Phase 2 A MSK Rachel Jones 140420 Contents

Phase 2 A MSK Rachel Jones 14/04/20

Contents � MSK Knowledge Disease classification � Inflammation and infection � Inflammatory vs degenerative � Malignancy � Pharmacology � � MSK conditions Osteoporosis � Osteoarthritis � Rheumatoid Arthritis � SLE � Systemic Sclerosis � Sjogren’s Syndrome � Polymyositis/Dermatomyositis � Psoriatic Arthritis � Ankylosing Spondylitis � Gout � Pseudogout � Osteomyelitis � Septic Arthritis �

MSK Knowledge

MSK disease classification Arthritis Seropositive • • • Rheumatoid SLE vasculitis Sjogren’s Systemic scleorsis Seronegative Non-inflammatory • osteoarthritis Inflammatory Immune Infection Crystal • ank spond • osteomyelitis • gout • psoriatic • septic arthritis • pseudogout • reactive Non –Arthritic MSK conditions Osteoporosis mechanical back pain fibromyalgia

Inflammation and Infection Healthy synovial cells are phagocytic Articular cartilage lacks nerve endings so is rarely the source of pain Damaged synovial membranes show neovascularisation, increasing risk of infection

Inflammatory vs Degenerative Inflammatory Pain eases with use Quiet Stiffness: >60 mins Early morning/at rest Synovial swelling Clinically inflamed Young Psoriasis FH Hands and feet NSAID responsive Degenerative Pain increases with use Clicks and clunks Stiffness: <30 mins Evening Bony Swelling Not clinically inflamed Older Prior occupation Sport Knees Carpometacarpal joint (thumb base) Distal interphalangeal joints Not responsive to NSAIDs

Malignancy Primary Tumours � Children � Ewings sarcoma – onion skin � Osteosarcoma – sunburst � Adults � Chondrosarcoma – pelvis � Consider Myeloma Red Flags Ø growing mass Ø loss of function Ø night pain Ø weight loss Ø pathological fracture ØNeurological symptoms Secondary Tumours � Adults � Breast, lung, prostate, kidney, thyroid

MSK Pharmacology Pain Relief Paracetamol – weak COX inhibitor so reduces prodtaglandin Celecoxib - inhibits COX 2 to reduce prostaglandin production DMARDs Methotrexate inhibits conversion of folic acid; anti inflammatory and immunosuppressive Sulfasalazine – unclear mechanism, used in severe RA Osteoporosis drugs Alendronic Acid – a bisphonate; inhibits osteoclasts and promotes their apoptosis. Can cause osteophagitis HRT – slows bone trunover and increases BMD

MSK Conditions

Osteoporosis Causes Diagnosis Inflammatory disease, endocrine disorder, reduced skeletal load DEXA scan T score Presentation • Multiple fractures • Low impact fractures • Stooped posture • Hip, wrist and spine fractures Management • Bisphonates • inhibit osteoclasts and promote their apoptosis • HRT • Desunomab • Lifestyle • Reduce falls risk

Osteoarthritis Causes Local trauma, obesity, Presentation • pain • altered gait • crepitus • tenderness • deformity due to bony enlargement, synovitis, effusion Management • analgesia • steroid injections • surgery if significant Diagnosis XR • joint space narrowing • osteophytes • subchondral sclerosis/cysts • loss of bone contours

Rheumatoid Arthritis Causes Smoking, genetics, female Presentation • symmetrical peripheral polyarthritis • pain • morning stiffness • common joints include MCP, PIP and MTP Diagnosis • XR • Soft tissue swelling • joint erosion • raised ESR and CRP • autoantibodies (rheumatoid factor, anti CCP) Management • DMARDs • methotrrexate • sulfasalazine • analgesics • TNF alpha blockers • surgery

SLE Causes Type 3 immune reaction Women of child bearing age Presentation S – serositis O – oral ulcers A – arthritis P – photosensitivity B – blood disorders R – renal involvement A – antinuclear antibodies I – immunologic phenomena N – neurological disorder M – malar rash D – discoid rash Diagnosis • anti ds. DNA antibody • low C 3 and C 4 due to consumption • high ESR Management • DMARDs e. g methotrexate • consider teratogenity • sunscreen!

Systemic Sclerosis Causes Autoimmune condition causing excess collagen deposition Diagnosis • ANA positive Presentation • • Skin sclerosis Raynaud’s phenom gastrooesphageal reflux Sclerodactyly Telangectasia lung impairment Pulmonary hypertension Management • immunosuppression with cyclophosphamide • annual spirometry and ECG • stringent blood pressure control

Sjogrens Syndrome Causes Immune destruction of exocrine glands Presentation • • • Diagnosis • ANA • Rheumatoid Factor • Schirmer test dry eyes dry mouth arthritis Raynaud’s renal impairment Management • artificial tears • saliva replacement

Polymyositis/Dermatomyositis Causes Diagnosis Autoimmune, paraneoplastic • high ALT, AST, LDH and CK • EMG shows fibrillation Presentation • • myositis macular rash purple eyelids rough and red knuckles Management • 1 st line: prednisolone • calcium screen

Psoriatic Arthritis Causes Diagnosis HLA B 27 • XR • erosion • pencil-in-cup Presentation • symmetrical polyarthritis • arthritis mutilans • DIP and spine involvement Management • NSAIDs • anti TNF • DMARDs e. g. sulfasalazine

Ankylosing Spondylitis Causes Presentation • • gradual onset lower back pain worse at night morning stiffness loss of motion • one of the only MSK conditions that is more common in young men Diagnosis • XR • bamboo spine • sacroiliac joint space changes • sclerosis • erosions Management • exercise • NSAIDs • TNF alpha blockers

Reactive Arthritis Causes Diagnosis GI or GU infection • high ESR and CRP • STI screen and stool culture • XR for arthritis Presentation Reiter’s syndrome: can’t see, can’t pee, can’t climb tree • Uveitis • conjunctivitis • arthritis Management • splint affected joint acutely • NSAIDs • consider local steroid injections

Gout Causes Under excretion: alcohol, high PTH, renal impairment Over production: hyperlipidaemia, cytotoxic drugs, psoriasis, shellfish Presentation • inflamed joint (often toe) • severe pain ‘the weight of the bedsheets is too much’ • Tophi if chronic Diagnosis • XR • Periarticular erosion • narrow joints • soft tissue swelling • joint aspirate • viscous • negative bifringent needles Management • xanthine oxidase inhibitors (allopurinol) • short term NSAIDs • dietary advice

Pseudogout Causes Parathyroidectomy, IV fluids, direct trauma Presentation Diagnosis • joint aspirate • sparse rhomboid crystals • X ray • monoarthritis (often the knee) • fever Management • short term NSAIDs • physiotherapy • steroid injections • if really severe or long term, consider methotrexate

Osteomyelitis Causes S. Aureus. Often underlying bone or immune conditions Presentation Often long bones in children Often vertebrae in adults • acute fever and chills • pain – severe • swelling Pott’s disease is vertebral osteomyelitis due to TB. Consider in patients with resp symptoms Diagnosis • • • WCC raised high ESR and CRP X ray after 2 weeks blood cultures bone biopsy Management • surgical debridement • antibiotics e. g. coamoxiclav

Septic Arthritis Causes S aureus, Group A strep or N. gonorrhoea Presentation • fever • limited range of movement • loss of function Diagnosis • • high ESR and CRP aspirate for culture/sensitivities ultrasound X ray Management Begin with broad spectrum IV antibiotics. Move to targeted IV antibiotics once cultures are back, then move to PO when the patient is stable. Surgically drain site.

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