MSK Flashcards
Describe rheumatoid arthritis and its risk factors
A chronic systemic inflammatory disease with symmetrical, destructive polyarthropathy.
Female 2:1
What is rheumatoid factor
IgM that binds to your own IgG
Not a sensitive or specific test
High titres are associated with more progressive disease
Investigation of suspected rheumatoid arthritis
FBC, CRP, U&Es, LFTs - Baseline Rheumatoid Factor Anti CCP antibodies Plain radiographs of hands and feet Always refer to rheumatology - even if results -ve
Radiographic changes in rheumatoid arthritis
SPADES Soft tissue swelling Peri-articular osteoporosis Absent osteophytes Deformity Erosions Subluxation
What pre-operative investigation needs to be performed on people with rheumatoid disease
A later upper cervical spine radiograph in gentle flexion
Atlanto-axial subluxation can compress the upper cervical cord
Management of rheumatoid arthritis
Patient education Smoking cessation Physiotherapy + Hand exercise programme Occupational therapy Psychological interventions
Treat to target strategy - remission or low activity
DMARD monotherpay +/- Prednisolone bridging
1st: Methotrexate, Sulfasalazine, leflunomide
+ basic analgesia
Monthly monitoring - CRP and DAS 28
At 6 months can step up to dual DMARD
If still severe - Consider offering Biological
What scoring system is used for monitoring of rheumatoid disease
DAS 28
Disease Activity Score 28
Presentation of septic arthritis
Acute monoarthropathy due to infection of the joint
Calor, dolor, rubor, tumor and loss of function
Systemic - Fever, malaise
Aetiology of septic arthritis and its risk factors
Haematogenous spread due to bacteraemia
Direct inoculation - penetrating injury, surgery or injection
Spread from bone (osteomyelitis) or tissue (cellulitis)
Abnormal, damaged joints (e.g. RA, OA) Prosthetic joints Immunocompromised – DM, MTX, Steroids, CRF Elderly and very young IV drug abuse
Investigation of suspected septic joint
Full set of observations
- Joint aspiration with MC&S
Blood cultures
FBC, CRP, ESR, U&E, Glucose
Management of septic arthritis
Immediate Abx pending culture results
Flucloxicillin 1g/6h IV (Clindamycin if allergic)
Vancomycin if MRSA positive
Cefotaxime 1g/8h I if gonococcal suspected
2 weeks IV abx then 4 weeks PO
Surgical washout
Red flag symptoms for Spinal cord compression
Motor weakness Loss of sensation Saddle anaesthesia Urinary retention Loss of continence Systemic symptoms - Fever, Night sweats, Weight loss Thoracic back pain: - Sudden onset, <20 or >50yo - High energy trauma or no mechanical cause - Worse lying down, wakes up at night Risk factors: - Previous cancer - IV drug user - Immunosuppressed
Management of metastatic spinal cord compression
Nurse flat
Urgent MRI whole spine - within 24hrs
Dexamethasone 16mg daily
Until Radiotherapy or surgery
Describe temporal arteritis and its risk factors
In Giant Cell Arteritis (GCA) there is granulomatous inflammation of the aorta and large vessels
Elderly - > 55yo
Polymyalgia rheumatica - 50%
Other inflammatory disorders eg. SLE/RA
Presentation of giant cell arteritis
Temporal headache Scalp tenderness e.g. when combing hair Jaw claudication Visual disturbance: - Amaurosis Fugax or sudden blindness, unilateral - Diplopia or ptosis may occur
Investigation and Immediate Management of giant cell arteritis
FBC - Low Hb, Plat elevated
CRP, ESR - elevated
Temporal artery biopsy within 7 days
- can be negative due to skip lesions
Prednisolone 60mg PO stat and daily Aspirin 75mg PPI cover - Omeprazole 20mg If visual symptoms - Ophthalmology A&E If none - safety net, review at 48hrs
Long term management of giant cell arteritis
Patient education
Smoking cessation
Manage co-morbidities - DM, CV
Referal to Rheumatology - Shared care
! Steroid card !
Continue high dose prednisolone until symptoms, CRP and ESR have returned to normal, then reduce.
Reduce by 10 mg every 2 weeks until 20 mg daily,
Reduce by 2.5 mg every 2–4 weeks until 10 mg daily,
Reduce by 1 mg every 1–2 months,
Review one week after a change in dose
Mange relapse by returning to previous dose
- Or if Jaw claudication then 60mg and seek advice
Monitor BP, Glucose, CRP and ESR 3 monthly
Risk assess - Bisphosphonates for bone protection
Presentation of Polymyalgia rheumatica
Over 50 years old with at least 2 weeks of:
- Bilateral shoulder and/or pelvic girdle pain.
- Stiffness lasting for at least 45 minutes after waking
Systemic symptoms: 50%
- fever, fatigue, anorexia, weight loss, and depression
Peripheral MSK signs: 50%
- Carpal tunnel syndrome.
- Peripheral arthritis (predominantly affecting the knees and wrists), which is asymmetric and self-limiting.
- Swelling with pitting oedema of hands, wrists, feet, and ankles.
Investigation and diagnosis of polymyalgia rheumatica
Polymyalgia rheumatica (PMR) is diagnosed by:
- Identifying core features of the condition,
- Excluding conditions that mimic PMR,
- A positive response to oral corticosteroids.
Management of Polymyalgia rheumatica
Patient education
Smoking cessation
Manage co-morbidities
Screen mental health
Trial of oral prednisolone 15 mg daily
- follow up after 1 week to assess clinical response.
After 3–4 weeks of treatment:
- Consider reducing the dose of prednisolone.
- Recheck ESR, CRP to assess response to treatment.
! Give Steroid card !
Review 1/52 after change in dose and at least every 3/12
Consider PPI
Assess Osteoporotic fracture risk
Description and aetiology of compartment syndrome
Increased pressure in a closed fascial space causing muscle ischaemia
Long bone fractures Plaster casts Crush injuries Vascular injuries Anticoagulants Burns
Presentation of compartment syndrome
Pain out of proportion to apparent injury - exacerbated by passive stretching Redness, swelling Parasthesia Weakness of distal limb Slow capillary refill Pallor and absent pulses is alate sign
Investigations for compartment syndrome
Urine dip - ?myoglobin in urine
FBC,
U&Es - monitor for AKI
CK - muscle damage
Clotting, G&S - for theatre
Manometre to measure pressure
Management of compartment syndrome
Elevate the limb Oxygen 15L Contact senior surgeon immediately - Urgent Fasciotomy Analgesia + antiemetic Catheterise - monitor for AKI
