Flashcards in Musculoskeletal Medicine Deck (130):
3 chronic inflammatory arthropathies?
2 chronic non-inflammatory arthropathies?
What is the pathophysiology behind gout?
Monosodium urate crystal deposition in joints due to increasing levels in bloodstream. Deposition occurs based on temperature so more common distally
What are the common reasons for high circulating monosodium urate?
Genetic under excretion
Metabolic syndrome - high cholesterol, high BP
Renal disease and diuretic use
What things can precipitate acute attacks of gout?
Presentation of gout?
Most commonly affected is 1st MTP joint or MCP joint
Red, swollen, painful, hot joints
Shiny peeling skin
Worse at night
Investigations for gout?
Blood urate levels (in clinical context)
Aspirate synovial fluid and look for MSU crystals/exclude septic arthritis
Management of acute gout attack?
NSAIDs, steroids or injections
Colchicine - not at same time as NSAIDS. Increase MSU excretion in pee
Long term management of gout?
Allopurinol (can precipitate an acute attack)
Long term complications of gout?
What crystals are implicated in pseudogout?
What joints are most commonly affected by pseudogout?
(Shoulders, ankles, elbows etc.)
What organism is most commonly implicated in septic arthritis in older adults?
What organism is most common in septic arthritis in younger, sexually active adults?
What non-articular feature of gonococcal septic arthritis is pathognomonic?
Maculopapular rash over trunk
Most common causative organism of septic arthritis in non-immunised children?
Risk factors for septic arthritis?
Immunosuppression incl DM, HIV
Prev joint damage incl RA, gout, connective tissue disease
Typical presentation of septic arthritis?
Acute inflammatory monoarthropathy (usually)
Intense pain on any movement, redness, swelling, warmth
Systemic features incl fever, rigors
On exam may be effusion
Most commonly affected joints for septic arthritis?
Shoulder, ankle, wrists
Appropriate investigations for septic arthritis?
FBC ESR CRP
Blood cultures if systemically unwell
FNA of joint and culture
Management of septic arthritis?
Drain joint - if a prosthetic joint it will need replacing
Broad spectrum IV Abx -> narrow spec
Splints, physio follow up etc.
What is reactive arthritis?
An acute inflammatory oligoarthropathy as a result of an autoimmune response following infection (no HLA B27 link)
Common infections that can precede reactive arthritis?
Campylobacter, shigella, salmonella
2 most common sites of infection that precede reactive arthritis? How long after initial infection may it take to precipitate?
Gut, sexual organs (enteric or venereal)
What is the triad that characterises Reiter's syndrome?
Urethritis and circinate balanitis
Keratoderma blenorrhagica and plantar fasciitis (arthritis)
What joints does reactive arthritis classically affect?
Large joints e.g. Inflammatory back pain, asymmetric oligoarthritis
Onset of reactive arthritis?
Acuteish 1-3 weeks post infection - typically with malaise, fever, fatigue
Acute phase management of reactive arthritis?
Rest, NSAIDs, steroids, analgesia and symptomatic relief
Aspirate synovial effusions
Abx of identifiable cause may prevent long-term complications
DMARDs e.g. Sulfasalazine
Prognosis and complications of reactive arthritis?
Usually self limiting within 12 months
Can be long term or recurrent (more common if HLA B27 +ve)
CV complications e.g. Aortic regurge, pericarditis
What is the pathophysiology behind rheumatoid arthritis?
Autoimmune disorder with HLA DR4 link causing a chronic, systemic inflammatory response primarily causing a symmetrical polyarthritis
-> synovial inflammation and hyperplasia, nerve ending irritation and capsule stretching
Non-articular features of RA?
Fatigue, depression, flu-like symptoms
Dermatology - pyoderma gangrenosum, erythema nodosum
Lung, kidney, heart and GI involvement
Triad of signs classical of RA?
Morning stiffness >30 mins (often >1 hour)
Positive MCP/MTP squeeze test
Investigations for rheumatoid arthritis?
Joint X Rays
Joint deformities characteristic of RA?
Management of RA?
Conservatively physio, exercise, footwear etc is important
Medically - NSAIDs, analgesia, DMARDs e.g. Azathioprine Sulfasalazine methotrexate, steroids and anti-TNFs (infliximab)
Surgical e.g. Joint replacement
What is Felty's syndrome?
Triad of seropositive rheumatoid arthritis (usually long standing), neutropenia and splenomegaly
Common presentation of Felty's syndrome?
Leg ulcers, recurrent or bad infection
Systemic features - malaise, fatigue, weight loss
In whom is Felty's syndrome more common?
Severe long standing RA, lots of extra-articular disease
Positive for HLA DR4, Rheumatoid factor and anti-CCP
Potential complications of Felty's syndrome?
Life threatening infection
What is ankylosing spondylitis?
A type of spondyloarthropathy
Chronic inflammation of spine and sacro-iliac joints (axial skeleton)
In whom is ankylosing spondylitis most common?
Men, age 15-25 typically
HLA B27 positive
Pathophysiological features of ankylosing spondylitis?
Vertebral joint and ligament inflammation
Syndesmophytes laid down, bony protuberances and disc fusion
Presentation of ankylosing spondylitis?
Lower back pain with inflammatory features worsening over months
Radiation down into buttocks, thighs
Other joints and ligaments e.g. Achilles may be involved
Eponymous test that can be done to investigate ankylosing spondylitis by quantification of lumbar flexion?
Important investigations of ankylosing spondylitis?
MRI - better shows sacroiliac inflammation
Management of ankylosing spondylitis?
Conservative - physio, exercise
Medical - NSAIDs and steroids
Immunomodulation e.g. Methotrexate, anti TNFa (etanercept)
Major complications of ankylosing spondylitis?
Osteoporosis and compression fractures
Vertebral and sacroiliac fusion
4 acute inflammatory arthropathies?
Pathophysiology behind osteoarthritis?
A chronic, degenerative non-inflammatory arthritis characterised by synovial inflammation and hyperplasia, cartilage erosion and a thick stretched capsule
Presentation of osteoarthritis?
Pain, stiffness, loss of function, +/- swelling
Crepitus on movement
Locking of joints
Worse at end of day or after use
Commonly affected joints in osteoarthritis?
Typical patient affected by osteoarthritis?
Old obese woman with previous joint injury or overuse
2 nodes characteristic of osteoarthritis?
Heberdens nodes (distal IP joints)
Bouchards nodes (proximal IP joints)
4 characteristic features on joint XR of osteoarthritis?
Joint space narrowing
Common complications of osteoarthritis?
Need for replacement
What is the pathophysiology behind osteopenia/osteoporosis?
Decrease in bone mass and density -> breakdown of trabecular (spongy/cancellous) bone in the middle of bones
RFs for osteoporosis?
Female post menopause/oophorectomy/low oestrogen
Long term progestogen contraception e.g. Depo
Malabsorbative disorders - coeliac, CF, IBD
Underweight or inactive
Common presentations of osteoporosis?
Atypical or recurrent fractures
Decreasing height (vertebral collapse)
Postural changes associated with osteoporosis?
Gibbus deformity (mega kyphosis)
Appropriate investigations for osteoporosis?
XR any fractures and look for osteoporotic changes
?biomarkers - calcium, magnesium, phosphate, PTH etc
Medical management of osteoporosis/osteoporosis risk?
HRT if early menopause
Bisphosphonates - alendronic acid, risedronate
Signs of rheumatoid arthritis on joint XR?
Soft tissue swelling
Narrowing of joint spaces
Subluxation of joints
What joints in the hand and wrist are typically affected by RA?
MCPs/PIPs, triquetrum, ulnar styled
Which arthritis commonly affects the ulnar styloid?
2 key XR changes in psoriatic arthritis?
Prominent erosion -> pencil in cup deformities
Bony proliferation (fuzzy edges)
What are dactylitis, prominent erosive features and pencil in cup deformities associated with?
Types of fractures more common in kids?
Mnemonic for remembering the carpal bones?
Some Lads Try Positions That They Can't Handle
Carpal bones in order from lateral to medial, proximal row then distal?
What is the bone shaft otherwise known as?
What is the most common distal radial fracture? Describe it
Colles fracture - caused by FOOSH with wrist dorsiflexed, leading to distal radial fracture with dorsal angulation and impaction of distal fragment
What else should be considered in an old man presenting with a Colles fracture following a fall?
Osteoporosis - hip fracture?
What fracture of the radius is often sustained by a FOOSH with the wrist in a natural position to break the fall?
What is a Barton fracture of the radius?
A distal radial fracture that extends to the articulate surface of the radius
2 extra-articular fractures of the radius?
2 fracture-dislocations of the radius/ulna?
What is Smiths fracture?
A backwards Colles - fall on a flexed wrist or trauma to back of wrist resulting in distal radial fracture with anterior/volar displacement of distal segment
What is a Chauffeur/Hutchinson fracture?
An intra articular fracture of the distal radius which involves the radial styloid process
What 2 types of fracture may be caused by direct trauma to the back of the wrist?
What is a Galeazzi fracture-dislocation?
Distal radial fracture with dislocation of distal radio-ulnar joint (intact ulna)
What is a Monteggia fracture-dislocation?
Ulnar shaft fracture with dislocation of the radial head at the elbow
What classification system is used for ankle fractures? Which is the worst type?
Weber classification - C being the worst
What typifies a type C weber fibular fracture?
Fracture above the ankle joint
Often with medial malleolar damage and avulsion
Describe the major arterial supply to the femoral head?
Retrograde blood supply - mostly from medial (and lateral) femoral circumflex arteries which form an anastomotic ring around femoral neck and ascend via ascending and transverse branches
Also superior and inferior gluteal, artery of lig of head and retinacular arteries
What type of hip fracture is most implicated with AVN of the femoral head? Why?
Intracapsular because the retrograde blood supply ascends under the joint capsule and is sheared in an intracapsular fracture
What is the major blood vessel responsible for blood supply to the femoral head and therefore implicated in AVN if restricted?
Medial circumflex femoral
What are the 3 types of intracapsular NOF fracture?
Criteria involved in describing intracapsular NOF fractures?
What is the classical position of the leg in someone with an intracapsular #NOF?
Externally rotated because of increased traction on greater trochanter
2 types of extracapsular #NOF?
How might external rotation of the femur due to hip fracture manifest on XR?
Increasingly visible lesser trochanter
What bones form shentons line?
Inferior border of superior pubic ramus and medial edge of femoral head and neck
What things can be done to assess osteoporosis?
DEXA scan of BMD
What is a fragility fracture?
One sustained from a fall at standing height or lower
What surgery definitely needs to be done for a displaced intracapsular NOF?
Hemiarthroplasty or THR for younger, fitter placements
Options for management of undisplaced intracapsular NOF?
Internal sliding screw fixation
Management of extracapsular NOF?
Internal sliding screw fixation or hemiarthroplasty
What is the key indication for arthroplasty?
5 extra things done in pGALS but not in GALS?
3 fingers in mouth (spine)
Arms in air
Look up at ceiling
Prayer and reverse prayer signs
Walk on tippy toes and heels
Most common cause of an acute limp in kids who are just starting to walk? (Age 1-3)
Transient synovitis/irritable hip
What is irritable hip otherwise known as?
What is transient synovitis otherwise known as?
Causes of an acute limp at any childhood age?
What is the long term implication of childhood osteomyelitis?
May destroy physis/epiphysis and so limit growth
What is the reason MRI is often used in MSK?
Best modality for differentiating bone from soft tissue injury e.g. And best for stuff like osteomyelitis
What signs are visible on radiography for osteomyelitis?
Subperiosteal pus/abscess, causing periosteal elevation
Presentation of irritable hip/transient synovitis?
2-12 year olds, acute non-weight bearing limp following or alongside viral infection
Doesn't appear unwell, fever mild or absent
Pain on movement only (particularly internal rotation)
What are bloods finding like in transient synovitis?
Normal or slightly high CRP
Most common cause of acute hip pain in children?
What investigation is best for transient synovitis? What does it show?
USS - shows effusion of affected hip
What cause of acute limp often follows or coincides with a viral infection?
What is the pathophysiology behind perthes disease?
Avascular necrosis of capital femoral epiphysis
Any long term complications of transient synovitis?
May precede perthes disease
What disease may precede perthes disease?
Who does perthes disease affect?
Young pre-pubescent boys
What sidedness is perthes disease?
Most often unilateral
Investigation for perthes disease?
XR including frog leg view
What is a slipped capital femoral epiphysis?
Postero-inferior displacement of capital femoral epiphysis which can potentially cause AVN
In whom does slipped capital femoral epiphysis occur?
Typically older adolescent boys, age 10-15 often of higher BMI
What is the most common arthritis overall in kids?
Commonest chronic inflammatory joint disease in kids?
What is JIA?
Persistent joint swelling, pain for at least 6 weeks in absence of any other cause in kids
Most common reasons for hip replacement failure?
Osteolysis and aseptic loosening (late)
Instability/deep infection (early)
Wear/erosion through acetabulum
Four types of knee replacement?
Requirements for uni compartments knee replacement?
Damage affecting only one compartment (often medial)
Needs strong healthy ligaments etc.
In whom are PMR and GCA most common?
Older women - over 50 but more commonly 70/80
Sx of PMR?
EMS >30mins of hips, shoulders
Constitutional - fever, malaise, depression, night sweats
Muscles are tender but passive movement fine
Mildly raised ESR
PMR exam findings?
Tenderness of axial muscles but fine on passive movement
Sx of GCA?
New onset temporal/occipital headache with visible temp arteries, non-pulsatile and tender to touch e.g. Combing, scalp touch
Jaw/TMJ irritation and claudication on eating
PMR and constitutional Sx