MSK - Level 1 Flashcards by Guy Dunbavand

Description of septic arthritis?

Infection producing inflammation in native/prosthetic joint or more than one joint
Medical emergency and can destroy joint or develop sepsis <24 hour
Reaches via bloodstream, adjacent osteomyelitis or external skin puncture wounds

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Epidemiology of septic arthritis?

Knee in >50% cases, followed by hip, shoulder, ankle and wrists
1-2% incidence

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Risk Factors of septic arthritis?

o	Age>80
o	Rheumatoid arthritis/Gout
o	DM
o	Immunosuppresion
o	Renal failure
o	Prosthetic joints/Recent surgery
o	IVDU

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Causative organisms of septic arthritis?

o	S.aureus (most common)
o	Streptococcus
o	N.gonorrhoea
o	TB
o	Salmonella
o	Coagulase neg staph – prosthetic joints

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Symptoms and signs of septic arthritis?

o Monoarticular
o Red, painful, swollen joint developing acutely
o Pain on active and passive movement and often held in position of most comfort (slightly flexed)
o May be fever, rigors, shaking, vomiting
- Signs may be less marked in elderly, IVDU, immunocompromised

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Investigations needed in septic arthritis?

Bloods
o FBC, ESR, CRP, blood cultures
Joint aspiration
o Send for leukocyte count, Gram staining, microscopy and culture, ?AAFB
o Infectious aspiration – yellow, turbid, purulent, >10000 cells, neutrophils, Gram stain and culture +ve
o Normal aspiration – colourless/pale yellow, clear, 200-1000 cells, mononuclear cells, Gram stain and culture -ve
X-rays
o Normal or soft tissue swelling with displacement of capsular fat planes and swelling of soft tissue
o Later, bone destruction occurs
CT/MRI scan reserved for difficult cases

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Initial Management of septic arthritis? Orthopaedic management after referral?

o Analgesia
o IV Flucloxacillin for 2 weeks then oral switch for 4 weeks
 If penicillin allergic - Clindamycin
 If MRSA – Vancomycin
 If gonococcal – cefotaxime
 Empirical and start after aspiration
o Refer to Orthopaedic team for Joint irrigation/drainage, Analgesia, Splinting (In position of function, once infection under control then mobilisation will promote healing)

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Management of osteomyelitis/septic arthritis?

Flucloxacillin for 6 weeks
o Consider adding fusidic acid or rifampicin for 1st 2 weeks
o If penicillin allergic – clindamycin
o If MRSA – vancomycin

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Prognosis of septic arthritis?

o Mortality is 10-20%

o Around half regain baseline joint function after treatment

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Description of giant cell arteritis?

Chronic immune-mediated vasculitis characterised by granulomatous inflammation in walls of medium and large arteries
Preferentially extracranial branches of carotid artery and branches of ophthalmic artery
GCA and polymyalgia rheumatica often occur together in 50%

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Epidemiology of giant cell arteritis?

Incidence rare before 50 and peaks at 70
White people 7x more common
3x more common in women

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Symptoms of giant cell arteritis?

Headache
	Unilateral over temporal region
Temporal artery and scalp tenderness
	When combing hair
Jaw claudication
	Pain while eating
Amaurosis fugax
Sudden blindness in eye
Diplopia
Fever, fatigue, anorexia
Other – Neuropathy, morning stiffness

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Signs of giant cell arteritis?

o Ischaemic disease on fundoscopy
o Temporal arteries – prominent, beaded, tender and pulseless
o Bruits may be heard over carotid

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Suspect giant cell arteritis if..?

Suspect if >50 and:
o New onset localised headache, unilateral in temporal area
o Temporal artery – tender, thickened, nodular, red, pulseless

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When to refer people with suspected giant cell arteritis?

Refer all people for temporal artery biopsy
o If visual impairment – same-day ophthalmology assessment
o If no visual impairment – urgent rheumatology assessment (biopsy within 7 days)

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What bloods tests to order in giant cell arteritis?

o ESR, CRP raised
o FBC – normochromic normocytic anaemia, elevated platelets
o LFT – mildly elevated

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Initial drug treatment of giant cell arteritis?

Immediate Prednisolone 60mg/d PO
 Assess response over 1st 48 hours – if poor seek specialist advice
 If develop visual symptoms – seek same-day assessment for IV methylprednisolone
 Treatment reduced slowly and required for 1-2 years
Aspirin 75mg OD
Omeprazole 20mg OD

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Ongoing management of giant cell arteritis?

o If symptoms controlled – reduce dose of prednisolone slowly
 60mg until ESR/CRP normal, then reduce by 10mg every 2 weeks until 20mg daily, then reduce 2.5mg every 2-4 weeks until on 10mg daily, then 1mg evert 1-2 months

o Review a week after dose change and every 3 months for 1st year then 3-6 monthly
 Do ESR, CRP, BP and glucose

o Assess fracture risk and whether need bisphosphonates

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Managing a relapse of giant cell arteritis?

o If visual disturbance – increase to 60mg prednisolone & same-day assessment with ophthalmologist
o If jaw claudication – increase to 60mg daily &seek specialist advice
o If headaches, or PMR – increase dose and seek specialist advice

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Prognosis of giant cell arteritis?

o Relapses common – especially when steroid treatment reduced or withdrawn too quickly
o Exacerbations occur in 30-50% of people during first 2 years

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Complications of giant cell arteritis?

o	Visual Loss – total or partial
o	Aortic aneurysm, aortic dissection, large artery stenosis and aortic regurgitation
o	CVD
o	Peripheral neuropathy
o	Confusion and encephalopathy

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Description of spinal cord compression?

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Acute spinal cord compression is a neurosurgical emergency
Cancers leading to MSCC – breast, bronchus, prostate, myeloma/lymphoma but can occur with any tumour
Caused by tumour or metastases in vertebral body or paraspinal region pressing on spinal cord

Epidemiology of spinal cord compression?

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2/3 in thoracic region

- Occurs in 20% of patients with spinal metastases

Aetiology of spinal cord compression?

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o Metastases (breast, lung, prostate, thyroid, kidney)
o Cancer
o Trauma
o Cervical disc prolapse

Symptoms of spinal cord compression?

o Back pain/nerve root pain  Either unilateral/bilateral, aggravated by movement, coughing or lying flat o Motor weakness – strength changes o Subjective sensory disturbances o Bladder/Bowel dysfunction generally occurs late

Signs of spinal cord compression?

o Weakness/Paraparesis/Paraplegia o Changes in sensation below level of compression o Hyperreflexia o Clonus and painless bladder distension o Can lead to paraparesis, paraplegia and incontinence

Red flags in spinal cord compression?

``` o Leg Weakness o Sensory Loss o Thoracic back pain o Constant pain o Urinary retention/incontinence o Saddle Anaesthesia & loss of anal tone ```

Management if suspected metastatic spinal cord compression?

o Contact MSCC coordinator urgently if:  Pain in thoracic or cervical spine, progressive lumbar spine, severe unremitting lower spinal pain, aggrevated by straining, local tenderness, nocturnal spinal pain o Contact MSCC coordinator immediately if signs of MSCC

Initial management of spinal cord compression?

Initial Management  Nurse flat with neutral spine  Offer graduated compression/anti-embolism stockings  Catheterise in bladder incontinent Medical  Urgent dexamethasone 16mg PO daily commenced at suspicion  PPI cover needed Imaging  Urgent Whole Spine MRI

Definitive management of spinal cord compression?

```  Surgery • Should have before they cannot walk • Postoperative radiotherapy  Radiotherapy • Urgent if surgery not suitable • Fractionated radiotherapy if epidural tumour without neurological involvement, pain or spinal instability ```

Prognosis of spinal cord compression?

- Outcomes correlate with level of function at the time of treatment - If treated within 24 hours, 57% will walk again - Complete paralysis, present for several days, is almost never reversible

What diseases have a positive rheumatoid factor?

```  Rheumatoid arthritis  Sjogrens syndrome  Felty’s syndrome  Infection  SLE, sclerosis ```

What diseases have a positive anti-CCP antibody?

 Rheumatoid arthritis

What diseases have a positive antinuclear antibody?

```  SLE  Autoimmune hepatitis  Sjogren’s syndrome  Systemic sclerosis  Rheumatoid arthritis ```

What diseases have a positive anti-double stranded DNA (dsDNA) & positive anti-Sm & positive anti-RNP??

 SLE

What diseases have a positive antihistone antibody?

 Drug-induced SLE

What diseases have a positive antiphospholipid antibody (anti-cardiolipin)?

 Antiphospholipid syndrome |  SLE

What diseases have a positive anti-Ro?

• SLE, Sjogren’s syndrome, systemic sclerosis

What diseases have a positive anti-La?

• Sjogren’s syndrome, SLE

What diseases have a positive anti-Jo-1 & anti-mi-2?

• Polymyositis, dermatomyositis

What diseases have a positive anti-Scl70?

• Diffuse systemic sclerosis

What diseases have a positive antimitochondrial antibodies (AMA)?

 Primary biliary cirrhosis  Autoimmune hepatitis  Idiopathic cirrhosis

What diseases have a positive anti-smooth muscle antibodies (SMA)?

 Autoimmune hepatitis |  Primary biliary cirrhosis

What diseases have a positive gastric parietal antibodies?

 Pernicious anaemia |  Atrophic gastritis

What diseases have a positive intrinsic factor antibodies?

 Pernicious anaemia

What diseases have a positive anti-tissue transglutaminase & anti-endomysial antibodies?

 Coeliac disease

What diseases have a positive thyroid peroxidase antibodies?

 Hashimoto’s thyroiditis |  Graves’ disease

What diseases have a positive islet cells Ab & glutamic acid decarboxylase?

 T1DM

What diseases have a positive anti-GBM?

 Goodpasture’s disease

What diseases have a positive antineutrophil cytoplasmic antibodies (ANCA) - cytoplasmic - specific for serine proteinase 3?

* Granulomatosis with polyangiitis (Wegeners) * Microscopic polyangiitis * Polyarteritis nodosa

What diseases have a positive antineutrophil cytoplasmic antibodies (ANCA) - perinuclear - specific for myeloperoxidase?

* Microscopic polyangiitis | * Churg-Strauss disease

What diseases also have a positive ANCA?

 ANCA also positive in Crohn’s, UC, sclerosing cholangitis, autoimmune hepatitis, Felty’s, SLE, RA, drugs (antithyroid, allopurinol, ciprofloxacin)

What diseases have a positive acetylcholine receptor antibodies?

 Myasthenia gravis

What diseases have a positive anti-voltage gated Ca-channel antibodies?

 Lambert Eaton Syndrome

MSK - Level 1 Flashcards

(54 cards)