MSK Flashcards
Joints most commonly affected in septic arthritis?
Organisms?
Joints = knee and hip
Organisms = Staph, Strep, gram -ve cocci (neisseria gonococcus), gram -ve bacilli
Risk factors for septic arthritis?
- Joint disease (RA)
- Immunosuppression
- Recent joint surgery
- IV drug abuse
- DM
- CKD
- Prosthetic joints
- Age >80 yrs
Investigations in septic arthritis?
- Bloods
- FBC (WCC), CRP, ESR, cultures
- Joint aspiraiton
- Yellow, purulent synovial fluid - MC+S
- Raised WCC, organisms on gram stain, +ve culture
- X-Ray
- As baseline - may show joint destruction later
Management of septic arthritis?
Urgent orthopaedic referral
- Joint aspiration until dry - rest joint
- May need arthrocentesis, lavage and debridement.
- Analgesia – NSAIDs
- High dose IV abx – local guidelines. (~2 weeks then 4 weeks PO) after diagnostic joint aspiration.
- Typical - Flucloxacillin (1g/6h IV) – Clindamycin if pen allergic.
- Gonococcal or Gram –ve - Cefotaxime (1g/8h IV)
What happens in GCA?
Caused by immune response to undefined stimulus causing vasculitis à vascular stenosis and occlusion
Symptoms and signs of GCA?
Symptoms
- >50, headache, jaw claudication, visual problems, aching muscles, weight loss, night sweats, scalp tendernes
- Extracranial symptoms = dyspnoea, morning stiffness, unequal or weak pulses
Signs
- Temporal artery and scalp tenderness, pulseless or nodular temporal artery
.
Complications of GCA?
Blindness (10-50%), TIA/stroke, scalp necrosis, lingual infarction, aortic dissection/aneurysm, complications of high-dose steroids
Investigations in GCA?
Bloods - ↑↑ESR (50mm/h), ↑CRP, ↑plts, ↓Hb all suggestive
Biopsy – within 7 days of starting steroids
Management of GCA?
- Prednisolone 60mg/day PO immediately (+ PPI/bisphosphonate protection)
- Urgent ESR
- IV methylprednisolone if visual involvement (consult ophthalmology)
Two year course of steroids à complete remission.
Causes of spinal cord compression?
Secondary malignancy = commonest cause (PB KTL)
- Infection (epidural abscess)
- Cervical disc prolapse
- Haematoma (warfarin)
- Intrinsic cord tumour
- Atlanto-axial subluxation
- Myeloma
Signs of cord compression?
- Weakness
- Numbness (+/- pain) below lesion
- Incontinence
- Dermatomal distribution; UMN below lesion, LMN at lesion (tone + reflexes can be reduced in acute compression)
- Spastic and hyper-reflexic
Signs in cauda equina?
- Leg weakness and pain (often bilateral)
- Urinary and/or faecal incontinence (retention –> overflow incontinence).
- ↓Perianal sensation
- ↓Anal tone
- ↓Leg power, sensation and reflexes
- Flaccid and areflexic - not spastic and hyper-reflexic
Investigations in cord compression/cauda equina?
- PR examination
- Bloods
- FBC, ESR, B12, syphilis serology, U+E, LFT, PSA, serum electrophoresis/bence jones protein
- URGENT MRI whole spine
- CXR (rule out malignancy)
Differentials for sudden onset leg weakness?
- Transverse myelitis/MS
- Spinal artery thrombosis
- Trauma
- Dissecting aneurysm
- Guillain-Barré
Management of cord compression?
- Lie flat to minimise spine movement
- Urgent MRI spine
- Analgesia
- Dex IV 16mg + PPI cover (if malignancy)
- Refer to neurosurgery/onc for palliative radiotherapy
Symptoms of OA?
Pain on movement and crepitus, worse at end of day; background pain at rest; joint gelling; joint instability
Complications of OA?
Assess effect of symptoms on occupation, family duties, hobbies and lifestyle
Investigations in OA?
X-Ray (LOSS)
- Loss of joint space
- Osteophytes
- Subarticular sclerosis
- Subchondral cysts
Bloods – CRP may be slightly elevated
Management of OA?
Conservative
- Exercise to improve muscle strength and general fitness
- Weight loss if overweight
- MDT approach – physios and OT
- Heat/cold packs at site of pain, walking aids, stretching/manipulation or TENS
Medical
- Regular paracetamol and topical NSAIDs
- Codeine or short-term oral NSAID (+PPI) if ineffective
- Intra-articular steroid injection – temporary relief in severe symptoms
Surgical
- Joint replacement (hips/knees)
Definition of osteoporosis and osteopenia?
- Defined as BMD >2.5 SDs bellow the young adult mean (T-score of -2.5).
- Osteopenia is diagnosed if T-score between -1 and -2.5
Factors contributing to osteoporosis?
Endocrine
Hypogonadism (prem menopause, anorexia, androgen blockade, aromatase inhibitors), hyperthyroidism, hyperparathyroidism, hyperprolactinaemia, Cushing’s disease, T1DM, steroid use
GI
Coeliac disease/other malabsorption, IBD, chronic liver disease, chronic pancreatitis
Rheumatological
RA, other inflammatory arthropathies
Other
Immobility, multiple myeloma, haemoglobinopathy, systemic mastocytosis, CF, COPD, CKD, homocystinuria
What is a fragility fracture?
- Fracture sustained from falling from < standing height
- Common fractures = hip, wrist (Colle’s), osteoporotic vertebral collapse
Investigations in osteoporosis?
Fracture Risk Prediction
- FRAX or QFracture – provide info on 10 year probability of hip or other osteoporotic fracture.
DEXA
- Gold standard for diagnosis – measures bone mineral density (BMD).
Bloods (identify underlying causes and rule out differentials – osteomalacia, myeloma)
- FBC, ESR/CRP
- U+E, LFT, TFT, serum calcium
- Testosterone/gonadotrophins in men
- Serum immunoglobulins and paraproteins, urinary Bence-Jones’ proteins
Management of osteoporosis?
Conservative
- Nutrition (Normal BMI, adequate intake of calcium and vitamin D)
- Regular Exercise
- Stop Smoking
- Reduce Alcohol
Medical
- Alendronate 10mg OD or 70mg once weekly, or risedronate 5mg OD or 35mg once weekly
- Vitamin D/calcium supplements (higher doses for housebound/elderly)
- HRT for women with premature menopause
Prevention of osteoporosis?
For patients taking oral/high-dose inhaled steroids for >3 months, or frequent courses, in addition:
- Add bone protection (bisphosphonates) for patients >65y or with history of fragility fracture, or
- Refer patients <65y without history of fragility fracture for DEXA scan, and add bone protection agent if T-score is <1.5.
Early and late signs of RA?
Early
- Swollen MCP, PIP, wrist or MTP joints (symmetrical)
Later
- Ulnar deviation of fingers and dorsal wrist subluxation.
- Boutonniére and swan-neck deformities of fingers, or Z-deformity of thumbs
- Hand extensor tendon rupture
Symptoms of RA?
- Peripheral joints affected – symmetrical joint pain, effusions, soft tissue swelling, early morning stiffness.
- ↓Grip strength and function –> disability
Non-articular signs of RA?
- Weight loss, fever, malaise.
- Rheumatoid nodules (extensor forearm)
- Vasculitis – digital infarction, skin ulcers, mononeuritis
- Eye – Sjogren’s syndrome, episcleritis, scleritis
- Lungs – pleural effusions, fibrosing alveolitis, nodules
- Heart – pericarditis, mitral valve disease, conduction defects
- Skin – palmar erythema, vasculitis, rashes
- Neurological – nerve entrapment (carpal tunnel, mononeuropathy)
- Felty’s syndrome – RA, splenomegaly and leucopenia
Complications of RA?
Physical disability, depression, osteoporosis, infections, lymphoma, cardiovascular disease, amyloidosis, side effects of treatment
Investigations in RA?
Bloods
- FBC (anaemia of chronic disease), ↑ESR/CRP, ↑platelets
- Rheumatoid factor (RhF) is +ve in the majority (associated with severe disease)
- ACPA/anti-CCP = highly specific for RA.
Imaging
- X-rays = soft tissue swelling, juxta-articular osteopenia, ↓joint space.
- Later may show bony erosions, subluxation or complete carpal destruction.
Medical Management of RA?
Analgesia
- NSAIDs/PCM - alter as necessary
Steroids
- Intra-articular injections (triamcinolone) can settle local flares and can be used up to 3x/year in any one joint.
- Daily low-dose oral steroids – can help symptoms and modify disease progression, but have adverse side-effects.
DMARDs
- Methotrexate, gold, sulfasalazine, penicillamine, azathioprine, leflunomide, hydroxychloroquine, ciclosporin, cyclophosphamide
- Biologic therapies = rituximab, infliximab, etanercept, adalimumab
- Can take months to show any effect
- Before starting, baseline bloods: U+E, creatinine, eGFR, LFTs, FBC, urinalysis
Surgical management of RA?
Aims to relieve pain and improve function – joint fusion, replacement or excision, tendon transfer and repair, nerve decompression
Who gets PMR?
- Elderly
- Female
- 50% of GCA have PMR, 15% of PMR have GCA
Non-specific signs/symptoms of PMR - same as GCA?
Malaise, anorexia, fever, night sweats, weight loss and depression.
Diganostic criteria for PMR?
- Age >50y; duration >2 wks
- Bilateral shoulder or pelvic girdle aching, or both
- Morning stiffness duration >45 min
- Evidence of acute phase response (↑ESR or CRP)
Can make diagnosis without inflammatory markers if classical clinical picture and rapid response to steroid treatment
Investigations in PMR?
Bloods
- ESR/CRP
- FBC, U+E, eGFR, LFT, TFT, CK
Others
- Bone profile (Ca2+, phosphate, PTH, albumin, alk phos)
- Protein electrophoresis (urinary Bence-Jones protein)
- Rheumatoid factor
Imaging
- Consider CXR and/or hip/pelvis/shoulder/cervical spine x-ray (rule out malignancy)
Differentials for PMR?
- Inflammatory arthritis (RA)
- OA
- Neoplasia (myeloma)
- Fibromyalgia
- Connective tissue/vaculitis (SLE)
Management of PMR?
Steroids
- Prednisolone 15mg OD – rapid response (within 1 week) – ESR/CRP should normalise within 4 weeks. Continue for 3 weeks.
- ↓Dose to 12.5mg OD for 3 weeks
- Then 10mg OD for 4-6 weeks,
- Then reduce by 1mg every 4-8 weeks (1-2y of treatment usually needed)
- Give osteoporosis prophylaxis and supply with steroid card.
What is gout associated with? What does this mean?
- CV disease, HTN, DM and CKD
- Patients with gout should be screened for these
Predisposing factors for gout?
- FH
- Obesity
- Alcohol
- High-purine diet
- Plaque psoriasis
- Diuretics
- Acute infection
- Surgery
- Renal failure
Complications of gout?
Chronic gout –> recurrent attacks, tophi (urate deposits) in pinna, tendons and joints, and joint damage. Refer to rheumatology.
Investigations in Gout?
Bloods
- WCC, ESR, blood urate (all raised but may be normal)
Microscopy of Synovial Fluid
- Polarised light microscopy of synovial fluid –> negatively bi-refringent urate crystals.
X-Rays
- Show soft tissue swelling only.
Management of acute gout?
Conservative
- Exclude infection
- Rest and elevate joint - apply ice pack
Pharmacological
- NSAIDs – naproxen 500mg BD
- Colchicine - 500 mcg BD, increased slowly to QDS until pain relieved.
- NO NSAIDs OR COLCHICINE IN RENAL IMPAIRMENT
- Steroids – joint injection or IM steroids
Gout prevention?
Conservative
- Lose weight; avoid purine-rich foods (offal, red meat, yeast extracts, pulses, mussels)
- Avoid thiazide diuretics and aspirin
Medical
- Allopurinol 100-300mg daily – wait until 1mo after acute attack and co-prescribed colchicine or NSAID for first 1-3mo to avoid precipitation of another acute attack
- Febuxostat is alternative
Most common joints for gout?
big toe, feet, ankles most commonly
What is pseudogout?
Calcium Pyrophosphate Deposition Disease (CPPD)
- Inflammatory arthritis due to deposition of pyrophosphate crystals.
- Associated with OA, hyperparathyroidism and haemochromatosis.
- Attacks are less severe than gout. Knee, wrist and shoulder are most commonly affected. Acute attacks can be triggered by intercurrent illness and metabolic disturbance.
Rhomboid-shaped calcium pyrophosphate dihydrate crystals – Pseudogout = Positive birefringence in polarised light
- Treat acute attacks like gout
Red flags for back pain?
Differentials for back pain?
Serious – cord compression, cauda equina, metastases, myeloma, infection, fracture, aortic aneurysm
Common – mechanical back pain, renal colic, prolapsed disc, postural, trauma
Investigations in back pain?
If suspect mechanical back pain and no worrying features, no investigations required.
Bloods – FBC, ESR, CRP, Ca2+, ALP, PSA
CXR - +/- spinal X-ray if post-trauma or risk of pathological fracture
MRI spine – as emergency if cord compression or cauda equina suspected; urgent if suspect malignancy, infection or fracture; routine if suspect inflammatory disorder.
DEXA
Do not X-ray for back pain routinely
Management of mechanical back pain?
- Early mobilisation, avoid lifting, maintain good posture
- Analgesia (consider tricyclic or strong opioids if paracetamol, NSAIDs and weak opioids ineffective)
- Diazepam 2mg/8h PO for muscular spasm
- Safety-net – if bilateral symptoms or incontinence
Cord Compression/Cauda Equina
- Neurological emergencies
What is ank spond?
Chronic inflammatory disease of the spine and sacroiliac joints (HLA-B27 +ve)
Conditions associated with HLA-B27?
PAIR
- Psoriaiss
- Ank spond
- IBD
- Reactive arthritis
Who gets ank spond?
♀:♂ = 1:6 at 16 years old, 2:1 at 30 years old
men present earlier
Symptoms of ank spond?
- Gradual onset low back pain, worse at night, spinal morning stiffness relieved by exercise.
- Pain radiates from sacroiliac joints to hips/buttocks, usually improves towards end of day.
- Progressive loss of spinal movement (all directions) –> ↓thoracic expansion.
Signs of ank spond?
Spinal kyphosis, sacroiliac joint fusion, neck hyperextension, neck rotation.
Complications and extra-articular signs of ank spond?
- ↓Chest Expansion
- Chest Pain
- Hip/Knee Arthritis
- Plantar fasciitis
- Iritis
- Crohn’s/UC
- Heart disease – carditis, aortic regurg, conduction defects
- Osteoporosis
- Psoriaform rashes
Investigations in ank spond?
Bloods
- FBC – normochromic or microcytic hypochromic anaemia.
- ESR – may be normal
- RF – usually -ve
X-Ray
- Initial – widening of SI joints and marginal sclerosis
- Later – SI joint fusion and bamboo spine (vertebral squaring/fusion)
Management of ank spond?
Conservative
- Exercise for backache – regimens to maintain posture and mobility.
Pharmacological
- NSAIDs – relieve pain and slow progression
- TNF-a blockers – indicated if NSAIDs fail
- Local steroid injections – temporary relief
- Bisphosphonates due to increased risk of osteoporotic spinal fractures.
Surgery
Hip replacement if hips involved – sometimes spinal osteotomy.
Large vessel vasculitis?
- GCA
- Takayasu’s Arteritis
- Buerger’s Disease
Medium vessel vasculitis?
- Polyarteritis Nodosa
- Kawasaki’s Disease
Small vessel vasculitis?
pANCA
- Churg-Strauss Syndrome
cANCA
- Wegener’s Granulomatosis
- Microscopic Polyangiitis
ANCA -ve
- HSP
- Goodpasture’s Disease
Takayasu’s Arteritis?
Epidemiology
- Rare outside Japan
- F>M
- 20-40 yrs
Features
- Constitutional symptoms (Fever, fatigue, weight loss)
- Weak pulses in upper limbs
- Visual disturbance
- HTN
Beurger’s Disease?
Strongly associated with smoking
- Extremity ischaemia: intermittent claudication, ischaemic ulcers etc.
- Superficial thrombophlebitis
- Raynaud’s phenomenon
Polyarteritis nodosa?
Epidemiology
- Rare in UK
- M>F
- Young adults
Features
- Associated with hep B
- Constitutional symptoms
- Rash
- Renal –> HTN
- GI –> melena and abdo pain
Management
- Prednisolone and cyclophosphamide
Kawasaki’s Disease?
Childhood PAN variant
Features
FEVER AND CREAM
- 5-day fever
- Conjunctivitis (bilateral)
- Rash (polymorophic, trunk)
- Extremity changes (erythema, desquamation)
- Adenopathy (cervical)
- Mucositis (oral)
Complication = coronary artery aneurysms
Management
- IV Ig and aspirin
Churg Strauss Syndrome?
- Late-onset asthma
- Eosinophilia
- Paranasal sinusitis
- Heart disease, skin lesions/ nasal polyps
- Granulomatous small-vessel vasculitis
- Rapidly progressing glomerulonephritis
- Palpable purpura
- GI bleeding
May be associated with montelukast
Microscopic polyangiitis?
- Rapidly progressing glomerulonephritis
- Haemoptysis
- Palpable purpura
Wegener’s Granulomatosis (Granulomatosis with Polyangiits - GPA)?
Necrotising granulomatous inflammation and small vessel vasculitis –> URT, LRT and kidneys
URT
- Chronic sinusitis
- Epistaxis
- Saddle-nose deformity
LRT
- Cough
- Haemoptysis
- Pleuritis
Renal
- Rapidly progressing glomerulonephritis
- Haematuria/proteinuria
Other
- Palpable purpura
- Ocular: conjunctivitis, keratitis, uveitis
Investigations in Wegener’s?
- cANCA
- Dipstick
- CXR - bilateral nodular and cavity infiltrates
HSP?
Childhood IgA nephropathy variant - 3-8 yrs
- Post URTI
- Palpable purpura on buttocks
- Colicky abdo pain
- Arthralgia
- Haematuria
Self-limiting - need to dip urine for a year after.
Goodpasture’s syndrome?
- Rapidly progressive glomerulonephritis
- Haemoptysis
- Anti-GBM Ab
- CXR –> bilateral lower zone infiltrates (haemorrhage)
Rx = Immunosuppression and plasmapheresis
Differences between GPA and Churg-Strauss?
Investigations in vasculitis?
Bedside
- Urine Dip
Bloods
- FBC, U+E, LFT, CRP, ESR, ANCA
Imaging
- Depends on syndrome - CXR, renal USS, doppler, angiogram of large vessels
Other
- Angiography/biopsy may be diagnostic
Causes of reactive arthritis? When does it present?
1-4 weeks after...
- Urethritis (chlamydia)
- Dysentery (campylobacter, salmonella, shigella)
Signs in reactive arthitits?
- Iritis
- Keratoderma blenorrhagica (brown, raised plaques on soles and palms)
- Circinate balanitis (painless penile ulceration secondary to Chlamydia)
- Mouth ulcers
- Enthesitis
Investigations in reactive arthritis?
Bloods
- Raised ESR and CRP
Others
- Stool MC+S if diarrhoea
- Infectious serology
- Sexual health review
Management of reactive arthritis?
General
- Splint affected joints acutely
Pharmacological
- NSAIDs
- Local steroid injections
- Consider sulfalazine or methotrexate if symptoms >6 months
What is Paget’s disease?
Increased bone turnover with resultant remodelling, bone enlargement, deformity and weakness.
Who gets Paget’s?
>40yrs, incidence increases with age
Symptoms of Paget’s? Complications?
- Usually asymptomatic
- Deep, boring pain
- Bony deformities and enlargement
- Pelvis, lumbar spine, skull, femur, tibia (bowed sabre tibia
Complications
- Pathological fractures, OA, hypercalcaemia, nerve compression, high output CCF, osteosarcoma
Investigations in Paget’s disease?
Bloods
- Ca2+ and PO43- normal
- Alk phos VERY raised
Imaging
- Localised enlargement of bone; patchy cortical thickening with sclerosis, osteolysis and deformity
- Cotton wool skull appearance
What is osteomalacia/rickets?
Normal amount of bone but mineral content low (opposite of osteoporosis)
- Rickets = this process during bone growth
- OM = after fusion of the epiphyses
Causes of osteomalacia?
- Vitamin D deficiency
- Renal osteodystrophy
- Drug induced
- Vitamin D resistance
- Liver disease
- Tumour induced
Presentation of osteomalacia/rickets?
Rickets
- Growth retardation, hypotonia, apathy
- Knock-knee/bow-leg and deformitites of metaphyseal-epiphyseal junction
Osteomalacia
- Bone pain, tenderness, fractures (especially femoral neck), proximal myopathy
Investigations in osteomalacia?
Bloods
- Mild ↓Ca2+, ↓PO43-, ↑alk phos, PTH high, ↓25(OH)-vitamin D
Imaging
- Cortical bone loss (lucency)
- Looser’s zone = apparent partial fractures without displacement – esp on lateral border of scapula, inferior femoral neck and medial femoral shaft.
What is SLE?
- Autoantibodies are made against a variety of autoantigens.
- Immunopathology –> polyclonal B-cell secretion of pathogenic autoantibodies causing tissue damage
- Immune complex formation/deposition, complement activation, other direct effects
Anitbodies = ANA, RhF (others = Anti-Ro, Anti-La, Anti-RNP)
General presentation of SLE? Specific features?
- Non-specific constitutional symptoms (malaise, fatigue, myalgia and fever)
- 95% = ANA +ve
- Increased risk of CV disease/osteoporosis
- Antiphospholipid syndrome associated with SLE
- Malar rash (butterfly rash)
- Discoid rash
- Photosensitivity
- Oral ulcers
- Non-erosive arthritis
- Serositis
- Renal disorder
- CNS disorder (seizures/psychosis)
- Haematological disorder
- Immunological disorder
- ANA +ve
Limited cutaneous sclerosis?
- More common type of SSc.
- Only the face, forearms and lower legs up to the knee.
- AKA CREST syndrome
Antibodies = ANA (anti-centromere), RhF
What does CREST stand for?
- Calcinosis
- Raynaud’s disease
- Esophageal dysmotility
- Sclerodactyly
- Telangiectasia
Diffuse systemic sclerosis? (dcSSc)
- Less common
- Also upper arms, thighs or trunk
- Higher risk of mortality – early organ fibrosis (lung, cardiac, GI, renal).
Anti-Scl70
Cardinal features of systemic sclerosis?
- Excessive collagen production and deposition
- Vascular damage
- Immune system activation via autoantibody production and cell-mediated autoimmune mechanisms
Rotator cuff tear?
Tears in supraspinatus tendon (or adjacent subscapularis and infraspinatus)
- Can present insidiously from degeneration in elderly or after trauma in younger patients (more rare)
- Shoulder weakness and pain
- Night pain may affect sleep as patient is unable to keep arm in comfortable position.
Imaging –> US/MRI
Management –> surgery (arthroscopic)
What is impingement syndrome?
Painful arc –> occurs as supraspinatus tendon catches under the acromion during abduction (70-140)
Frozen Shoulder (Adhesive Capsulitis)?
No obvious triggers. Pain may be severe and worse at night. Natural history can be divided into:
- Painful phase (up to 1 year) – active and passive movement range reduced
- Frozen phase (6-12 months) – pain usually settles but shoulder remains stiff
- Thawing phase (1-3 years) – shoulder slowly regains range of movement.
Can be associated with cervical spondylosis, diabetes and thyroid disease.
Management = early physio and NSAIDs. Steroid injections may reduce pain in early phases. Surgical release is most effective treatment.
Lateral epicondylitis (Tennis elbow)?
Inflammation where forearm extensor tendon arises from lateral epicondyle.
- Usually clear history of repetitive strain
- Pain is felt at the front of the lateral condyle, and is exacerbated when the tendon is most stretched (wrist and finger flexion with hand pronated).
- Ask the patient to extend the wrist, and then to resist extension of the middle finger: is pain elicited?
Management –> Restriction of activities that overload the tendons à usually lasts 6-24 months; 90% recover in 1 year.
Medial Epicondylitis (golfer’s elbow)?
Inflammation of forearm flexor muscles at insertion on medial epicondyle
- Most common cause of medial elbow pain, but 1⁄5 as common as tennis elbow.
- Pain is exacerbated by pronation and forearm flexion.
- Occasionally associated with ulnar neuropathy as the ulnar nerve runs behind the epicondyle.
Same treatment and prognosis as LE
Differentials for limping child at different ages?
Investigations for limping child?
- Temperature
- Bloods - FBC, CRP, ESR, Blood cultures, RF, ANA, ASOT – anti streptolysin titre, HLA B27
-
Urine
- Dipstick + MSU
-
X-rays
- AP/ Lateral frog imaging
-
USS
- Can demonstrate effusion
-
MRI/bone scan
- May aid diagnosis
