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171 Cards in this Set
- Front
- Back
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Define Osteoarthritis? |
Synovial Joint Disease Result of active (sometimes inflammatory) potentially reparative process = Progressive destruction / loss of articular cartilage |
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Risk Factors for OA? |
Obese Fracture through a joint Congenital Joint dysplasia Occupation (Farmer/Labourer) Repetitive use or injury in sports |
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Clinical Features of LOCALISED OA |
Usually knee or hip - LOCALISED Pain on movement & crepitus Worse at night Background pain at rest Joint GELLING (pain after 30 mins rest - some stiffness after rest) Unstable Joint |
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Clinical Features of GENERALISED OA |
DIP joint Thumb carpo-metacarparpal joints Knees
Tenderness/Derangement/Bony swellings/ Decreased ROM/ Mild Synovitis
BOUCHARDS HEBERDENS SQUARING of the Carpometacarpal joint of the thumb
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Investigations for OA |
RF and ANA Negative Normal FBC and ESR Slightly raised CRP/ hsCRP MRI = Subchondral bone changes Arthroscopy Aspiration of synovial fluid |
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XRAY changes in OA |
LOSS
Loss of joint space Osteophyte formation Subchondral cysts Subarticular sclerosis |
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DD for OA |
RA (Joint involvement different + morning stiffness) Pseudo-OA Chronic tophaceous gout Psoriatic arthritis affecting DIPJs |
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Management of OA |
CORE = Weight loss/ Exercise/ Aerobic Fitness
Pharmacological 1) Analgesia (Paracetamol + Topical/Oral NSAIDs /Codeine) 2) Intra-articular corticosteroid injections
Non-Pharmacological 1) Physiotherapy / OT 2) Heat or cold / Walking aids / TENS/ Joint support/ Insoles/ Brace
Surgery 1) JOINT REPLACEMENT (When substantial impact on QOL/Preventing from sleep) |
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Define RA |
Chronic systemic inflammatory disease characterised by symmetrical/deforming/peripheral polyarthritis |
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Aetiology of RA? |
HLA DR4/DR1 Female 30-50 Autoimmune Disease Smoking |
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Pathology behind RA |
Widespread and persistent synovitis Synovial hypertrophy + proliferation == PANNUS of inflamed synovium The PANNUS damaged underlying articular cartilage and subchondral bone by blocking nutrition / direct cytokine effect
= Produces BONY EROSIONS |
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SYMPTOMS of RA |
Symmetrical swollen, painful, stiff joints Worse in the morning (>30 minutes) Tiredness Disturbed Sleep
RARELY 1) Sudden onset/widespread 2) Recurrent (Palindromic RA) 3) Systemic Illness 4) Polymylagic onset 5) Recurrent soft tissue problems (frozen shoulder/carpal tunnel) |
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SIGNS of RA in the Hands? |
Early - Inflammation / No joint damage: MCP/PIP/Wrist MTP/Bursitis/Tensosynovitis
Late = JOINT DEFORMITY 1) Ulnar Deviation 2) Swan Neck Deformity 3) Boutonniere Deformity 4) Z-Deformity of the thumb 5) Rupture of the hand extensoer tendons 6) Dorsal Wrist Subluxation 7) Muscle wasting |
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Extra-Articular Features of RA |
RHEUMATOID NODULES - Subcutaenous - Firm (Elbow/Achilles)
1) Episcleritis 2) Sjogren's Syndrome (Ketaoconjunctivitis Sicca) 3) Lymphadenopathy 4) Atlanto-axial subluxation 5) Fibrosing Alveolitis 6) Pleural Effusion 7) Caplan's Syndrome 8) Pericarditis 9) Vasculitis 10) Raynaud's 11) Peripheral Neuropathy 12) Felty's Syndrome (RA+Splenomegaly+Neutropenia) 13) Osteoporosis 14) Amyloidosis |
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Investigations for RA? |
1) Rheumatoid Factor 2) Anti-CCP 3) Normocytic Anaemia 4) Raised ESR/CRP/Platelets 5) XRAY = Loss of joint space / soft tissue swelling/ Bony Erosions/ Subluxation / Carpal Destruction 6) USS/MRI |
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Diagnosis of RA |
ABCD A) Joint Involvement B) Serology C) Acute Phase Reactants D) Duration > 6 weeks |
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Management of RA |
Measured using 28 Joint Disease Activity Score
Non Pharmacological Exercise/Physio/OT/Orthotics (e.g. wrist splint)
Surgical Joint Replacement = Pain relief / Improve ROM
Pharmacological 1) NSAIDs (Ibuprofen + PPIs - or Celecoxib for long term) 2) Steroids (IM depot Methylprednisolone / Intra-articular corticosteroid
3) DMARDS Methotrexate / Sulfasalazine / Hydroxychloroquine = Immunosuppression xx = Pancytopenia/Increased infections
4) BIOLOGICAL AGENTS A) TNF-Alpha Inhibitors = Infliximab/Etanercept/Adalimumab **No response to 2 DMARDs + >5.1 on DAS28
B) B-CELL depletion = Rituximab
C) IL-1 & IL-6 Inhibition= Tocilizumab |
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Side Effects of DMARDs |
Methotrexate = Oral ulcers/pneumonitis/hepatotoxicity
Sulfasalazine = Oral ulcers/ Rash/ Reversible oligospermia
Hydroxychloroquine= Irreversible retinopathy |
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Side Effects of Biological Treatments |
1) Serious Infection (Reactivate TB/ HepB) 2) Hypersensitivity 3) Injection site reaction 4) Blood Disorders 5) Skin cancer |
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Define Osteoporosis |
Reduction in BONE MASS and MICRO-ARCHITECTURAL DETERIORATION OF BONE TISSUE --> Bone Fragility --> Fracture
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Criteria for Osteoporosis |
Bone Mineral Density >2.5 SD below the mean 1 -- 2.5 SD = Osteopenia |
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Risk factors for developing OP |
ACCES
Alcohol Corticosteroids Calcium LOW Estrogen LOW Smoking
Female Vitamin D deficiency Chronic liver or renal disease |
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Aetiology of OP? |
Either inadequate PEAK bone mass OR ongoing bone loss
PEAK depends on: 1) Genetics 2) Nutrition 3) Sex hormones 4) Physical Activity
WOMEN ACCELERATE at the menopause due to lack of sex hormones |
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Clinical Features of Osteoporosis |
Pathological Fractures Thoracic (Kyphosis + Loss of height = Widows stoop) Lumbar Vertebrae Proximal Femur Distal Radius (Colles' Fracture) |
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Investigation for Osteoporosis? |
Dual-Energy X-Ray Absorptiometry = DEXA Scan
Also look for secondary causes = Hyperthyroid/Myeloma/Hypogonadism |
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How do you assess risk of Fracture? |
WHO FRAX WHO Fracture Risk Assessment Tool |
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When is a DEXA indicated? |
BMI < 19 Maternal Hip Fracture Radiographic Osteopenia Glucocorticoid Therapy < 65 years old |
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Management of a vertebral fracture? |
Bed Rest Diazepam SC Calcitonin IV Pamidronate |
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Management of OP |
Stop smoking / alcohol Increase intake of calcium and vitamin D Weight bearing exercises
ALENDRONATE (Bisphosphonate) = Inhibits bone resorption through inhibition of osteoclast activity XX = Flu like symptoms/Uveitis/Osteonecrosis of Jaw
STRONTIUM RANELATE (If not compliant with above)
Raloxifine Teriparatide = SEVERE OP Denosumab Reduce Steroids
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Define SLE |
Multisystem autoimmune disease in which autoantibodies are made against a variety of autoantigens |
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Pathophysiology of SLE |
Polyclonal B-Cell secretion of pathogenic autoantibodies causing tissue damage via multiple mechanisms 1) Immune complex formation and deposition 2) Complement Activation 3) Neutrophil influx |
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Clinical Features of SLE |
Remitting and Relapsing illness of VARIABLE presentation and course **Malaise/Fever/Myalgia/Fatigue**
ORDER HIS ANA Oral Ulcers Rash (Malar) Discoid Rash Eye involvement (Scleritis/Episcleritis) Renal disorders / Recurrent Abortions (Proteinuria)
Haematological (Haemolytic Anaemia/ Leukopenia/Lymphopenia) Immunological Disorders (Antiphospholipid, Anti- dsDNA, Anti-SM) Serositis (Pleuritis/Pericarditis)
Arthritis (>2 peripheral joints - Jaccoud's Arthropathy) Neurological Involvement (Seizures/Psychosis) Alopecia
ALSO Lymphadenopathy Weight Loss Nail-Fold Infarcts Raynaud's Migraine |
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How do you Diagnose SLE? |
4 out of 11 symptoms
ANA Positive Anti-dsDNA Positive ENA (Anti-Ro/Anti-La/Anti-SM/Anti-RNP RF |
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How do you monitor SLE activity? |
1) Anti-dsDNA antibody titres 2) Complement: Low C3/C4 3) ESR 4) BP 5) Raised ESR but NORMAL CRP |
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3 drugs that induce lupus |
Isoniazid Phenytoin Hydralazine |
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Management of SLE |
1) Acute Flare = IV Cyclophosphamide + Prednisolone
2) Topical Steroids 3) Maintenance = NSAIDs/ Hydroxycholoquine/Prednisolone/Azathioprine 4) Lupus Nephritis? = Prednisolone / Cyclophosphamide / Control BP |
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What is Antiphospholipid Syndrome? |
THROMBOTIC TENDENCY CLOT
Coagulation Defects (Stroke/TIA/MI/DV = Thrombosis) Livedo Reticularis Obstetric (Recurrent Miscarriage) Thrombocytopenia (Low platelets)
ALSO Valvular heart disease Migraine Epilepsy Renal Impairment |
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Management of Antiphospholipid Syndrome |
Low dose aspirin Long term warfarin |
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What is Sjogren's Syndrome? |
Chronic Inflammatory Autoimmune Disorder Lymphocytic infiltration + Fibrosis of EXOCRINE glands = e.g. Lacrimal & Salivary |
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Clinical Features of Sjogren's Syndrome? |
Keratoconjunctivitis Sicca Xerostomia (Decreased salivation) Parotid swelling Vaginal Discharge/Dyspareunia/Dry Cough Systemic Signs = Polyarthritis/Raynauds/Vasculitis/Fatigue
Associated with other AI disease + INCREASED risk of Non-Hodgkin's B-cell |
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Investigations for Sjogren's Syndrome? |
Schirmer's Test Rose Bengal Stain Labial Gland Biopsy Anti-Ro/Anti-La/ANA/RF |
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Management of Sjogrens |
Increase Fluids + Hypromellose (Artifical Tears) NSAIDs Hydroxychloroquine = for ARTHRALGIA |
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What happens in LIMITED cutaneous systemic sclerosis? |
CREST Calcinosis (Subcutaneous Tissues) Raynaud's oEsophageal & Gut dysmotility (dysphagia) Sclerodactyly (Swollen tight digits) Telangectasia
Skin involvement is LIMITED to face/hands/feet Microstomia (Limitation of mouth opening) Anticentromere Antibody Pulmonary Hypertension |
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What is DIFFUSE cutaneous systemic sclerosis? |
'Diffuse' skin involvement + EARLY organ fibrosis =Lung /Cardiac/GI/Renal ** Lung Fibrosis ** Pseudo-obstruction of colon ** AKI/CKD ** Myocardial fibrosis = Arrhythmias
= ANTI-TOPOISOMERASE-1 Antibodies = ANTI-RNA POLYMERASE
Rx= Control BP/Annual Echo + Spirometry |
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How do you manage Systemic Sclerosis? |
NO CURE IV Cyclophosphamide Monitor BP & Renal Function ACE-I or ARB = Reduce risk of renal crises Nifedipine (For Raynauds) |
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What is mixed connective tissue disease? |
Systemic Sclerosis SLE Polymyositis |
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What happens in Polymyositis/Dermatomyositis? |
Insidious onset of PROGRESSIVE symmetrical proximal muscle weakness + autoimmune mediated striated muscle inflammation (myositis) - Associated with myalgia + arthralgia
Also: Dysphagia/Dysphonia/Respiratory Weaekness |
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Clinical Features of Polymyositis/Dermatomyositis? |
Shoulder + Pelvic Girdle usually Difficulty: Squatting/Stairs/Rising from chair/Raising hands above head |
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What happens in DERMATOmyositis? |
1) Macular Rash (Shawl's sign = back & shoulder) 2) Heliotrope (lilac-purple) = rash on eyelids + oedema 3) Gottron's Papules (Red papules over knuckles/elbow/kneed) 4) Nail fold erythema 5) Sub-Cutaneous Calcification
Pathognomic = Gottron's Papules + Raised CK + Muscle Weakness |
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What are extra-muscular signs of Polymyositis/Dermatomyositis? |
Fever Arthralgia Raynaud's Interstitial Lung Fibrosis Myocardial Involvement |
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Investigations for polymyositis/dermatomyositis? |
Increase in muscle enzymes Creatinine Kinase ALT/AST/LDH/Aldolase EMG Anti-MI-2/Anti-JO-1
MUSCLE BIOPSY //// |
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Management of Polymyositis/Dermatomyositis? |
PREDNISOLONE
Methotrexate/Cyclophosphamide/Azathioprine Hyroxychloroquine = Skin Disease |
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Define Raynaud's Phenomenon? |
Peripheral digital ischaemia due to PAROXYSMAL vasospasm Precipitated by COLD or EMOTION |
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Clinical Features of Raynaud's |
Fingers or Toes ACHE and CHANGE COLOR Pale (Ischaemia) --> Blue (Deoxygenation) --> Red (Reactive Hyperaemia) |
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Causes of Raynaud's Phenomenon |
Idiopathic (Young women = Raynaud's Disease) Underlying Cause (Raynaud's Phenomenon) 1) Connective tissue disorders (SLE/RA/CREST) 2) Occupational (Vibrating Tools) 3) Obstructive (Buerger's Disease) 4) Blood (Polycythaemia Rubra Vera) 5) B-Blockers 6) Hypothyroidism |
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Management of Raynaud's Phenomenon |
Keep Hands Warm Stop smoking Stop B-Blockers NIFEDIPINE / Primrose oil / Sildenafil Chemical or surgical sympathectomy |
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7 distinct features of the Spondyloarthropathies |
1) Seronegative 2) Associated with HLA-B27 3) Axial Arthritis: Spine/SI Joints 4) Asymmetrical Large Joint oligoarthritis (<5) or monoarthritis 5) Enthesitis: Inflammation of the SITE of insertion of tendon or ligament into bone (e.g. Plantar fasciitis) 6) Dactylitis : Inflammation of the digit (Sausage) 7) Extra-articular manifestations (e.g. Iritis/ORal ulcers/ Aortic Regurge/IBD) |
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What are the 4 spondyloarthropathies? |
PEAR
Psoriatic Enteric Ankylosing Spondylitis Reactive |
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What is Enteric Arthritis |
Associated with IBD/GI bypass/coeliac/Whipples Arthropathy often improves with treatment of bowel symptoms
Use DMARDS for resistant cases |
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What happens in Ankylosing Spondylitis? |
Chronic inflammatory disease of the spine and SI joints |
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Clinical Features of AS |
Male/<30/Gradual onset of lower back pain/stiffness Relieved by exercise WORSE in second half of the night in sleep Pain: SI Joints --> hips/buttocks (alternating)
Progressive loss of spinal movement = Kyphosis Spino-cranial ankylosis Neck Hyperextension (question mark posture) |
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Extra-articular features associated with AS? |
Anterior mechanical chest pain due to costochondritis Aortic Regurge Hip/Knee involvement Plantar Fasciitis / Achilles Tendonitis Crohn's/UC/Amyloid Acute IRITIS Osteoporosis Pulmonary Apical Fibrosis |
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Diagnosis of AS |
3/4 in adults under 50 years old
1) Morning Stiffness >30 minutes 2) Improvement with exercise but NOT rest 3) Awakening due to back pain in the 2nd half of the night ONLY 4) Alternating Buttock Pain |
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Investigations for AS |
MRI/XRAY = Sarcroiliitis / Irregularities / Erosions / Sclerosis
VERTEBRAL SYNDESMOPHYTES - Bony proliferations due to enthesitis between ligaments and vertebrae = these fuse = Ankylosis
Later = Calcification of ligaments with ankylosis leads to BAMBOO SPINE appearance
FBC (anaemia) / Raised ESR/ Raised CRP/ HLA-B27 +ve |
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Management of AS? |
Non-Pharmacological - Exercise - Physiotherapy
Pharmacological NSAIDs = Ibuprofen / Naproxen TNF-A Blockers = Etanercept/ Adalimumab / Golimumab Intra-Articular Corticosteroid injections Long term bisphosphonates
Surgical Hip Replacement Spinal Osteotomy |
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Clinical Features of Psoriatic Arthritis |
Arthritis / Enthesitis in patients with psoriasis or FH of psoriasis
- Asymmetrical arthritis affecting DIP JOINTs (like OA) and spine - Dactylisis - Psoriatic Arthritis Mutilans - Nail Changes -Acneiform Rashes - Palmo-plantar pustulosis
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What do you see on XRAY with psoriatic arthritis? |
Erosive changes "PENCIL-IN-CUP" deformities = Pointed appearance |
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Management of Psoriatic Arthritis? |
NSAIDs Sulfasalazine/Methotrexate Cyclophosphamide Anti-TNF-A = Etanercept/ Adalimumab / Golimumab |
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What happens in Reactive Arthritis? |
Sterile Arthritis Lower limb usually 1-4 weeks POST infection
Persistent bacterial antigen in the inflamed synovium of affected joints drives the inflammatory process |
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Organisms that cause reactive arthritis? |
Urethritis = Chlamydia Trachomatis / Ureaplasma Urealyticum
Dysentry = Campylobacter/ Shigella/ Salmonella/Yersinia |
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Clinical Features of Reactive Arthritis? |
TRIAD = Reiter's Syndrome - CANT PEE CANT SEE CANT CLIMB A MOFO TREE - Urethritis - Conjunctivitis - Asymmetrical Arthritis (Hip/knee/ankles/feet)
ALso Keratoderma Blenorrhagica Circinate balanitis Mouth ulcers Enthesitis
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Investigations for Reactive Arthritis? |
Raised ESR & CRP Culture stool if diarrhoea Infectious serology Aspirated Synovial Fluid = Raised Neutrophils |
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Management of Reactive Arthritis? |
Rest / Splint Joints NSAIDs / Local Corticosteroid injections Methotrexate or Sulfasalazine IF symptoms > 6 months |
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Define vasculitis? |
Inflammatory disorder of blood vessel walls ==> Destruction (Aneurysm / Rupture) or Stenosis
Primary or Secondary to: SLE/RA/HepB&C/HIV |
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2 examples of large vessel vasculitis? |
GCA Takayasu's Arteritis |
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2 examples of medium vessel vasculitis? |
Polyarteritis Nodosa Kawasaki Disease |
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Small vessels vasculitis? |
P-ANCA = Microscopic polyangiitis/ Glomerulonephritis / Churg-Strauss syndrome
C-ANCA = Wegner's Granulomatosis
ANCA NEGATIVE = Goodpastures |
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Clinical Features of Vasculitis? |
1) Systemic = Fever/Malaise/Weight Loss/Arhtralgia 2) Skin = Purpura/Ulcers/ Livdeo reticularis / Nailbed infarct
3) Epistaxis/Deafness/Scleritis 4) Pulmonary = Haemoptysis/SOB 5) Cardiac = Angina/MI 6) Renal = HTN/Haematuria/Proteinuria 7) Stroke/Fits/Orchtis |
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Investigations for vasculitis
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Raised ESR & CRP ANCA Creatinine (renal failure) ANGIOGRAPHY + BIOPSY |
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Management of vasculitis? |
Large vessels = Prednisolone Medium/Small vessels = IV Cyclophosphamide + Prednisolone |
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What happens in POLYARTERITIS NODOSA? (PAN) |
Associated with Hep B ANCA NEGATIVE
Necrotising vasculitis that causes ANEURYSMS and THROMBOSIS in medium sized arteries ==> Infarction |
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Clinical Features of PAN |
Fever/Malaise/Weight Loss/Arthralgia/Myalgia Rash and "punched out" ulcers Renal Impairment + HTN Mononeuritis Multiplex Abdominal pain (Visceral Infarcts) |
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Investigations for PAN |
Renal or mesenteric angiography RENAL BIOPSY //// |
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Management of PAN |
Control BP Prednisolone + Cyclophosphamide |
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What is GOUT? |
Acute mononeuropathy caused by hyperuricaemia and intra-articular sodium urate crystals |
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Pathogenesis of Gout |
Hyperuricaemia results from the overproduction of uric acid or renal under-excretion
Urate is derived from the breakdown of purines (adenine&guanine)
Deposition of monosodium urate crystals |
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Clinical Features of GOUT |
30-60 years old MALE Sudden onset - usually during night PAINFUL- RED-SWOLLEN joint (shiny = polished apple)
50% occur at MTP joint of the big toe (Podagra) Rest: Ankle/Foot/Small joints of hand/Wrist/Elbow/Knee
Long Term = Chronic polyarticular gout Chronic tophaceous gout (White deposits - pinna/tendon/fingers) Urate renal stones / interstitial nephritis
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DD for Gout? |
Septic Arthritis Haemarthrosis CPPD (Pseudogout) Palindromic RA |
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Gout percipitants |
Surgery Starvation Aggressive hypouricaemia induction/ cessation (allopurinol) Diuretics Alcohol Dietary Purine Binge (Shellfish/Offal/Spinach) Trauma/Surgery Leukaemia MI Sepsis Infection
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Investigations for Gout |
POLARISED LIGHT MICROSCOPY OF SYNOVIAL FLUID: "Negatively Birefringent needles/urate crystals"
Also: Hyperuricaemia X-Ray = Soft Tissue swelling ---> "punched out erosions" |
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Management of ACUTE gout |
NSAIDs (Naproxen / Diclofenac) OR Coxib (Etoricoxib) OR Colchine OR Steroids (If renal impairment)
ALSO = Rest/Elevate Joint/Ice Pack |
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Prevention of Gout |
Lose weight Don't fast Reduce alcohol Reduce purine rich foods Stop aspirin
If >1 in 12 months/stones/tophi = ALLOPURINOL (Xanthine oxidase inhibitor = converts xanthine -> urate)
OR
FEBUXOSTAT |
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Aetiology of PSEUDOGOUT |
FEMALES this time - Elderly - KNEES/WRIST Caused by Calcium Pyrophosphate Deposition (CPPD) |
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Define Pseudogout |
Deposition of calcium pyrophosphate dihydrate in the articular cartilage & periarticular tissues |
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What do you see radiologically in pseudgout? |
CHONDROCALCINOSIS |
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Clinical Features of psedogout? |
Acute = Similar to gout except elderly/spontaneous/self-limiting
Chronic = Inflammatory RA-like (symmetrical) polyarthritis & synovitis
OA + CPPD = Chronic polyarticular OA with superimposed acute CPP attacks |
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Risk Factors for pseudogout? |
Old Age Hyperparathyroidism Haemachromatosis Wilson's Hypophosphataemia Acromegaly Dehydration OA Myxoedema |
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Investigations for Pseudogout? |
POLARISED LIGHT MICROSCOPY OF THE SYNOVIAL FLUID
= Weekly positively birefringent rhomboidal crystals
XRAY = Chondrocalcinosis |
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Management of Pseudogout? |
Acute Attack? Cool pack/Rest/Aspiration/Intra-Articular Steroids
NSAIDs + Colchine
Chronic? Methotrexate |
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What is Paget's Disease of the bone? |
OSTEITIS DEFORMANS = MY HAT DONT FIT BITCH
Increased bone turnover associated with increased numbers of osteoblasts and osteoclasts (resorption) ---> Remodelling / Bone enlargement / Deformity / Weakness |
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Aetiology of Pagets |
40 year old WHITE DUDE Unknown MAYBE latent viral infection in osteoclasts in a genetically susceptible host Possible viruses = Canine Distemper Virus / Measles |
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Clinical Features of Paget's |
Deep BORING pain with bony deformity & enlargement = Pelvis / Lumbar Spine / Skull / Femur / Thoracic Spine / Tibia (Bowed Sabre Tibia) |
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6 Complications of Paget's |
1) Pathological Fractures 2) Osteoarthritis 3) Hypercalcaemia 4) Nerve compression (Deafness / Paraparesis due to cord compression) 5) High output CCF (when over 40% of skeleton involved) = due to INCREASED blood flow 6) Osteosarcoma (Suspect if sudden onset worsening) |
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Investigations for Paget's Disease of the BONE |
1) X-RAY = Localised bone enlargement = Patchy cortical thickening = Sclerosis / Osteolysis / Deformity e.g. Osteoporosis Circumscripta of the skull
2) Radionuclide Bone Scan = "Hot Spots" = Increased bone uptake
3) Blood Chemistry = Raised Alkaline Phosphatase = Raised Urinary Hydroxyproline |
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Management of Paget's |
NSAIDs ALENDRONATE / PAMIDRONATE (Bisphosphonate) *Inhibit bone resorption by decreasing osteoclastic activity *Help to reduce pain and or deformity |
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What happens in OSTEOMALACIA |
Normal amount of BONE but the MINERAL CONTENT IS LOW (There is excess uncalcified osteoid & cartilage)
Reverse of osteoporosis (mineralisation unchanged BUT bone is lost) |
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What is Rickets? |
When a lack of mineral content (osteomalacia) occurs BEFORE the fusion of the epiphyses |
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Risk Factors for Osteomalacia? |
HIJABIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII PIGMENTED SKIN Concealed clothing Elderly Malabsorption diseases |
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Clinical Features of Rickets? |
Bow-legged Knock-kneed Hypotonia Growth Retardation |
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Clinical Features of Osteomalacia? |
Bone pain and tenderness Fractures (Femoral Neck) Proximal Myopathy Severe Vitamin D deficiency = Hypocalcaemia / Tetany / Seizures |
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Causes of Osteomalacia? |
1) LACK OF VITAMIN D = Malabsorption = Poor Diet = Lack of Sun
2) Renal Osteodystrophy = Renal Failure = 1,25 Dihydroxy-calciferol deficiency
3) Drug Induced = Epilepsy drugs may induce liver enzymes = Breakdown of 25-hydroxyvitamin D
4) Vitamin D Resistance (Congenital)
5) Liver Disease (Cirrhosis) Decreased Hydroxylation of Vitamin D to 25-hydroxy-calciferol and malabsorption of Vitamin D
6) Tumour-induced Osteomalacia (Oncogenic hypophosphataemia) Raised production of FGF-23 = Hyperphosphaturia
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Investigations for Osteomalacia? |
1) Plasma = Decreased Calcium = Decreased PO43- = Decreased 25(OH) - Vitamin D (in renal failure) = RAISED PTH = RAISED ALK PHOS
2) Bone Biopsy = Incomplete mineralisation
3) X-RAY = LOOSER'S ZONES (Apparent fractures WITHOUT displacement) **Scapula/Inferior Femoral Neck/Medial Femoral Shaft** = Loss of cortical bone |
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Management of Osteomalacia |
Dietary Insufficiency? Calcium D3 Forte Malabsorption / Liver disease? Ergocalciferol Renal Disease / Vitamin D resistance? Calcitriol
MONITOR PLASMA Ca2+ WEEKLY |
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Name 2 congenital genetic causes of Rickets? |
Vitamin D resistant rickets Type 1 = LOW Renal 1alpha Hydroxylase Activity Type 2 = End-Organ Resistance to 1,25 (OH)2 D Rx = HIGH DOSE CALCITRIOL
X-linked hypophosphataemic rickets **AD inheritance - defect in renal phosphate handling Mutation in PEX or PHEX genes Rx = Oral phosphate + Calcitriol |
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3 red flags that would suggest Cauda Equina syndrome? |
Saddle Anaesthesia Bladder dysfunction Faecal incontinence |
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2 red flags that would suggest a spinal fracture? |
Sudden onset pain - relieved by LYING down Major trauma |
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3 red flags that suggest cancer/infection? |
<20/>50 years old Weight loss / Fever IV Drugs / Recent Infections |
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What happens in ACUTE disc disease? |
Nucleus puloses herniates --> irritating/ compressing the nerve root --> sciatica
*Traumatic or secondary to degenerative disc disease
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Where is ACUTE disc disease most likely to occur? |
L5-S1 |
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Why is acute disc prolapse only in younger patients? |
Because the disc degenerates with AGE The elderly are not capable of prolapsing it |
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What are the clinical features of a LUMBOSACRAL disc herniation? |
(If nerve entrapment) Unilateral leg pain -----> Toes Leg Pain is GREATER than back pain Numbness/Paraesthesiae/Weakness Positive straight leg raise test |
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Where would you experience pain and weakness if L2 was damaged? |
Upper Thigh Hip Flexion & Adduction
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Where would you experience pain and weakness if L3 was damaged? |
Lower Thigh Hip Adduction & Knee extension Knee Jerk Affected |
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Where would you experience pain and weakness if L4 was damaged? |
Knee-->Medial Malleolus
Knee extension Foot inversion Dorsiflexion
Knee Jerk Affected |
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Where would you experience pain and weakness if L5 was damaged? |
Lateral Shin --> Dorsum & Big Toe
Hip EXTENSION/Abduction Foot and great toe dorsiflexion
Big Toe Jerk affected |
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Where would you experience pain and weakness if S1 was damaged? |
Posterior calf to the lateral foot & big toe
Knee flexion Foot and Big Toe Plantar Flexion Foot eversion
ANKLE JERK affected |
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What is the GOLD standard investigation for vertebral disc diseases? |
MRI
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Management of vertebral disc degeneration / slipped disc |
1) Analgesia = Paracetamol/NSAIDs --> Tramadol -> Diazepam ---> Amitriptyline
2) Physiotherapy
3) Firm mattress / heat / massage
4) Surgery = Discectomy / Spinal Fusion *ONLY for severe neurological impairment / chronic intractable pain* |
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Name 5 causes of degenerative disc disease? |
AGE IT
Ageing Genetic Environmental Infections Traumatic
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Clinical features of degenerative disc disease? |
Mechanical Type pain --> Can lead to disc herniation or sciatica LONG standing pain --> prospects for cure are limited
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Management of degenerative disc disease |
NSAIDs / Physiotherapy / Weight Reduction Surgery ONLY if the pain is arising from a SINGLE IDENTIFIABLE LEVEL Fails to respond to conservative measures
Fusion with decompression of the affected nerve root |
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5 places that metastasise to the bone? |
BIG BREASTS THINK KATY PERRY
Breast Bronchus Thyroid Kidney Prostate |
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Name 6 benign bone tumours |
Osteoid Osteoma Osteochondroma Chondroma Osteoclastoma (Giant-cell tumour) Osteoblastoma Aneurysmal Cyst |
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What happens in Osteoid Osteoma? |
Young adults - pain worse at night XR = Radiolucency surrounded by dense bone Rx = LOCAL EXCISION |
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What happens in Osteochondroma? |
MOST MOST COMMON
Sessile or pedunculated lesions arising from the cortex of a long bone adjacent to the epiphyseal plate
CF = Nerve compression / Ankle diastasis / Angular Deformities
Rx = LOCAL EXCISION |
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What happens in Chondroma? |
Single/Multiple --> Tubular bones in hands or feet XR = Well-defined osteopenic area in the medulla
Rx = Excision + Bone Graft |
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What happens in Giant cell tumours (Osteoclastoma)? |
AGGRESSIVE locally recurrent tumour with LOW metastatic potential ONLY occurs after the closure of the epiphyses (20-40 years old)
Rx = Wide Excision + Joint replacement |
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What happens in Osteoblastoma? |
Locally destructive progressive lesions commonly found in the vertebrae DULL ACHING PAIN Needs FREQUENT BIOPSY to exclude malignancy
Rx = Bone Grafting / Curettage |
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What happens in an aneurysmal cyst? |
Pain and swelling Cavernous space filled with blood and tissue Can lead to cord/nerve root compression
Management = Bone Grafting |
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What happens in osteosarcoma? |
Knee/proximal humerus ---> DESTROYS bone ---> Metastasis to the lung
Rx = Surgery + Chemotherapy |
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What happens in Ewing's Sarcoma? |
Primitive neuroectodermal tumor (PNET) = from MESENCHYMAL STEM CELLS
CF = Pain/redness/malaise/anorexia/weight loss/ fever
BIOPSY = Diagnostics Rx = VIDE chemotherapy Vincristine / Ifosfamide / Doxorubicin / Etoposide
ALSO surgery + radiotherapy |
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What happens in CHRONDOsarcoma |
May arise from osteochondromas or be primary DULL/DEEP pain
Central = Pelvis / proximal bones Peripheral = Cartilagenous cap of the osteochondroma
Rx = WIDE LOCAL EXCISION |
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Define Fibromyalgia? |
Chronic symptoms of fatigue and WIDESPREAD pain with no discernable cause |
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Risk Factors for fibromyalgia? |
Female Middle Age Low Income Divorced Low education |
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Yellow flags for Fibromyalgia? |
Social withdrawal Sickness behaviours (extended rest) Low mood / Anxiety / Stress Problems at work Overprotective family / lack of support |
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Diseases associated with fibromyalgia? |
Chronic fatigue syndrome IBS Chronic headache syndrome RA AS SLE |
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Clinical Features of Fibromyalgia? |
SLEEP disturbance Chronic > 3 months = WIDESPREAD = Left and Right / Above and below waist / Axial skeleton Tender Points (See next question) Morning Stiffness Fatigue - Low Mood Poor concentration |
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Name 4 tender points in fibromyalgia? |
SPCU Suboccipital muscle insertions Posterior to the greater trochanter Chostochondral junction of the 2nd rib Upper outer gluteal quadrant |
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What should you investigate for even if you strongly suspect fibromyalgia? |
RA PMR Vasculitis Hypothyroidism Myeloma |
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Management of Fibromyalgia |
1) Education of the pain and family 2) EXPLAIN that it is relapsing & remitting with NO easy cures 3) Reassurance - no serious pathology 4) Discuss psychological issues 5) COGNITIVE BEHAVIOURAL THERAPY **Coping strategies & Achievable goals** **Long term graded exercise programme**
6) Pharmacotherapy -- Amitriptyline -- Pregabalin -- Tramadol -- Venlafaxine |
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Define MECHANICAL (non-specific) lower back pain |
Pain that is not due to any specific or underlying disease |
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Clinical Features of mechanical back pain |
** May happen for no reason / after lifting heavy item / after awkward twisting movement
** Eased by lying flat - worse by movement/cough/sneeze
** Symptoms improve within a week - BUT may have reoccurences |
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Potential causes of mechanical back pain? |
Lumbar disc prolapse Osteoarthritis Fractures Spondylolisthesis |
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Inflammatory causes of back pain? |
AS Infection ** GRADUAL ONSET with morning stiffness** |
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Name 5 serious causes of back pain |
1) Metastases 2) Myeloma 3) Tuberculosis osteomyelitis 4) Bacterial osteomyelitis 5) Spinal and root canal stenosis |
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Age groups and most likely cause of back pain? |
15-30? Mechanical / Prolapse IV disc / AS / Spondylolisthesis
30-50? Mechanical / Prolapsed IV disc / Malignancy/ Degenerative
>50 Degenerative / Osteoporosis / Malignancy / Myeloma / Paget's disease
ALL = Fractures / Infections |
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Management of mechanical lower back pain? |
Education + Self-Management Be ACTIVE Paracetamol + NSAIDs + Codeine Low dose Amitripyline Physiotherapy / Accupuncture / Exercise Address psychological issues
ANY NEURO ISSUES = Referral |
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Define septic arthritis |
Medical EMERGENCY Acutely inflamed joint - can destroy in <24 hours KNEE usually NB = Low inflammation signs if immunocompromised
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Risk Factors for septic arthritis? |
Pre-existing joint disease (RA) DM Immunosuppression CKD Recent joint surgery Prosthetic joint IVDU |
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Clinical Features of septic arthritis |
Hot/painful/swollen RED joint = ACUTE |
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Potential Causes of septic arthritis |
Recent infection? IV lines? Pneumonia? Infected skin? Recent joint replacement infection on wound? |
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Investigations for septic arthritis? |
URGENT JOINT aspiration + synovial fluid microscopy
Septic fluid = Opaque Neutrophils = 75 000 WCC/mm3 Gram Stain Polarised light microscopy (Gout?)
Blood Cultures
Swab if Gonococcal suspected
XRAY/CRP = NOT DIAGNOSTIC
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4 organisms that can cause septic arthritis? |
Staph. Aureus Streptococci Neisseria gonococcus Gram negative bacilli
Meningococcal / Tuberculous |
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Management of Septic Arthritis |
FLUCLOXACILLIN (Vancomycin if MRSA)
Gonococcal / Gram -VE? = CEFOTAXIME
Usually 2 weeks IV + 2-4 weeks PO NSAIDs/Immobilise/Joint Drainage |
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3 side effects of NSAIDs |
Peptic ulcers Renal impairment Increased risk of MI/Stroke (Diclofenac / Celecoxib / Ibuprofen) |
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Define osteomyelitis? |
Infection of the BONE MARROW - May spread to bone cortex periostium
Either through Haematogenous (Catheter) Direct (Following trauma) |
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4 organisms that cause osteomyelitis |
STAPH.AUREUS H.INFLUENZAE Salmonella (More common in sickle cell) Escherichia Coli |
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6 Risk factors for osteomyelitis? |
1) Trauma (Surgery/Open fracture) 2) Diabetes 3) Peripheral arterial disease 4) IVDU 5) TB 6) Sickle Cell Disease
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Clinical Features of osteomyelitis? |
1) Painful/Immobile limb/ Swelling/Erythema/Tenderness
2) Back Pain? Pott's Disease?
3) Fever
4) Diabetic foot ulcers |
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Investigations for Osteomyelitis? |
BONE CULTURE = GOLD STANDARD Also MRI/Blood culture/ESR/CRP/FBC |
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Management of Osteomyelitis |
Flucloxacillin (or Vanco if MRSA) + Rifampicin / Fusidic Acid
Surgical debridement of sequestrum (dead bone) |
