MSK - Preading Flashcards
(56 cards)
1
Q
How many categories of ‘Arthritis’ are there, generally speaking?
What are they?
A
4 categories of Arthritis:
- Inflammatory e.g. RA, ankylosing spondylitis, psoriatic arthritis etc.
- Non-inflammatory i.e. OA
- Septic
- Crystal i.e. gout or pseudogout
2
Q
What are common ‘early’ presenting features of Rheumatoid Arthritis?
A
- Swollen, painful joints (commonly small joints of hands / feet)
- Stiffness worse in morning
- Develops over a few months
- Positive ‘squeeze test’ = discomfort when squeezing across metacarpal or metatarsal joints
3
Q
What are common ‘later’ presenting features of Rheumatoid Arthritis?
A
- Ulnar deviation = swelling of MCP joints causes finger displacement towards little finger (ulnar)
- Z-thumb = IP hyperextension + MCP flexion and subluxation (partial dislocation)
- Swan neck joints = DIP flexion + PIP hyperextension
-
Boutonnière deformities = DIP hyperextension + PIP flexion
- Can also be caused by trauma to dorsum of a flexed middle phalynx
-
Guttering on dorsum of hand
- Local inflammation causes inhibition of nerve afferents resulting in ↓ muscle tone and thus lack of use –> atrophy
- Large joint involvement
4
Q
Swelling of the DIP joint is more commonly associated with which, Rheumatoid arthritis or Osteoarthritis?
A
Osteoarthritis
- DIP join is the most commonly affected joint in the hand
- DIP involvement in RA often occurs following MCP + PIP involvement
5
Q
What do Boutonnière deformities look like?
A
6
Q
What do Swan neck deformities look like?
A
7
Q
What extra-articular complications occur in Rheumatoid Arthritis?
A
-
Respiratory:
- Pulmonary fibrosis
- Pleural effusion
- Bronchiolitis obliterans
- Methotrexate pneumonitis
- Pleurisy
-
Ocular:
- Keratoconjunctivitis sicca - dry eyes (most common)
- Episcleritis
- Scleritis
- Scleromalacia perforans ‘corneal melt’
- Corneal ulceration
- Keratitis
- Steroid-induced cataracts
- Chloroquine retinopathy
- Osteoporosis
-
Heart:
- Ischaemic heart disease (RA carries similar risk to T2DM)
- Pericardial effusion
- Pericarditis
-
Hand / wrist:
- Carpal tunnel
- Peripheral neuropathy
- Palmar erythema
- Nailfold infarcts
-
General:
- Fatigue
- Weight loss
- Depression
- Low-grade fever
-
Blood:
- Normocytic anaemia
- Leukopenia
- Pancytopenia
- Amyloidosis
- ↑ Infections
8
Q
How common are extra-articular symptoms of RA?
A
~ 40% of patients have extra-articular symptoms
9
Q
What is the initial treatment step for Rheumatoid Arthritis (NICE 2018)?
A
DMARD (disease-modifying anti-rheumatic drugs) monotherapy +/- a short-course of bridging prednisolone
10
Q
Name 5 common DMARDs
A
- Methotrexate
- Azathioprine
- Sulfasalazine
- Leflunomide
- Hydroxychloroquine
11
Q
What monitoring is required when taking Methotrexate?
A
- FBC - risk of myelosuppression (decreased production of RBCs, WBCs and platelets)
- Creatinine / calculated GFR (U+Es)
- LFTs - risk of liver cirrhosis
12
Q
What medication is also prescribed alongside Methotrexate?
A
Folinic Acid (Leucovorin)
- Given to reduce toxicity of methotrexate (Folic acid antagonist)
- 5mg once weekly
- Take >24hrs after methotrexate dose
13
Q
What is the starting dose of Methotrexate for RA?
What is the maximum dose for moderate RA vs severe RA?
A
- 7.5 mg once weekly
- Moderate RA max = 20mg once weekly
- Severe RA max = 25mg once weekly
14
Q
What are the steps of escalation in treatment of RA?
A
- DMARD monotherapy +/- bridging prednisolone
- methotrexate or leflunomide or sulfasalazine
- DMARD duel therapy
- TNF-inhibitors (indicated when response to at least 2 DMARDs including methotrexate is inadequate)
15
Q
Name 3 common TNF-inhibitors used for RA
A
-
Etanercept
- Recombitant human protein, subcut administration, acts as decoy for TNF-α
-
Infliximab
- Monoclonal antibody, subcut administration, binds to TNF-α and prevents it from binding with TNF receptors
-
Adalimumab
- Monoclonal antibody, subcutaneous administration
16
Q
What does it mean when a fracture is ‘open’?
A
- That the bone is protruding through the skin
OR
- A wound penetrates down to the broken bone
17
Q
What do the following terms mean in reference to a fracture?
- Stable
- Transverse
- Oblique
- Comminuted
- Segmental
A
- Stable = The broken ends of the bone line up and are barely out of place
- Transverse = This type of fracture has a horizontal fracture line
- Oblique = This type of fracture has an angled pattern
- Comminuted = The bone shatters into three or more pieces
- Segmental = Fracture (often of a long bone) at two different levels with a middle whole segment of bone
18
Q
What is the medical term for repositioning of bone fragments?
A
Reduction
19
Q
What is a ‘Hills-Sachs’ lesion?
A
It is a flattening or indentation of the posterior humeral head following forceful impaction of the humeral head against the anteroinferior glenoid rim, when the shoulder is dislocated anteriorly
20
Q
What is a Bankart Lesion?
A
Is an injury of the anteroinferior glenoid labrum of the shoulder due to anterior shoulder dislocation –> a pocket forms at the front of the glenoid allowing humeral dislocation
Bony Bankart = Bankart lesion includes a fracture of the anteroinferior gelnoid cavity (see image)
21
Q
What is a simple way to distinguish between anterior and posterior dislocations of the shoulder?
A
- Anterior = humeral head is often dislocated anterior to glenoid and inferior to coracoid process
-
Posterior = humeral head is often dislocated posterior to glenoid and on the same level as the coracoid process
- Glenohumeral joint is widened
22
Q
Seperate the following features into those most common to inflammatory MSK conditions vs non-inflammatory MSK conditions
- Pain after use/at end of day
- Morning stiffness for > 30 mins
- Systemic symptoms
- Acute/subacute presentation
- Chronic symptoms
- No night-time pain
- No systemic symptoms
- Morning stiffness for < 30 mins
- Pain worse after rest/in morning
- Night-time pain
A
Inflammatory MSK:
- Pain worse after rest/in morning
- Morning stiffness for > 30 mins
- Night-time pain
- Systemic symptoms
- Acute/subacute presentation
Non-inflammatory MSK:
- Pain after use/at end of day
- Morning stiffness for < 30 mins
- No night-time pain
- No systemic symptoms
- Chronic symptoms
23
Q
Which joints does Osteoarthritis tend to affect most?
A
Weight-bearing joints and parts of the spine that move the most (lumbar and cervical)
24
Q
Does established RA tend to affect joints unilaterally or bilaterally?
A
Bilaterally
N.B. that early stage RA can affect any pattern of joints
25
Why is compression applied over the site of a simple fracture?
Can compression be used if the fracture is comminuted?
1. Compression of a fracture site allows primary bone healing without callus formation
2. No
26
What is the Garden Classification used for?
Categorising intracapsular hip fractures of the femoral neck
* This fracture can disrupt the blood supply to the femoral head
27
What are the 4 Garden Classifications?
1. **Undisplaced**, **incomplete fracture - stable**
* Includes fractures with impaction in valgus (bone segment distal to join is angled laterally)
2. **Undisplaced**, **complete fracture**
* No disturbance of medial trabeculae (principal compressive trabeculae)
3. **Incompletely displaced**, **complete fracture**
* Femoral head tilts into a varus position causing its medial trabeculae to be out of line with the pelvic trabeculae
4. **Completely displaced**, **complete fracture**
* Femoral head aligned normally in the acetabulum and its medial trabeculae are in line with the pelvic trabeculae
28
How are intracapsular hip fractures treated according to Garden classification?
* 1 or 2 --\> give it a screw
* 3 or 4 --\> Austin-Moore (old type of hip replacement)
Pts requiring athroplasty for hip fracture who:
1. Have no cognitive impairment AND
2. Are independently mobile
--\> are considered for total hip replacement (hemi-arthroplasty only replaces the femoral head/component not the acetabular component)
29
What is the mnemonic for identifying Osetoarthritis on X-rays?
* L = loss of joint space
* O = osteophytes
* S = subchondral cysts (look like dark patches of bone relative to surroundings)
* S = subchondral sclerosis (looks like area of increased density i.e. more white)
30
Should you joint aspirate in a patient with septic arthritis or give broad-spectrum antibiotics first?
Joint aspirate
(you only give antibiotics first if the pt is systemically unwell)
31
If a prosthetic joint appears swollen and you suspect joint infection and wish to aspirate, what important measure needs to be taken?
Aspiration of prosthetic joints should only be done in theatre
32
What is the escalation of antibiotics for treating osteomyelitis?
1. Flucloxacillin
2. Clindamycin (if penicillin-allergic)
3. Vancomycin (suspected MRSA)
Abx to be given for 6 weeks
33
What is the escalation of antibiotics for treating Septic Arthritis?
1. Flucloxacillin
2. Clindamycin (if penicillin-allergic)
3. Vancomycin (if suspected MRSA)
4. Cefotaxime (if gonococcal arthritis or gram -ve suspected)
All to be given for 4-6 weeks (seek specialist if a prosthetic is involved)
34
What is the mnemonic for identifying Osetoarthritis on X-rays?
* L = loss of joint space
* O = osteophytes
* S = subchondral cysts (look like dark patches of bone relative to surroundings)
* S = subchondral sclerosis (looks like area of increased density i.e. more white)
35
Patient with infective endocarditis has new onset back pain - what is the likely pathogenesis?
Septic embolism could be causing spinal osteomyelitis
N.B. a septic embolism is infected with bacteria and a feature of infective endocarditis)
36
Which 2 bacteria are the most common causes of
septic arthritis and osteomyelitis?
Staph or Strep
91% of cases
37
Which bacteria is associated with osteomyelitis
in sickle cell child patients?
Salmonella
38
What are the crystals in Gout composed of?
What causes the crystals to form?
Which organ is mainly responsible for excretion of the agent which encourages crystal formation?
1. Monosodium urate
2. ↑ uric acid concentration (hyperuricemia)
3. Kidneys
39
A patient has a unilateral, red, hot, swollen knee joint.
What is the gold standard diagnostic test here?
Joint aspiration
* Fluid can be sent for: gram staining, cytology, microscopy and culture
* Aid differentiating: crystal arthropathy (e.g. Gout or pseudogout), inflammatory arthritis, joint infection (septic arthritis)
40
Antibodies can aid diagnosis of rheumatological pathologies!
For each of the following which conditions are they suggestive of?
1. Anti-CCP (anti-cyclic citrullinated peptide)
2. Anti-dsDNA (anti-double stranded DNA)
3. RhF (rheumatoid factor)
4. ANCA (anti-neutrophilic cytoplasmic antibody)
5. ANA (anti-nuclear antibody)
1. **Anti CCP** --\> Rheumatoid arthritis (high specificity and sensitivity)
2. **Anti-dsDNA** --\> (High sensitivity and specificity for SLE, can monitor disease flare)
3. **RhF** --\> Present in a proportion of RA but can be positive in numerous other rheumatological conditions
4. **ANCA** --\> Small vessel vasculitis (diagnosis and monitoring)
* c-ANCA = more common in GPA (Granulomatosis with polyangiitis i.e. Wegener's granulomatosis)
* p-ANCA = more common in EGPA (Eosinophilic granulomatosis with polyangiitis i.e. Churg-Strauss syndrome)
5. **ANA** --\> Present in the normal population (5%) but can be associated with rheumatology conditions (in the right context)
* SLE - High sensitivity but low specificity
41
What is the Eaton and Littler Classification for?
Classification of **Basilar thumb arthritis**
* Basilar thumb arthritis is OA of the CMC thumb joint (2nd most common OA hand joint)
* Stage 1 = Slight joint space widening (pre-arthritis)
* Stage 2 = slight narrowing of CMC joint with sclerosis, osteophytes \< 2mm
* Stage 3 = marked narrowing of CMC joint with osteophytes \> 2mm
* Stage 4 = pantrapezial arthritis (i.e. STT - scaphotrapeiotrapezoidal arthritis)
42
How are glucocorticoids used in treatment of RA?
1. Glucocorticoids have 'disease-modifying effects' during the first 2 years of treatment in early RA
2. Medium/high dose glucocorticoids are used to bridge the interval between initiation of DMARDs and onset of therapeutic effect
43
For the following DMARDs what are some adverse effects?
1. Methotrexate
2. Azathioprine
3. Sulfasalazine
4. Leflunomide
5. Hydroxychloroquine
Adverse effects
1. **Methotrexate**
* Mouth ulcers
* Liver fibrosis --\> deranged LFTs
* Pneumonitis / pulmonary fibrosis
* Bone marrow supression --\> pancytopenia
2. **Azathioprine**
* Bone marrow suppression --\> pancytopenia + immunosuppression
* Must test for TPMT deficiency as drug can reduce metabolism causing toxicity
* Co-prescibed with allopurinol can cause toxicity due to shared clearance
3. **Sulfasalazine**
* Oligospermia (reduced sperm count)
* Haemolytic anaemia --\> megaloblastic anaemia
* Deranged LFTs
* Pneumonitis / pulmonary fibrosis
* Bone marrow supression --\> pancytopenia
4. **Leflunomide**
* Alopecia
* HTN
* Pneumonitis
* Peripheral neruopathy
* Hepatotoxicity
* Bone marrow supression --\> pancytopenia
5. **Hydroxychloroquine**
* Photosensitivity
* Haemolytic anaemia
* Retinal toxicity
* Bone marrow supression --\> pancytopenia
44
When are monoclonal antibodies to be used as rheumatological therapy?
Monoclonal antibodies are only to be used if convential DMARDs have failed (NICE)
45
Why do prospective monoclonal antibody recipients need to be screened for latent TB?
Because monocloncal antibodies can impair long term suppression and reactivate the TB
46
What diagnosis must be ruled out if your patient is systemically unwell with an acute, red, hot, swollen, tender joint?
Septic arthritis
* Joint must be aspirated and sent for culture
* Broad-spectrum antibiotics
* Treatment must be started even in absence of pt being systemically unwell
47
Which of these is a common target for monoclonal antibody therapy?
* Dihydrofolate reductase
* DNA gyrase
* PSA
* Tumour necrosis factor (TNF)
* Xanthine oxidase
Tumour necrosis factor (TNF)
48
What is the main adverse effect of bisphosphonate?
* Atypical femur fracture
* Hypercalcaemia
* Hypocalcaemia
* Oesophagitis
* Osteonecrosis
Oesophagitis
Advise pt to take 30mins prior to breakfast, drinks lots of water with it and sit up right
* Hypocalcaemia - bisphosphonate is given for hypercalcaemia but Ca2+ is tightly regulated so it rarely causes hypocalcaemia
* Osetonecrosis - very rare side effect but common exam question
* Atypical femur fracture - rare adverse side effect
49
What is the typical appearance of a lower limb with a neck of femur fracture?
Shortened and externally rotated
* Due to the relative strength of the psoas muscle pulling the femur (and whole leg) upwards. Because it inserts medially, there is a external rotational component to this.
50
What is the gold standard imaging for osteomyelitis?
MRI
Provides detailed soft tissue image and enables visualisation of 'infective collection' produced by inflammatory response
51
Name the 7 most common forms of Inflammatory Arthritis
1. Rheumatoid arthritis
2. Connective tissue disease
3. Vaculitis
4. Ankylosing Spondylitis
5. Psoriatic arthritis
6. Reactive arthritis
7. Inflammatory bowel disease (IBD) arthritis
52
In rheumatology if a patient is seropositive what does that mean?
It means that their blood test is positive for one of, or both, of the autoantibodies used to detect **Rheumatoid** arthritis i.e.
1. Rheumatoid Factor (RF)
2. Anti-CCP
53
A 64 year old lady with Rheumatoid arthritis is on
treatment with sulphasalazine.
Which blood test is most likely to be abnormal if it is affecting her liver?
1. FBC
2. ALT
3. Bilirubin
4. ALP
5. APTT
**ALT**
* ALT is quite sensitive and may rise quickily if a patient is sensitive to the medication
* ALP is more commonly raised in obstructive liver disease, it can also be up in inflammation (such as caused by rheumatoid arthritis)
* Biliruben ↑ common in obstructive liver disease
* The FBC can also be affected by sulphasalazine - watch out for pancytopenia (but this is blood not liver related)
* In significant liver disease clotting (APTT) may be affected but this might take a while to develop and is not as sensitive as ALT.
54
Blood supply disruption to head of femur is most common in which Garden classifications?
Type III and IV
55
What does seronegative mean in the context of seronegative spondyloarthropathies?
That these conditions are negative for
1) rheumatoid factor
and 2) anti-CCP
56
Why are rheumatological biological medications (e.g. TNF-inhibitors) often referred to by their trade names?
Because many companies make biologics but each uses different methods, so may produce drugs of slightly differing efficacy etc.
