosteal reaction
Cortical breaches*
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Tx of osteomyelitis
Immobilise area+ antibiotics:
Flucloxacillin (aureus / salmonella)
Vancomycin (MRSA)
*Teicoplannin is longer-lasting than vancomycin, but increased SE: GI upset/pruritus*
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Which antibiotic is longer lasting than vancomycin
Teicoplannin
Stronger Side effects:
GI upset
Pruritus
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What needs to be ruled out in osteomyelitis using BM biopsy
Rule out **TUBERCULOUS OSTEOMYELITIS**
(+ve for caseating granuloma)
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Define Paget’s disease
Focal **disorder of bone remodelling** (areas of patchy bone due to improper osteoblast/osteoclast function) — *Areas of sclerosis + lysis*
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Signs and Sx of Paget’s disease
Bone pain
Bone deformity
Fractures
Hearing loss -
*Nerve compression of CN8
Hydrocephalus (Sylvian aqueduct) blockage *
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Investigation and Dx of Paget’s disease
XRay:
**Cotton-wool skull
Osteoporosis circumscripta**
Urinary hydroxyproline —> protein constituents of bone collagen (marker for disease progression)
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Tx for pagets
1st line:
Bisphosphonates
*Aledronic / zoledronic acid*
2nd line:
Calcitonin
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Define fibromyalgia
*MSK equivalent to IBS*; Chronic widespread musculoskeletal pain for **≥ 3 months** with all other causes ruled out
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Risk factors for fibromyalgia
**Females**
**Depression + stress**
Poor
60+ y/o
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Signs and Sx of fibromyalgia
Sleep disturbance
Morning stiffness
Esp. back and neck stiffness
Px: *Stressed, depressed female 60+ and fatigue*
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Investigation and dx of fibromyalgia
No serological markers
No ESR or CRP raised
+ pain 11/18 regions palpated… clinical dx is made!
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Tx for fibromyalgia
Educate Px + physiotherapy
**Antidepressants** for severe neuropathic pain (*Amytryptyline; Tricyclic Antidepressant*) + CBT
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Differential dx of fibromyalgia
Polymyalgia rheumatica (PMR)
Large cell vasculitis presenting as chronic pain syndrome (affects muscles and joints) - *similar to fibromyalgia*
Dx of PMR:
Increased ESR + CRP (diagnostic)
Tx:
Oral prednisolone
