Yr4 MSK - Lectures Flashcards

Question

What is Pyrophosphate Arthropathy?

Answer 1

**Pyrophosphate Arthropathy** - A chronic arthropathy in which the deposition of calcium pyrophosphate in the articular cartilage is considered pathogenic. - There may be a family history - up to 30% of cases are now thought to be heritable. - Like gout it may present in an acute form, usually as a monoarthritis (pseudogout), generally affects large joints and is characterized by an intense synovitis, which may be accompanied by systemic symptoms and signs, such as fever, very rarely it may be migratory. - CPPD is rarely palpable in the soft tissues , unlike urate in gouty tophi - An example of pseudogout affecting the shoulder is shown in the next slide.

Answer 2

**Chondrocalcinosis** - Calcification in the articular cartilage or meniscal cartilage or fibrocartilage ( e.g. triangular ligament in the carpus) - Increases with age and very common in the elderly (affects approx. 30% of persons over 80 yrs). - Pseudogout or pyrophosphate arthropathy should be suspected if there is chondrocalcinosis in a symptomatic joint.

Answer 3

**One form of PPA is referred to as pseudorheumatoid pyrophosphate arthropathy** - Multiple affected joints - Often symmetrical joint involvement - Due to the pattern of joint involvement and the symmetry, it can be difficult to distinguish from RA - The presence of chondrocalcinosis in X-rays and CPPD crystals in joint tissue or aspirates is discriminatory. - An example is shown in the next slide.

Answer 4

**Arthroscopic appearance of CPPD deposits** - In some cases, CPPD can be seen in the articular cartilage. - It can be difficult to distinguish from Urate deposits. - Sometimes CPPD and Urate co-exist. - Biopsies of joint tissue should be placed in absolute alcohol (which preserves the crystalline material), NOT formalin. **Morphology of CPPD** - CPPD crystals are rhomboidal and are positively birefringent under polarized light. - Urate crystals in contrast are needle shaped and negatively birefringent under polarized light

Answer 5

**Gout** - Still the commonest inflammatory disease of the joints in men. - Affects 1.4% of the adult population in urban Australia and 4% of Aboriginal Australians. - Acute attacks may be infrequent in the “prodromal phase” of chronic and destructive gout. - 90% of attacks of gout are monoarticular and the MTP1 joint is most commonly affected. - Distal joints (e.g. IPs in fingers, IT and MTP joints in the feet) are much more often affected than proximal. - Prevalence in USA has doubled in the past 20 years – dietary factors may be highly important, especially in men (increased fructose intake).

Answer 6

**Risk Factors for Gout** **Natural** 1. Renal disease 2. Alcohol 3. Dietary fructose intake 4. High cell turnover e.g. leukaemia, lymphoma, psoriasis **Iatrogenic** 1. Chemotherapy 2. Diuretics 3. Low dose aspirin 4. Other drugs e.g. cyclosporin

Answer 7

**Laboratory Findings** - Identification of urate (sodium monourate or SMU) crystals either in an inflamed or uninflamed joint is diagnostic. - Serum urate can be misleading as it may fall during an acute attack and is not always elevated in between attacks. - An elevated serum urate does not confirm gout and a normal or low serum urate does not exclude it.

Answer 8

**Use of Imaging studies to diagnose gout** - **Plain X-rays** – have the capacity to identify gouty erosions - **US** - has the capacity to identify gouty erosions in multiple joints without use of ionising radiation - **MRI** – high sensitivity for gouty erosions and tophaceous deposits, also very useful for assessing the extent of gouty synovitis - **Dual energy CT** – capable of detecting urate deposits in joints and soft tissues, high sensitivity and specificty, exposure to moderate ionising radiation, may be pos. when aspirate reveals no crystals. Could be a game changer! A new imaging modality which has a high sensitivity for urate deposition (deposits shown in green). CPPD crystal deposits cannot be imaged with this methodology.

Answer 9

**Treatment of Gout** - For the acute attack, moderate to high dose short acting NSAIDs are best (eg Indocid 50 mg qid) together with immobilisation of the affected part) - Following the acute attack consider whether there are reversible factors eg excess alcohol, diuretics, inappropriate diet. - Check for renal disease

Answer 10

**Spondyloarthropathies** 1. Ankylosing spondylitis 2. Psoriatic arthritis 3. Reactive arthritis 4. Enteropathic arthritis 5. Undifferentiated spondyloarthritis **Characteristic features** 1. Enthesitis 2. Inflammatory back pain 3. Asymmetrical peripheral oligoarthritis 4. Dactylitis 5. Extra skeletal features 6. Association with HLA-B27

Answer 11

**Enthesis** - Site of attachment of ligament/ tendon into bone - Inflammation (enthesitis) = primary site of pathology in SpA - Affects the vertebrae, sacroiliac jts, peripheral joints - Leads to underlying bony reaction - Also manifest by Achilles tendonitis, plantar fasciitis

Answer 12

**Inflammatory Back Pain** 1. Morning stiffness >30 min 2. Improvement with exercise, Not with rest 3. Insidious onset 4. Onset <40yo 5. Persistence >3mon 6. Improvement with NSAIDs 7. Alternating buttock pain 8. Awakening in the second half of the night - Due to back/ buttock pain (Family history of SpA)

Answer 13

**Peripheral Arthritis** - Asymmetrical - Oligoarthritis < 4 joints - Lower limb - Knees, hips, ankles

Answer 14

**Ankylosing Spondylitis** **Epidemiology** - Prevalence ~ 1% - M:F 2.5:1 - 90% HLA-B27+ - Onset <45yo **Features** 1. Inflammatory back pain 2. Alternating buttock pain 3. Enthesitis, Oligoarthritis, Iritis/Colitis/Rash 4. (Cardiac disease, lung fibrosis) **Clinical Findings**: Limitation of spinal mobility - Modified Schober’s test, Occiput-to-wall, lumbar side flexion, chest expansion **Imaging** - Radiographic sacroiliitis - May lag 5-10 yrs after symptom onset - Spinal syndesmophytes - MRI - Enthesitis, bone marrow oedema, erosions, sclerosis

Answer 15

**Management** - Exercise & NSAIDs - For all! = May be enough - DMARDs if peripheral arthritis = Methotrexate, sulfasalazine - TNF inhibitors: Adalimumab, Etanercept, & Infliximab

Answer 16

**Psoriatic Arthritis** - Up to 30% of patients with psoriasis **Various joint patterns** - Asymmetrical LL oligoarthritis - Symmetrical polyarthritis - Spondylarthritis - 50% HLA-B27+ - DIP arthritis - Arthritis mutilans

Answer 17

**Clues** - Psoriasis! - Check extensor surfaces, scalp (postauricular), natal cleft, umbilicus - Family history - Nail changes - Pitting, ridging, onycholysis, hyperkeratosis - Dactylitis - X-ray changes = “Chunky” syndesmophytes & Osteolysis, new bone formation

Answer 18

**Overview** - Sterile peripheral arthritis - Within 1/12 of primary infection elsewhere - Developed countries - Urogenital infection = Chlamydia trachomatis - Returned travellers - Gastrointestinal infection = Salmonella, Shigella, Yersinia, Campylobacter **Pattern** = Usually an asymmetrical LL oligoarthritis - Often florid **Other features** 1. Urethritis / diarrhoea 2. Ocular inflammation 3. Enthesitis 4. Dactylitis 5. Mucocutaneous lesions

Answer 19

**Mechanical Back Pain** - Older age group - Gradual onset - Intermittent exacerbations - Worse in pm - Worse with activity - Can be stiff in am, 5-10 mins **Back Pain - Red Flags** 1. Sudden onset 2. Nocturnal pain - Wakes from sleep 3. Weight loss 4. Fevers, sweats 5. Neurological symptoms - Lower limb, sphincters 6. PHx of Cancer - X-ray, bone scan, other Ix (mammogram)

Answer 20

**Connective Tissue Diseases** 1. Systemic Lupus Erythematosus (SLE) - Anti-phospholipid syndrome 2. Scleroderma 3. Sjogren’s Syndrome 4. Inflammatory myopathies 5. Other - Mixed CTD, Vasculitis, Sarcoidosis

Answer 21

**SLE – Risk Factors** 1. Genetics - Twin studies o 25-50% concordance for monozygotic twins o 2-5 % for dizygotic twins 2. Susceptibility alleles - HLA-DR2, DR3 o RR 2-5x 3. Inherited complement deficiencies - C4a deficiency & C1q deficiency 4. Environment - Hormonal factors  No convincing increased risk with OCP - Smoking - Infections - eg. EBV - Stress

Answer 22

**Organ-specific autoimmune disease** 1. Thyroid - Hashimoto's, primary myxedema, thyrotoxicosis 2. Stomach - pernicious anaemia 3. Adrenal - Addison's disease 4. Pancreas - insulin dependent DM **Systemic autoimmune diseases - SLE** 1. CNS Disease 2. Rash 3. Pleuritis 4. Pericarditis 5. Glomerulonephritis 6. Raynaud's phenomenon 7. Arthritis

Answer 23

**SLE – ACR criteria (not diagnostic criteria)** 1. Malar rash 2. Discoid rash 3. Photosensitivity 4. Mouth ulcers 5. Arthritis 6. Serositis 7. Renal 8. CNS 9. Haematological 10. Immunological – DNA, Sm, APAs 11. ANA

Answer 24

**Musculoskeletal (60-80%)** **1 - Arthritis** - Often pain, tenderness > objective signs of inflammation - Small joints of the hands (MCP, PIP) o Also wrists, knees – can be any joint - Non-erosive, usu non-deforming o Deformities typically reducible **2 - Osteonecrosis** - Hips most common - Often following steroid treatment **3 - Myalgia** - Overt myositis uncommon

Answer 25

**CNS Clinical Features of SLE** 1. "Anything" 2. Headache 3. Seizures 4. Transverse myelitis 5. Vasculitis 6. Thrombosis 7. Psychiatric 8. Movement disorders – e.g. chorea

Answer 26

**SLE – Clinical features - Other** 1. Constitutional - Lethargy, fevers, sweats 2. Haematological - Cytopaenias & Haemolytic anaemia 3. Vasculitis **Anti-phospholipid syndrome = EXAM Q!** * Anti-cardiolipin antibody, lupus anticoagulant - Arterial / venous clots - Livedo reticularis - Recurrent miscarriage - due to failure of placenta to develop (early loss) = Prevention – clexane (LWMH)

Answer 27

**Other Autoimmune diseases with ANA+ other than SLE** 1. RA 2. Thyroid disease 3. Autoimmune hepatitis 4. Lyme disease 5. Sjogrens 6. Scleroderma 7. Myositis 8. MCTD

Answer 28

= Homogenous

Answer 29

**SLE – Treatment** **1 - Hydroxychloroquine (Plaquenil)** - Anti-malarial - 200-400mg/d - < 6.5 mg/kg – minimal ocular toxicity - Slow-acting = 2-3 months onset/ offset - Reduces: musculoskeletal, mucocutaneous symptoms, disease flares **2 - NSAIDs** - Adjunctive for arthralgia **3 - Prednisolone** - Acute treatment of disease flares - High-dose may be required for acute renal/ CNS disease, vasculitis - Rarely required for long-term disease suppression

Answer 30

**Scleroderma** - Rare multisystem disorder - Small blood vessel abnormalities - Fibrosis of skin and internal organs = “skleros” – hard, “derma” – skin - Autoimmunity **Epidemiology** - Incidence 20/106 per year - Prevalence 20-70/105 - F:M ?7-12:1 - Onset: 35-65yo

Answer 31

**Limited Scleroderma – Clinical features** = Skin involvement restricted to the distal limbs + face - Includes CREST syndrome: Calcinosis, Raynaud’s phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasia - Centromere-pattern ANA characteristic - Isolated pulmonary hypertension, digital ischaemia more common cf diffuse disease - Lung, cardiac, renal involvement less common

Answer 32

= Anti-centromere pattern

Answer 33

**Sjogren’s Syndrome - Clinical Features** 1. Sicca symptoms – eyes and mouth - May be the only manifestations 2. Arthritis 3. Increased lymphoma risk 4. Peripheral neuropathy, respiratory disease 5. May be primary/ secondary to other autoimmune disease

Answer 34

**Old classification:** 1 - Polymyositis (PM) - Proximal muscle weakness 2 - Dermatomyositis (DM) - Proximal muscle weakness - Rash – Gottren’s papules, heliotrope rash, shawl sign 3 - Inclusion body myositis (IBM) - Weakness of quadriceps, forearm flexors - Often older patients **Presentation** = Progressive proximal, symmetrical weakness **Diagnosis** 1. Elevated CK = NO 1! 2. Pos ANA, ENA (Anti-Jo1), Myositis Ab 3. Muscle biopsy 4. EMG 5. MRI

Answer 35

**Myopathy - Treatment** 1 - Cease trigger (statin) 2 - Immune suppression - Prednisolone - IVIG, Rituximab (DM) - Azathioprine, Methotrexate 3 - Treat related conditions - Underlying malignancy (DM, PM) - Interstitial lung disease Myopathy – can be paraneoplastic - consider cancer diagnosis in newly presenting myopathy!

Answer 36

**Lower Motor Neuron Lesions** 1. Muscle fasciculation 2. Muscle wasting 3. Weakness 4. Reduced tone 5. Absent reflexes 6. No predominance of flexor or extensor weakness - NB: UMN lesions, extensor > flexor weakness in upper limbs and flexor > extensor weakness in lower limbs

Answer 37

**Types of Neuropathies** **1 - Polyneuropathy: most are chronic axonal degeneration** 1. Diabetes mellitus (most common) 2. Alcohol 3. Critical illness (neuropathy or myopathy) 4. Vitamin B12 deficiency (copper deficiency with bariatric surgery) 5. Drugs 6. Uraemia, hypothyroidism and liver disease 7. SLE 8. Hereditary 9. Immune (acute, chronic) 10. Idiopathic **2 - Mononeuropathy: usually vascular compromise** 1. Diabetes mellitus 2. Vasculitis (hepatitis C with cryoglobulins most common, PAN) 3. Trauma

Answer 38

**Common hereditary polyneuropathies** 1. Charcot-Marie-Tooth (most common, most are demyelinating, palpable peripheral nerves) 2. Hereditary sensory neuropathy (pain and temperature) 3. Friedrich’s ataxia (spino-cerebellar and corticospinal tracts also involved; die from cardiomyopathy) While hereditary causes are very uncommon in general practice, always check the family history and don’t assume all neuropathies are due to diabetes mellitus.

Answer 39

**Cervical Spine** - NOTE: Cervical nerves (C1-C7) are above their numbered vertebra, whereas all others (C8 and below) are below their numbered vertebra - Patients with long standing rheumatoid arthritis and psoriatic arthritis may develop involvement of the upper cervical spine. - Be very careful with intubating a patient with atlanto-axial subluxation and avoid damage to the upper cervical cord. - Prior to surgery, if subluxation is a possibility, check lateral X-rays of the cervical spine in flexion and extension. Usually in patients with long-standing arthritis with erosions at other sites

Answer 40

**Pancoast’s Syndrome** * Apical lung cancer * Erosion of the 1st rib * Horner’s syndrome * T1 radiculopathy (wasting of small muscles of the hand)

Answer 41

**Involvement of brachial plexus is seen in:** 1. Microvascular disease (diabetes, radiation, inflammation) 2. Trauma 3. Malignancy (lung and breast, lymphoma) 4. Thoracic outlet syndrome (compressive)

Answer 42

**Diabetic plexopathy** * Involves the lumbar plexus more than the brachial plexus. * Also called diabetic amyotrophy * Severe pain, weakness (>>> sensory), wasting and weight loss * Unrelated to diabetic control * Motor manifestations are more common than sensory

Answer 43

**Ulnar Nerve Entrapment in the Cubital Tunnel** Lesions of the ulnar nerve below the elbow cause greater ulnar nerve clawing due to preservation of the flexor digitorum profundus.

Answer 44

Median Nerve = Carpal Tunnel Syndrome

Answer 45

1. **Tinel sign** = a way to detect irritated nerves. It is performed by lightly tapping over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve. 2. **Phalen's test** = A positive test is defined as the occurrence of pain or paresthesias in at least one finger innervated by the median nerve when the hands are put back to back. 3. **Opponens pollicis weakness test** = opposing the thumb to little finger against resistance.

Answer 46

**Saturday Night Palsy = Radial Nerve Palsy in Humeral Groove** - Fracture or direct injury - Results in both motor and sensory changes. - A wrist drop occurs if the lesion is above the origin of the posterior interosseous nerve. - All radial nerve palsies result in inability to extend the MCPs. - Lesions above the humeral groove also result in triceps weakness.

Answer 47

**Common Peroneal Nerve Injury at the fibular head** * A common nerve injury (L5, S1, S2) * Due to tight plaster casts, pressure on the nerve in the operating theatre, vasculitis, diabetes, and fibular head fracture * Causes foot drop, weak dorsiflexion of ankle and weak eversion of the subtaloid joint

Answer 48

**Ilio-inguinal neuralgia** - Nerve injury can occur following repair of inguinal hernia - Surgeons frequently cut the nerve to avoid pain post-op

Answer 49

Meralgia Paraesthetica = Lateral Femoral Cutaneous Nerve

Answer 50

1. Adult Flatfoot 2. Cavovarus Foot 3. Ankle Arthritis 4. Hallux Valgus (Bunions) 5. Metatarsalgia 6. Ankle Sprains and Associated Injuries

Answer 51

**Flatfoot = Planovalgus** **Overview** - Flattened medial longitudinal arch and Valgus Heel - Normal alignment hindfoot / heel is 6 deg valgus **Presentation** - Asymptomatic Concerned - Pain with running, sport, work, certain footwear - Persistent Pain……..often medial first, lateral later - “Fallen Arches” **Assessment of Adult Flatfoot** - Painful or Not - Severity (normal physiologic valgus = 6deg) - Flexible or Rigid…… Subtalar Complex and Arch - Treatment so far…….orthotics, injections, analgesia

Answer 52

**Differential Diagnosis Flatfoot** 1. Mobile Flatfoot usually persisting from childhood 2. Spastic Peroneal Flatfoot…..rigid and painful 3. Accessory Navicular 4. Inflammatory Arthritis 5. Osteoarthritis with arch collapse 6. Neuromuscular including Charcot 7. Post-traumatic 8. Adult Acquired Flatfoot = result of Tib Post Tendon dysfunction

Answer 53

**Treatment Symptomatic Flexible Flatfoot** - Footwear advice - Orthotics with medial heel wedge - If more severe (and flexible)….. 1. UCBL heel cup 2. Hinged brace / Caliper 3. Injection: Beware 4. Surgery **Flatfoot Reconstruction** - Calcaneal Osteotomy (medialise heel) - Medial Cuneiform (open wedge) - Lateral column lengthening (corrects abductn) - Achilles lengthening - FDL tendon transfer - Much improved comfort and function but long rehab >4mths

Answer 54

**Clinical Features of Ankle OA** 1. Pain 2. Stiffness 3. Swelling 4. Loss of Alignment **Aetiology: often Post Traumatic** 1. Inflammatory 2. Chronic Instability /Malalignment eg untreated Cavovarus 3. Primary OA 4. Haemochromatosis **Imaging Ankle OA** - Plain Xrays Standing - CT only if unsure re surrounding joints esp subtalar, talo-navic - MRI only if ?other diagnosis eg osteochondral defect talus

Answer 55

**Management** - Activity moderation - Simple analgesia, occasional NSAID - Steroid injection for special occasions - Brace?? - Surgery if impignement or advanced OA (or if malaligned) **Surgery for Severe Ankle OA** - Ankle Replacements sometimes excellent, sometimes terrible - Ankle fusions very effective pain relief but issues - Pt satisfaction variable - Young and active always fuse - Older, multi joints involved TAJR

Answer 56

**Overview** * Very common injury * Incomplete damage to lateral ligament(s) * Inversion * RICE, avoid re-injury * Temporary crutches / boot for relief * Review if not steadily improving first few weeks * Complete ATFL rupture still non-Op

Answer 57

**Bunions = Hallux Valgus - Proceed with Caution** - Christian Louboutin +ve - “Have to wear these shoes for work” - Need to get them done before they look like my Grandmother’s feet - Over-emotional - Teenagers - ”Gross! …… like, total Goober Feet!” - Cringe / air quotes if mention “sensible shoes” - The commonest cause of a disappointing outcome is unrealistic expectations

Answer 58

**Kids are Different** * Congenital malformations * Developmental abnormalities * Dependence - NAI - Psychological abuse - Nutritional deficiencies

Answer 59

**Developmental Dysplasia of the Hip (DDH)** * Formerly “Congenital” or CDH * Broad spectrum - Dysplasia = abnormality of development - Subluxation = femoral head sits within the acetabulum, but is decentred or able to be displaced within the acetabulum - Dislocation = femoral head sits outside the acetabulum. Either reducible or irreducible Incidence: - 1/1000 dislocated - 10/1000 subluxed/dysplastic - Left 60%, Right 20%, Bilateral 20%

Answer 60

**Diagnosis of Developmental Hip Dysplasia (DDH)** - In the newborn period DDH is a clinical diagnosis, and a radiographic one (USS not XR!) - Earlier diagnosis, better outcome **Examination for DDH** 1. Asymmetrical crease 2. Decreased abduction 3. Leg length discrepancy – Galeazzi’s sign 4. Limp 5. Beware of bilateral DDH

Answer 61

**Overview** - Lateral curvature of the spine in the coronal plane of >10° - Can be: - 1 - Structural o Passively non-correctible o Vertebral rotation - 2 - Non-Structural o Fully passively correctible o No rotational component **Red Flags in Scoliosis** 1. Male 2. Left sided curves 3. Pain 4. Rapid progression 5. Neurology Any of these abnormalities requires further investigation (ie MRI)

Answer 62

**Non-Accidental Injury** * Any act or failure to act that results in harm. * Abuse second most common cause of death in infants 1-6 months. * **Risk factors include**: 1. First born 2. Prematurity 3. Step-children 4. Disabled children 5. Lower socioeconomic class

Answer 63

= Breaking of a bone or cartilage **Physical Signs Of Fractures** 1. Deformity 2. Abnormal Mobility 3. Crepitus 4. Loss Of Function 5. Local Bone Tenderness

Answer 64

**YOUNG** - CHILDREN’S FRACTURES: Greenstick, Salter Harris (1-5) **OLD - OSTEOPOROTIC FRACTURES (insufficiency):** - Neck of femur - Colles - Neck of humerus - Spine **FRACTURE CLASSIFICATION PATHOLOGICAL:** 1. Pagets 2. Osteogenesis Imperfecta 3. Tumour 4. Osteoporosis

Answer 65

PRIMARY FRACTURE HEALING - “No movement = No Callus” - Absolute stability SECONDARY Fracture Healing - “Movement = Callus” - Relative Stability

Answer 66

**NON SURGICAL** **IMMEDIATE/EARLY** 1. First aid 2. Stop bleeding 3. Splint limb 4. Cover open wounds 5. Early-fluid replacement 6. Tetanus prophylaxis 7. Antibiotic cover 8. Pain relief LATE - Definitive therapy

Answer 67

**SURGICAL TREATMENT IMMEDIATE & EARLY** - same as non-operative **LATE** - debridement of tissues - fixation of bone-internal or external - tissue repair and grafting - compromise surgery-late amputation

Yr4 MSK - Lectures Flashcards

(119 cards)