Musculoskeletal. Gemma Nixon

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1 Musculoskeletal Gemma Nixon

2 Introduction Joints Bones Osteoarthritis Inflammatory arthritis Acute monoarthropathy; septic arthritis, gout & pseudogout Osteoporosis Osteomalacia

3 Joints

4 Types of joints Joints Solid Synovial Fibrous Cartilagenous Hinge, ball & socket, saddle, pivot Sutures, gomphosis, syndesmosis Pubic symphysis, synchondrosis

5 Types of joints Features of synovial joints Layer of hyaline cartilage over articulating surfaces Joint capsule; inner synovial membrane & outer fibrous membrane Synovial membrane produces synovial fluid Fibrous membrane formed by dense CT surrounding and adding stability to joint

6 Bones

7 Bone structure

8 Bone structure "Illu compact spongy bone" by SEER U.S. National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Program adress. Licensed under Public Domain via Wikimedia Commons

9 Bone remodelling Life long process Two main cell types involved: Osteoblasts secrete new bone Osteoclasts breaks bone down Modulated by: Vitamin D Stimulates osteoclasts PTH stimulates osteocytes/osteoclasts Calcitonin Inhibits osteoclasts, stimulates osteoblasts

10 Bone healing 1. Reactive Phase Fracture and inflammatory phase Granulation tissue formation 2. Reparative Phase Cartilage Callus formation Lamellar bone deposition 3. Remodeling Phase Remodeling to original bone contour

11 Bone healing

12 Osteoarthritis

13 Overview Extremely common 8.5 million in the UK (good for exams) Degenerative process affecting the whole joint cartilage, bone, synovium, capsule and muscle. Risk factors: age, FHx, obesity, previous injury, occupation, and being female Any joint but most commonly load bearing and high usage joints: hips, knees, spine, hands.

14 Pathophysiology Severe wear and tear/faulty repair/damage to joint Cartilage becomes damaged Bone rubs against bone Bone overgrowth Inflammation of soft tissues around joint PAIN and loss of function

15 Symptoms and signs Symptoms: pain, stiffness and swelling in a joint. Progressive onset usually over months/years. Worst at the end of the day. <30 mins in the morning Signs: soft tissue swelling (not red and hot), bony swelling, limited movement, crepitation. Heberden s Bouchard s

16 Investigations Common exam question XR signs LOSS Loss of joint space Osteophytes Subchondral cysts Subarticular sclerosis

17 Management Conservative most important! Exercise, weight control, walking aids, knee supports, physiotherapy, occupational therapy. Pharmacological Pain control WHO pain ladder Anti inflammatory NSAIDs and steroid injections Surgical Arthroscopy and debridement Replacement Hip replacements have better outcomes than knee replacements Both will last around 20 years depending on use considerage

18 Rheumatoid arthritis

19 Inflammatory arthritis Rheumatoid arthritis Spondyloarthropathies Ankylosing spondylitis Psoriatic arthritis Reactive arthritis Reiter s syndrome Behçet s disease Enteropathic arthropathies Whipples disease Don t worry about these.

20 Overview Affects 1% of UK population Autoimmune symmetrical deforming polyarthropathy Presents at any age, most commonly middle age Risk factors: smoking, HLA DR1/DR4, rheumatoid factor, anti CCP antibody status, FHx Usually affects small joints (hands and feet) but can affect any joint

Pathophysiology Immune mediated inflammatory process

cascade and producing a synovitis Formation of an

erosion of joint Joint becomes deformed and tendons

21 Pathophysiology Immune mediated inflammatory process monocyte invasion of joint setting up an inflammatory cascade and producing a synovitis Formation of an inflammatory pannus Chronic inflammation leads to erosion of joint Joint becomes deformed and tendons rupture RA is a systemic disease therefore has extrarticular manifestations

22 Symptoms and signs Symptoms: Painful, stiff, swollen joints in a symmetrical pattern. Worse in the morning and >30mins duration. Relieved by activity. Signs: Early boggy swelling in small joints of the hand. Later joint damage, deformity Hand signs Z thumb Ulnar deviation of fingers Subluxation of MCPJs Boutonniere/swan neck Rupture of extensor tendons Muscle wasting Wrist subluxation

23 Symptoms and signs Extra articular manifestations Rheumatoid nodules skinand lung Pulmonary fibrosis Atlanto axial joint subluxation Pericardial effusion Many more!

24 Investigations Rheumatoid factor +ve in 70% Anti CCP 98% specific FBP normocytic anaemia (anaemia of chronic disease) Inflammatory markers ESR and CRP X ray LESS Loss of joint space Extra articular osteopaenia Soft tissue swelling Subluxation

25 Management Refer to rheumatology early and be aggressive Monitor DAS 28 (Disease Activity Score) Start 2 DMARDS at the same time (methotrexate/penicillamine) Then if failed after 6 months use biologics Treat flares with steroids Control pain with NSAIDs and paracetamol Exercise/physio/OT Control cardiovascular risk Surgery if severe disease

26 Drugs in rheumatology: analgaesia WHO pain ladder Most pain will be controlled with paracetamol and NSAIDs (ibuprofen, naproxen, meloxicam, indomethacin, NOT diclofenac risk of cardiac events) NSAIDs be careful if poor renal function. Usually co prescribe a PPI (e.g. omeprazole) If require opiates start with cocodamol or tramadol if night pain Rarely require strong opiates

Drugs in rheumatology: steroids Used in OA/RA injected directly into the joint to reduce pain Begins working within a few days Lasts for weeks/months Short

27 Drugs in rheumatology: steroids Used in OA/RA injected directly into the joint to reduce pain Begins working within a few days Lasts for weeks/months Short courses of IM/IV steroid in pulses reduces the severity and duration of a flare but carries the risk of side effects Long term oral steroids Cushingoid symptoms

28 Drugs in rheumatology: DMARDS Disease Modifying Anti Rheumatic Drugs Slow the progression of inflammatory arthritis by altering the immune response Many types but and lots of side effects. A few examples are given below Often teratogenic and often cause immunosuppression Initiate 2 simultaneously to speed access to biologics at 6 months Mechanism Side effect 1 Side effect 2 Methotrexate Dihydrofolate reductase inhibitor Mucositis Pulmonary fibrosis Leflunomide Inhibits pyrimidine synthesis Bone marrow suppression Life threatening hepatic toxicity

29 OA vs RA Important in exams

30 The acute monoarthropathy Common presentation Common examination topic Requires rapid differentiation to rule out septic arthritis Investigate with; thorough history, joint examination, joint aspiration

31 Acute monoarthropathy History: Onset: sudden or gradual How many joints are involved Which joints are affected? Systemic symptoms History of trauma Loss of function Recent GI or GU symptoms

32 Differential diagnosis Septic arthritis Crystal arthropathies Trauma Haemarthrosis Inflammatory arthropathies Reactive arthritis

33 Septic arthritis Presentation: Single swollen joint with pain on active or passive movementmay present as polyarticular arthritis in 15% Fevers/ rigors common, but not universal Patient maybe systemically unwell Common sites: Knee 50%, Wrists (7%), ankles (7%) and hips (20%) also common Risk factors: Previous joint damage/diseases Joint prostheses Immunosupression HIV, steroid injection, STIs, IVDUs

34 Septic arthritis Treatment Joint drainage IV Antibiotics empirical Rx to cover s.aureus, Strep spp. Analgesia Splinting

35 Crystal arthropathies: gout Deposition of monosodium urate crystals within joint Reflects an imbalance between urate production and secretion Presentation: Acute pain in a swelling joint peaks at 6 12 hours 50% of attacks affect first metatarsal joint Other sites; knee, midtarsal, wrist, ankle, small hand joints, elbows Risk factors; Drugs (thiazide and loop diuretics, low dose salicylates), hypertension, FHx, alcohol excess, impaired renal function, hyperlipidaemia, vascular disease, chemotherapy, high purine foods

36 Gout Ix: Joint aspiration shows needle shaped monosodium urate crystals with negative birefringence under polarised light Serum urate may be raised Management: Strong NSAID (diclofenac) Colchicine Corticosteroids Prevention: Manage risk factors Allopurinol don t start during acute attack, don t stop during acute attack Febuxostat if allopurinol c/i

37 Crystal arthropathies: pseudogout Calcium pyrophosphate crystals DDx for acute monoarthropathy Tends to affect larger joints than gout (knee, wrist, hip) Risk factors; age, OA, DM, hypothyroidism, hyperparathyroidism Ix: Joint aspiration shows rhomboid shaped calcium pyrophosphate crystals and positive birefringence under polarised light Management: analgesia, NSAIDs, trial of steroids. Self limiting

38 Osteoporosis- brittle bones progressive systemic skeletal disease with reduced bone density and micro architecture deterioration Increases markedly with age: 2% at 50 years, >25% at 80 years in women

39 Osteoporosis Risk factors : Family history, older, female AND SHATTERED Steroids >5mg/day pred Hyperthyroidism Alcohol intake > 4 units/day and smoking Thin (BMI <22) Testosterone levels decreased (prostate Ca) Early menopause Renal or liver failure Erosive/inflammatory bone disease Dietary deficiency of calcium/diabetes

40 Osteoporosis Diagnosis: DEXA scan T score Low bone mass (osteopenia) T score 1 to 2.5 Osteoporosis T score < 2.5 Severe osteoporosis T score < 2.5. TREAT & repeat DEXA in 2 years

41 Osteoporosis Bisphosphonates: AVN of jaw Atypical femoral fractures GI irritation Combination of: Drugs Bisphosphonates > 65yrs without fracture, <65yrs with fracture AND addition RF Denosumab monoclonal ab against osteoclasts Strontium ranelate Diet calcium/ vitamin D supplements Exercise Manage falls risk reduce polypharmacy, modify home, hip protectors

42 Osteomalacia- soft bones Inadequate mineralisation of bone matrix Vitamin D deficiency leads to low calcium/phosphate, causing secondary hyperparathyroidism Causes: lack of sunlight, poor diet, malabsorption, liver & kidney disease Management Dietician input Sunlight exposure Vit D supplementation Pain management Orthopaedic intervention

43 Bones are not filled with red marrow, they are filled with black ingrattitude J Pyper, orthopaedic surgeon

Musculoskeletal. Zara Mullan

Musculoskeletal. Zara Mullan Musculoskeletal Zara Mullan zmullan01@qub.ac.uk Introduction Sample Questions Joints Bones Osteoarthritis Inflammatory arthritis Acute monoarthropathy; septic arthritis, gout & pseudogout Osteoporosis