MSK/Rheumatology 6/7/20 Flashcards
(73 cards)
1
Q
contraindicated drugs for patients on methotrexate
A
- trimethoprim
- cotrimoxazole (septrin)
- high dose aspirin
cause bone marrow toxicity
2
Q
inflammatory vs degenerative
A
- stiffness
> over 30-60 mins/better with exercise/morning = inflammatory
> under 30 mins/worse with exercise = degenerative - joint distribution
> hands and feet = inflammatory
> knees, fingers, thumb base = degenerative
3
Q
MSK history red flags
A
BONE PAIN
- at rest/at night - possibly tumour/infection/fracture
NEURALGIC
- pain/paraesthesia in dermatomal distribution - possibly root or periph nerve compression
INFECTIVE
- warm, usually monoarthralgia
4
Q
complications of rheumatoid arthritis
A
- interstitial lung disease (pul fibrosis)
- pleural effusion
- pericardial effusion leading to cardiomegaly
- nephrotic syndrome, check kidney function and oedema
- vasculitis, small vessels of nose/digits more commonly
5
Q
blood tests to monitor methotrexate
A
3 monthly when stable on drug, fortnightly before stable
- FBC (pancytopenia risk)
- U+Es (renally excreted)
- LFTs (methotrexate binds to albumin)
6
Q
ecg changes in pericarditis
A
- ‘saddle-shaped’ ST elevation
- PR depression: most specific ECG marker for pericarditis
7
Q
methotrexate in those trying for baby
A
remember methotrexate is teratogenic (men and women come off methotrexate for 3 months before trying for baby)
8
Q
safe alternatives to methotrexate in pregnancy/breastfeeding
A
- sulfasalazine
- hydroxychloroquine
9
Q
co-prescribe methotrexate with…?
A
weekly folic acid (>24hrs after methotrexate dose)
10
Q
biologic DMARDs key points
A
- more potent immunosuppressants than regular DMARDs, at risk of atypical and typical infections
- stop bDMARDs for duration of Abx and 2 weeks after
- for elective surgery stop bDMARDs for half life + 1 wk
11
Q
radiological changes of rheumatoid arthritis
A
LESS
Loss of joint space
Erosions
Soft tissue swelling
Soft bones (oteopenia)
12
Q
examples of anti-TNF biologic DMARDs
A
- infliximab
- etanercept
13
Q
examples of lymphocyte suppressing biologic DMARDs
A
T cells = abatacept
B cells = rituximab
14
Q
example of anti-IL6 biologic DMARDs
A
Tocilizumab
15
Q
fractures that have highest risk of compartment syndrome as a complication
A
- supracondylar fracture (humerus just above elbow)
- tibial shaft fracture
16
Q
diagnosis of compartment syndrome
A
measurement of intracompartmental pressure:
- pressure >20mmHg = abnormal
- pressure >40mmHg is diagnostic
compartment syndrome does not typically show pathology on x-ray
17
Q
features of compartment syndrome
A
6 Ps but not always all 6
- severe Pain, especially on passive movement and not relieved even by morphine
- Parasthesiae
- Pallor/Poikilothermia may be present
- Pulselessness (pulse may still be felt as the necrosis occurs as a result of microvascular compromise)
- Paralysis of the muscle group may occur
18
Q
complications of compartment syndrome
A
- necrosis (can lead to muscle contractures eg. Volkmann’s contracture)
- rhabdomyolysis/AKI
19
Q
management of compartment syndrome
A
- surgical (fasciotomy) to relieve pressure
- give fluids to prevent AKI if rhabdomyolysis occurs
- if due to an external factor (eg. misplaced cast) removal may provide spontaneous recovery
management must be prompt as muscle group death may occur within 4-6hrs
20
Q
causes of compartment syndrome
A
- trauma (fracture, crush, gunshot)
- external (tight cast, burns)
- internal (fluid overload, post-ischaemic swelling, bleeding disorders)
21
Q
muscles and function of anterior compartment
A
muscles: - tibialis anterior - extensor hallucis longus - extensor digitorum longus - peroneus tertius function: - dorsiflexion of ankle/foot
22
Q
muscles and function of lateral compartment
A
muscles: - peroneus longus - peroneus brevis function: - plantarflexion of foot - eversion of foot
23
Q
muscles and function of deep posterior compartment
A
muscles: - tibialis posterior - flexor digitorum longus - flexor hallucis longus function: - plantarflexion of foot - inversion of foot
24
Q
muscles and function of superficial posterior compartment
A
muscles: - gastrocnemius - soleus - plantaris function: - plantarflexion of foot
25
FRAX criteria
- age
- sex
- height, weight, BMI (frailty)
- previous fracture
- parent fractured hip
- glucocorticoids
- rheumatoid arthritis
- secondary osteoporosis (type 1 diabetes, hyperthyroid/parathyroidism, chronic liver disease, premature menopause, IBD/coeliac , etc.)
- diet/alcohol/smoking
- BMD scan result
26
osteoporosis/penia T score
```
osteopenia = -1 to -2.5
osteoporosis = -2.5 or lower
```
confirm osteoporosis wit DEXA scan
27
side effects of bisphosphonates
- oesophagitis (orally), dosing instructions reduce risk
- IV bisphosphonates may cause flu-like symptoms
- AF risk
RARE
> osteonecrosis of jaw
> atypical femoral fractures
28
bisphosphonate dosing instructions PO
- take on empty stomach in morning
- swallow with big glass of water
- no food/drink/meds for at least 30 mins
- stay sat/stood up after taking to reduce oesophagitis/reflux risk
29
denosumab
- monoclonal antibody to RANK ligand
- prevents osteoclast differentiation and reduces activity
- 6 monthly subcut injection
- suited to older/frailer patients
30
teriparatide
- PTH analogue
- stimulates osteoblast activity
- daily subcut injection for 2 yrs
- expensive so reserved for those with severe osteoporosis unresponsive to bisphosphonates
31
Paget's disease of bone pathophysiology
genetic and geographical factors
- bone remodelling disorder
- overactive osteoclasts
- compensatory increased osteoblast activity
- disorganised mosaic of woven (weak) and lamellar (strong) bone
32
Paget's disease of bone features
```
triad of:
- pain
- deformity
- fracture
RARELY:
- deafness
- myelopathy (-> spinal cord compression)
```
33
radiological signs of Paget's disease of bone
- expansion of bone
- cortical thickening
- abnormal texture
34
biochemistry of Paget's
- high AlkPhos
| - Ca/Phos usually normal
35
management of Paget's
- bisphosphonate eg. alendronate (counter overactive osteoclasts)
- surgery may be required for complications
36
symptoms of hypercalcaemia
- polydipsia
- polyuria
- constipation
- nausea
later:
- confusion/coma
- renal stones
- short QT interval
37
skin manifestations of systemic lupus erythematosus (SLE)
- photosensitive 'butterfly' rash
- discoid lupus
- alopecia
- livedo reticularis: net-like rash
- Raynaud's phenomenon
38
cardiovascular manifestations of systemic lupus erythematosus (SLE)
- pericarditis
- myocarditis
- cardiomyopathy
39
renal manifestations of systemic lupus erythematosus (SLE)
- proteinuria
| - glomerulonephritis (diffuse proliferative glomerulonephritis is the most common type)
40
respiratory manifestations of systemic lupus erythematosus (SLE)
- pleurisy and pleural effusions
| - fibrosing alveolitis
41
neuropsychiatric manifestations of systemic lupus erythematosus (SLE)
- anxiety and depression
- psychosis
- seizures
42
general features of SLE
- fatigue
- fever
- mouth ulcers
- lymphadenopathy
- ANA and anti-dsDNA autoantibodies
43
adverse effects of methotrexate
- mucositis
- myelosuppression
- pulmonary fibrosis
- liver fibrosis
44
treatment of methotrexate toxicity
folinic acid
45
adverse effects of sulfasalazine
- oligospermia
- Stevens-Johnson syndrome
- lung fibrosis
- myelosuppression
- may colour tears → stained contact lenses
46
sulfasalazine cautions
- G6PD deficiency
| - allergy to aspirin or sulphonamides (trimethoprim)
47
osteoarthritis radiological signs
JOSS
- joint space narrowing
- osteophytes
- subchondral sclerosis
- subchondral cysts
48
features of cauda equina syndrome
- lower back or sciatica pain
- urinary incontinence/retention
- saddle paraesthesia
- decreased anal tone
49
management of cauda equina syndrome
Urgent MRI
```
acute:
- surgery to decompress
- Abx if abscess is cause
degenerative:
- surgery if possible
- NSAIDs/corticosteroids
```
50
management of a fracture
ALL FRACTURES
- Immobilise the fracture (including the proximal and distal joints)
- Monitor neurovascular status
OPEN FRACTURES
- IV broad spectrum antibiotics
- Lavage and debridement within 6 hours of injury
51
GU complications of pelvic injury
- haematuria
- urinary retention
- urethral injury
- bladder injury
52
causes of anaemia of chronic disease
- malignancy
- chronic infections eg. TB
- connective tissues disease eg. rheumatoid arthritis
53
RFs for adhesive capsulitis (frozen shoulder)
- age 40-60
- diabetes
- cardiovascular disease
54
management of adhesive capsulitis (frozen shoulder)
stiffness may persist for months/years
- analgesia
- physio and exercise
- intracapsular steroid injection
55
upper brachial plexus injury
- Erb's palsy
| - associated C5, C6 dermatomal sensory loss
56
lower brachial plexus injury
- Klumpke's palsy (claw hand due to myotomal loss)
- associated C8, T1 dermatomal sensory loss
- T1 can lead to ipsilateral Horner's
57
features of shoulder impingement
- pain and stiffness
- particularly when doing overhead movements
- management is with analgesia, physio, rarely surgical decompression
58
osteosarcoma
most common bone malignancy
- adolescent males typically
- warm, painful swelling
- periosteal sunburst appearance
59
Ewing's sarcoma
- adolescents
- warm, painful, growing mass along long bone
- systemic features (inc WCC, ESR, fever, anaemia)
- onion skin periosteal reaction
60
chondrosarcoma
- older patients
- pain with a mass in cartilage
- 'fluffy popcorn calcification' lesion
61
assessment for C-spine injury
ABCDE
- full immobilisation until C-Spine 'cleared'
- detailed history and examination
- imaging as required
62
management of confirmed C-spine injury
ABCDE
- airway management
- secure patient with full in-line stabilisation
- maintain 'neutral' neck position, use a jaw thrust if required rather than chin lift
- semi-rigid collar
- secure head with blocks and tape
63
most common nerve lesion causing foot drop
common peroneal nerve injury
64
management of OA
- weight loss and aerobic exercise are effective at reducing pain and maintaining joint function
- weight-bearing exercise should be avoided as it can accelerate the progression of the disease
- physiotherapy and occupational therapy input
- walking aids may be useful
- NSAIDs particularly effective
- surgery may be required
65
management of osteomyelitis/septic arthritis
commonly due to staph aureus
- flucloxacillin (clindamycin if pen allergy) for 4-6 wks (12+ in chronic OM)
- surgical debridement useful in OM
- may add fusidic acid/rifampicin in severe OA for first 2 weeks
66
RFs for osteoporosis
```
SHATTERED FAMILY
S – Steroid use
H – Hyperthyroidism, hyperparathyroidism
A – Alcohol and smoking
T – Thin (BMI<22)
T – Testosterone deficiency
E – Early menopause
R – Renal/liver failure
E – Erosive/inflammatory bone disease
D – Diabetes
FAMILY HISTORY
```
67
autoantibodies in RA
anti-CCP (anti-cyclic citrullinated peptide)
| rheumatoid factor
68
management of RA
- oral methotrexate and bridging steroid initially
- treat flares with oral/IA prednisolone
- second line = sulfasalazine then TNFa biologics eg. etanacept
69
SPINEACHE mnemonic for seronegative spondyloarthropathies
```
Sausage digits
Psoriasis
Inflammation
NSAIDs effective
Enthesitis
Arthritis
Crohn's/colitis
HLA-B27
Eyes (uveitis)
```
70
management of SLE
start off with NSAIDs and hydroxychloroquine
71
gout crystals + management
urate crystals
negatively birefringent needles
- colchicine acutely then allopurinol
- lifestyle changes
72
pseudogout crystals
apatite crystals
| positively birefringent rhomboids
73
which cancers spread to bone?
```
Prostate – blastic = growth-promoting
Breast – mixed pattern
Kidney – lytic = breakdown
Thyroid – lytic
Lungs – lytic
```
