Musculoskeletal & Rheumatology Flashcards

Question

What are the diagnosis differentials in OM?

Answer 1

Soft tissue infection (Cellulitis and erysipelas) Charcot joint Avascular necrosis of bone = Causes: steroid, radiation, or bisphosphonate use. Gout = uric acid crystals in joint fluid / more acute presentation Fracture Bursitis Malignancy

Answer 2

1. 6 weeks of flucloxacillin, possibly with rifampicin or fusidic acid added for the first 2 weeks 2. Clindamycin if penicillin allergy 3. Vancomycin in MRSA Chronic requires 3 months of antibiotics

Answer 3

1. Surgical Debridement Hardware placement or removal 2. Antimicrobial therapy Initial broad spectrum empirical therapy “start SMART” - S. aureus or MRSA? - gram-negative organisms? - Special population: IVDU/HbSS? Tailored to culture and sensitivity findings - - “then FOCUS”. Bone penetration of drug Prolonged duration - unreliable antibiotic penetration into bone if vascular disease - shorter duration possible if all infected bone resected

Answer 4

- May be slower onset - Systemic symptoms - Epidemiology is different from pyogenic OM - Blood Culture less useful - Biopsy essential: prolonged mycobacterial culture Caseating Granolumata on histology Induced sputum may help (sometimes occult pulmonary TB) - Longer treatment 6 months (oral instead of IV)

Answer 5

Staphylococcus aureus, coagulase-negative staphylococci, aerobic gram-negative bacilli (30%) Others: Streptococci (skin, oral) Enterococci (bladder, bowel) Anaerobes (bowel) fungi, Mycobacterium tuberculosis

Answer 6

Acute changes: Inflammatory cells Oedema Vascular congestion Small vessel thrombosis Chronic changes: neutrophil exudates lymphocytes & histiocytes Necrotic bone ‘sequestra’ new bone formation ‘involucrum’

Answer 7

pain but few other signs

Answer 8

- Posterior extension - epidural and subdural abscesses or even meningitis. - Extension anteriorly or laterally can lead to paravertebral, retropharyngeal, mediastinal, subphrenic, retroperitoneal, or psoas abscesses

Answer 9

(can also present as septic arthritis.) when infection breaks through cortex resulting in discharge of pus into the joint (knee, hip, and shoulder). More common in infants due to patent transphyseal blood vessels and immature growth plate

Answer 10

Septic arthritis - if infection spreads to joints Growth disturbance in children and adolescents Amputations

Answer 11

staphylococcus aureus

Answer 12

double the dose

Answer 13

An infection of 1 or more joints caused by pathogenic inoculation of microbes. (infection within a joint)

Answer 14

- 2-8 cases in 100,000 more common in Rheumatoid arthritis M =F prosthetic joint infection > native joint infection

Answer 15

- joint inflammation occurs within disseminated gonococcal infection - affects multiple joints = polyarticular compared to septic - maculopapular = pustular rash

Answer 16

Any cause for bacteraemia Direct/ penetrating trauma Local skin breaks/ ulcers Damaged joints/ undelrying joint disease IV drug user prosthetic joint Immunosuppression (including steroids only) Elderly Rheumatoid arthritis (or other immune-driven disease) Diabetes

Answer 17

Painful, red, swollen, hot joint Remember children may just not use it Fever 90% monoarthritis (So don’t rule out in polyarticular presentations) Knee > hip > shoulder

Answer 18

Aspirate and send fluid for culture

Answer 19

FBC Elevated CRP and ESR Blood cultures Plain x-ray

Answer 20

Knee - normally only one joint is affected

Answer 21

Kocher criteria a score of 2 suggests 40% likelihood and score of 3 suggest 93%

Answer 22

Empirical therapy = flucloxacillin plus rifampicin is first-line Penicillin allergy = clindamycin Suspected or confirmed MRSA = vancomycin Gonococcal arthritis or gram-negative infection = cefotaxime or ceftriaxone Continue for 3-6 weeks

Answer 23

Mortality from septic arthritis ranges from 10 to 20% with treatment,

Answer 24

Local = been there since surgery, symptoms occur quickly Haematogenous spread = takes longer to present

Answer 25

Aspiration - identifies organisms - must be done with patient off antibiotics for at least 2 weeks

Answer 26

- eradicate sepsis - relieve pain - restore function

Answer 27

1. Antibiotic suppression = will NOT eliminate sepsis 2. Debridement and retention of prosthesis = for acute infections 3. Excision arthroplasty = cutting tissue away within the joint to allow it to move again 4. One stage exchange arthroplasty = remove + add in new prothesis in same surgery 5. Two stage exchange arthroplasty = remove and wait to do reconstruction 6. Amputation

Answer 28

Propionibacteria - They are colonisers of humans from the above the waist - Can even be shed by blinking the eyes - Therefore may represent more of a threat in upper limb prostheses and Spines

Answer 29

1. Inflammatory arthritis: Rheumatoid arthritis Seronegative spondyloarthritis - Psoriatic - Ank Spond - Reactive Arthritis - Enteropathic – Crohns and Ulcerative Colitis related Crystal arthrits – gout and pseudogout 2. septic arthritis

Answer 30

- F>M - smokers - middle aged - family history

Answer 31

Symmetrical small joints, hands wrists feet Big joints involved later, bad prognostic sign if involved at presentation No spinal involvement

Answer 32

- Asymmetrical big joints, with spinal involvement - More common in men - Associated symptoms = Inflammatory bowel, or GI infection, eye inflammation and psoriasis - Nail involvement predicts arthritis in patients with psoriasis

Answer 33

RA like Distal interphalangeal involvement (OA more common) Mutilans - rare Dactylitis – sausage digit / toe Asymetrical large joints + spine CRP may not be significantly raised

Answer 34

An inflammatory arthritis associated with psoriasis. Can vary in severity from mild stiffening and soreness in the joint or the joint can be completely destroyed arthritis mutilans

Answer 35

10-20% and it usually occurs within 10 years of developing the skin change

Answer 36

It has a strong genetic component and although not fully understood the activation of CD8+ T cells is thought to play a crucial role

Answer 37

Joint tenderness and warmth Dactylitis: swelling of the whole digit (sausage fingers) Enthesitis: Inflammation of the tendons Plaques of psoriasis on the skin Pitting of the nails Onycholysis (separation of the nail from the nail bed)

Answer 38

Eye disease Aortitis Amyloidosis

Answer 39

not a single pattern of affected joints like osteoarthritis or rheumatoid: Symmetrical polyarthritis presents similarly to rheumatoid arthritis and is more common in women. The hands, wrists, ankles and DIP joints are affected. Asymmetrical pauciarthritis affecting mainly the digits (fingers and toes) and feet. Pauciarthritis describes when the arthritis only affects a few joints. Spondylitic pattern is more common in men.

Answer 40

PEST screening tool Patients are asked about: joint pain, swelling, nail pitting Can also use the CASPAR criteria

Answer 41

1. Periostitis- thickened and irregular outline of the bone 2. Ankylosis- where bones are joined together 3. Pencil-in-cup appearance- the classic x-ray change to the digits is the “pencil-in-cup appearance”. - central erosions of the bone beside the joints - appearance of one bone in the joint being hollow and looking like a cup whilst the other is narrow and sits in the cup.

Answer 42

Typically acute intermittent episodes joint inflammation 1. Gout (6x more common in men = MC type) feet, ankles, knees, elbows, hands Hyperuricaemia Risks – beer, renal impairment, diuretics, aspirin, FH (affect how kidney deals with uric acid) 2. Pseudogout – 3 x more common in women calcium pyrophosphate crystals deposits wrists, knees, hands Typically on background of OA Chondrocalcinosis on xray

Answer 43

NOT INFLAMMATORY (would be sudden onset) Usually slow onset – months to years Typically weight bearing joints DIPs, PIPs, thumb bases, big toes Minimal early morning stiffness (gelling) No variability to joint swelling Normal CRP Clear changes on xray

Answer 44

Inflammatory - happen at any age - rapid onset - symmetrical - small joints of hand and feet - stiffness worse in mornings - fatigue, fever, night sweats Osteoarthritis: - later in life - slow onset, years - initially asymmetrical, polyarthritis - weight bearing joints - stiffness <1 hour + worse at end of day

Answer 45

A type of crystal arthritis which is associated with chronically high levels of uric acid. Urate crystals are deposited in the joint causing it to become hot swollen and painful

Answer 46

Normal - as the uric acid is in the joints not the blood - if measured when not having a flareup then the uric acid levels would be high

Answer 47

1. Uric acid formed as a breakdown product of purines 2. uric acid has a limited solubility in the blood and when there is too much uric acid it can become a urate ion and bind to sodium 3. this forms urate crystals which deposit in areas with slow blood flow the joints and kidney tubules 4. The immunological reaction initiated to try and remove them, leads to acute pain and swelling ( Only ‘Curable’ form of inflammatory arthritis)

Answer 48

- beer - diet = red meat, shellfish, offal, purine rich - sweetened soft drinks (fructose shares renal uric acid transporter) - conditions leading to increased cell turnover (haematological malignancy + psoriasis)

Answer 49

Beer / lager / stout equally bad All rich in guanosine and then converted into uric acid Small increased risk with spirits No increased risk with wine

Answer 50

- Renal impairment (any cause) - Drugs: Low dose aspirin reduces renal clearance by 10% Diuretics – worse with higher dose Cyclosporin, TB drugs, theophyllines Genetics – affects renal clearance of uric acid Fructose – shares renal uric acid transporter

Answer 51

Sudden acute swollen big toe

Answer 52

Renal impairment Beer Diuretics Aspirin Family History Fructose

Answer 53

1st MTPJ 90% Midfoot, ankle, knee, wrist, elbow hand Periarticular involvement - Olecranon bursitis Systemic features can occur

Answer 54

FBC (expect raised WCC) U+E LFT if concern re alcohol Serum Uric Acid (often normal during acute attack) CRP Joint aspiration (to exclude septic arthritis) Xray if recurrent episodes or concern re sepsis

Answer 55

 asymptomatic hyperuricemia,  acute/recurrent gout,  intercritical gout,  chronic tophaceous (uric acid deposits in the skin) gout

Answer 56

Joint space maintained Lytic lesions Punched out erosions Sclerotic borders with overhanging edges

Answer 57

1. NSAID (short course) - unless Renal failure, Peptic Ulcer Disease, Some pts with asthma 2. Colchicine - 500ug 2-3 times daily 3. Corticosteroids - Intra-articular, Oral - low dose (5-10mg short course) Other analgesics don’t work!! (as don't deal with inflammation) 4. advice about lifestyle 5. ensure patient knows to return if further attacks

Answer 58

Indication: 1. Recurrent attacks 2. Evidence of tophi or chronic gouty arthritis 3. Associated renal disease 4. Normal serum Uric acid cannot be achieved by life-style modifications Medication: 1. Allopurinol – Xanthine Oxidase Inhibitor 2. Febuxostat – more potent Xanthine Oxidase Inhibitor 3. Benzbromarone / Probencid – if allergic / intollerant

Answer 59

Aim of chronic gout management is to reduce Uric acid below <300 umol/l - Start at 100mg allopurinol and increase every 2-4 weeks until target met. - Engage patient in this – more likely to comply and make lifestyle modification

Answer 60

Lifestyle management and a Xanthine oxidase inhibitor First-line Allopurinol Second-line Febuxostat

Answer 61

Disability and misery Tophi (punched out erosions) Renal disease: Calculi 10 -15% Chronic urate nephropathy Acute urate nephropathy (cytotoxics)

Answer 62

Is a form of inflammatory arthritis caused by the deposition of calcium pyrophosphate crystals in the synovium

Answer 63

Hyperparathyroidism Hemochromatosis Hypomagnesaemia Hypophosphatemia Wilson’s disease Acromegaly

Answer 64

Deposition of calcium pyrophosphate triggers synovitis with the knee, shoulder and wrist most commonly being affected Can be acute or chronic

Answer 65

No bacterial growth Calcium pyrophosphate crystals Rhomboid shaped needles Positive birefringent of polarised light

Answer 66

Chondrocalcinosis is the classic x-ray change in pseudogout. It appears as a thin white line in the middle of the joint space caused by the calcium deposition. This is pathognomonic (diagnostic) of pseudogout.

Answer 67

only 6 months after onset would you see an abnormal X-ray

Answer 68

if treated within 'window of opportunity' can control disease and prevent damage

Answer 69

Pain and Swelling of joints = typically small joints hands, wrists, forefeet Early morning stiffness (often prolonged) Sudden change in function Intermittent, Migratory or Additive involvement

Answer 70

- Z shaped deformity to the thumb - Swan neck deformity - Boutonnieres deformity- due to a tear in the central slip of the extensor components of the finger. This means when they try to straighten their finger it cause it to bend and flex - Ulnar deviation of the fingers at the knuckles

Answer 71

Pulmonary fibrosis Anaemia Cardiovascular disease - pericardial effusion Amyloidosis Bronchiolitis obliterans (inflammation causing small airway destruction** Felty’s syndrome (RA, neutropenia and splenomegaly) Sjogren’s syndrome Subcutaneous nodules Peripheral sensory neuropathy Episcleritis (redness + pain of sclera)

Answer 72

- struggle to form a fist - doesn't involved DIP joint - symmetrical - deformity unusual at presentation

Answer 73

CRP (+/- ESR) raised Rheumatoid Factor - Falsely positive in 10-15% population - 70% of patients with RA are positive Anti-CCP (cyclic citrullinated peptide) - Almost never falsely positive - 70% of patients with RA are positive - Selects the subset of patients with most aggressive disease Joint X-rays

Answer 74

- to suppress inflammation as completely and quickly as possible once diagnosis confirmed without making our patients ill - Improve symptoms, prevent/reduce damage, prevent premature mortality

Answer 75

Comes from the American college of rheumatology 1. The joints involved (more and smaller joints score higher) 2. Serology 3. Inflammatory markers 4. Duration of symptoms longer or less than 6 weeks Score is added up and a score of greater than 6 indicates rheumatoid arthritis

Answer 76

younger onset Male Presence of RF and anti-CCG

Answer 77

1. DMARD treatment = methotrexate, sulphasalazine, leflunomide, hydroxychloroquine 2. referral to physio, OT 3. escalate to biologic treatment if resistant disease e.g. anti-TNF, rituximab, JAK inhibitors

Answer 78

Any one of methotrexate, leflunomide or sulfasalazine

Answer 79

Two of methotrexate, leflunomide or sulfasalazine

Answer 80

Methotrexate plus a TNF inhibitor e.g., infliximab

Answer 81

Methotrexate plus rituximab (monoclonal antibody)

Answer 82

(DMARD) - competitively inhibits dihydrofolate reductase > inhibits folate synthesis - 100,000 times greater affinity than dihydrofolate (Must give 5mg of Folic Acid ONCE weekly not on the same day as Methotrexate)

Answer 83

CRP levels and DAS28

Answer 84

Accelerated atherosclerosis leading to cardiovascular disease

Answer 85

1. Environmental triggers cause modification of self-antigens e.g., arginine is converted to citrulline in type 2 collagen. 2. Due to susceptibility due to genes the immune cells cannot differentiate between self and non-self antigen. 3. This causes an inflammatory response and cytokines Interferon gamma, IL-17, TNF, Il-1 and IL6 are secreted 4. This creates a pannus (thick synovial membrane). This damages the cartilage, soft tissue and bones. The cytokines can also escape and affect multiple organ systems

Answer 86

1. Rheumatoid factor = - 70% of patients with rheumatoid arthritis. - It targets the Fc portion of the IgG antibody. - This causes activation of the immune system against own IgG antibodies. - RF is mainly IgM antibodies 2. Cyclic citrullinated peptide antibodies (anti-CCP antibodies) = - target citrullinated proteins. - This forms immune complexes which can accumulate and activate the complement system. - Often found before development of rheumatoid arthritis

Answer 87

Symmetrical polyarthritis: (on both sides of body) Pain, swelling and stiffness in the small joints of the hands and feet. The onset can be rapid or over months to years

Answer 88

usually helpful for most inflammatory causes of pain

Answer 89

crystal arthritis

Answer 90

1. inherited - Marfans' syndrome - Ehler Danlos syndrome (super stretchy skin + hypermobile joints) 2. autoimmune - SLE - Sjogren's syndrome - systemic sclerosis - dermatomyositis

Answer 91

Pathology: inflammation leading to scarring in organs affected - can lead to organ failure - any system can be affected

Answer 92

Afro-Carribean and Asian Women (14-64 years) Genetic association: HLA DR2/DR3, C4 A null allele (low C4)

Answer 93

Is a chronic systemic autoimmune condition (type III hypersensitivity) due to a complex interplay between genetic and environmental factors. It often takes a relapsing-remitting course. This results in chronic inflammation

Answer 94

It refers to the typical red malar rash that occurs across the face. It is more common in women and Asians

Answer 95

Cardiovascular disease Infections

Answer 96

UV light Smoking EBV Sex hormones

Answer 97

1. Environmental triggers e.g., UV light causes cell death. Due to genetic factors there is reduced clearance of these cellular debris 2. genetics - play a further role as the immune system of these patients do not recognise the cellular debris as self so they attack them forming antibody-antigen complexes which get deposited in different tissues activating the complement pathway (type III hypersensitivity)

Answer 98

Anti-nuclear antibodies

Answer 99

Fatigue Weight loss Joint and muscle pain Fever Photosensitive malar rash. Get’s worse with sunlight and is butterfly shaped across the cheeks Hair loss Mouth ulcers Shortness of breath

Answer 100

Antibodies FBC will show anaemia of chronic disease C3 and C4 levels will be low Increased CRP and ESR Renal biopsy to asses for lupus nephritis

Answer 101

1. Anti-nuclear antibodies (ANA): - 85% positive - The initial step in testing for SLE. - Antinuclear antibodies can be positive in healthy patients and with other conditions (e.g. hepatitis). 2. Anti-double stranded DNA (anti-dsDNA): - is specific to SLE, meaning patients without the condition are very unlikely to have these antibodies. - 70% of patients

Answer 102

CVD Infections Pericarditis Lupus nephritis Recurrent miscarriage

Answer 103

NSAIDs Steroids (prednisolone) Anti-malarials = Hydroxychloroquine first line for mild Topical = Sun cream for malar rash

Answer 104

Rituximab = targets B cells Belimumab = targets B-cell activating factor

Answer 105

- blood vessels go into a temporary spasm - block blood flow - affected area goes to white, then blue and then red as the bloodflow returns

Answer 106

An autoimmune inflammatory and fibrotic connective tissue disease. It affects the skin in all areas and also the internal organs

Answer 107

1. Limited cutaneous systemic sclerosis 2. Diffuse cutaneous systemic sclerosis

Answer 108

Used to be called CREST syndrome. (sleroderma) C- calcinosis R- Raynaud’s phenomenon E- oEsophageal dysmotility S- Sclerodactyly (tightening of skin) T- Telangiectasia (spider veins)

Answer 109

Includes the CREST symptoms but also has systemic features Cardiovascular e.g., CAD and hypertension- Lung problems e.g., pulmonary hypertension and fibrosis Kidney problems causes glomerulonephritis and a condition called scleroderma renal crisis

Answer 110

Telangiectasia are dilated small blood vessels in the skin. They are tiny veins that have dilated. They have a fine, thready appearance.

Answer 111

Oesophageal dysmotility is caused by connective tissue dysfunction in the oesophagus. This is commonly associated with swallowing difficulties, acid reflux and oesophagitis

Answer 112

An acute condition where there is a combination of severe hypertension and renal failure.

Answer 113

1. Antinuclear antibodies (ANA) = positive in most 2. Anti-centromere antibodies = most associated with limited cutaneous systemic sclerosis. 3. Anti-Scl-70 antibodies = most associated with diffuse cutaneous systemic sclerosis. They are associated with more severe disease.

Answer 114

Nailfold capillaroscopy- examines the health of the peripheral capillaries. micro-haemorrhages indicate systemic sclerosis

Answer 115

Nifedipine

Answer 116

muscle and skin affected - rash + muscle weakness - no cure but treatment to reduce symptoms

Answer 117

Giant cell arteritis = large vessel Polyarteritis nodosa = medium vessel ANCA associated vasculitis (includes granlomatosis + eosinophilic granulomatosis w/ polyangitis) = small vessels

Answer 118

1. Primary (idiopathic autoimmune) or secondary (drugs, infection) trigger 2. activate immune cells infiltrate into vessel wall 3. direct damage stimulates vascular smooth muscle remodelling 4. leads to ischaemia, infarction, aneurysm

Answer 119

1. by vessel size 2. Consensus classification (Chapel-Hill) = hybrid of vessel size, pathophysiology + underlying cause

Answer 120

A disorder associated with antiphospholipid antibodies where the blood becomes prone to clotting as the patient is in a hypercoagulable state. It presents with a variety of clinical features characterised by thromboses and pregnancy related morbidity

Answer 121

Systemic lupus erythematous in 20-30% of cases

Answer 122

Antiphospholipid antibodies can cause thrombosis by binding to the phospholipid on the surface of cells such as endothelial cells, platelets and monocytes. Once they bind to these cells it can result in thrombosis formation and/or miscarriage. They tend to affect cerebral and renal vessels

Answer 123

C- Coagulation defects L- livedo reticularis - lace-like purplish discolouration of skin O- Obstetric issues e.g., miscarriage T- Thrombocytopenia (low platelets) CLOT

Answer 124

Stroke MI Renal thrombosis

Answer 125

Recurrent miscarriage Still birth Preeclampsia

Answer 126

Libmann-Sacks endocarditis: - is a type of non-bacterial endocarditis - growths (vegetations) on the valves of the heart. - The mitral valve is affected. It is associated with SLE and antiphospholipid syndrome.

Answer 127

Libmann-Sacks endocarditis: - is a type of non-bacterial endocarditis - growths (vegetations) on the valves of the heart. - The mitral valve is MC affected. It is associated with SLE and antiphospholipid syndrome.

Answer 128

Diagnosis would be made when there is a history of thrombosis or pregnancy related complications plus the presence of: Lupus anticoagulant antibodies Anticardiolipin antibodies Anti-beta-2 glycoprotein I antibodies The presence of them needs to be persistent positive test more than 12 weeks apart --

Answer 129

Long term warfarin with an INR range of 2-3 Pregnant women are put on low molecular weight heparin plus aspirin

Answer 130

Autoimmune disorders where there is inflammation in the muscles. Polymyositis refers to chronic inflammation of the muscles. Dermatomyositis is a connective tissue disorder where there is chronic inflammation of the skin and muscles

Answer 131

The creatine kinase blood test. It is an enzyme that is found inside muscle. Inflammation of the muscles can lead to the release of it.

Answer 132

Rhabdomyolysis Acute kidney injury Myocardial infarction Statins Strenuous exercise

Answer 133

They can be caused by an underlying malignancy. This makes them paraneoplastic syndromes

Answer 134

Lung Breast Ovarian Gastric

Answer 135

Muscle pain, fatigue and weakness Occurs bilaterally and typically affects the proximal muscles Mostly affects the Shoulder and pelvic girdle Develops over weeks

Answer 136

Polymyositis occurs without skin features Gottron lesions (erythematous macules over elbows/knees) Photosensitive rash on back shoulders and neck Purple rash on face and eyelids Periorbital oedema Subcutaneous calcinosis

Answer 137

Anti-Mi-2 antibodies Anti-nuclear antibodies

Answer 138

Clinical presentation Elevated creatine kinase levels Autoantibodies

Answer 139

Muscle biopsy

Answer 140

Patients should be assessed for underlying cancer Corticosteroids are first line Then immunosuppressants Then infliximab

Answer 141

Osteoporosis is a condition where there is a reduction in the density of the bones. Osteopenia refers to a less severe reduction in bone density than osteoporosis. Reduced bone density makes bone less strong and more prone to fractures.

Answer 142

Primary disease Malignancy Endocrine dysfunction COPD IBD CLD CKD Reduced skeletal loading = if skeleton not being used it will increase bone resorption

Answer 143

S- Steroid use (can increase cortisol = ⬆️ bone resorption + osteoblast apoptosis) H- Hyperthyroidism, hyperparathyroidism (⬆bone turnover) A- Alcohol and tobacco use (poisons osteoblasts) T- Thin = not exercising/using skeleton enough T- Testosterone decrease E- early menopause- oestrogen is protective R- renal or liver failure E- Erosive/inflammatory bone disease D- dietary e.g., reduced Ca2+, malabsorption, diabetes

Answer 144

Osteoclasts are responsible for the breakdown of bone and osteoblasts are responsible for the formation. As we age osteoclast activity is increased however this is not matched by osteoblast activity The peak mass we reach as young adults is key a higher peak bone mass can be protective

Answer 145

Reduced bone strength + fall = fracture reduced bone strength caused by: - reduced bone mineral density - reduced bone quality (reduced bone turnover + architecture)

Answer 146

Oestrogen deficiency leads to an increased rate of bone loss. It is key to the activity of bone cell receptors found on osteoblasts, osteocytes, and osteoclasts. It is thought that osteoclasts survive longer in the absence of oestrogen and there is an arrest of osteoblastic synthetic architecture resorption > formation

Answer 147

- They cause an increased turnover of bone. - Prolonged use can result in reduced turnover state however the synthesis is affected resulting in bone mass reduction

Answer 148

Decrease in trabecular thickness, more pronounced for non load-bearing horizontal trabeculae * Decrease in connections between horizontal trabeculae (falls put more strain on vertical so preserve vertical connections more) * Decrease in trabecular strength and increased susceptibility to fracture

Answer 149

There is an increased frequency of fractures. The most common ones include, vertebral crush fracture, and those of the distal wrist (Colles’ fracture) and proximal femur

Answer 150

It gives a prediction of the risk of a fragility fracture over the next 10 years It involves the inputting of information such as age, BMI, co-morbidities, smoking, family history and if done you can enter a bone mineral score from a DEXA scan

Answer 151

It gives the result as a percentage probability of a: Major osteoporotic fracture Hip fracture

Answer 152

20% die within one year of post hip fracture - usually in elderly so makes them very immobile

Answer 153

It stands for dual-energy x-ray absorptiometry. - low radiation dose It assess how much radiation is absorbed by the bones indicating how dense the bone is. - measures important fracture sites The measurement is usually taken from the Hip (lumbar spine, proximal femur + distal radius MC)

Answer 154

T-score: represents the number of standard deviations compared with the mean for a healthy young adult Z-score: represents the number of standard deviations the bone density falls below a person for their age T-score is more relevant

Answer 155

More than -1 = Normal -1 to -2.5 = Osteopenia Less than -2.5 = Osteoporosis Less than -2.5 plus a fracture = Severe Osteoporosis

Answer 156

Low risk- reassure Medium risk- offer DEXA scan and recalculate the risk with the results High risk: offer treatment

Answer 157

- Activty and exercise - Weight control - Reduce alcohol/stop smoking - calcium supplementation with vitamin D = in patients at risk of fragility fractures with an inadequate intake of calcium. (An example of this would be Calcichew-D3, which contains 1000mg of calcium and 800 units of vitamin D (colecalciferol).) Patients with an adequate calcium intake but lacking sun exposure should have vitamin D supplementation.

Answer 158

1. Bisphosphonates - they interfere with osteoclast activity reducing their activity E.g. Alendronate 70mg once weekly Riseronate 35mg once weekly Zoledronic acid 5 mg once yearly (intravenous)

Answer 159

HMG-CoA pathway same as statins but a different part of it

Answer 160

Reflux and oesophageal erosions. They are taken 30 minuets before food to prevent this Osteonecrosis of the jaw and external auditory canal

Answer 161

Denosumab = is a monoclonal antibody that works by blocking the activity of osteoclasts. - rebound increase of bon turnover when stopped, making bones even weaker than before Strontium ranelate = is a similar element to calcium that stimulates osteoblasts and blocks osteoclasts but increases the risk of DVT, PE and myocardial infarction. Raloxifene = is used as secondary prevention only. It is a selective oestrogen receptor modulator that stimulates oestrogen receptors on bone but blocks them in the breasts and uterus. Hormone replacement therapy = should be considered in women that go through menopause early.

Answer 162

Teriparatide - increase bon density + improves trabecular structure - very expensive

Answer 163

Low risk patients should have a follow up within 5 years Patients being treated should have a repeat FRAX and DEXA after 3-5 years and a treatment holiday if BMD has improved (this is 18months to 3 years of treatment before a repeat assessment)

Answer 164

Progressive synovial joint damage resulting in structural changes, pain and reduced function

Answer 165

More common in women Most common form of arthritis 8.75 million people over 45 with it in the UK

Answer 166

Age high BMI Joint injury or trauma Excessive stress for exercise or certain occupations

Answer 167

COL2A1- collagen type 2 gene

Answer 168

It is classified as non-inflammatory however inflammatory mediators play a role as inflammatory cytokines interrupt the normal repair of cartilage damage. Cartilage is lost and joint space narrows this causes bone on bone interaction.

Answer 169

Metalloproteinases = secreted by chondrocytes degrade the collagen and proteoglycan IL-1 and TNF-alpha = stimulate metalloproteinase production and inhibit collagen production Deficiency in growth factors such as insulin-like growth factor impairs matrix repair Gene susceptibility has a 35-60% influence

Answer 170

Knees Hips Sacro-ileac joints Cervical spine Wrist base of thumb (carpometacarpal) finger joints (interphalangeal)

Answer 171

Heberden’s nodes = swelling in the distal interphalangeal joints Bouchard’s nodes = swelling in the proximal interphalangeal joint Weak grip Reduced range of motion

Answer 172

Joint pain Mechanical locking giving way Crepitus - crunching sensation when moving joint

Answer 173

If someone is over 45 and has typical activity related pain with no morning stiffness or stiffness lasting less than 30 minuets

Answer 174

L- Loss of joint space O- Osteophytes S- Subchondral sclerosis increased density of bone along the joint line S- Subchondral cysts (fluid filled holes in the bone)

Answer 175

Patient education lifestyle changes such as weight loss and physiotherapy Oral paracetamol and topical NSAIDs or topical capsaicin (chilli pepper extract - reduce substance P, pain transmitter to nerves) Intra-articular steroid injection (don’t use these I’ve had loads and they destroy your joint even more) Joint replacement

Answer 176

A chronic systemic inflammatory disease. It leads to a deforming and symmetrical inflammatory arthritis of the small joints which progress to involve larger joint and other organs such as the skin and lungs

Answer 177

HLA-DR1 HLA-DR4 They are both crucial in activating T-cells

Answer 178

Smoking Other pathogens e.g., bacteria

Answer 179

A group of related chronic inflammatory conditions. They tend to affect the axial Skelton adn share similar clinical features.

Answer 180

Rheumatoid factor negative HLA-B27 positive Pathology in the spine Asymmetrical inflammation of an entire joints = Sausage fingers Extra-articular manifestations

Answer 181

S- Sausage digit P- Psoriasis I- inflammatory back pain N- NSAIDs illicit a good response E- Enthesitis inflammation where tendon meets joint (plantar fasciitis) A- Arthritis C- Crohn’s/colitis/CRP H- HLA-B27 E- eye uveitis

Answer 182

A chronic progressive inflammatory arthropathy. It mainly affects the spine and cause progressive stiffness and pain. Ankylosis= abnormal stiffening and immobility of a joint due to the fusion of a bone

Answer 183

More common in males Most commonly presents in teens/20s Women present later and are underdiagnosed 90% are HLA-B27 positive

Answer 184

There is lymphocyte and plasma infiltration with local erosion of bone at the attachments of the intervertebral and other ligaments. Inflammation of these tendons/ligaments when they heal they heal with new bone formation

Answer 185

Symptoms tend to occur gradually over 3 months -Lower back pain stiffness and sacroiliac pain in the buttock region. The pain and stiffness is worse with rest and improves with movement it is worse at night and morning and improves throughout the day

Answer 186

Weight loss and fatigue Chest pain Anaemia Heart block Pulmonary fibrosis Aortitis inflammation of the aorta Note that any of the SPINEACHE symptoms may be present

Answer 187

FBC normocytic anaemia CRP and ESR elevated Genetic testing for HLA-B27 X-ray (MRI if x-ray of the spine is normal may show bone marrow oedema)

Answer 188

1. Bamboo spine- calcification of ligaments 2. Syndesmophytes - areas of boney growth where the ligament normally inserts into the bone. 3. Ossification - structures such as ligaments turn into bone like tissue 4. Fusion - seen in facet joints, sacroiliac joints and costovertebral joints

Answer 189

Schober’s test

Answer 190

Have the patient stand straight. Find the L5 vertebrae. Mark a point 10cm above and 5cm below this point (15cm apart from each other). Then ask the patient to bend forward as far as they can and measure the distance between the points. If the distance with them bending forwards is less than 20cm, this indicates a restriction in lumbar movement and will help support a diagnosis of ankylosing spondylitis.

Answer 191

NSAIDs Steroids TNF-alpha infliximab Monoclonal antibodies targeting IL-7 (secukinumab)

Answer 192

Vertebral fractures Osteoporosis Aortitis Restrictive lung disease Heart block

Answer 193

It refers to synovitis occurring due to a recent infective trigger. This is an autoimmune response to infection elsewhere in the body

Answer 194

30-50 fold increase if someone is HLA-B27 positive Women less commonly affected Mainly occurs in adults

Answer 195

Gastroenteritis- Salmonella, shigella Sexually transmitted disease- chlamydia, Gonorrhoea

Answer 196

Immune system is responding to the recent infection. This results in antibodies and inflammation that also affect the joints It presents a lot like septic arthritis without infection at site of the bone it is somewhere else in the body

Answer 197

Acute, asymmetrical monoarthritis typically in lower leg (knee). Can also present with triad of: Urethritis, arthritis and conjunctivitis Can’t see, pee or climb a tree

Answer 198

Iritis - swelling and irritation of eye Keratoderma blennorrhagia - painless, red, raised plaques and pustules Circinate balanitis - dermatitis of the head of the penis -Mouth ulcers

Answer 199

Aspirate joints to rule out septic arthritis/Gout Infectious serology Sexual health review/ask about diarrhoea if present do a stool sample

Answer 200

If patient presents with acute, warm, swollen and painful joint - Hot joint policy - presume patient has septic arthritis until its excluded = Antibiotics = Aspirate joint - MCS & crystal examination

Answer 201

Most cases resolve within 6 months

Answer 202

Widespread chronic pain

Answer 203

female Middle age Genetics Environmental e.g., child abuse, low household income divorced

Answer 204

It is a problem with how the brain receives pain signals. Most patients have low levels of serotonin which is involved in inhibiting pain signals and elevated levels of substance P which increase pain signals This together is though to paly a role in the hypersensitivity towards pain. Therefore the patient may perceive pain more readily compared to other people. The pain can be affected by lots of things e.g., sleep and emotions

Answer 205

Allodynia- pain in response to non-painful stimuli Hyperaesthesia- exaggerated perception of pain to mild stimuli

Answer 206

Widespread pain that is aggravated by stress, cold and activity Extreme tiredness Sleep disturbance Low mood Poor concentration and headaches

Answer 207

- Chronic pain that has been present for at least 3 months - Widespread pain - involved left and right sides, above and below waist, and the axial skeleton. - Palpate tender point sites - severe pain in 3 to 6 different areas of your body, or you have milder pain in 7 or more different areas - No other reason for symptoms has been found ALL INVESTIGATIONS WILL BE NORMAL

Answer 208

Rheumatoid arthritis Chronic fatigue Hypothyroidism SLE Polymyalgia rheumatica (PMR) High calcium Low vitamin D Inflammatory arthritis

Answer 209

- Amitriptyline - tricyclic antidepressant - Serotonin-norepinephrinereuptake inhibitors (SNRIs) e.g. duloxetine Help by elevating serotonin and norepinephrine levels. - Anticonvulsants like pregabalin and gabapentinwhich slow nerve impulses can help with sleep problems.

Answer 210

An autoimmune condition that affects the exocrine glands. It leads to symptoms such as dry mouth, eyes and vagina

Answer 211

Primary SS: where the condition occurs in isolation Secondary SS; where the condition occurs with SLE or rheumatoid arthritis

Answer 212

Hepatitis PBC Graves’ disease Antiphospholipid syndrome

Answer 213

Anti-Ro Anti-La

Answer 214

Involves inserting a folded piece of filter paper under the lower eyelid with a strip hanging out over the eyelid This is left for 5 minuets and the distance travelled along the strip is measured. Anything less than 10mm is significant

Answer 215

Eye infections Oral problems such as cavities and candida infections Vaginal problems such as candidiasis and sexual dysfunction

Answer 216

Pneumonia and bronchiectasis Non-Hodgkin’s lymphoma Peripheral neuropathy Vasculitis Renal impairment

Answer 217

Artificial tears Artificial saliva Vaginal lubricants Hydroxychloroquine is used to halt the progression of the disease.

Answer 218

Inflammation of a blood vessel. It is characterised by the presence of an inflammatory infiltrate and destruction of vessel walls

Answer 219

Giant cell arteritis Takayasu’s arteritis

Answer 220

Polyarteritis nodosa Kawasaki disease

Answer 221

Microscopic polyangiitis Wegener’s granulomatosis Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss syndrome)

Answer 222

Henoch-schonlein purpura

Answer 223

Anti neutrophil cytoplasmic antibodies (ANCA) There are two types of blood test p-ANCA (anti-MPO) and c-ANCA (anti-PR3). p-ANCA are positive in: Microscopic polyangiitis and Churg-Strauss syndrome c-ANCA are positive in Granulomatosis with polyangiitis

Answer 224

It is vasculitis of the medium and large arteries. It is the most common form of systemic vasculitis that affects and adults. It usually affects branches of the carotid artery

Answer 225

Age usually over 50 Female Caucasians Polymyalgia rheumatica associated in 50% of cases

Answer 226

It is a granulomatous vasculitis. Arteries become inflamed and thickened and there is a narrowed vascular lumen and can obstruct blood flow. Cerebral arteries are particularly affected.: - Superficial temporal: headache and scalp tenderness - Mandibular: Jaw claudication - Ophthalmic artery: visual loss due to retinal ischaemia

Answer 227

Superficial temporal artery tenderness Absent temporal pulse Reduced visual activity

Answer 228

Main symptom is headache that us unilateral and around forehead and temple. Irreversible painless complete sight loss Jaw claudication Scalp tenderness may be noticed when brushing hair

Answer 229

Fever Muscle aches Fatigue Weight loss Loss of appetite Peripheral oedema

Answer 230

ESR a value of greater than 50mm/h makes up 1 of the 5 criteria Definitive diagnosis- is made doing a temporal artery biopsy: - presence of Multinucleated giant cells. (negative results don’t rule out GCA due to presence of skip lesions)

Answer 231

Corticosteroids 40-60mg IV methylprednisolone Oral aspirin to prevent ischaemic cranial complications

Answer 232

Aortic aneurysms Glucocorticoid toxicity Vision loss Cerebrovascular accident

Answer 233

- Once the diagnosis is confirmed they will need to continue high dose steroids (40-60mg) until the symptoms have resolved. - They then need to slowly wean off the steroids. - This can take several years. This is a similar process to managing polymyalgia rheumatica.

Answer 234

A multi-system disorder of unknown cause characterised by necrotising granulomatous inflammation

Answer 235

B-cells mistakenly target their antibodies to granules made by a person’s own neutrophils. These are ‘cytoplasmic anti-neutrophilic cytoplasmic antibodies’ or c-ANCAs. Once they are bound to the neutrophil it causes free radical release which damages nearby cells

Answer 236

It affects the respiratory tract and the kidneys. Nose bleeds Sinusitis Crusty nail secretions Saddle shaped nose Cough Wheeze Haemoptysis glomerulonephritis

Answer 237

Steroids combined with cyclophosphamide Methotrexate and azathioprine usually used for maintenance

Answer 238

Polyarteritis nodosa (PAN) is a medium vessel vasculitis. It is most associated with hepatitis B but can also occur without a clear cause or with hepatitis C and HIV. It affects the medium sized vessels in locations such as the skin, gastrointestinal tract, kidneys and heart. This can cause renal impairment, strokes and myocardial infarction. It is associated with a rash called livedo reticularis. This is a mottled, purplish, lace like rash.

Answer 239

Eosinophilic granulomatosis with polyangiitis used to be called Churg-Strauss syndrome and is still often referred to by this name. It is a small and medium vessel vasculitis. It is most associated with lung and skin problems, but can affect other organs such as kidneys. It often presents with severe asthma in late teenage years or adulthood. A characteristic finding is elevated eosinophil levels on the full blood count.

Answer 240

a central area of fibrinoid necrosis surrounded by a palisade layer of histiocytes and peripherally by a zone of loose connective tissue

Answer 241

Dairy products increase excretion of uric acid by the kidneys

Answer 242

RA = shape change and bone erosions SLE = shape change but no erosions so hands can be pushed back into normal position

Answer 243

OA LOSS - loss of joint space - osteophytes (bony lumps) - subchondral sclerosis - subchondral cysts RA LESS - loss of joint space - eroded bone - soft tissue swelling (subcutaneous nodules) - soft bone (osteopenia)

Answer 244

anti-malarials = hydroxychloroquine

Answer 245

Coagulase negative staphylococcus

Answer 246

Pain across the costochrondral joints

Answer 247

HLA-DR4 = RA HLA-DR7 = phospholipid syndrome HLA-DR2 = SLE HLA-DR5 = RA HLA-DR8 = ankylosing spondylitis

Answer 248

Scabies is a parasitic skin infection characterized by superficail burrows, intense pruritis and secondary infections

Answer 249

Sarcoptes Scabiei - transmitted by skin to skin contact

Answer 250

Pruritis burrows papules - found on flexor surfaces of wrist, finger webs, elbows, axillary folds, areola of breast in women and genital of males scabies dig into skin at skin folds

Answer 251

1st: Permethrin 5% 2nd: Malathion 0.5% Close contacts: treated same way even if asymptomatic

Answer 252

- xanthine oxidase inhibitor - xanthine oxidase metabolises xanthine into uric acid - lowers plasma uric and precipitation of uric acid in joints

Musculoskeletal & Rheumatology Flashcards

(280 cards)