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Flashcards in Musculoskeletal Medicine Deck (130):
1

3 chronic inflammatory arthropathies?

Psoriatic arthritis
Rheumatoid arthritis
Ankylosing spondylitis

2

2 chronic non-inflammatory arthropathies?

Osteoarthritis
Scoliosis

3

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

4

What are the common reasons for high circulating monosodium urate?

Genetic under excretion
Obesity
Metabolic syndrome - high cholesterol, high BP
Renal disease and diuretic use

5

What things can precipitate acute attacks of gout?

Alcohol
Injury
Illness
Surgery
Dehydration

6

Presentation of gout?

Most commonly affected is 1st MTP joint or MCP joint
Red, swollen, painful, hot joints
Shiny peeling skin
Worse at night

7

Investigations for gout?

Blood urate levels (in clinical context)
Aspirate synovial fluid and look for MSU crystals/exclude septic arthritis

8

Management of acute gout attack?

NSAIDs, steroids or injections
Colchicine - not at same time as NSAIDS. Increase MSU excretion in pee

9

Long term management of gout?

Allopurinol (can precipitate an acute attack)
Febuxostat

10

Long term complications of gout?

Tophi deposition
Joint damage

11

What crystals are implicated in pseudogout?

Calcium pyrophosphate

12

What joints are most commonly affected by pseudogout?

Knees, wrists
(Shoulders, ankles, elbows etc.)

13

What organism is most commonly implicated in septic arthritis in older adults?

Staph aureus

14

What organism is most common in septic arthritis in younger, sexually active adults?

Neisseria gonorrhoea

15

What non-articular feature of gonococcal septic arthritis is pathognomonic?

Maculopapular rash over trunk

16

Most common causative organism of septic arthritis in non-immunised children?

Haemophilus influenzae

17

Risk factors for septic arthritis?

Joint replacement
Immunosuppression incl DM, HIV
Prev joint damage incl RA, gout, connective tissue disease

18

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

19

Most commonly affected joints for septic arthritis?

Knee
Hip
Shoulder, ankle, wrists

20

Appropriate investigations for septic arthritis?

FBC ESR CRP
Joint XR
Blood cultures if systemically unwell
FNA of joint and culture

21

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.

22

What is reactive arthritis?

An acute inflammatory oligoarthropathy as a result of an autoimmune response following infection (no HLA B27 link)

23

Common infections that can precede reactive arthritis?

Campylobacter, shigella, salmonella
Chlamydia, HIV
Viral infections

24

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)
1-3 weeks

25

What is the triad that characterises Reiter's syndrome?

Uveitis, conjunctivitis
Urethritis and circinate balanitis
Keratoderma blenorrhagica and plantar fasciitis (arthritis)

26

What joints does reactive arthritis classically affect?

Large joints e.g. Inflammatory back pain, asymmetric oligoarthritis

27

Onset of reactive arthritis?

Acuteish 1-3 weeks post infection - typically with malaise, fever, fatigue

28

Acute phase management of reactive arthritis?

Rest, NSAIDs, steroids, analgesia and symptomatic relief
Aspirate synovial effusions
Physiotherapy
Abx of identifiable cause may prevent long-term complications
DMARDs e.g. Sulfasalazine

29

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

30

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

31

Non-articular features of RA?

Fatigue, depression, flu-like symptoms
Rheumatoid nodules
Dermatology - pyoderma gangrenosum, erythema nodosum
Lung, kidney, heart and GI involvement

32

Triad of signs classical of RA?

Swelling
Morning stiffness >30 mins (often >1 hour)
Positive MCP/MTP squeeze test

33

Investigations for rheumatoid arthritis?

ESR, CRP
Rheumatoid factor
Anti-CCP
Joint X Rays

34

Joint deformities characteristic of RA?

Z thumb
Boutonierre
Swan-neck
Ulnar deviation

35

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

36

What is Felty's syndrome?

Triad of seropositive rheumatoid arthritis (usually long standing), neutropenia and splenomegaly

37

Common presentation of Felty's syndrome?

Leg ulcers, recurrent or bad infection
Systemic features - malaise, fatigue, weight loss
Sjorgrens

38

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

39

Potential complications of Felty's syndrome?

Life threatening infection
Splenic rupture
Hepatic involvement
Visual complications

40

What is ankylosing spondylitis?

A type of spondyloarthropathy
Chronic inflammation of spine and sacro-iliac joints (axial skeleton)

41

In whom is ankylosing spondylitis most common?

Men, age 15-25 typically
HLA B27 positive

42

Pathophysiological features of ankylosing spondylitis?

Vertebral joint and ligament inflammation
Syndesmophytes laid down, bony protuberances and disc fusion

43

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

44

Eponymous test that can be done to investigate ankylosing spondylitis by quantification of lumbar flexion?

Schobers test

45

Important investigations of ankylosing spondylitis?

XR
MRI - better shows sacroiliac inflammation

46

Management of ankylosing spondylitis?

Conservative - physio, exercise
Medical - NSAIDs and steroids
Immunomodulation e.g. Methotrexate, anti TNFa (etanercept)

47

Major complications of ankylosing spondylitis?

Osteoporosis and compression fractures
Vertebral and sacroiliac fusion

48

4 acute inflammatory arthropathies?

Septic arthritis
Gout
Reactive arthritis
Discitis

49

Pathophysiology behind osteoarthritis?

A chronic, degenerative non-inflammatory arthritis characterised by synovial inflammation and hyperplasia, cartilage erosion and a thick stretched capsule

50

Presentation of osteoarthritis?

Pain, stiffness, loss of function, +/- swelling
Crepitus on movement
Effusions
Locking of joints
Worse at end of day or after use

51

Commonly affected joints in osteoarthritis?

Knees, hips

52

Typical patient affected by osteoarthritis?

Old obese woman with previous joint injury or overuse

53

2 nodes characteristic of osteoarthritis?

Heberdens nodes (distal IP joints)
Bouchards nodes (proximal IP joints)

54

4 characteristic features on joint XR of osteoarthritis?

Joint space narrowing
Osteophytes
Subchondral sclerosis
Subchondral cysts

55

Common complications of osteoarthritis?

Dislocation
Need for replacement

56

What is the pathophysiology behind osteopenia/osteoporosis?

Decrease in bone mass and density -> breakdown of trabecular (spongy/cancellous) bone in the middle of bones

57

RFs for osteoporosis?

Female post menopause/oophorectomy/low oestrogen
Long term progestogen contraception e.g. Depo
Age
FH
Steroid use
Alcoholism, smoking
Malabsorbative disorders - coeliac, CF, IBD
Underweight or inactive
Rheumatic disorders
Hyperthyroidism

58

Common presentations of osteoporosis?

Atypical or recurrent fractures
Decreasing height (vertebral collapse)

59

Postural changes associated with osteoporosis?

Gibbus deformity (mega kyphosis)
'Dowager's hump'

60

Appropriate investigations for osteoporosis?

XR any fractures and look for osteoporotic changes
DEXA scans
?biomarkers - calcium, magnesium, phosphate, PTH etc

61

Medical management of osteoporosis/osteoporosis risk?

HRT if early menopause
Bisphosphonates - alendronic acid, risedronate

62

Signs of rheumatoid arthritis on joint XR?

Soft tissue swelling
Narrowing of joint spaces
Subluxation of joints
Bony erosion

63

What joints in the hand and wrist are typically affected by RA?

MCPs/PIPs, triquetrum, ulnar styled

64

Which arthritis commonly affects the ulnar styloid?

RA

65

2 key XR changes in psoriatic arthritis?

Prominent erosion -> pencil in cup deformities
Bony proliferation (fuzzy edges)

66

What are dactylitis, prominent erosive features and pencil in cup deformities associated with?

Psoriatic arthritis

67

Types of fractures more common in kids?

Buckle/torus
Greenstick

68

Mnemonic for remembering the carpal bones?

Some Lads Try Positions That They Can't Handle

69

Carpal bones in order from lateral to medial, proximal row then distal?

Scaphoid
Lunate
Triquetrum
Pisiform
Trapezium
Trapezoid
Capitate
Hamitate

70

What is the bone shaft otherwise known as?

Diaphysis

71

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

72

What else should be considered in an old man presenting with a Colles fracture following a fall?

Osteoporosis - hip fracture?

73

What fracture of the radius is often sustained by a FOOSH with the wrist in a natural position to break the fall?

Colles

74

What is a Barton fracture of the radius?

A distal radial fracture that extends to the articulate surface of the radius

75

2 extra-articular fractures of the radius?

Colles
Smiths

76

2 fracture-dislocations of the radius/ulna?

Galeazzi
Monteggia

77

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

78

What is a Chauffeur/Hutchinson fracture?

An intra articular fracture of the distal radius which involves the radial styloid process

79

What 2 types of fracture may be caused by direct trauma to the back of the wrist?

Smiths
Chauffeur/Hutchinson

80

What is a Galeazzi fracture-dislocation?

Distal radial fracture with dislocation of distal radio-ulnar joint (intact ulna)

81

What is a Monteggia fracture-dislocation?

Ulnar shaft fracture with dislocation of the radial head at the elbow

82

What classification system is used for ankle fractures? Which is the worst type?

Weber classification - C being the worst

83

What typifies a type C weber fibular fracture?

Fracture above the ankle joint
Unstable
Often with medial malleolar damage and avulsion

84

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

85

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

86

What is the major blood vessel responsible for blood supply to the femoral head and therefore implicated in AVN if restricted?

Medial circumflex femoral

87

What are the 3 types of intracapsular NOF fracture?

Subcapital
Transcervical
Basicervical

88

Criteria involved in describing intracapsular NOF fractures?

Garden criteria

89

What is the classical position of the leg in someone with an intracapsular #NOF?

Externally rotated because of increased traction on greater trochanter

90

2 types of extracapsular #NOF?

Intertrochanteric
Subtrochanteric

91

How might external rotation of the femur due to hip fracture manifest on XR?

Increasingly visible lesser trochanter

92

What bones form shentons line?

Inferior border of superior pubic ramus and medial edge of femoral head and neck

93

What things can be done to assess osteoporosis?

Frax score
DEXA scan of BMD

94

What is a fragility fracture?

One sustained from a fall at standing height or lower

95

What surgery definitely needs to be done for a displaced intracapsular NOF?

Hemiarthroplasty or THR for younger, fitter placements

96

Options for management of undisplaced intracapsular NOF?

Hemiarthroplasty/THR
Internal sliding screw fixation

97

Management of extracapsular NOF?

Internal sliding screw fixation or hemiarthroplasty

98

What is the key indication for arthroplasty?

Pain

99

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

100

Most common cause of an acute limp in kids who are just starting to walk? (Age 1-3)

Transient synovitis/irritable hip

101

What is irritable hip otherwise known as?

Transient synovitis

102

What is transient synovitis otherwise known as?

Irritable hip

103

Causes of an acute limp at any childhood age?

Septic arthritis/osteomyelitis
Trauma
NAI
Malignancy

104

What is the long term implication of childhood osteomyelitis?

May destroy physis/epiphysis and so limit growth

105

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

106

What signs are visible on radiography for osteomyelitis?

Subperiosteal pus/abscess, causing periosteal elevation

107

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)

108

What are bloods finding like in transient synovitis?

Normal or slightly high CRP
Wbc fine

109

Most common cause of acute hip pain in children?

Transient synovitis

110

What investigation is best for transient synovitis? What does it show?

USS - shows effusion of affected hip

111

What cause of acute limp often follows or coincides with a viral infection?

Transient synovitis

112

What is the pathophysiology behind perthes disease?

Avascular necrosis of capital femoral epiphysis

113

Any long term complications of transient synovitis?

May precede perthes disease

114

What disease may precede perthes disease?

Transient synovitis

115

Who does perthes disease affect?

Young pre-pubescent boys

116

What sidedness is perthes disease?

Most often unilateral

117

Investigation for perthes disease?

XR including frog leg view

118

What is a slipped capital femoral epiphysis?

Postero-inferior displacement of capital femoral epiphysis which can potentially cause AVN

119

In whom does slipped capital femoral epiphysis occur?

Typically older adolescent boys, age 10-15 often of higher BMI

120

What is the most common arthritis overall in kids?

Reactive arthritis

121

Commonest chronic inflammatory joint disease in kids?

JIA

122

What is JIA?

Persistent joint swelling, pain for at least 6 weeks in absence of any other cause in kids

123

Most common reasons for hip replacement failure?

Osteolysis and aseptic loosening (late)
Instability/deep infection (early)
Component failure
Wear/erosion through acetabulum
Periprosthetic fractures

124

Four types of knee replacement?

Total
Unicompartmental (partial)
Patellofemoral (kneecap)
Complex/revision

125

Requirements for uni compartments knee replacement?

Damage affecting only one compartment (often medial)
Needs strong healthy ligaments etc.

126

In whom are PMR and GCA most common?

Older women - over 50 but more commonly 70/80

127

Sx of PMR?

EMS >30mins of hips, shoulders
Constitutional - fever, malaise, depression, night sweats
Muscles are tender but passive movement fine
Mildly raised ESR

128

PMR exam findings?

Tenderness of axial muscles but fine on passive movement

129

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
Ameurosis fugax
PMR and constitutional Sx

130

Ix GCA?

Give steroids anyway if suspected to preserve vision
Send of ESR
Temp artery biopsy is gold standard - narrowed lumen, thickened Tunica intima