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MSK/Rheumatology Flashcards

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1
Q

What is rheumatology?

A

Medical management of MSK disease. Prevalence increases with age. Mainly inflammatory joint pain.

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2
Q

What is inflammation?

A

Reaction of the microcirculation. Movement of fluid and white blood cells into extravascular tissues due to pro inflammatory cytokines.

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3
Q

What are the 4 pillars of inflammation?

A

Rubor (redness)
Calor (heat)
Dolor (painful)
Tumour (swollen)

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4
Q

How can an inflamed joint present?

A
  1. Hot, painful, red, swollen joint
  2. Deformity
  3. Stiffness
  4. Poor mobility/function
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5
Q

Give the main differences between inflammatory and degenerative joint pain.

A
  1. Pain - in inflammatory, pain eases with use whereas degenerative pain gets worse with use
  2. Stiffness - inflammatory stiffness is significant (>60mins) whereas degenerative generally less than 30 mins. Degenerative stiffness is generally morning and evening and inflammatory stiffness generally morning and at rest.
  3. Hot and red - only inflammatory
  4. Joint distrubution - inflammatory generally hands and feet whereas degenerative - carpometacarpel joint, distal interpharangeal joints, and knees.
  5. Swelling - inflammatory = synovial+/- bony. Degenerative = bony
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6
Q

Which type of joint pain generally responds to NSAIDs?

A

Inflammatory joint pain

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7
Q

Typically patient that presents with inflammatory joint pain vs one that presents with degenerative joint pain?

A

Inflammatory - often younger, with family history of inflammatory joint pain. May have psoriasis

Degenerative - older, prior occupation/sport

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8
Q

What is the relationship between work and mortality?

A

Higher mortality if don’t work

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9
Q

What are the Bradford Hill criteria?

A

Guidelines useful for providing evidence of a causal relationship between an apparent cause and effect.

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10
Q

Name 6 of the Bradford-Hill criteria?

A
  1. Strength of association (high and significant odds ratio)
  2. Consistency in association
  3. Exposure-response relationship
  4. Temporal relationship (effect after cause)
  5. Specificity
  6. Coherence
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11
Q

Name some high risk activities for MSK issues.

A
  1. Heavy manual handling
  2. Lifting above shoulders
  3. Lifting below knees
  4. Incorrect manual handling technique
  5. Forceful repetitive work
  6. Poor postures
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12
Q

What type of disease is carpal tunnel syndrome?

A

Entrapment neuropathy

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13
Q

Carpal tunnel syndrome is a result of pressure on what nerve?

A

Median nerve

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14
Q

What factors are associated with carpal tunnel syndrome?

A

Diabetes, obesity, pregnancy, OCP, hypothyroidism, RA, acromegaly

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15
Q

What is Tinel’s sign and what does it test for?

A

Tapping over carpel tunnel in attempt to elicit paraesthesia in median nerve distrubution

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16
Q

What is Phalen’s test and what does it test for?

A

Maximal wrist flexion for one min. May elicit symptoms of carpal tunnel syndrome, equally can be unreliable.

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17
Q

Typical clinical features of carpal tunnel syndrome?

A
  1. Aching pain in hand and arm - especially at night

2. Paraesthesia in thumb index and middle finger - relieved by hanging over end of bed and shaking ‘wake and shake’

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18
Q

What muscles does the median nerve supply?

A

LOAF

Lumbricals, opponens pollicis, abductor pollicis brevis, flexor pollicis brevis

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19
Q

What is the difference between Raynaud’s phenomenon and Raynaud’s disease?

A

Raynaud’s disease, the cause of the Raynaud’s is unknown and arises spontaneously. Whereas Raynaud’s phenomenon there is an underlying cause..

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20
Q

What is Raynaud’s?

A

Peripheral digital ischaemia due to paraoxysmal vasospasm, precipitated by cold or emotion.

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21
Q

What precipitates Raynaud’s?

A

Cold or emotion

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22
Q

What are some of the underlying causes of Raynaud’s phenomenon?

A
  1. Connective tissue disorders
  2. Occupational (vibrating tools)
  3. Obstructive e.g. atheroma
  4. Blood condition (cold agglutinin disease, monoclonal gammopathy)
  5. Drugs (B-blocker)
  6. Hypothyroidism
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23
Q

What drugs can cause Raynaud’s phenomenon?

A

Beta blockers

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24
Q

What is the colour change in Raynaud’s?

A

Yellow –> Blue –> Red

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25
What are the symptoms of Raynaud's?
1. Fingers and toes ache 2. Fingers and toes change colour 3. Tingling, numbness and loss of dexterity
26
What is the management of Raynaud's?
1. Keep warm 2. Stop smoking 3. Nifedipine (CCB)
27
Why is Nifedipine used to treat Raynaud's?
Is a CCB and so relaxes blood vessels
28
Differential of Raynaud's?
Hypothenar hammer syndrome (occlusion of ulnar artery)
29
Age range normally affected by Raynaud's disease?
Young women
30
Common workplace injuries that classify for industrial injuries disablement benefit (IIDB)?
- Carpal tunnel syndrome - Tenosynovitis - Writer's cramp (RSD) - Osteoarthritis of hip for farmers (10 years plus in job) - Osteoarthritis of knee for floor layers, miners (10 years plus in job)
31
What is tenosynovitis?
Inflammation of tendon or sheath around tendon causing pain, swelling and dysfunction.
32
What causes tenosynovitis?
Forceful and repetitive hand movements, or previous injury or strain
33
How is tenosynovitis managed?
1. NSAIDs 2. Steroid injection 3. Rest 4. Change job 5. IIDB
34
What are the symptoms of tenosynovitis?
Pain and swelling in the wrist and forearm. | O/E crepitus
35
What test is used to detect tenosynovitis?
Finkelstein test
36
What crystal causes gout?
Monosodium urate
37
What crystal causes pseudogout?
Calcium pyrophosphate
38
Is gout more common in men or women?
10 x more common in men
39
What is the main cause of gout?
Impaired renal excretion of uric acid
40
What are the four clinical syndromes caused by deposition of sodium urate crystals and hyperuricaemia?
1. Acute sodium urate synovitis 2. Chronic polyarticular gout 3. Chronic tophaceous gout 4. Urate renal stone formation
41
Where does acute monoarthropathy usually occur in gout?
MTP joint of big toe
42
Differential diagnosis of acute monoarthropathy that must always first be ruled out?
Septic arthritis
43
What are the main causes of gout?
Increased production of uric acid - Diet (increased intake of purines), cell death (chemotherapy), errors of metabolism (Lesch Nyan syndrome), cell damage (surgery) Failure of uric acid to be excreted- Drugs (low dose aspirin and diuretics), fructose, high insulin levels. Assosciations with: hypertensive patients, diabetic patients and patients with chronic renal failure
44
What is the most common inflammatory arthritis in the UK?
Gout
45
What is the saturation point of uric acid in the blood and what is the normal range? What does this show?
Sat point = 380 mmol/l Normal range = 200-430 - indicating that some people will normally be above saturation point. However only 1 in 5 with hyperuricaemia will develop gout.
46
If gout is left untreated what can happen to the bone?
Periarticular punched out erosion
47
In terms of diet, what are the biggest risk factors for developing gout?
1. High alcohol intake (beer>spirits>wine) 2. High red meat intake 3. High seafood intake 4. High fructose intake (sugary drinks, sweets)
48
What food products are protective against gout?
Dairy products, cherries, things with Vit C
49
What advice is given to a patient with gout to attempt to improve management?
1. Low calorie diet/lose weight 2. Avoid alcohol excess, red meat, and low dose aspirin 3. Rest and elevate affected joint
50
Where is the most common site for tophi to form in gout?
Pinna
51
What is the main investigation done in gout? What would you expect to see?
Aspirate joint and polarized light microscopy of synovial fluid Would see negatively birefringent urate crystals
52
What can trigger an attack of acute gout?
Dietary or alcoholic excess, dehydration, starting a diuretic, cold, trauma or sepsis
53
What are the main renal causes for gout?
Genetics, insulin levels, diuretics, fructose
54
What is the treatment of acute gout?
Colchicine NSAIDS Steroids Ice Cherries and Vit C help shorten attacks
55
What is the treatment of chronic gout?
1. Uricosuric drugs (Losartan, fenofibrate) - increase excretion of urate 2. Allopurinol start at 100mg / 24 and titrate upwards every 3 weeks until urate <300μm/L (gout prophylaxis) 3. Colchicine for up to 6 months 4. NSAIDs for up to 6 weeks
56
How is allopurinol dosage decided for gout?
Start at 100mg/24 hours and titrate upwards every 3 weeks until urate <300μm/L
57
What is a normal eGFR?
90-120 ml/min/1.73m2
58
If an individuals eGFR is less than 50, how is the dosage of allopurinol decided in gout?
Start 1.5mg/unit eGFR/ day and titrate upwards by 1.5mg/ unit eGFR/ day every 3 weeks until serum urate is less than 300.
59
What drug is used in gout if allopurinol is CI or there are side effects?
Febuxostat
60
If patient's eGFR is between 20 and 30, what drug is used instead of allopurinol?
Benzbromarone
61
What are tophi and how do they cause bone erosion?
Smooth white onion like aggregates of urate crystals with inflammatory cells. They release local proteolytic enzymes
62
What can gout increase the risk of ?
Hypertension, renal disease, CVS disease, Type 2 diabetes and OA damage to joints
63
What is another term for pseudogout?
Pyrophosphate arthropathy
64
What crystals are deposited on joint surface in pseudogout?
Calcium pyrophosphate
65
What is the typically clinical presentation of a patient with pseudogout?
Hot, red, swollen joints (in particular larger joints such as wrist, ankle, knee or MCP joint) Generally elderly patients Generally monoarthropathy
66
What are the risk factors for pseudogout?
Older age, hyperparathyroidism, haemachromatosis, hypophosphataemia, diabetes
67
On xray, how does pseudogout present?
Chondrocalcinosis
68
How is pseudogout diagnosed?
Aspirate joint Culture (can be infected) and polarised light microscopy On polarised light microscopy will see weakly positive birefringent crystals
69
Management of pseudogout?
Intrarticular steroids +- colchicine Methotextrate in chronic Ice pack in acute attacks
70
Typical joints that are involved in degenerative joint pain?
CMCJ, DIPJ, knees

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