Flashcards in Musculoskeletal and rheumatological conditions Deck (98):
Worldwide, uncommon in black population, twice as common in women, occurs in over 50s.
Mostly over 60s.
Women over 55 more likely to have it than men of a similar age.
Osteoarthritis: clinical symptoms.
Joint pain - pain exacerbated by movement, relieved by rest. Gelling on rest.
Osteoarthritis: clinical signs
Joint effusion and variable levels of inflammation.
Blood tests, X-rays, MRIs, aspiration of synovial fluid.
Osteoarthritis investigations: blood tests.
ESR normal, sometimes high-sensitivity CRP elevated. Rheumatoid factor and anti-nuclear antibodies are negative.
Osteoarthritis investigations: X-rays.
Abnormal only when advanced. Used pre-operatively.
Osteoarthritis investigations: MRI
Used to look for for meniscal tears, early cartilage injury and subchondral bone marrow changes.
Osteoarthritis investigations: aspiration
Shows viscous fluid with few leukocytes.
All aimed at relieving symptoms. Physical measures, paracetamol, NSAIDs, intra-articular steroids or surgery.
Multifactorial process, mostly mechanical factors. Significant inflammation and also alteration of cartilage structure.
Red flag symptoms for back pain (divisions to help memory)
Divide into age, type of pain, associated symptoms, cancer, neuro and infectious to remember
Red flag symptoms for back pain (actual)
Age: under 20 or over 55.
Type of pain: If the pain is constant/progressive, nocturnal/worse when in a supine position, or if it is thoracic.
Associated symptoms: fever/night sweats/weight loss, morning stiffness or claudication in the leg.
Cancer: history of malignancy, abdo mass (also AAA).
Neuro: neurological disturbance (inc sciatica), leg pain (bilateral or alternating unilateral), sphincter disturbance.
Infection: current infection or immunosuppression.
Normal distribution of psoriasis
Forearm extensor surfaces.
Complications of chronic kidney failure
Hyperkalaemia, high levels of erythropoietin, hypocalcaemia.
Rheumatological conditions causing diffuse pain with no early morning stiffness
Chronic pain syndromes
Rheumatological conditions causing diffuse pain with early morning stiffness
Rheumatological conditions causing localised pain, with no early morning stiffness and no joint swelling
Rheumatological conditions causing localised joint pain with early morning stiffness, in a single joint.
Rheumatological conditions causing localised joint swelling and pain with early morning stiffness, in multiple joints
Viral (if less than 6 weeks)
Joints commonly affected by osteoarthritis
Distal interphalangeal joints, first CMC joint in hand, MTP joint of foot, and weight-bearing joints.
Bony swellings at DIPJ
Bony swellings at PIPJ
Rheumatoid arthritis definition
A chronic symmetrical bony arthritis caused by a systemic autoimmune disorder with extra-articular involvement
Rheumatoid arthritis - epidemiology
Peak prevalence 30-50 years, pre-menopausal women affected more than men, familial association.
Rheumatoid arthritis - pathology
Activation of synovial T cells by unknown antigen leads to synovitis, synovial infiltration, angiogenesis and formation of a pannus. This leads to destruction of articular cartilage and subchondral bone. Rheumatoid nodules also form in the skin, pleura, pericardium and lung.
Rheumatoid arthritis - clinical features
Pain, early morning stiffness, and swelling of small joints. Joint effusions and wasting of surrounding muscles.
Periarticular features. Rheumatoid nodules at pressure points.
Progressive disease: joint instability, subluxation and deformity
Rheumatoid arthritis - investigations
Bloods: anaemia, raised inflammatory markers
Serum autoantibodies:RhF, antinuclear factor and anti-citrulline-contaiining peptide antibodies.
Aspiration: synovial fluid stirle with high neutrophil count.
Rheumatoid arthritis - treatment
Smoking cessation, NSAIDs, disease-modifying drugs (DMARDs). Anticytokine agents, coricosteroids, surgery.
Rheumatoid arthritis - joints affected
PIPJ, MCPs and wrist. Can involve elbows, shoulders, spine, knees, ankles and feet.
Ankylosing spondylitis - definition
An inflammatory disorder of the back
Ankylosing spondylitis - epidemiology
Typically young men
Ankylosing spondylitis - clinical features
Increasing pain and morning stiffness in lower back, alleviated by exercise not rest. Progressive loss of spinal movement.
Increased loss of lumbar lordosis and increased kyphosis. Limitation of lumbar mobility and chest expansion.
Ankylosing spondylitis - investigations
Bloods: raised inflammatory markers
X-ray may be normal or show erosion.
MR shows early changes suggestive of osteitis and oedema.
Ankylosing spondylitis - treatment
Slow release NSAIDs taken at night.
What is a greenstick fracture?
A fracture in a child that involves partial cortical disruption.
Pars interarticularis position
A fracture of the area on a vertebra between the superior and inferior facet
Pars interarticularis result.
The fracture may lead to the vertebral body slipping anteriorly and leading to vertebral canal compression. Common in athletes at LIV and LV levels.
Which nerve weakness leads to inablility to raise the arm above the head and weakness in attempting to raise the shoulder?
Which nerve damage leads to inability to do a pull up?
When do you see polyarticular gout?
Occasionally, but in chronic renal failure particularly
Which crystals cause gout?
Monosodium urate monophosphate
Which crystals cause pseudogout?
Calcium pyrophosphate dihydrate
Pattern of gout
Usually feet, esp first metatarsalphalangeal joint in men, and knee in women, but can affect any foot joint. Generally in men, affecting 1% of population.
Timescale of gout
Acute onset of swelling, pain and redness for a few days, before returning to normal. These intermittent attacks occur more frequently without treatment leading to chronic problems, as severity of flares decreases.
Examination findings in gout
Low grade pyrexia, redness, swelling and tenderness of joint. If chronic, tophi over pinna of ear, elbow and lateral hand.
DD is septic arthritis, gout and pseudogout.
Risk factors of gout.
What increases serum uric acid level?
Diet: animal purines, alcohol, seafood
Decreased renal excretion
Metabolic pathway key to pathogenesis of gout
Nucleic acids --> purines --> hypoxanthine --> xanthine --> URIC ACID (which we can't metabolise and is not v water soluble, so is supersaturation level of serum)
Paediatric condition due to mutation in uric acid pathway, leading to hyperuracemia in children.
What interferes with renal excretion of uric acid?
mutation in URAT1 channel in Mauris; drugs inc loop and thiazide diuretics, cyclosporin and low dose aspirin; lead toxicity; INSULIN RESISTANCE and high levels of insulin which interfere with excretion
What alters uric acid synthesis in the body?
Increased cellular turnover - lymphoproliferative disorders and malignancy;
Increased uric acid synthesis - fructose high diets.
How do uric acid crystals cause gout?
They are unstable, and can be released into the joint leading to recognition by innate immune system activating the inflammasome leading to neutrophil activation and symptoms of gout
What triggers gout attacks?
Intercurrent infection, acute increase or decrease in serum uric acid (commencing treatment, alcohol or dietary changes), possibly trauma.
Investigations when faced with suspected gout?
SYNOVIAL FLUID ANALYSIS (exclude septic arthritis)
Renal function (increased creatinine is a risk for gout)
Serum uric acid - a NEGATIVE marker as drops in an acute attack, so likely to be normal but can still be high.
Synovial fluid appearance in septic arthritis and crystal synovitis
Runny, greenish, opaque. (crystal synovitis can be more yellowish)
Synovial fluid appearance in inflammatory arthritis and crystal synovitis
Cloudy, straw-coloured, low viscosity. (crystal synovitis can be more greenish).
Normal synovial fluid looks like...
What investigation is used to diagnose gout definitively?
Polarised light microscopy. Needle shaped crystals visible.
Treatment of gout - matches causing fire in joint. Fire extinguisher, dampen matches, reduce number of matches.
A fire extinguisher: NSAIDs very effective - carry with them, and take at start immediately. Steroidal anti-inflammatories also work if NSAIDs contraindicated.
Dampen matches: colchicine interferes with neutrophil microtubules. OD, BD or TD.
Reduce the number of matches: reduce uric acid levels in body. Decrease insulin - weight reduction. Check drugs. This risks flares.
Allopurinol inhibits xanthine oxidase.
What is pseudogout?
A crystal arthropathy that can be thought of as an aggressive form of nodal osteoarthritis.
What is likely to be a background history for patients with pseudogout?
What is a 'flare' of osteoarthritis likely to be?
Presentation of pseudogout
Episodes of pain, early morning stiffness, swelling and redness of affected joint, lasting weeks (not days).
Triggers for pseudogout
Intercurrent infection, dehydration, local trauma.
Investigations for suspected pseudogout
Joint aspiration - look for crystals, but can be difficult to see. Exclude septic arthritis
Blood cultures negative
Uric acid normal
X-ray as crystals are radioopaque
Management of pseudogout
Fire extinguisher: anti-inflammatories.
Dampening: colchicine BD/TD but no randomised trials.
Not possible to reduce crystals yet.
What would you find on examination of a fibromyalgic patient?
Multiple tender points along spine and in her limbs.
Secondary causes of fibromyalgia syndrome
Failures: liver and renal
Autoimmune conditions (e.g. RA, SLE, PMR)
Disorders of bone metabolism (low Vitamin D, hyperparathyroidism)
Dysfunction: thyroid and pituitary.
Viral illnesses (e.g. influenza, parvovirus, rubella)
What are some polymyalgia symptoms?
>2 weeks of bilateral, shoulder and/or pelvic girdle myalgia, early morning stiffness >45 minutes, +/- evidence of an acute-phase response, in a patient over 50
If someone has polymyalgia symptoms, and is over 50, what else should you consider?
What are some systemic symptoms of giant cell arteritis?
fever, weight loss, decreased appetite, fatigue.
What is a common presentation of GCA?
An abrupt onset unilateral headache in the temporal region (although it can be diffuse or bilateral). Often with scalp hyperalgesia.
What is the most concerning symptom of GCA
Visual symptoms: amaurosis fugax, blurring and diplopia. Patients with GCA are at risk of permanent blindness.
What are the red flags for GCA?
Visual loss and jaw claudication.
What are digital infarcts with necrotic ulceration a sign of?
What is likely to be the cause of an inflammatory polyarthritis with a photosensitive rash and mouth ulcers?
What are the characteristic results in SLE for:
ESR is often raised with a normal CRP
ANA is positive in 95%
dsDNA is often positive, but a negative result does not rule out SLE
ENA is positive in severe disease.
What therapy is used in an SLE flare-up?
What therapy is used for an SLE associated vasculitis?
Epidemiology of SLE
More women than men. More in African ethnicities.
What are the major dangerous renal complication of SLE?
Glomerulonephritis leading to nephrotic syndrome.
What are some blood changes associated with SLE
What are some cardiac issues associated with SLE?
Pericarditis, endocarditis and aortic valve lesions.
What are some neurological issues associated with SLE?
Fits, hemiplegia, ataxia, polyneuropathy, cranial nerve lesions, psychosis or demyelinating syndrome.
What eye and skin conditions can be associated with SLE?
Photosensitivity and butterfly rash
Vasculitis, purpura, urticaria.
What respiratory conditions can be associated with SLE?
Are urate crystals negatively or positively birefringent?
Are calcium pyrophosphate crystals negatively or positively birefringent?
What is diclofenac?
An NSAID used in MSK conditions
Histological features of giant cell arteritis?
Intimal hypertrophy and inflammation of intima and sub-intima.
Breaking up of internal elastic lamina.
Treatment for GCA?
What is the reactive arthritis triad?
Urethritis, arthritis and conjunctivitis.
Mitral valve prolapse, hyperelastic skin and aneurysms/GI bleeds. Joints loose and hypermobile, mutations exist e.g. in genes for procollagen.
Ankylosing spondylitis - presentation
typically a young man who presents with lower back pain and stiffness of insidious onset
stiffness is usually worse in the morning and improves with exercise
the patient may experience pain at night which improves on getting up
Ankylosing spondylitis - other features (the As)
AV node block
and cauda equina syndrome
peripheral arthritis (25%, more common if female)
What is Felty's syndrome?
Splenomegaly and neutropenia in a patient with rheumatoid arthritis.