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MSK Clincal 2 Flashcards

(102 cards)

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1
Q

What evidence of autoimmunity is there in rheumatoid arthritis

A

High serum levels of autoantibodies such as rheumatoid factors and anti-citrullated peptide antibodies

They recognise either joint antigens or systemic antigens

  • can be present for many years before the onset of clinical arthritis
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2
Q

The rheumatoid synovitis (pannus) is characterised by

A

inflammatory cell infiltration, synoviocyte proliferation and neoangiogenesis

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3
Q

Autoantibodies in seropositive rheumatoid arthritis

A

Rheumatoid factor

Anti citrullinated protein antibody

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4
Q

How does ACPA+ disease affect the prognosis of RA

A

Less favourable

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5
Q

Environmental factors that are associated with RA

A

Smoking and bronchial stress

Infectious agents - EBV, CMV, e.coli, mycoplasma, peridontal disease

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6
Q

What does repeated environmental insults in a susceptible individual lead to (in RA)

A

Formation of immune complexes triggers rheumatoid factor

Altered citrullination (change aminoacids) of proteins and breakdown of tolerance resulting in ACPA response

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7
Q

ACPA response in RA

A

Gingiva insult causes uptake Tcell activation in genetically susceptible individuals causing B cells and ACPA production (antibodies)

–> immune complexes

–> joint inflammation
(–>citrillinated human joint proteins
–> Immune complexes)

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8
Q

Systemic consequences of RA

A

Vasculitis, nodules, scleritis, amyloidosis = secondary to uncontrolled chronic inflammation

CV disease (altered lipid metabolism and increased endothelial activation)

Fatigue and reduced cognitive function

Liver (Elevated acute phase response; anaemia of chronic disease)

Lungs (interstitial lung disease, fibrosis)

Muscles - sarcopoenia

Bone - osteoporosis

Secondary sjorgen’s syndrome (multisystem autoimmune disease)

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9
Q

Male vs female prevalence of RA

A

1M: 3F

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10
Q

Drugs for symptomatic relief of RA

A

Analgesics +/- NSAIDs

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11
Q

Adverse effects of NSAIDs

A

GI irritation - indigestion, ulceration - consider PPI for gastroprotection

Bronchospasm in asthmatics

Renal impairment

Hypersensitivity reactions

Increased BP, fluid retention

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12
Q

Disease modifying anti-rheumatic drugs - DMARDS

A 
Methotrexate 
Sulphasalazine 
Leflunomide 
Hydroxychloroquine
Azathioprine 
Mycophenolate mofetil
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13
Q

Most effective DMARD

A

Methotrexate

Because faster onset of action (6 weeks to 3 months) compared to other

Can be given parenterally

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14
Q

Side effects of methotrexate

A

Nausea, stomatitis

Haematological toxicity

Hepatic toxicity
- LFTs, cirrhosis, hepatic fibrosis

Pulmonary toxicity

  • TERATOGENIC
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15
Q

What can be given to reduce side effects of methotrexate

A

Folic acid

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16
Q

Biologics in RA

A

Specifically target pro-inflammatory mediators

Anti-TNF
- infliximab

Anti B cell
- rituximab

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17
Q

Safety concerns with biologic DMARDs

A 
Serious infections 
Opportunistic infections (TB)
Malignancies/lymphoma 
Demyelination 
Administration reactions 
Hepatic side effects 
Autoantibodies and drug induced lupus
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18
Q

Treatment of RA

A

Disease modifying anti-reumatic drugs

  • methotrexate
  • sulfasalazine

Corticosteroids
- prednisolone

Biologics

  • anti TNF
  • anti B
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19
Q

Osteoporosis risk factors

A

Old age
Genetic predisposition
Nutritional factors - low body weight and poor calcium and vit D
Immobility
Diseases influencing bone turn over; thyrotoxicosis, malabsorption, inflammatory arthritis
Medications: steroids, warfarin, TCA, diabetic medications, anticonvulsants

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20
Q

Antiresorptive agents for use in osteoporosis

A

HRT - not into 60s as increases stroke risk

SERMS

Biphosphonates (alendronate, risedronate)

RANKL inhibitors

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21
Q

Side effects of bisphosphonates

A

Oesophagitis

Iritis/uveitis

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22
Q

What is denosumab and what are the indications

A

Monoclonal antibody against RANKL
- for when bisphosphonates not well tolerated as treatment for osteoporosis

Reduces osteoclastic bone resorption

Subcut injection every 6 months

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23
Q

Side effects of denosumab

A

Allergy/rash

Symptomatic hypocalcaemia when vit D deplete

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24
Q

Side effects of strontium

A

Increased clotting risk

Increased cardiovascular risks

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25
Causes of osteomalacia
VITAMIN D DEFICIENCY Primary - environmental due to not making enough e.g. No sunlight exposure or nutritional deficit if vegan and don't eat fish oils, and egg yolk Secondary - partial gastrectomy, small bowel malabsorption, pancreatic disease; chronic renal failure; anti-convulsants
26
Clinical features of osteomalacia
Mose assymptomatic Bone pain (worse on weight bearing) Bone tenderness Proximal muscle weakness without atrophy
27
Aetiology of pagets disease
Viral - paramyoxoviruses | Genetic
28
Paget's disease clinical features
Monostotic or polystotic Axial skeleton and long bones are common sites Some may experience bone pain (at night especially)
29
Which genes are implicated in susceptibility to RA and severity of disease
Class II makpr histocompatibility complex genes PTPN22 and peptiylarginine transferases
30
Impingement syndrome symptoms
Pain in shoulder that may radiate down arm - worse when activities above shoulder level
31
Impingement syndrome may lead to
Rotator cuff tendinitis/tear
32
Examination findings of impingement syndrome
Painful arc and positive hawkin's test
33
Rotator cuff tear partial vs complete
Partial - able to abduct, painful and weak Complete - passively able to abduct
34
Frozen shoulder
More common in diabetes May present with acute, severe pain Limitation of passive as well as active range of motion (hence not like rotator cuff tear)
35
Presentation of bicipital tendonitis
Resisted supination Resisted forwards flexion of arm in supination Pain in biceps tendon
36
Classification of clavicle fracture
Medial, middle and lateral thirds Undisplaced/displaced
37
Common way to injure proximal humerus
Fall onto outstretched hand
38
Symptoms of shoulder dislocation
Axillary nerve - deltoid power and badge area sensation
39
Most common direction of dislocation for shoulder
Anterior 80-85% Posterior 10% Inferior
40
Treatment for shoulder dislocation
Acute - reduction under anaesthetic/sedation Non-operative - physiotherapy Operative - arthroscopic (key-hole) stablisation - open stabilisation +/- bone block
41
Presentation of medial epicondylitis
Pain worse on wrist flexion and forearm pronation against resistance
42
Treatment medial epicondylitis
Tendinopathy at flexor tendon origin NSAIDs Physiotherapy Steroid injection Surgery
43
Common name for medial epicondylitis
Golfer's elbow
44
Common name for lateral epicondylitis
Tennis elbow
45
Presentation of lateral epicondylitis
Pain worse on resisted wrist extension and forearm supination
46
Cubital tunnel syndrome presentation
Entrapment is of the ulnar nerve - parasthesia in ulnar 1 and 1/2 fingers - weakness in interosseus fingers of hand - symptoms worse on elbow flexion q
47
Treatment of cubital tunnel syndrome
Night splint | Surgical release
48
Where is the cubital tunnel
Between the olecranon process and medial epicondyle at elbow
49
After a first time anterior shoulder dislocation in a 18 yr old male rugby player, the risk of recurrence is
90%
50
Who gets dupuytrens
More common in males and earlier Is an autosomal dominant trait with variable penetrance (may be sex linked onset) 30% sporadic Associated conditions
51
Conditions associated with dupuytrens
Diabetes Alcohol Tobacco HIV Epilepsy
52
Functional problems associated with dupuytrens
Usually not painful Loss of finger extension - active or passive Hand in pocket Gripping things Washing face
53
Treatment of dupuytren's disease
Non operative - observe, radiotherapy (splints dont work) Operative - PARTIAL FASCIECTOMY, dermofasciectomy, arthrodesis, amputation; percutaneous needle fasciotomy; collagenase
54
Recurrence of dupuytrens after partial fasciectomy
50% at 5 years
55
Who gets trigger finger
Women more frequently than men 40-60s Ring>thumb>hand Associated with RA, DM, gout
56
Diagnosis of trigger finger
Patient history Clicking sensation with movement of digit Palpable lump in palm over a1 pulley; feel the triggering
57
Treatment of trigger finger
Non-operative Splintage Steroids Operative Percutaneous release Open surgery
58
Symptoms of de quervain's syndrome
Several weeks pain localised to radial side of thumb Aggrevated by movement of the thumb May have seen a localised swelling Localised tenderness over tunnel
59
Who gets de quervain's syndrome
Females 6:1 m 50-60 Increased in post partum and lactating females Activities with frequent thumb abduction and ulnar deviation --> washerwoman's sprain
60
What is affected by de quervain's syndrome
1st dorsal extensor compartment Fibro-osseos tunnel at distal radius Thickening of localised segment
61
Treatment of de quervain's syndrome
Non-operative - splints and steroid injection Operative - decompression
62
Muscles affected by carpal tunnel syndrome
Lumbricals Opponens pollicis Abdctor pollicis brevis Flexor pollicis brevis
63
Who gets carpal tunnel syndrome
Female > M 3:1 Idiopathic Inflammatory arthritis Fracture Pregnancy or other conditions with abnormal fluid homeostasis
64
Symptoms of carpal tunnel syndrome
Numbness and tingling Pins and needles Night symptoms Drop things Occasionally pain
65
Diagnosis of carpal tunnel syndrome
Both hands Wasting of thenar eminence Power of thenar muscles Thumb abduction Phalen's test Tinel's test Nerve conduction studies
66
Describe phalen's test
Ask the patient to hold hands in upside down prayer for 30 seconds/manually extend?
67
Tinel's test
...
68
Treatment of carpal tunnel syndrome
Non-operative - underlying problem - splint - steroid injection Operative - carpal tunnel release - open - endoscopic
69
Diagnosis of cubital tunnel syndrome
Numbness and tingling in little and ring finger Increased with activity (especially involving elbow bending) Hand clumsiness Occasionally pain around elbow
70
Treatment of cubital tunnel syndrome
Non-operative - activity modificaiton - extension splint Operative - surgical decompression
71
What is a ganglion
A myxoid degeneration from joint synovia - arise from joint capsule, tendon sheath or ligament
72
Who gets ganglia
70% of all discrete swellings in the hand and wrist More common in females Wide age distribution but peak 20-40 Dorsal>volar May be associated with recurrent injury around wrist
73
Ganglia diagnosis
Lump Firm non tender Smooth Occasionally lobulated Normally not fixed to underlying tissues NEVER fixed to skin
74
Treatment for ganglia
Reassure and observe Needle aspiration Operative - excision - including the root
75
Aetiology of meniscal injury
twisting movement on a loaded fixed knee
76
clinical features of meniscal injury
painful "squelch" slow swelling painful to weight bear "locked" knee
77
Aetiology of ACL tear
forward momentum, leg fixed +/- rotation
78
clinical features of ACL tear
"pop" quick swelling often able to weight bear
79
collateral tears
lateralised pain feel of "crack", sharp pain no or minimal effusion bruising to one side
80
in knee pain Xray is best examination for
``` fracture loose bodies ligament avulsion osteochondral defect degenerative joint disease lipohaemarthrosis ```
81
in knee pain ultrasound is best for
tendon rupture some meniscal tears swellings cysts
82
valgus deformity vs varus
> = varus
83
main causes of swollen knee
bony swellings synocial thickening fluid collection
84
fluid collection in the knee
``` effusion = generalised localised = inflamed bursa ```
85
how to test for knee effusions
bulge test for small | patellar tap for large effusions
86
how to differentiate a baker's cyst from a DVT
both produce calf swelling, pitting oedema, pain (when cyst ruptures) and redness Ultrasound
87
tendon injury categories
``` degeneration inflammation enthesiopathy (muscle origin commonly) traction apophysitis avulsion +/- bone fragment tear/rupture ```
88
mechanism of rupture of Achilles tendon
1) pushing off with weightbearing forefoot whilst extending knee joint (e.g. sprint starts) 2) unexpected dorsiflexion 3) violent dorsiflexion of plantar flexed foot (e.g. fall from height)
89
repair of Achilles tendon rupture
conservative - cast for 10 weeks | operative - especially for younger active patients
90
Most common site for Achilles tendon to rupture
musculotendinous junction | - medial head of gastrocnemius at musculotendinous junction with tendon
91
Sacral dermatomes short cut
STAND on S1 SLEEP on S2 SIT on S3 SHIT on S4
92
Roots of femoral nerve
L2,3,4
93
path of the femoral nerve
Through the psoas; exits pelvis under inguinal ligament, lateral to femoral artery, vein and lymphatic channels in femoral triangle - VAN with Vein next to V of legs supplies quadriceps terminates in saphenous nerve
94
saphenous nerve
termination of femoral nerve - long fine sensory branch that accompanies femoral artery goes in front of medial malleolus to supply great toe
95
which nerve supplies sensory innervation to lateral aspect of thigh
lateral femoral cutaneous nerve
96
roots of sciatic nerve
L4-S3
97
what does the sciatic nerve supply
posterior thigh (hamstrings), part of adductor magnus and all lower leg and foot via terminal branches
98
sciatic nerve is at risk from
posterior dislocation of hip, intra-muscular injections and during surgery
99
divisions of sciatic nerve
tibial and common fibular
100
roots of common fibular nerve
L4-S2
101
when is the common fibular nerve at risk
as passes round lateral aspect of neck of fibula
102
deficit of common fibular nerve causes
foot drop and slapping gait

MSK (12 decks)

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