Musculoskeletal & Rheumatology

Features to suggest an underlying inflammatory condition.

EMS >60mins

Better after exercise - worse after rest.

Hx of joint swelling.

Systemic Features

Good response to anti-inflammatory drugs.

Fox

Typical joints involved in different arthritis'.

Rheumatoid - wrists, hands - symmetrical.

Psoriatic - any.

Gout - big toe, ankle, knee..

CPPD - knees, wrists.

Septic Arthritis - single joint.

OA - 1st CMC, PIPJ, DIPJ, knees, big toe.

SpA - spine + SIJ.

MSK/rheum., presentations that present with severe pain.

Septic Arthritis, Gout/CPPD, fracture.

MSK/rheum., presentations that present with fluctuating symptoms.

CPPD, RA (palindromic)

Extra-articular presentations of rheum., diseases.

Psoriasis

CTD - Raynaud's, rash, sciatica, SoB, weakness, bowel changes.

Common locations of rheumatoid nodules.

Elbows, hands, achilles tendon + intra-pulmonary.

Causes of an increased rheumatoid factor - not specific to RA.

5-10% of population - older, multigravida.

Chronic Inflammation

SLE

Criteria used to diagnose RA (6+)

2010 ACR EULAR Classification Criteria

Management of RA (X3)

1) Lifestyle - smoking.

2) Pharm

Steroid Use - IM, PO or minimal dose.

DMARDs

If failed 2 X DMARDs - consider biological.

3) Physiotherapy

How might spondyloarthropathies present (X4)?

Peripheral

Dactylics

Axial - inflammatory back pain.

Ehthesitis - where tendon or ligament meets the bone.

Typical demographic that presents with ankylosing spondylitis.

Male - late teens-20s

XR features of ankylosing spondylitis.

Sclerosis/Erosions of SIJ

Vertebral Corner Erosions

Bamboo Spine

Insufficiency Fractures

MRI features of anklylosing spondylitis.

Romanus Lesions - enteritis at the insertion points of the longitudinal spinal ligaments.

XR changes associated with psoriatic arthritis.

Joint space narrowing, pencil-in-cup erosions, perilosteal new bone formation.

Key treatment for axial disease in ankylosing spondylitis - biologics.

anti-TNFi and anti-IL17 agents

Microscopy from affected joint in gout.

needle shaped negatively birefringent monosodium urate crystals under polarised light

Microscopy in acute calcium pyrophosphate crystal deposition disease.

weakly-positively birefringent rhomboid-shaped crystals

Mx of Ca++ pyrophosphate crystal deposition disease.

aspiration of joint fluid, to exclude septic arthritis

NSAIDs or intra-articular, intra-muscular or oral steroids as for gout

Risk factors in septic arthritis.

Recent infection, instrumentation and Hx of trauma.

Joint most likely affected in septic arthritis.

Knee - adults.

Hip - children.

Investigations in Raynaud's syndrome.

ANA

Nail-Fold Capillaroscopy

Features of PMR.

Shoulder and hip girdle - pain, stiffness and weakness.

EMS >60mins

Constitutional Symptoms

Initial Tx for PMR.

15mg Prednisolone

Systemic vasculitis with a preference for extra cranial branches of the carotid branches.

Giant Cell Arteritis

Features of temporal artery that would prompt investigation for GCA.

Palpable, non-pulsatile + tender.

USS findings of GCA.

Halo Sign

Steroid regime in GCA.

Prednisolone 40mg (60mg w/ visual Sx, IV if vision loss).

Specific Ab test for SLE - as ANA+ve is non-specific.

Anti-dsDNA

Common demographic features associated with SLE (X3).

Women

Africa, African, Caribbean + Hispanic

Young-Middle Aged

Typical rash associated with SLE - triggered/worsened by sunlight.

Malar Rash

Leading cause of death in SLE patients.

CVD

1st line options for SLE treatment (X3).

- Hydroxychloroquine

- NSAIDs

- Steroids

- Sun Cream

Tx options for resistant or more severe SLE (X2).

DMARDs

Biologics (i.e., rituximab, belimunab)

What type of hypersensitivity reaction is SLE an EG of?

Type III Hypersensitivity Reaction

Marker of lupus nephritis that should be checked frequently.

Proteinuria

General features of SLE

Fatigue, fever, mouth ulcer + lymphadenopathy.

Most common type of glomerulonephritis seen in SLE.

diffuse proliferative glomerulonephritis

Typical pattern of joints affected by rheumatoid arthritis.

Symmetrical Polyarthritis

3 X Key RFs for rheumatoid arthritis.

Women

Smoking

Obesity

Most common gene association with rheumatoid arthritis.

HLA-DR4

Antibodies associated with rheumatoid arthritis

RF (70%)

Anti-CCP (80%)

Joints (X4) most commonly affected by rheumatoid arthritis - pain, stiffness + swelling - worse in the AM.

Metacarpophalangeal (MCP) joints

Proximal interphalangeal (PIP) joints

Wrist

Metatarsophalangeal (MTP) joints (in the foot)

This involves self limiting short episodes of inflammatory arthritis with joint pain, stiffness and swelling typically affecting only a few joints. The episodes only last 1-2 days and then completely resolve. Having positive antibodies (RF and anti-CCP) may indicate that it will progress to full rheumatoid arthritis.

Palindromic Rheumatism

Hand signs (X4) seen in advanced rheumatoid arthritis.

1. Z-shaped deformity to the thumb

2. Swan neck deformity (hyperextended PIP and flexed DIP)

3. Boutonniere deformity (hyperextended DIP and flexed PIP)

4. Ulnar deviation of the fingers at the MCP joints

Triad of Sx associated w/ Felty's syndrome.

rheumatoid arthritis, neutropenia + splenomegaly

Necessary investigations to be performed w/in 3W when someone presents with persistent synovitis (X5).

Rheumatoid Factor (RF)

Anti-CCP

Inflammatory Markers (CRP, ESR)

XR

USS/MRI - synotivits

Drugs preferred for Mx of rheumatoid arthritis flares in pregnancy.

Hydroxychloroquine and sulfasalazine

Key side Fx of methotrexate to remember.

Bone marrow suppression, leukopenia + highly teratogenic.

Key side Fx of leflunomide.

HTN + peripheral neuropathy

Key side Fx of sulfasalazine.

Orange urine + temp., male infertility.

Key side Fx of hydroxychloroquine.

Retinal toxicity, blue-grey skin pigmentation + hair bleaching.

Rules regarding NSAID use in pregnancy.

withdraw NSAIDs at 32W - due to early closure of PDA

Ocular manifestations of rheumatoid arthritis.

Ocular manifestations

keratoconjunctivitis sicca (most common)

episcleritis (erythema)

scleritis (erythema and pain)

corneal ulceration

keratitis

Iatrogenic

steroid-induced cataracts

chloroquine retinopathy

NICE recommended intial therapy for rheumatoid arthritis.

DMARD monotherapy +/- a short-course of bridging prednisolone

How is response to Tx monitored in rheumatoid arthritis?

CRP + Disease Activity

Classical triad of Sx associated with reactive arthritis.

Conjunctivitis, urethritis + arthritis (can't see, pee or climb a tree)

Genetic link associated with reactive arthritis.

HLA-B27

Management of reactive arthritis (X4).

1. Treatment of the triggering infection (e.g., chlamydia)

2. NSAIDs

3. Steroid injection into the affected joints

4. Systemic steroids may be required, particularly where multiple joints are affected

Tx for recurrent cases of reactive arthritis.

DMARDs or Anti-TNF

Preceding infections seen in reactive arthritis.

Gastroenteritis or STIs

Inflammatory condition affecting the axial skeleton causing progressive stiffness + pain.

Ankylosing Spondylitis

Typical presentation of ankylosing spondylitis.

Male in 20s

Pain and Stiffness in the Lower Back - came on over 3M

Sacroiliac Pain (Buttock)

5 As of associated conditions when it comes to ankylosing spondylitis.

A - Anterior Uveitis

A - Aortic Regurgitation

A - Atrioventricular Block

A - Apical Lung Fibrosis

A - Anaemia of Chronic Disease

Test for lower back mobility in AS - 10cm above L5 + 5cm below - >20cm is normal.

Schober's Test

Key investigations when it comes to ankylosing spondylitis.

Inflammatory Markers

HLA B27

XR

MRI

XR findings in ankylosing spondylitis (X6).

1. Squaring of the vertebral bodies

2, Subchondral sclerosis and erosions

3. Syndesmophytes (areas of bone growth where the ligaments insert into the bone)

4. Ossification of the ligaments, discs and joints (these structures start turning into bone)

5. Fusion of the facet, sacroiliac and costovertebral joints

6. Bamboo Spine - late XR sign.

Management available in cases of ankylosing spondylitis.

- Regular exercise.

- NSAIDs

- Physiotherapy

- Anti-TNF - if persistently high disease activity.

Linear calcification of the cartilage in joints - consistent with psuedogout.

chondrocalcinosis

Source and nature of blood supply to the scaphoid.

Dorsal Carpal Branch (radia artery) - retrograde

4 X clinical signs associated with scaphoid fracture.

- ASB Tenderness

- Wrist Joint Effusion

- Pain on telescoping of the thumb.

- Tenderness of scaphoid tubercle.

Possible locations of scaphoid fracture - relative to the shape of the bone.

Distal tubercle, waist or proximal pole.

Necessary Mx in cases of suspected scaphoid fracture.

1) Immobilisation - futuro splint or below-elbow backslab.

2) Referral to ortho - 7-10D

Possible complications associated with scaphoid fracture.

Non-union causing pain + early OA

Avascular necrosis

Arthritis without any other cause - lasting >6W in a patient <16y/o.

Juvenile Idiopathic Arthritis

5 X types of JIA

Systemic JIA

Polyarticular JIA

Oligoarticular JIA

Enthesitis Related Arthritis

Juvenile Psoriatic Arthritis

Triad of Sx classical to Still's disease (systemic JIA).

Salmon-pink rash, fevers + joint pain.

Idiopathic inflammatory arthritis in 5 joints+ - tends to be symmetrical.

Polyarticular JIA

JIA that affects 4 joints or less - normally just 1 (mainly large joints).

Oligoarticular JIA

Classic associated feature w/ oligoarticular JIA + enthesitis-related arthritis that warrants opthalmology referral.

Anterior Uveitis

Available Tx for JIA

NSAIDs

Steroids

DMARDs (i.e., methotrexate)

Biologics

Softening of the bones secondary to low vitamin D levels that in turn lead to decreased bone mineral content - adult rickets.

Osteomalacia

Features seen in osteomalacia (X4).

Bone Pain

Muscle Tenderness

Fractures

Proximal Myopathy + Waddling Gait

B/T results that would suggest osteomalacia.

Low Vit D, Low Ca++/PO4 + Raised ALP

Necessary Mx in patients w/ osteomalacia.

Vitamin D Supplementation

Investigation of note in PMR

Raised ESR

Typical presentation of PMR

>60 F w/ rapid onset morning stiffness in proximal limb muscles

Tx of PMR

15mg Prednisolone OD - dramatic response

NICE recommended investigations in ?PMR before initiating steroids.

1. Full blood count

2. Renal profile (U&E)

3. Liver function tests

4. Calcium (abnormal in hyperparathyroidism, cancer and osteomalacia)

5. Serum protein electrophoresis for myeloma

6. Thyroid-stimulating hormone for thyroid function

7. Creatine kinase for myositis

8. Rheumatoid factor for rheumatoid arthritis

Don't STOP mnemonic for steroid treatment.

Don't - don't stop abruptly as this risks adrenal crisis.

S - Sick Day Rules

T - Treatment Card

O - Osteoporosis prevention - bisphosphanates, Ca++ + Vit D.

P - PPIs for gastroprotection

NICE recommend that PSA should not be done within:

6 weeks of a prostate biopsy

4 weeks following a proven urinary infection

1 week of digital rectal examination

48 hours of vigorous exercise

48 hours of ejaculation

XR finding that is specific to rheumatoid arthritis.

Periarticular Erosions

What imaging is most supportive of a diagnosis of ankylosing spondylitis?

sacro-ilitis on a pelvic X-ray

Number of standard deviations that the patient is from an average healthy young adult.

T-Score

X-ray that measures how much radiation is absorbed by the bones - specifically the femoral neck for T-scores.

DEXA Scan

Number of standard deviations the patients is from the average for their age, sex and ethnicity.

Z-Score

Who (X4) do NICE recommend assessing for risk of osteoporosis?

- LT PO Corticosteroids

- >50 w/ RFs

- All Women 65+

- Men 75+

2 X factors that define the 10-year risk of a major osteoporotic fracture + hip fracture - if >10% DEXA scan is recommended.

QFracture Tool

FRAX Tool

Who can have a DEXA scan immediatley without calculation of risk?

>50 w/ fragility fracture

<40 with major risk factors

What patients can be started on Tx for osteoporosis immediatley without a DEXA scan?

Vertebral Fracture

4 X important SFx of bisphosphanates.

1. Reflux + Oesophageal Erosions

2. Atypical Fractures

3. Osteonecrosis of the Jaw

4. Osteonecrosis of External Auditory Canal