msk Flashcards
(187 cards)
1
Q
what is rheumatology?
A
medical management of MSK disease (as opposed to surgical approaches)
2
Q
what are the 2 types of joint pain?
A
inflammatory and non-inflammatory
3
Q
what are some types of inflammatory joint pain?
A
auto-immune
crystal arthritis
infection
4
Q
what are some non-inflammatory types of joint pain?
A
degenerative eg osteoarthritis
non-degenerative eg fibromyalgia
5
Q
what are some types of inflammatory, autoimmune conditions?
A
rheumatoid arthritis
spondylo-arthropathy
connective tissue disease
6
Q
what is inflammation?
A
reaction of microcirculation
movement of fluid and WBC into extra-vascular tissues
7
Q
what does inflammation look like?
A
red (rubor)
painful (dolor)
hot (calor)
swollen (tumor)
8
Q
how may inflammation present?
A
- hot, painful, red, swollen joint
- stiffness
- poor mobility/function
- deformity
9
Q
what is the difference in pain in inflammatory vs degenerative disease?
A
inflammatory - pain eases with use
degenerative - pain increases with use, clicks/clunks
10
Q
what is stiffness like in inflammatory vs degenerative disease?
A
inflammatory - stiffness is sign, >60 mins, esp at early morning/evening (rest)
degenerative - not prolonged, <30 mins, morning/evening
11
Q
what is swelling like in inflammatory disease?
A
synovial ± bony
12
Q
what is swelling like in degenerative disease?
A
none, bony
13
Q
is inflammatory pain inflamed?
A
yes, hot n red
14
Q
is degenerative pain inflamed?
A
not clinically
15
Q
what are pt demographics for inflammatory disease like?
A
young
psoriasis
FHx
16
Q
what are pt demographics for degenerative disease like?
A
older
prior occupation/sport
17
Q
what is joint distribution in inflammatory disease like vs degenerative?
A
inflammatory - hands n feet
degenerative - CMCJ, DIPJ, knees
CMCJ = carpometacarpal joint DIPJ = distal interphalangeal joints
18
Q
how does inflammatory n degenerative disease respond to NSAIDs?
A
inflammatory responds
degenerative doesn’t respond as well
19
Q
what is asked in an MSK history?
A
- where is the pain?
- what is the nature of the pain?
- is there any stiffness?
- is there any swelling?
- what is the history of these symptoms?
- how has this affected function?
20
Q
what is ?degenerative? bone pain like?
A
at rest and at night
21
Q
what is inflammatory joint pain like?
A
pain n stiffness in joints in morning, at rest nd with use
22
Q
what is osteoarthritis pain like?
A
pain on use, at the end of the day
23
Q
what is neuralgic pain like? (neuralgia = nerve pain)
A
pain n paraesthesia in dermatomal distribution, worsened by specific activity
24
Q
what is paraesthesia?
A
pins n needles
25
what is referred pain like?
unaffected by local movement
26
which node is at the end of fingertips?
heberden's node
27
which node is in the middle/knuckle area of fingertips?
Bouchard's nose
28
what happens w SLE?
photosensitivity
| mouth ulcers
29
what is a good inflammatory marker?
ESR
| or CRP
30
what does ESR stand for?
erythrocyte sedimentation rate
31
what is the significance of ESR?
inflammatory marker
- rises w inflammation/infection
- increased fibrinogen = RBCs stick together = fall faster
- therefore ESR rises
- ESR rises and falls slowly
so its the rate RBC settle to bottom fo test tube after centrifugation
32
what is CRP?
acute phase protein
| - released in inflammation/infection
33
when is CRP produced?
produced in the liver in response to IL-6
34
what are auto-antibodies?
immunoglobulins that bind to self antigens
35
what do u look @ biochemistry-wise with rheumatoid arthritis?
RF (rheumatoid factor)
| CCP (cyclic citrullinated peptide)
36
what do u look @ biochemistry-wise with SLE?
ANA (anti-nuclear antibody)
| dsDNA (double stranded DNA)
37
what is the acronym for features of SpA? (Spondyloarthritis)
SPINEACHE
```
Sausage digit (dactylitis)
Psoriasis
Inflammatory back pain
Nsaid good response
Enthesitis (heel)
Arthritis
Crohns/Colitis/elevated CRP
Hla B27
Eye (uveitis)
```
38
what is enthesitis?
inflammation of the entheses (sites where tendons or ligaments insert into the bone)
39
what is uveitis?
inflammation of the uvea — middle layer of the eye that consists of the iris, ciliary body and choroid
40
what is axial spondylitis/spondyloarthritis like?
bamboo spine
41
how to treat spondylitis?
NSAIDs for long-term
physiotherapy
now also: anti-TNF drugs! (works v welllll)
42
what is a hidden site for psoriasis?
behind the ear, nails
43
how do u manage psoriatic arthritis? (PSA)
similar to RA
- early intervention with DMARDs
- anti TNF drugs
44
what is reactive arthritis?
sterile inflammation of the synovial membrane, tendons and fascia triggered by an infection at a distant site, usually GI / genital
GI eg salmonella, shigella
STI eg chlamydia, ureaplasma urealyticum
45
what was reactive arthritis formerly known as?
reiter's disease
46
when does reactive arthritis usually occur?
2d-2w post infection
47
what is the investigation for reactive arthritis?
```
- hot, swollen joint
EXCLUDE septic arthritis and gout
- raised ESR/CRP
- aspirate joint to exclude infection/crystals
- urethral swab, stool culture
```
48
what is enteropathic arthritis?
episodic peripheral synovitis that occurs in 1 in 5 IBD patients
- asymmetric lower limb arthritis
- usually reflects disease activity
49
if there's inflammatory back pain, asymmetrical (large jt arthritis), skin psoriasis, IBD, inflammatory eye disease .. think?
spondyloarthritis !
50
what is a normal synovial jt like?
2 articulating bone surfaces covered w/ hyaline cartilage
fibrous capsule lined w/ synovium
inflammation of these structures = arthritis
51
what is rheumatoid arthritis a disease of?
synovial joints
52
what is RA inflammation like?
chronic inflammatory reaction
| infiltration of lymphocytes, macrophages, plasma cells
53
what is RA proliferation like?
tumour like mass "pannus"
| grows over articular cartilage
54
what is cartilage loss?
joint space narrowing caused by loss of cartilage in arthritis
55
when cartilage is lost, what happens?
- release of proteinases eg MMPs (matrix metalloproteinases)
| - pro inflammatory cytokines eg TNF, IL-1
56
is RA more common in women or men?
2-3x more in women
57
what is an arthropathy?
disease of a joint (used regardless of whether there is inflammation or not)
58
what is spondyloarthropathy?
any form of arthropathy in vertebral column
59
what are symptoms of RA?
```
joint pain worse in morning
morning stiffness lasts hrs
loss of function
fatigue, malaise
extra-articular involvement
```
60
what causes RA?
immunological basis
- autiantibodies present eg rheumatoid factor
- immune complexes
- Ig's and cytokines in synovial fluid
61
RA can affect extra-articular-soft tissues like?
nodules
bursitits
tenosynovitis
muscle wasting
62
how can eyes be impacted w/ RA?
```
sicca (dry eyes)
corneal ulceration (scleritis)
```
63
what are lymph nodes n spleen like in RA?
lymph nodes may be palpable
| spleen may be enlarged
64
what are some neurological effects of RA?
mild, sensory peripheral neuropathy
cervical instability
spinal instability
65
what are some resp impacts of RA?
pleural effusion
rheumatoid nodules
small airways disease
66
what are some CVS impacts of RA?
pericardial rub
pericarditis
pericardial effusion
67
define vasculitis sis
inflammation n necrosis of blood vessel with subsequent impaired blood flow
68
how can vasculitis be classified?
by:
- size of vessel affected
- target organ(s)
- presence/absence of anti-neutrophil cytoplasmic antibodies (ANCA)
69
how does vasculitis present?
no single typical presentation
| - systemically unwell, fever, arthritis, rash, weight loss, headache, foot drop, major event eg stroke
70
what must be excluded in a vasculitis diagnosis to ensure correct treatment?
sepsis, hepatitis
malignancy
other eg cholesterol emboli
71
name an example of large vessel vasculitis
giant cell (temporal) arteritis
72
name an example of giant cell (temporal arteritis)
granulomatous arteritis of aorta and larger vessels
73
how can giant cell arteritis be treated?
prompt corticosteroids
| prednisolone
74
what is the most common condition affecting synovial joints?
osteoarthritis
75
what is OA?
age-related, dynamic reaction pattern of a joint in response to insult or injury
all tissues of joint are involved, articular cartilage most affected
76
what is OA mediated by?
cytokines (IL-1, TNF-a, NO)
| driven by mechanical forces
77
what are the 2 main pathological features of OA?
loss of cartilage
| disordered bone repair
78
what is the gender bias with OA like?
female preponderance
| - increased prevalence after menopause
79
what is there a linear relationship btwn OA and?
BMI
80
what is obesity, inflammatory wise?
a low grade inflammatory state
| release of: IL-1, TNF, adipokines (leptin, adiponectin)
81
which occupations are associated with OA?
manual labor - OA of small joints of hands
farming - hip OA
footballers - knee OA
82
what are symptoms of OA?
pain (may not be present despite X-ray changes) and functional impairment (walking, activities of daily living)
83
what are signs of OA?
gait alterations
| joint swelling: bony enlargement, effusion, synovitis
84
what are some radiological features of OA? ("MEMORISE THIS")
JOSSA
JOINT SPACE NARROWING
OSTEOPHYTE FORMATION
SUBCHONDRAL SCLEROSIS
SUBCHONDRAL CYSTS
ABNORMALITIES OF BONE CONTOUR
85
what is a good rule of thumb with arthritis?
less than 30min joint pain: non inflammatory
more than 60m: likely
exception: fibromyalgia.. not inflammatory but almost all patients have morning stiffness
86
which joints are heberden's nodes
DIP
87
which joints are Bouchard's nodes?
PIP
88
what are the 3 compartments of the knee?
medial (inside)
lateral (outside)
patellofemoral (behind kneecap)
89
what is knee locking associated with?
loose body in the knee
| often bone or cartilage fragment
90
how can OA be managed?
non-medically: patient ed, activity, weight loss, physio, footwear, walking aids
pharmacological: topical (NSAIDs), oral (paracetamol), transdermal patches, intra-articular steroid injections
surgical: arthroscopy, osteotomy (realign knees)
91
what are some indications for arthroplasty?
uncontrolled pain, esp at night
sig limitation of function
patient age
92
what happens in SLE?
| according to diff body symptoms: resp, joints, skin, kidneys, constitutional
```
resp - pleuritic chest pain
joints - synovitis
skin - rash
kidneys - nephritis
constitutional - fatigue, fever
```
93
discuss Marfan's syndrome
```
tend to be tall
arms longer than height
skeletal abnormalities
concave chest
collagen in blood vessels
```
94
what is a butterfly rash a medical sign of?
lupus
95
what are some clinical features of SLE
```
fatigue
arthritis
skin rashes
mucosal ulceration
pericarditis
raynaud's phenomenon
venous/arterial thrombosis
```
96
what is SLE arthritis like?
symmetrical
less proliferative than RA
non-erosive
97
anyone w lupus should have regular _____ checks
urine.... to see high protein levels/RBC - has lupus affected the kidneys?
98
what is does an abnormal Coombs test mean?
positive result means you have antibodies that act against your RBC ://
99
what are some haematological features of SLE?
anaemia (haemolytic, Coombs +)
thrombocytopaenia
neutropaenia
100
how do u manage SLE?
patient education and support
UV protection
assessment of lupus activity
screening for major organ involvement
101
what is Raynaud's phenomenon?
fingers/toes ache or change colour (pale - blue)
102
how can Raynaud's be managed?
physical protection eg handwarmers
vasodilators eg nifedipine
fluoxetine
103
what is sjogren's syndrome?
disorder of your immune system identified by its 2 most common symptoms — dry eyes & a dry mouth.
condition often accompanies other immune system disorders eg RA and lupus.
104
what are some clinical features of sjogren's syndrome?
dry eyes
dry mouth
arthritis
rash
105
what are important questions to ask in the history of an msk patient?
what is your job? (what is he/she exposed to that may be harmful)
tell me what you do (is there anything ant this job that sounds hazardous)
106
what about someone's job cold be hazardous?
harmful exposure to eg dust, fumes etc
| does their job involve manual handling? are they using tools that might vibrate?
107
what are the benefits of work?
```
lower mortality
pay
feelings of accomplishment
social relationships
structure to life
improved fitness
```
108
when is an illness due to work ?
when symptoms improve away from work or on holiday eg occupational asthma
SO when it has been CAUSED BY WORK, OR WORK HAS SUBSTANTIALLY CONTRIBUTED TO THE INJURY
characteristic distriubtion of rash eg contact dermatitis
a cluster of cases in a workplace
109
what are some high risk activities for MSK problems?
heavy manual handling
lifting above shoulder weight
incorrect manual handling techniques
fast repetitive work
110
what is the correct way to manually handle (5)
```
legs apart
feet slightly everted
bend knees rather than back
lift and hold close to trunk
lift ideally from knee height
```
111
what is the diff btwn tennis n golfer's elbow
tennis - lateral epicondylitis (lots of extension and rotation of the wrist)
golfers - medial epicondylitis (lots of flexion and rotation)
112
what is repetitive strain disorder like?
non-specific
| often when there's "unexplained" cramps in the hand
113
in severe cases of carpal tunnel syndrome, u can get what?
wasting of the thenar eminence (thenar atrophy)
114
what is carpal tunnel syndrome associated with?
```
obesity
short stature
pregnancy
OCP
diabetes
hypothyroidism
RA
acromegaly
```
may be caused by forceful and repetitive work
115
what are some tests for carpal tunnel syndrome? n what is sig abt them?
tinel's
phalen's
if in either of those tests - u get tingling in median ner
116
GO OVER NERVE DISTRIBUTIONS
!
117
what is phalen's test?
back of hands facing each other weird thing
occurs when the median nerve is compressed or squeezed at the wrist.
118
what is tinel's sign (test) like ?
performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve
119
what is a cause of secondary Raynaud's phenomenon?
hand-arm vibration syndrome
120
how can we distinguish white fingers?
primary raynaud's
| other types of secondary raynaud's
121
what is tenosynovitis caused by
inflammation of APL and EPB tendon-sheath
122
how can tenosynovitis be treated?
NSAIDs
steroid injection
rest
123
what is tenosynovitis?
inflammation of synovial that surrounds a tendon - typically leading to joint pain/swelling/stiffness
124
what are the 2 types of epicondylitis?
```
tennis players (lateral)
golfers (medial)
```
125
what is epicondylitis associated with?
forceful flexion-extension of wrist/forceful pronation-supination
126
what is repetitive strain disorder?
non-specific pain in the hand
127
what do rotator cuff problems usually affect?
supraspinatus tendon
| or shoulder impingement/osteoarthritis of acriomicoclavicular joint
128
what is thoracic outlet syndrome?
pain/tingling down or blanching of fingers related to posture of arm
because of: compression of trunks of brachial plexus/subclavian artery in neck under clavicle
129
what is thoracic outlet syndrome associated with?
poor posture or loading of shoulders
130
what is OA of hip associated with?
CDH (Congenital Diaphragmatic Hernia?)
slipped epiphyses
perthe's disease
obesity, trauma and menisectomy
131
how do you get a patient back to work?
are there any barriers?
footnotes
rehab - phased return, restricted duties
132
what is mechanical back pain associated with?
manual handling
twisting while lifting
smoking
133
if u have a joint that might be infected, what is the only way to find out?
joint aspiration !!!!
| blood cultures
134
what is joint aspirate like?
no logturgid fluid
leucocytes ++
gram stain + cocci
135
what is infected joint aspirate like?
no longer see through
yellow
pus-y
meant to be yellow, see through, light viscosity
136
what is staphylococcus aureus sensitive to?
flucloxacillin
erythromycin
doxy/tetracycline
137
with a flare of RA, u might expect CRP up to 100; If this high, suspect what?
infection
138
what are some risk factors for septic joint?
```
any cause for bacteraemia
direct/penetrating trauma
local skin ulcers
damaged joints
immunosuppression
```
139
what is a typical clinical presentation of a septic joint?
painful, red, swollen, hot joint
fever
90% mono arthritis
knee > hip > shoulder
140
how do u manage a septic joint?
aspiration !!!
| ABs, joint washout, analgesia
141
what is the commonest infecting organism overall?
staphylococcus aureus
142
what is ESR?
erythrocyte sedimentation rate
blood test
done to check for diseases causing inflammation
143
what is ESR aka
sedimentation rate
| sed rate
144
what is osteomyelitis?
infection localised to bone
145
what is arthroplasty?
surgical reconstruction/replacement of a joint
146
what are some symptoms of MSK tumours?
pain, swelling, erythema
limp/loss of use of limb
failure to thrive
pyrexia, raised WCC
147
what is pyrexia?
temp
148
what is erythema?
redness of the skin or mucous membranes, caused by hyperemia (increased blood flow) in superficial capillaries.
occurs with any skin injury, infection, or inflammation.
149
what are lab tests for MSK tumours like
often non-specific but consider PSA, ESR/CRP
150
what is MSK exam like ?
```
look
feel
move
special test
examine joint proximal n distal
general/neuro exam
```
151
name some different fracture patterns
```
transverse
oblique
spiral
butterfly
comminution
segmental
```
152
what are the 3 principles of treatment?
reduce
hold
rehabilitate
153
what is a crystal?
homogenous solid
| stable, hard, high density
154
what does deposition of crystals result in?
local inflammatory response
| tissue damage
155
what is crystal arthropathy?
arthritis caused by crystal deposition in joint lining
156
what is the diff btwn gout and pseudo gout?
gout = urate crystals
| pseudo gout = pyrophosphate crystals
157
what crystals are in gout?
urate
158
what crystals are in pseudo gout?
pyrophosphate crystals
159
how does crystal arthropathy present?
acutely with hot, swollen joints
| chronically with longer term damage
160
how is crystal arthropathy diagnosed?
history
pattern
aspiration of joint to look for crystals
blood tests/XRs
161
what is a gout attack?
acute inflammation
162
what is diff btwn acute inflammation n LT deposition in gout?
```
acute = gouty arthritis, gout attack
LT = tophaceous gout
```
163
how does gout happen?
uric acid - prod from purines/nucleic acids
| key enzyme: xanthine oxidase
164
how do purines go to gout?
purines - hypoxanthine - xanthine - uric acid - monosodium urate
165
what is the path of gout?
renal, diet, drugs --> excessive urate --> urate crystals --> phagocyte activation --> inflammation
166
whats hyperuricaemia a major risk factor for?
gout
167
what is SUA
serum uric acid
168
what is a precipitant?
cause of a particular action/event
169
what are common precipitants of uric acid conc incr?
alcohol/shellfish binges
sepsis
MI/trauma
170
what causes pseudo gout?
deposition of calcium pyrophosphate crystals on joint surface
crystals elicit acute inflammatory response
171
what are some clinical features of pseudo gout?
```
incidental finding on radiology
acute synovitis (severe pain/stiffness, fever)
```
172
what can trigger an acute attack of pseudo gout?
direct trauma
surgery
blood transfusion
173
how do u manage pseudo gout?
acute: NSAIDs, analgesia, aspiration, physio
LT: surgery, anti rheumatics
174
define osteoporosis
a systemic skeletal disease characterised by LOW BONE MASS and MICROARCHITECTURAL DETERIORATION of bone tissue with a consequent increase in BONE FRAGILITY/SUSCEPTIBILITY TO FRACTURE
175
what is the bone remodelling cycle?
quiescence - resorption - formation - quiescence
176
why does postmenopausal OA happen?
loss of restraining effects of oestrogen on bone turnover
177
how can postmenopausal OA be prevented?
oestrogen replacement
178
what is high bone turnover?
resorption > formation
179
how is postmenopausal OA characteriseD?
high bone turnover
| predominantly cancellous bone loss- -
180
how does trabecular architecture change with age?
decrease n trabecular thickness
decrease in connections btwn horizontal trabecular
decrease in trabecular strength/increased susceptibility to fracture
181
what are some risk factors for inflammatory disease?
rheumatoid arthritis
connective tissue disease
IBD
182
which hormones influence bone turnover?
thyroid hormone/PTH increase bone turnover
cortisol increases bone resorption/induces osteoblast apoptosis
oestrogen/testosterone control bone turnover
183
how can drugs treat osteoporosis?
anti-resorptive - decrease osteoclast activity and bone turnover
anabolic - increase osteoblast activity and bone formation
184
what are the benefits of HRT
educe risk of fractures by 50%
stop bone loss; density may increase by 10%
prevents hot flushes/other menopausal symptoms
reduces colon cancer risk
185
what is a DEXA scan?
special type of X-ray that measures bone mineral density (BMD)
186
what does a DXA scan measure
BMD
187
define osteophyte
a bony projection associated with the degeneration of cartilage at joints
