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123 Cards in this Set
- Front
- Back
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Describe the timing of stiffness in inflammatory arthritis |
Early in the morning - better with use Then worse in evening |
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Describe the pain in degenerative arthritis |
Increases with use Clicks/clunks |
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How long does the pain last in the morning in degenerative arthritis? |
< 30 mins |
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When is bone pain felt? |
At rest and at night |
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Which joints does osteoarthritis typically affect? |
Base of thumb Distal interphalangeal Not symmetrical |
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What are characteristically seen in the hands in osteoarthritis? |
Bouchard's node Herbeden's nodes - distal |
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What is seen on x-ray in RA? |
Cauliflower erosion |
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What joints are affected by RA? |
Sinovial joints Small joints Symmetrical |
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Why does ESR rise in inflammation? |
Increased fibrinogen - RBCs stick together |
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What can cause falsely high ESR? |
Age, female, obesity, racial difference, hypercholesteraemia, high immunoglobulins, aenamia |
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Which condition produces high ESR but normal CRP? |
SLE |
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What does CRP do? |
Binds to damaged cells, activates complement and increases macrophage phagocytosis |
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Where is CRP produced? |
Liver |
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Which stays higher for longer in inflammation? CRP or ESR? |
ESR |
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What factors are found in the serum in RA? |
rheumatoid factor cyclic citrullinated peptide |
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What factors are found in the blood in SLE? |
ANA - anti nuclear antibody dsDNA - double stranded DNA - v. specific |
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Which antigen is important in spondyloarthritis? |
HLA B27 |
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Where is HLA B27 encoded? |
chromosome 6 |
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What are the names of the theories on why HLA B27 causes spondyloarthritis? |
Molecular mimicry - by infection Mis-folding HLA B27 heavy chain |
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How does ankylosing spondylitis present? |
SPINEACHE Sausage digit Inflammatory back pain NSAID response Enthesitis - heel Arthritis Crohn's/colitis/CRP HLA B27 Eye (uveitis) |
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When does ankylosing spondylitis present? |
Late teenage years/20s |
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How is ankylosing spondylitis treated? |
Anti-TNF drugs High dose anti-inflammatories IL-17 blockers |
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How does psoriatic arthritis present? |
pits on nails thickened nail bed Swollen fingers Psoriasis on elbows and knees, behind ears Distal IP joint |
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How can psoriatic arthritis be treated? |
methotrexate, leflunomide, ciclosporin, sulfasaliazine Anti-TNF drugs - etanercept, adalimumab, infliximab |
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What triggers reactive arthritis? |
Infection - usually GI or genital |
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How does reactive arthritis present? |
Arthritis Conjunctivitis Urethritis Skin lesions - keratoderma |
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What factors increase the 'volume' of pain? |
Substance P Glutamate Serotonin - 2a, 3a Neurotensin Nerve growth factor |
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What factors turn down the 'volume' of pain? |
Descending analgesis pathways - noradrenaline, serotonin (1a,b) , opioids GABA Cannaboids Adenosine |
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How is fibromyalgia diagnosed? |
Widespread pain after other diseases excluded Symptoms > 3 months Pain at 11/18 tender point sites |
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What disorders are closely related to fibromyalgia? |
Depression Chronic headache IBS Chronic fatigue |
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What are the princial symptoms of fibromyalgia? |
Pain Fatigue Non-restorative sleep Headache Abdo pain |
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What are the differential diagnoses of fibromyalgia? How would you test for these? |
Hypothyroid - TSH SLE - ANA, dsDNA PMR - ESR/CRP High calcium - Ca Low vitamin D - Vit D |
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What can be given at low dose in fibromyalgia? |
Amitriptyline |
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What should you check in juvenile arthritis? |
EYES - for uveitis |
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What is the gold standard treatment for JIA? |
Methotrexate |
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Which joint must you not forget in JIA? |
The jaw! |
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What are the primary large vessel vasculitis conditions? |
giant cell Takyasu's |
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What vasculitis conditions affect the medium and small vessels? |
Kawasaki Wegener's Churg strauss Henoch Schonlein purpura |
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Who does Takyasu's arteritis affect? |
Young women |
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Is Giant Cell arteritis ANCaA +ve or -ve? |
-ve |
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What do you find on examination of giant cell arteritis? |
Palpable, tender temporal arteries Reduced pulsation anterior ischaemic optic neuropathy |
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What is the nose deformity in Wegener's |
Saddle nose |
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What growths form in RA? |
Pannus |
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How does RA affect the eyes? |
Dry eyes Episcleritis Scleritis |
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How does RA affect the brain and nerves? |
sensory peripheral neuropathy Entrapment neuropathies Cervical instability |
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How does RA affect the haematological system? |
Palpable lymph nodes Enlarged spleen Anaemia - normochromic, normocytic |
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How does RA affect the lungs? |
Pleural effusion Fibrosing alveolitis Rheumatoid nodules |
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How does RA affect the heart? |
Pericardial rub Pericarditis Pericardial effusion |
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How does RA affect the kidneys? |
Amyloidosis Analgesic nephropathy |
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In whom is the vast majority of SLE seen? |
Women |
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Outline the pathogenesis of SLE |
Immune complex mediated |
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What are the clinical features of SLE? |
Fatigue Arthritis Butterfly rash - photosensitive Alopecia Mucosal ulceration Pleurisy Pericarditis Raynaud's Glomerulonephritis Thrombosis |
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Describe the arthritis in SLE? |
Symmetrical Less proliferative than RA Can be deforming Non-erosive |
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What are the haematological features of lupus? |
Anaemia - haemolytic thrombocytopenia Neutropenia Lymphopenia |
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How does anti phosopholipid syndrome present? |
Arterial thrombosis Venous thrombosis Recurrent foetal loss thrombocytopenia |
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How is SLE treated? |
Prednisolone Topical steroids NSAIDs Cyclophosphamide Methotrexate Belimumab |
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What are there antibodies to in systemic sclerosis? |
Centromeres |
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How is raynaud's treated? |
Vasodilators - Nifedipine - Sildenafil |
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How does Sjogren's present? |
Dry eyes Dry mouth Enlarged salivary glands Inflammatroy arthritis Rash Vasculitis |
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By 65yrs, what percentage of people have some OA? |
100% |
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What are the two most common joints affected by osteoarthritis? |
Hip and knee |
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What factors are important in OA? |
Chondrocytes Metalloproteinases Catabolic cytokines - IL-1, TNF-a |
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What is found on examination of OA? |
Swelling Muscle wasting Deformity Decreased ROM Crepitus Osteophytes palpable Joint instability |
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What are the radiological hallmarks of OA? |
Joint space narrowing Sub chondral cysts Abnormalities of bone contour osteophyte formation Subchondral sclerosis |
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How is OA managed? |
Lifestyle modification - low impact exercise Splints + orthotics Analgesics Topical NSAIDS, capsaicin Steroid injection Surgical - debridement, replacement, fusion |
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When should you not inject a joint with steroids? |
If its going to be operated on - infection risk! |
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Which joint is classically spared in RA? |
Distal IP |
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Who is at risk of work-related MSK disorders? |
Heavy manual labour Lifting above shoulder height lifting below knee height Incorrect technique Forceful repetitive movement Poor posture |
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What is seen in carpal tunnel syndrome? |
Pain/tingling/numbness in median distribution |
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How does the abbreviated injury score work? |
Six body regions 1-6 rating with 6 being unsurvivable 3 highest scores squared and added - max score = 75 A 6 anywhere = 75 |
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What structures are on the anterior leg? |
All Hospitals Are Not Dirty Places Tibialis anterior Extensor hallucis longus Artery Nerve Extensor digitorum longus Peroneus tertius |
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What structures pass posterior to the medial malleolus? |
Tom Dick a Very Naughty Harry Tibialis posterior flexor digitorum artery vein nerve flexor hallucis longus |
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What is the diaphysis? |
Shaft of bone in an adult or child |
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What is the metaphysis? |
End of adult bone |
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What is the physis? |
Growth plate in children |
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What is the epiphysis? |
Part of bone between joint and physis |
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What paediatric fractures are strong indicators of abuse? |
Corner fractures |
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How are paediatric fractures classified? |
Salter-Harris I-V |
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What do children's bones have more of, meaning they bend and break more easily? |
Collagen |
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Why do children's bones heal more quickly? |
Thick periosteum - good blood supply |
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What commonly causes supracondylar fractures in the wrist? |
Falling on outstretched hand |
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Which fractures are specific to children? |
Greenstick - partial fracture - thick periosteum |
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What increases serum urate? |
Increased uptake Cell damage Cell turnover Cell death In born errors of metabolism Reduced excretion - renal |
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What diet increases risk of gout? |
Alcohol - beer Red meat and sea food fructose Low dairy product intake |
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What precipitates acute gout? |
Sudden overload, cold, trauma, sespis, dehydration, drugs |
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How does acute gout present? |
Hot swollen joints - particularly big toes Lumps - tophi Punched out bones |
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What is used to treat acute gout? |
Colchicine NSAIDs Steroids Ice Vit C |
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What is used to treat longer term gout? |
Allopurinol Colchicine |
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What is used in gout if allopurinol isn't an option? |
Febuxostat |
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What causes pseudogout? |
Deposition of calcium pyrophosphate crystals on joint surface |
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What significantly decreases bone mass in women? |
Menopause |
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How is osteoporosis diagnoed? |
Bone densitometry DEXA - dual energy x-ray absorptiometry DXA T-score FRAX score |
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What can cause osteoporosis? |
Inflammatory disease Thyroid and parathyroid hormone Cortisol Oestrogen lack Lack of skeletal loading Glucocorticoids |
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How is osteoporosis managed? |
bisphosphonates HRT Denosumab calcium + phosphate |
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What drug increases osteoblast activity? |
Teriparatide |
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Name some oral bisphosphonates |
Alendronate Risedronate Ibondronate |
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What are sarcomas? |
tumours of the mesencymal tissue - usually soft tissue |
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What are the types of bone sarcoma? |
Osteosarcoma Ewing's sarcoma Chondrosarcoma Spindle |
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Who gets Ewing's sarcoma? |
Young males |
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What are the side effects of chemotherapy? |
Anaemia, thrombocytopenia, neutropenia, mouth ulcers, N +V, constipation, neurotoxicity, hair loss, tiredness Cardiotoxicity, nephrotoxicity, osteopenia, fertility |
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What features are suggestive of malignancy in a lump? |
> 5cm Increase in size deep to fascia Pain |
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What toxicity is associated with NSAIDs? |
GI bleeding - decreased PGs Renal impairment Increased CV risk More in diclofenac |
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What are the side effects of corticosteroids? |
Diabetes, muscle wasting, osteoporosi, moon face, skin atrophy, hirsutism (hair), acne, hypertension, adrenal suppression, infection, emotional disturbance |
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What are the side effects of DMARDs? |
Bone marrow suppression - low WCC, Hb, platelets Abnormal liver enzymes GI - nausea, diarrhoea Oral ulceration Hair loss Teratogenic |
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What is given with methotrexate to reduce side effects? |
Folic acid It inhibits folate |
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Name some DMARDS |
Methotrexate Sulphasalazine Leflunomide |
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What does rituximab inhibit? |
B lymphocytes |
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What does abataceot inhibit? |
T cell activation |
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What does tocilizumab inhibit? |
IL-6
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How does prosthetic joint infection present? |
Pain Swelling Redness and hot |
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Why does the metaphysis get infected? |
Slow blood flow Endothelial basement membranes absent capillaries lack phagocytic lining |
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What organisms commonly cause joint infection? |
Staph a Coagulase -ve staph Aerobic gram -ve Strep Neisseria gonorrhoea |
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How is joint infection diagnosed? |
High WCC Raised inflammatory markers cortical erosion, periosteal reaction, mixed lucency, sclerosis |
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How is infected joint treated? |
Surgical Antimicrobial - flucloxacillin Aspirate Stop immunosuppression if you can |
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Which COX is responsible for inflammation? |
COX 2 |
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Which digit is usually spared in Raynaud's? |
Thumb |
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What is notable about the white skin in Raynaud's? |
Very clear line between affected and normal skin |
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What is Paget's disease? |
Disorder of bone remodelling Increased resorption and compensatory bone formation Increased blood flow Formation > resorption - weaker bone |
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How does Paget's present? |
Bone pain/deformity Pain at rest Pathological fractures |
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What is used to diagnose Paget's? |
Raised alkaline phosphatase X-rays - cotton wool in skull |
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What is osteomalacia> |
Defective mineralisation of new bone Lack of calcium/phospate |
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How does osteomalacia present? |
Fragility fractures Muscle weakness Waddling gait, difficulty climbing stairs Dull ache Neonatal rickets |
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How is osteomalacia diagnosed? |
raised alkaline phosphatase Low calcium and phosphate Elevated PTH Low vit D elevated FGF-23 |
