MSK Flashcards
(188 cards)
1
Q
Causes of primary vasculitis
Large
Medium
Small
A
L -> giant cell / Takayasu
M -> PAN, kawasaki
S -> HSP, Wegener’s, Churg-Strauss, microscopic poyangitis
2
Q
Causes of secondary vasculitis
A
aortitis in RA
autoimmune, malignancy, drugs, infection
3
Q
Eg of infective / drug / autoimmune causes of secondary vasculitis
A
Infective -> BBV, strep
Drugs -> penicillin, steroids
Autoimmune-> RA, SLE, Sjogrens
4
Q
ANCA assos vasculitis?
A
Wegener’s
microscopic poyangitis
Churg-Strauss
5
Q
What is ANCA?
how detected?
2 types?
A
Anti-neutrophil cytoplasmic antibodies
detected with indirect immunofluorescence microscopy
c-ANCA (cytoplasmic)
p-ANCA (peri-nuclear)
6
Q
Pres of wegeners?
A
Nasal/sinus problems - epistaxis; saddle-nose deformity
Lungs - haemoptysis
Kidneys - rapidly progressing glomerulonephritis
+/- conductive hearing loss, arthritis, subcutaneous nodules, neuropathy
7
Q
c-ANCA / PR3 = ?
A
Wegeners –>
now should instead be called ‘granulomatosis with polyangitis’
8
Q
p-ANCA / MPO = ?
A
Churg-Strauss
9
Q
Triad of affected areas in Wegeners?
A
lung
kidney
ENT
10
Q
usual vasculitis with raised eosinophils?
A
Churg-strauss
–> often get new onset / worsening asthma
11
Q
New name for Wegeners?
A
granulomatosis with polyangitis
12
Q
Who does wegeners affect?
A
Men 25-60
13
Q
Causes of cavitation on CXR?
A
wegeners, malignancy, TB, klebsiella
14
Q
alternate name for churg strauss?
A
Eosinophilic granulomatosis with poyangitis
15
Q
Pres of churg-strauss
A
Lungs - new/worsening asthma, pulmonary infiltrates, alveolar haemorrhage
CNS - neuropathy
ENT - polyps, conductive hearing loss, allergic rhinitis
Skin - purpura, nodules
RENAL DISEASE IS RARE
16
Q
How to differentiate wegeners/churg-strauss?
A
wegeners affects kidneys (c-ANCA)
eosinophilia in churg (p-ANCA)
17
Q
Mx of Churg-Strauss / Wegners?
A
Induce remission [high dose steroids + cyclophosphomide/Rituximab]
Maintain remission [MTX + pred + folic acid]
18
Q
Features of HSP
A
children IgA purpuric rash arthritis abdo pain glomerulonephritis
19
Q
Features of polyarteritis nodosa
A
Medium vessel
Aneurysms
20
Q
Mx of GCA?
if no visual sx?
if visual sx?
A
Prednisolone
40mg if no visual disturbance
60mg if visual disturbance
21
Q
Condition linked to GCA?
A
polymyalgia rheumatica
22
Q
Sx of GCA
A
headache, severe, sharp, dull throbbing, (won’t stop without steroids)
TA -> swollen, tender, pulseless
23
Q
Features of PMR
A
shoulder/pelvic pain
morning stiffness
weakness on exertion (due to pain)
24
Q
ix in PMR?
r/o?
A
ESR/CRP RhF/Anti-CCP ANA CK - to r/o muscle pathology eg polymyositis TFT
25
Mx of PMR
Prednisolone 15mg
Bone protection
PPI
26
Vasculitic screen?
```
FBC
Urinalysis
ESR/CRP
LFTs
ANCA
CXR
Biopsy
```
27
How to describe fracture?
```
Complexity
Type (FIG-TACOS)
Comminution
Location
Displacement
```
28
what is FRAX score for?
10 year risk of fracture
Age, sex, BMI
Prev fracture, FH fracture, low femoral neck BMD
Alcohol, smoking, glucocorticoids
RA, secondary osteoporosis
29
2 fractures which can lead to avascular necrosis?
femoral head
| scaphoid
30
what is a colles fracture?
distal radius with dorsal displacement of fragments
(fall onto wrist in extension)
FOOSH
31
Mx of wrist fracture
reduction via manipulation + anaesthesia
immobilise -> avoid full cast initially due to swelling
32
Sign of scaphoid fracture
tenderness in anatomical snuffbox
33
what runs through anatomical snuff box
Radial nerve - sensory branch
34
comps of Colles?
median nerve damage
35
Fall backwards?
| what is opposite of Colles?
```
Smiths fracture (fall onto flexed wrist)
distal fracture of radius with ventral displacement
```
Garden spade deformity
36
Seen on lateral X-Ray of colles?
dinner fork sign
37
How does NOF fracture present
affected leg shortened, adducted and externally rotated
38
main types of NOF fracture?
| which is worse?
intracapsular
extra-capsular
intra = worse -> avascular necrosis more likely
39
Ix in fractured NOF
AP + lateral X-Ray
FBC, cross match, U+Es, glucose, ECG
40
Mx of intracapsular fracture
analgesia (NOT NSAIDs)
| surgery in 1d
41
when to X-Ray an ankle?
ottawa ankle rules
>55
Inability to wt bear
Bony tenderness
42
Mx of ankle fracture if dislocated
reduce immediately under sedation
43
Signs of compartment syndrome?
pain out of proportion
+ signs of compartment syndrome
-> pain, paraesthesia, pallor, paralysis, pulseless, perishingly cold
44
mx of compartment syndrome
fasciotomy
45
stages of fracture healing
1. haematoma
2. soft callus
3. bony callus
4. bone remodelling
46
what is frozen shoulder?
thickening and contraction of glenohumeral joint capsule +/- adhesions
47
pres of frozen shoulder
pain + loss of function
-> external rotation lost
48
osteoporosis?
low bone mass + micro-architectural deterioration leading to fragility and fracture risk
49
DEXA for osteoporosis?
| osteopenia?
Osteoporosis < - 2.5SDs
-2.5
50
Pathogenesis of osteoporosis?
increased osteoclast
decreased osteoblast
51
osteoporotic fractures
spine
distal radius
NOF
pelvis
52
secondary RFs for osteorporosis
```
SHATTERED
Steroids
Hyper -thyroid; -PTH
Alcohol/tobacco
Thin
Testosterone decreased
Early menopause
Renal/liver function
Erosive/inflam disease
Dietary
```
53
Why do steroids increase risk of osteoporosis?
Decreased Ca absorption from gut
increased osteoclast
decreased muscle mass
54
DDx in osteoporosis
myeloma
55
ix in osteoporosis
FBC, ESR, CRP
Bone profile (NAD in osteoporosis)
U+Es, LFT, TFT, Ca
Serum Ig
56
Mx for osteoporosis
lifestyle (exercise, stop smoking+alcohol)
Calcium+Vit D
Bisphosphonates
57
Fall prevention?
avoid polypharmacy
58
alternative medication if intolerant of bisphosphonates
Denosumab
| monoclonal antibody to RANKL
59
how do bisphosphonates work
inhibit osteoclasts
60
SEs of bisphosphonates
oesophagitis
gastric ulcers
osteonecrosis of the jaw
61
osteomalacia?
disorder of mineralisation due to Vit D deficiency
In kids = Rickets
62
Functions of Vit D?
Bone - increase Ca mobilisation, increase osteoclast
Intestine - increase Ca absorp, PO4 absorp
Decreases PTH
63
PTH mech?
Bone - increase osteoclasts
Kidney - increase 1,25vD3 + decrease Ca excretion + increase PO4 excretion
64
What stimulates PTH
low Ca
65
Pres of Rickets
leg bowing, knock knees, softening of skull, frontal bossing, waddling gait
widespread bone pain + tenderness
66
Paget's disease of bone?
increased bone turnover
Lytic - osteoclasts
Sclerotic - rapid bone formation by osteoblasts -> deformed
67
Where affected by Paget's?
axial skeleton
68
sx in pagets
bone pain
| deformity
69
comps of pagets
pathological fractures + lots of bleeding (vascular)
deafness/tinnitus
70
ix in pagets
ALP - high
(Ca, PO4, PTH normal)
isotope bone scans
71
XR of pagets?
osteolysis and osteosclerosis
'blade of grass lesion'
'cotton wool pattern' in skull
72
mx pagets
NSAIDs
| bisphosphonates
73
inflam vs degenerative arthritis?
inflam -> ease on use, stiff in morning (>60mins), hot and red, responds to NSAIDs, swelling
Degenerative -> worse with use, morning (<30mins), no swelling, not inflamed, 'gelling'
74
joints affected in OA
knees, hips, thumb base, spine
75
signs of OA
reduced ROM
crepitus
pain on movement
heberdens, bouchards
76
XR of OA
Loss of jt space
Ostophytes
Subchondral cysts
Subchondral sclerosis
77
Mx of OA
lifestyle
analgesia
+/- intra-articular steroids (methyl prednisolone)
+/- replacement [arthroplasty], fusion [arthrodesis]
78
RA XR?
Loss of jt space
Erosions
Soft bones
Soft tissue swelling
79
What is formed in proliferation of RA
pannus
80
extra-articular pres of RA
```
rheumatoid nodules
vasculitis
pleuritic chest pain
eye problems
neuro
anaemia of chronic disease
```
81
Ix in RA
RhF
Anti-CCP
Xray hands + feet
82
Mx of RA?
physio
1. DMARD
2. biologics
83
how often give MTX
weekly
84
SEs of MTX
bone marrow suppression
mouth ulcers
pulmonary fibrosis
85
monitoring in MTX
CXR, FBC, LFT, U+Es
86
biologics used in RA
Anti-TNFa
| infliximab, adalimumab, enteracept
87
when can you give biologics in RA
failure to respond to 2xDMARDs after trials of 6months
88
RFs for gout
alcohol, purine rich foods, fructose, diuretics, DM, CKD, CHD, HTN,
89
ix in gout
```
serum urate (can be N)
joint aspiration
XR
```
90
seen on joint aspiration in gout
negatively birefringent needles of mono sodium urate
91
mx of acute gout
NSAID - naproxen
+/- colchicine
92
prophylaxis in gout
lifestyle
allopurinol / febuxostat
93
crystal in pseudogout?
| where common?
calcium pyrophosphate
| knee/wrist
94
mx pseudogout
RICE
NSAIDs
IA steroid injection
95
antibodies in SLE?
ANA
96
genetics in SLE?
HLA DR2/DR3
97
common pres of SLE
raynauds
98
Drug mx of SLE
hydroxychloroquine
99
signs of SLE
```
Oral ulcers
Photosensitive rash
arthritis
malar rash
seizures/psychosis
ESR raised (CRP normal)
renal disorder
pleuritis/pericarditis
```
100
ix in SLE
```
autoantibodies [ANA, anti-dsDNA, antiSmith]
Complement [low C3+C4]
ESR raised, CRP normal
FBC
Urinalysis
U+Es
CXR
ECG
```
101
mx of joints in SLE?
NSAID, hydroxychloroquine, steroids
102
mx of kidney/neuro sx in SLE?
cyclophosphamide
103
antibody in antiphospholipid syndrome
anti-cardiolipin
104
pres of antiphospholipid
thrombosis, DVT, recurrent miscarriages, pre-eclampsia, thrombocytopenia, stroke
105
mx of antiphospholipid
warfarin (aim 2-3)
| lifestlye -> avoid smoking, COCP, poor diet, alcohol
106
clotting studies of antiphospholipid?
paradoxically low platelets
| prolonged APTT
107
gene in Sjogrens
HLA DR3
108
complex in Sjogrens
sicca complex diminished lacrimal and salivary glands
109
pres of sjogrens
dry eyes
dry mouth
enlarged parotid
110
ix in sjogrens
schirmer tear test
autoantibodies
sialography
biopsy salivary gland
111
mx of sjogrens
artificial tears
oral pilocarpine
joint involvement -> NSAID + hydroxychloroquine + steroid
112
sx of limited sclerosis
```
CREST
Calcium deposits in skin
Raynauds
Esophageal dysfunction
Scleordactyly
Telangiectasia
```
+ fatigue, wt loss
113
Features of systemic sclerosis
pulm HTN
GI bleed
Renal crisis
114
ix in systemic sclerosis?
```
spirometry
CXR
autoantibodies - ANA
ECG
FBC
U+E
Barium swallow if oesophageal disorder
```
115
drug for raynauds
nifedipine
116
mx of pulm HTN/fibrosis in systemic sclerosis
sildenafil
cyclophosphamide
117
monitoring in systemic sclerosis
BP (weekly)
| spirometry (annually)
118
pres of polymyositis?
```
not painful, progressive symmetrical proximal muslce weakness (chair, stairs, hair)
pharyngeal weakness (dysphagia)
```
119
ix of polymyositis?
CK elevated x 50
autoantibodies - anti-Jo1
muscle enzymes - LDH
muscle biopsy
120
what is the worry with polymyositis?
| what ix?
can be paraneoplastic (lung, ovarian, bowel)
Ca125, Ca19-9, CEA
CXR
121
Pres of dermatomyositis?
rash, purple scaly patches on extensors -> Gottron's papules
nailfold erythema
fever, weight loss,
122
ix in dermatomyositis
CK, LDH, aldolase
autoantibodies -> Anti-Mi2, ANA
EMG + muscle biopsy
123
mx of polymyositis and dermatomyositis?
if lungs involved?
steroids
if fail -> immunosuppresants
lungs -> cyclophosphamide
124
features of Ehler-Danos
increased elasticity + fragility of skin
hypermobile joints
mitral valve prolapse, aortic root dilatation
125
mx of Ehler-Danos
physio, regular gentle exercise, genetic counselling
echo screening for heart comps (MV prolapse, aortic root dilatation)
126
gene in Marfans
AD fibrillin gene
127
usual cause of death in Marfans
aortic root dilatation and aortic dissection
128
features of Marfans
hypermobility
arachnodactyly
pectus excavatum
high arched palate
pneumothorax
aortic dilatation/dissection
mitral regurgitatoin
closed angle glaucoma
129
monitoring in marfans
annual echo
| CV MRI every 5years
130
prophylactic medication in marfans
propanolol
131
sero-negative arthropathies?
| where do they effect?
RhF -ve
axial skeleton, peripeheral joint, enthesitis and dactylitis
Anterior uveitis, IBD
132
gene in seronegative arthropathies
HLA B27
133
egs of seronegative arthropathies
```
ankylosing spondylitis
Reiter's syndrome
enteropathic arthritis
psoriatic arthritis
Behcet's disease
JIA
OA
```
134
features of ankylosing spondylitis?
<40 onset
inflammatory back pain + enthesitis
tender sacroiliac region, limited spinal RoM
peripheral enthesitis -> achilles, plantar fascia
peripheral arthritis -> asymmetrical
135
extra articular sx of ankylosing spondylitis
eyes -> ant uveitis
CV -> aortitis, AR
Lung -> apical fibrosis
136
o/e ankylosing spondylitis
reduced chest expansion
schober's test -> reduced forward flexion + loss of lumbar lordosis
reduced lateral flexion
137
ix in ankylosing spondylitis
HLA-B27
XR whole spine
Spirometry
Pelvic XR -> sacroiliitis
138
associations with ankylosing spondylitis
```
A's
Apical fibrosis
Anterior uveitis
Aortic regurg
Achilles tendonitis
AV node block
Amyloidosis
```
139
Mx for ankylosing spondylitis
physio + rehab + exercise
NSAIDs
steroids/sulfasalazine for tendon/joint involvement
140
mx of enthesitis in ankylosing spondylitis?
intra-articular corticosteroid injection
141
mx of peripheral arthritis in ankylosing spondylitis
DMARD - sulfasalazine
142
Most common joint in psoriatic arthritis
DIPJ
(+nail changes)
remember that closest to the nail..
143
XR of feet/hands in psoriatic arthritis?
erosion in DIP
'pencil in cup' deformity
periarticular new bone formation
144
ix in psoriatic arthritis?
RhF -ve
Anti-CCP -ve
ESR/CRP
145
Mx of psoriatic arthritis?
if limited -> NSAID + physio +/- joint injection
if severe -> DMARD (methotrexate)
146
When does reactive arthritis occur?
egs
1-4 weeks post GI/GU infection
eg. chlamydia, campylobacter, salmonella, shigella
147
sx of reactive arthritis
conjunctivitis
urethritis
post-infectious arthritis
"cant see, cant wee, cant bend your knee"
148
ix in reactive arthritis?
ESR, CRP, FBC
joint aspiration -> r/o septic/crystal arthropathies
serology
cultures
149
mx of reactive arthritis?
NSAID + rest +/- intra-articular steroids
| +/- abx -> azithromycin for chlamydia
150
enteropathic arthritis?
arthritis assos with IBD or coeliac
151
mx of enteropathic arthritis?
sulfasalazine
152
Behcet's disease?
| Genetics?
recurrent oral ulcers
joints -> non-erosive arthritis (lower limb)
HLA B51
153
mx of Behcet's disease?
topical corticosteroids
| systemic steroids
154
pres of Takayasu's vasculitis?
aka pulseless disease
young women 20-40
chronic, progressive, inflammatory, occlusive disease of aorta and branches
155
stages of Takayasus?
systemic: fever, fatigue, wt loss, arthralgia, tender arteries
occlusive: limb claudication, TIA, HTN, angina
156
o/e takayasus?
SBP differs between arms
impalpable peripheral pulse
arterial bruits + AR
157
ix in takayasus
ESR>50
| aortic angiography
158
mx takayasus?
glucocorticoids + aspirin + bone protection
2nd line = TNFa
159
Polyareteritis nodosa (PAN) association?
HBV
160
what is PAN?
necrotising inflammation of M / S arteries
161
pres of PAN?
nerves - mononeuritis
skin - purpura, nodules, ulcers
GI - post prandial pain (from ischaemia)
renal - HTN
162
ix in PAN?
Look for Hep B (HBsAg)
p-ANCA (negative)
arteriography
biopsy
163
mx of PAN?
prednisolone +/- cyclophosphamide
164
Causes of septic arthritis?
S. aureus
GBS
gonorrhoea
165
RFs for septic arthritis
```
prosthetic joint
IVDU
DM
skin infection
immunocomp
```
166
ix in septic arthritis
joint aspiration for MC+S, gram stain
| blood cultures
167
mx of septic arthritis
surgical drainage + lavage
| IV abx
168
which abx in septic arthritis?
Gonorrhoeal
Staph
MRSA
Gon -> vancomycin/ceftriaxone
Staph -> fluclox
MRSA -> vancomycin
169
what is Pott's disease?
vertebral osteomyelitis from haematogenous spread of TB -> abscess
170
ix osteomyelitis
X-ray
FBC
Blood cultures
bone culture
171
seen on XR of osteomyelitis
dark, soft tissue swelling, periosteal thickening, patchy osteopenia
172
mx of ostemoyelitis
bone/soft tissue debridement
stabilise + immobilise
IV abx
173
mx of fibromyalgia
amitryptiline + CBT
174
Red flags of back pain
```
TUNA FISH
Trauma
Unexplained wt loss
Neuro sx
Age >50 / <20
Fever+night sweats
Immunocomp
Steroids
Hx of cancer
```
175
Main worries in back pain
Cauda equina
multiple myeloma
metastatic cancer
psoas abscess
176
usual cause of cervical back pain
cervical spondylosis
177
pres of cervical spondylosis
neck pain
+ radiculopathy
+myelopathy
178
ix cervical spondylosis
XR
| MRI
179
pres of disk prolapse
pain localised to spine + radiculopathy, sensory disturbance in dermatomal distribution
180
Differentiate pain between spinal fracture and Ca/infection?
spinal fracture: sudden onset pain relieved by lying down
Cancer/infection -> pain REMAINS on lying down, night pain
181
mx of herniation disk?
active!
analgesia
discectomy if severe nerve compression
182
What is osteoid sarcoma?
dense osteoid, cancer in young adults (15-19yo)
183
Ewings sarcoma?
primitive neuroectodermal tumour
184
who gets ewings sarcoma?
15yo boy
185
pres of ewings sarcoma?
mass or swelling on long bones
186
ewings on XR?
bone destruction with onion skin layers of periosteal bone formation
187
mets to bone?
lytic lesions?
sclerotic lesions?
both?
lytic - myeloma [pepperpot skull]
sclerotic - prostate
both - breast
188
Mx of NOF fracture
ABCDE
analgesia + nerve block
VTE prophylaxis
early surgery -> mobilise on day 1, physio
