musculoskeletal - gout and some arthritis

Question 1

risk factors for osteoarthritis

Answer 1

age
obesity (pro-inflammatory state)
high impact sports
trauma
genetics

Question 2

is osteoarthritis more common in males or females?

Answer 2

more common in men before 45

more common in women after 55

Question 3

non-inflammatory pathology of osteoarthritis

Answer 3

deterioration of articular cartilage by wear and tear

formation of new bone at the joint surfaces and margins

Question 4

crepitus

Answer 4

cracking sensation when knee bends

Question 5

inflammatory pathology of osteoarthritis

Answer 5

proteases
metalloproteases
catabolic and anabolic cytokines
IL-1
TNF-alpha
insulin like growth factor
TGF-beta

Question 6

joints most commonly affected by osteoarthritis

Answer 6

knee
hip 
DIPJ
PIPJ
1st CMC
spine
1st MTPJ

Question 7

signs of osteoarthritis

Answer 7

muscle wasting
osteophytes
Heberden’s and Bouchard’s nodes

Question 8

symptoms of osteoarthritis

Answer 8

pain
aggravated by activity
relieved by rest

Question 9

complications of osteoarthritis

Answer 9

poor mobility and its associated illnesses

Question 10

where does OA of knees start?

Answer 10

starts medially and moves laterally

Question 11

XR signs of OA

Answer 11

sclerosis
osteophytes
cysts
asymmetric loss of joint space

Question 12

diagnostic tests for OA

Answer 12

XR
CT
isotope bone scan
blood tests (ESR, FBC, rheumatoid factor, ALP, calcium) - should all be normal 
diagnostic injection 
arthroscopy

Question 13

what causes the pain in OA?

Answer 13

capsular stretching and vascular congestion of the bone

Question 14

treatment of osteoarthritis

Answer 14

lifestyle modification and exercise
physiotherapy
walking aids
analgesics (NSAIDs and glucosamine)
capsaicin cream 
steroid injections
hyaluronic acid 
surgery

Question 15

surgical options for osteoarthritis

Answer 15

debridement of joint 
realignment of osteotomies
joint excision 
joint fusion (arthrodesis)
joint replacement (arthroplasty)

Question 16

risk factors for rheumatoid arthritis

Answer 16

female
caucasian
family history
smoking
HLA DR4 mutation

Question 17

pathology of rheumatoid arthritis

Answer 17

inflamed synovium proliferates to form pannus –> pannus invades bone –> erosion of bone

destruction of cartilage causes release of proteinases and cytokines

Question 18

characteristics of inflammatory joint pain

Answer 18

pain eases with use
prolonged stiffness in the morning and at rest
hot and red joint
tends to affect hands and feet

Question 19

characteristics of degenerative joint pain

Answer 19

pain increases with use
stiffness is not prolonged
stiffness in morning and evening
tends to affect 1st CMCJ, DIPJ, and knees

Question 20

late signs of rheumatoid arthritis

Answer 20

ulnar deviation
subluxation
Boutonierre deformity (button pressing 2nd digit)
swan neck dextrous deformity

Question 21

complications of rheumatoid arthritis

Answer 21

vasculitis
osteophytes
tenosynovitis
eye involvement
amyloid

Question 22

eye involvement in rheumatoid arthritis

Answer 22

sicca
secondary Sjogrens
episcleritis
scleritis

Question 23

what percentage of patients are negative for all rheumatoid investigations?

Answer 23

20%

Question 24

diagnosis of rheumatoid arthritis

Answer 24

increase rheumatoid factor
high ESR
CCP increase (highly specific)
anaemia
anti-cyclic citrullinated peptide
do joint aspirate to rule out crystal disease

Question 25

treatment of rheumatoid arthritis

Answer 25

physiotherapy surgery anti-inflammatory drugs

Question 26

risk factors for gout

Answer 26

``` genetics diet alcohol male diuretics obesity hypertension ```

Question 27

at what level does deposition of uric acid become a risk?

Answer 27

>0.36 mmol/L

Question 28

what causes high uric acid levels in gout?

Answer 28

under excretion | over production

Question 29

pathology of gout

Answer 29

high blood monosodium urate concentration --> crystallisation and deposition in joints --> phagocyte activation --> inflammation

Question 30

what is the key enzyme in purine metabolism that prevents gout?

Answer 30

xanthine oxidase

Question 31

symptoms of gout

Answer 31

joint pain swelling redness shiny looking joint (typically base of big toe)

Question 32

complications of gout

Answer 32

rate nephropathy kidney stones tophaceous gout (can ulcerate and get infected)

Question 33

diagnosis of gout

Answer 33

monosodium urate crystals in synovial fluid (which are blue and yellow under polarised light) bloods: hyperuricaemia (NB: will be low in acute gout), WBCs, ESR XR is good for chronic gout

Question 34

treatment of gout

Answer 34

hydration NSAIDs or steroids allopurinol and probenecid for long term reduction of symptoms vitamin C for prevention

Question 35

differential diagnosis of gout

Answer 35

sepsis

Question 36

what should you give to gout patients who have renal problems and so can't have NSAIDs?

Answer 36

colchicine

Question 37

risk factors for pseudogout

Answer 37

``` old age hyperparathyroidism haemachromatosis male gender acromegaly ```

Question 38

what is usually deposited at joints in pseudo gout?

Answer 38

calcium phosphate

Question 39

pathology of acute (spontaneous) pseudogout

Answer 39

monoarthropathy usually in large joints in the elderly

Question 40

pathology of chronic pseudogout

Answer 40

inflammatory RA-like polyarthritis and synovitis

Question 41

signs of pseudogout

Answer 41

inflammation | chronic arthritis

Question 42

symptoms of pseudogout

Answer 42

pain

Question 43

complications of pseudogout

Answer 43

permanent joint damage | acute synovitis

Question 44

diagnosis of pseduogout

Answer 44

polarised light microscopy of synovial joint fluid - crystals rhomboid and not colourful soft tissue calcium deposition

Question 45

how to treat acute pseudogout

Answer 45

``` cool packs rest aspiratoin intra-articular steroids NSAIDs ```

Question 46

how to treat chronic pseudogout

Answer 46

methotrexate | hydrochloroquine

Question 47

risk factors for ankylosing spondylosis

Answer 47

HLA B27 (95% patients)

Question 48

definition of ankylosing spondylosis

Answer 48

a chronic inflammatory disease of the spine and the sacroiliac joints, aetiology unknown.

Question 49

signs of spondylosing arthritis

Answer 49

SPINE ACHE ``` Sausage digit (dactylitis) Psoriasis Inflammatory back pain NSAIDs - responds well Enthesitis (inflammation of tendon sheath) Arthritis Crohn's / colitis / elevated CRP HLA-B27 Eye - uveitis ```

Question 50

symptoms of ankylosing spondylitis

Answer 50

low back pain radiating from sacro-iliac joints to hips/buttocks pain improves towards end of day

Question 51

complications of ankylosing spondylitis

Answer 51

spine fracture

Question 52

diagnosis of ankylosing spondylitis

Answer 52

clinical diagnosis MRI to detect bone marrow oedema XR bloods

Question 53

blood tests results for a patient with ankylosing spondylitis

Answer 53

increased ESR and CRP | HLA B27 positive

Question 54

X-ray results of a patient with ankylosing spondylitis

Answer 54

joint narrowing or widening sclerosis erosions ankylosis/fusion

Question 55

treatment of ankylosing spondylitis

Answer 55

exercise to maintain posture and mobility NSAIDs for symptomatic relief TNF alpha blockers (etanercept, adalimumab) local steroid injection