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FINALS > MSK/Rheumatology > Flashcards

MSK/Rheumatology Flashcards

1
Q

Gene associated with seronegative spondyloarthritis

A

HLA-B27

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2
Q

Felty’s Syndrome features

A
  1. Rheumatoid arthritis
  2. Splenomegaly
  3. Neutropenia
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3
Q

Sjogren’s Syndrome: What does it affect/ Symptoms ?

A

Autoimmune condition affecting EXOCRINE GLANDS
—> dry mucous membranes (Dry mouth, dry eyes, dry vagina)

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4
Q

What is Primary Sjogren’s Syndrome?

A

Disease occurs in isolation

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5
Q

What is secondary Sjogren’s Syndrome?

A

Disease occurs related to SLE or Rheumatoid arthritis

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6
Q

What is Schirmer Test?

A

Test for Sjogren’s Syndrome

Insert filter paper under lower eyelid with strip hanging down
Leave for 5 mins
Distance along strip that becomes moist measured
Normal = > 15 mm
Significant for Sjogren’s < 10 mm

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7
Q

Management of Sjogren’s Syndrome

A

Artificial tears, saliva, vaginal lubricants

Hydroxychloroquine - to halt progression of disease

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8
Q

What is dermatomyositis ?

A

Rare disease that causes muscle weakness and skin rash
Connective tissue disorder —> chronic inflammation of the skin and muscles

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9
Q

Skin features of dermatomyositis

A

Scaly erythematous patches (Gottron lesions) on knuckles, elbows, knees
Photosensitive erythematous rash on back, shoulders, neck
Purple rash on face and eyelids
Perioribital swelling
Subcutaneous calcinosis (calcium deposits in subcutaneous tissue)

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10
Q

Auto-antibodies associated with dermatomyositis

A

Anti-Jo-1
Anti-Mi-2
Anti-nuclear

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11
Q

Dermatomyositis cause

A

Idiopathic
But associated with underlying malignancy in 1/4 of patients

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12
Q

Treatment of GCA (temporal arteritis)

A

High dose prednisolone (40-60mg/d) PO

Or IV methylprednisolone if rapidly progressing visual impairment

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13
Q

What are antiphospholipid antibodies?

A

E.g. anticardiolipin antibodies, Anti-beta-2-glycoprotein-I antibodies, Lupus anticoagulants

These antibodies interfere with coagulation and create a hypercoagulable state where the blood is more prone to clotting.

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14
Q

What is antiphospholipid syndrome?

A

Antiphospholipid syndrome is a disorder associated with antiphospholipid antibodies where the blood becomes prone to clotting. The patient is in a hyper-coagulable state. The main associations are with thrombosis and complications in pregnancy, particularly recurrent miscarriage.

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15
Q

What condition is antiphospholipid syndrome often secondary to?

A

Systemic Lupus Erythematosus

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16
Q

Complications of antiphospholipid syndrome

A
  1. Venous thromboembolism (DVT, PE)
  2. Arterial thrombus (Stroke, MI, Renal thrombosis)
  3. Pregnancy complications (recurrent miscarriage, stillbirth, preeclampisa)
  4. Livedo reticularis (mottled, lace like rash on skin)
  5. Libmann-sacks Endocarditis (Non bacterial vegetations on valves)
  6. Thrombocytopenia (low platelets)
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17
Q

Management of antiphospholipid syndrome

A

Long term warfarin (INR 2-3)

Pregnant women - low molecular weight heparin (e.g. enoxaparin) plus aspirin

(warfarin CI in pregnancy)

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18
Q

Causes of ACUTE monoarthritis (one joint)

A

Septic arthritis until proven otherwise !!!
Gout
Pseudogout
Trauma
Haemarthrosis

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19
Q

Causes of CHRONIC monoarthritis

A

TB
Psoriatic arthritis
Reactive arthritis
Osteoarthritis
Traumatic e.g. meniscus tear
Osteonecrosis
Neuropathic e.g. Charcot’s joint

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20
Q

What is charcot’s (neuropathic) Joint?

A

Most commonly seen as a complication of diabetes due to peripheral neuropathy
Damaged and deformed joint due to loss of sensation

Swelling, redness, pain, typically in the ankle
Can cause gross structural deformities, skin ulceration - osteoclast activation causes rapid bone destruction
Could lead to lower limb amputation!

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21
Q

Causes of ACUTE polyarthritis

A

Rheumatoid arthritis
Reactive arthritis
Psoriatic arthritis
SLE
Vasculitis
Uncontrolled gout

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22
Q

Causes of CHRONIC (> 3 months) polyarthritis

A

Rheumatoid arthritis
Reactive arthritis
Psoriatic arthritis
SLE
Vasculitis
Uncontrolled gout

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23
Q

Causes of arthritis affecting the DIPJs

A

Osteoarthritis- Heberden’s nodes
Psoriatic arthritis - + nail dystrophy on affected digit

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24
Q

What are Heberden’s nodes

A

Small, pea-sized boney growths that occur at DIPJ (closest to tip of finger)
Occur in osteoarthritis

Pick up “He(r)bs” with tips of fingers

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25
Q

What are Bouchard’s nodes

A

Boney swelling affecting the proximal interphalangeal joint
Occur in osteoarthritis

Anatomically closer to “bouch” (mouth)

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26
Q

What is calcinosis?

A

Calcium salts deposited in the skin and subcutaneous tissue
Hard yellowish lumps
Associated with various disorders such as:
- Systemic sclerosis
- Dermatomyositis
- Cutaneous lupus erythematosis
- Connective tissue disorders

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27
Q

How to distinguish inflammatory from mechanial disease?

A

Inflammatory
- morning stiffness > 1 hour
- improvement with activity
- rest makes it worse
- fatigue
- systemic symptoms

Mechanical
- morning stiffness < 30 mins
- Activity makes it worse
- Rest makes it better
- no systemic symptoms

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28
Q

What is the GALS assessment

A

Quick screening assessment for MSK disorders

Gait
Arms (Hands, wrists, elbows, shoulders)
Legs
Spine

Then proceed to detailed regional examination of a joint if any problem detected

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29
Q

What is an antalgic gait?

A

Pain causing a limp (reduced time on affected side)

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30
Q

What is a trendelenberg gait?

A

Due to poor hip abduction (weak gluteus medialis)

Pelvis drops down when standing - opposite side to affected leg

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31
Q

What is a sensory ataxic gait?

A

Wide based, stamping
Worse when eyes shut

(Stamping = to compensate for lack of sensory input)

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32
Q

What is a cerebella ataxic gait?

A

Wide based, staggering gait
Arms often flung out to try improve balance
Looks like “drunk”

33
Q

What is a Hemiplegic gait?

A

Narrow-based
Legs swung forward
Toes scrape the ground

34
Q

What is a Parkinsonian gait?

A

Difficulty initiating walking
Shuffling
Reduced arm swing

35
Q

What is a waddling gait ?

A

Duck-like
Due to bilateral hip weakness

36
Q

What is Tinel’s test?

A

Used to diagnose carpal tunnel syndrome
Tap over carpal tunnel for 30-60 seconds
If patient develops tingling in thumb and radial 2.5 fingers - suggests median nerve irritation

37
Q

What is phalen’s test ?

A

To help diagnose carpel tunnel syndrome

Patient holds wrist in complete forced flexion (pushing dorsal sides of both hands together for 60 seconds)
If patient develops symptoms then test is positive

38
Q

When to use ESR test and what does it reflect?

A

Done if signs of inflammation
Reflects presence of fibrinogen, immunoglobulins

39
Q

What does seropositive and seronegative mean?

A

Seropositive = RF+

Seronegative = RF-

40
Q

What is “CREST” syndrome and what does it stand for?

A

A subtype of systemic sclerosis (scleroderma)
= LIMITED scleroderma

Calcinosis
Raynaud’s
Esophageal dysmotility (GORD)
Sclerodactyly (thick, swollen fingers)
Telangiectasia

41
Q

Subtypes of systemic sclerosis (scleroderma)

A

Limited - peripheral skin involvement (distal to elbows and knees)

Diffuse - widespread skin changes (may involve whole body)

42
Q

Lung problems associated with methotrexate

A

Pneumonitis (similar presentation to hypersensitivity pneumonitis)
- develops within 1 year of starting treatment
- acute / sub acute
- Cough, Fever, dyspnoea

Pulmonary fibrosis
- develops due to long-term exposure to methotrexate

43
Q

What is Felty’s Syndrome

A

Rheumatoid arthritis + Splenomegaly + Low WCC

44
Q

What medication has a severe interaction with azathioprine

A

Allopurinol
- bone marrow suppression

45
Q

Causes of Dactylitis

A

Spondyloarthritis e.g. psoriatic and reactive arthritis
Sickle-cell disease

More rare: TB, Sarcoidosis, syphilis

46
Q

Important pre-operative imaging in patient with rheumatoid arthritis

A

Anteroposterior and lateral cervical spine radiographs

Because atlantoaxial subluxation is a rare complication of RA
Can lead to cervical cord compression
Screen for this pre-op
Pt would need to go to surgery in C-Spine collar so the neck is not hyperextended on intubation

47
Q

Osteoporosis bone profile blood test results

A

Commonly all normal !

48
Q

Diagnostic test for osteoporosis and normal/osteoporosis/osteopenia values

A

Dual energy X-ray absorptiometry (DEXA) Scan of lumbar spine

T-score < - 2.5 = Osteoporosis
T-Score between -2.5 to -1 = Osteopenia
T-Score >= -1 = normal

(T-Score is the number of SDs from the mean bone density for same gender at age of peak density (25 yrs))

49
Q

Osteoporosis vs osteopenia

A

Osteopenia is a less severe reduction in done density than osteoporosis

50
Q

Non-modifiable risk factors for osteoporosis

A

Advanced age
Female gender
Caucasian or south Asian
FHx of osteoporosis-gene

51
Q

Modifiable risk factors for osteoporosis

A

Low BMI
Premature menopause (<45)
Calcium/VitD deficiency
Alcohol/smoking
Reduced activity
Iatrogenic
- Long term steroids
- SSRis, PPIs, anti-epileptics and anti-oestrogens

52
Q

Tool used to give prediction of fragility fracture over next 10 years

A

FRAX

53
Q

Components of FRAX scoring tool

A

Age
BMI
Co-morbidities
Smoking/alcohol
FHx
+/- DEXA scan score

54
Q

Management of osteoporosis

A
  1. Lifestyle changes
    - activity
    - healthy weight
    - calcium/vitD intake
    - avoid falls
    - stop smoking/drinking
  2. Vitamin D & Calcium
    - e.g. calcichew-D3
  3. Bisphosphonates (reduced osteoclast activity)
    - Alendronate (weekly)
    - Risedronate (weekly)
    - Zoledronic acid (yearly IV)

Other options
- Denosumab (monoclonal Ab that blocks osteoclast activity)
- Raloxifene (selective oestrogen receptor modulator - stimulates on bone but blocks in breasts and uterus)
- HRT (in early menopause)

55
Q

Important side effects of bisphosphonates

A

Reflux/oesophageal erosisons - sit upright for 30 mins after taking them
Atypical fractures
Osteonecrosis of Jaw
Osteonecrosis of external auditory canal

56
Q

Follow up for osteoporosis patients on bisphosphonates

A

Repeat FRAX and DEXA scan after 3-5 years
Consider a “treatment holiday” if BMD has improved and they have not had any fragility fractures (break from Tx for 18months - 3 yrs)

57
Q

What are gout trophi

A

Subcutaneous deposits of uric acid
Typically affecting small joints and connective issues of the hands, elbows and ears
DIP joints are the most affected in the hands

58
Q

Joints commonly affected in gout

A

Metatarsophalangeal joint (base of big toe)
Wrists
Carpometacarpal joints (base of thumb)

59
Q

What does aspirate fluid show in gout?

A

No bacterial growth - important to rule out septic arthritis
Needle shaped crystals
Negatively birefringent of polarised light
Monosodium urate crystals

60
Q

What does joint X-ray show in gout?

A

Early signs = soft tissue swelling
Late signs = “punched out erosions” in juxa-articular bone
with sclerotic borders and overhanging edges
Joint space maintained

61
Q

Management during acute gout flare

A

NSAIDs
Colchicine
Steroids (3rd line)

If patient already taking allopurinol then it should be continued

62
Q

Prophylactic mangement of gout

A

Allopurinol (xanthine oxidase inhibitor)
Lifestyle changes - weight loss, stay hydrated, minimise alcohol and purine-based food consumption (Meat, seafood)

63
Q

NICE guidlines for starting Allopurinol for gout

A

urate-lowering therapy (ULT) for gout patients who suffer from ≥2 attacks per year

When commencing ULT (allopurinol) colchicine cover should be co-prescribed for up to 6 months from initiation.

If colchicine is unsuitable, NICE recommends considering NSAID cover as an alternative.

64
Q

Crystals that cause gout vs pseudogout

A

Gout –> URIC ACID (monosodium urate monohydrate crystals)

Pseudogout –> CALCIUM PYROPHOSPHATE (calcium pyrophosphate crystals)

65
Q

Risk factors for pseudogout

A

Associated with trauma and osteoarthritis
Hyperparathyroidism
Hemochromatosis
Look diuretics causing hypomagnesemia
Wilsons disease

66
Q

What needs to be corrected before starting bisphosphonates and why?

A

Vitamin D and calcium

because bisphosphonates may worsen hypocalcaemia due to reduced calcium efflux from bones, potentially resulting in arrhythmias/seizures

67
Q

What is Osteomalacia

A

a condition where bones become soft and weak
Often caused by not having enough VitD
Similar to rickets seen in children

68
Q

Causes of osteomalacia

A

Vit D deficiency (malabsorption, lack of sunlight, diet)
CKD
Drug induced (e.g. anticonvulsants)
Liver disease
Coeliac disease

69
Q

Signs of osteomalacia on X-ray

A

Translucent bands (Looser’s zones or pseudofractures)

70
Q

Management of osteomalacia

A

VitD supplements
Calcium supplements if dietary Ca is inadequate

71
Q

Raynauds disease vs Raynauds phenomenon

A

Disease = genetic component (young females)

Phenomenon = secondary to another condition

72
Q

Management of mild/moderate Raynaud’s

A

Lifestyle: stop smoking, warm clothes, avoid triggers / meds (COCP, BBs)

Vasodilators: CCBs (nifedipine)

73
Q

Management of severe Raynaud’s

A

IV prostaglandins (Iloprost)

+/- surgery (last resort) - e.g. embolectomy

74
Q

Triad associated with reactive arthritis

A

Arthritis
Urethritis
Conjunctivitis

“Cant see, cant wee, can’t bend a knee”

(formally called REITER’S SYNDROME)

75
Q

Causes of reactive arthritis

A
  1. Post-STI (men mostly)
    - Chlamydia trachomatis
    = sexually acquired reactive arthrtits
  2. Post-dysenteric
    - shigella, salmonella, campylobacter etc.
76
Q

Management of reactive arthritis

A

Symptomatic: Analgesia, NSAIDs, Intra-articulation steroids

Persistent disease - sulfalazine and methotrexate may be used

**Sx rarely last > 12 months

77
Q

When to test for Anti-cyclic citrullinated peptide antibody (Anti-CCP) ?

A

Suspected rheumatoid arthritis but the patient is rheumatoid factor negative

Test for anti CCP next (much higher specificity)

78
Q

Red flags for lower back pain

A

age < 20 years or > 50 years
history of previous malignancy
night pain
history of trauma
systemically unwell e.g. weight loss, fever

FINALS (19 decks)

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